# EMT Bs and a 12 lead



## Medic744 (Jul 13, 2009)

I searched the threads and didnt find what I was looking for so here it goes.  We just got back to the station from a CP that we had to mutual aid over to another city for.  Unfortunately they have 5 trucks (all out on calls) except for one that was a BLS truck.  It took us 14 min to get there and on arrival the EMT Bs had already gotten vitals and went ahead and hooked the patient up to their 3 lead.  My question to my partner when it was all said and done is how he felt about having the BLS be able to run a 12 lead prior to our arrival so that we at least have a baseline EKG to compare with.  We both agreed that it would not be a bad thing.  Even if they can't read it, it would be nice to have to compare to mine.   I realize there are a few hurdles in that dept, but like with my patient today she literally had at least one of everything we have ever learned to look for at least once during transport (ST depression, PVCs, PACs, Sinus Tach, Sinus Brady).  And it would just have been nice to get there and have one to compare to mine and the one at the hospital.  So I guess what I want to know is how others feel about allowing EMT Bs to at least run the EKG for us before we arrive on scene.


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## firecoins (Jul 13, 2009)

I don't see the point.  BLS rigs here do not carry a monitor and spending thousands of more dollars to equipment seems extraneous.


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## gicts (Jul 13, 2009)

If I am not mistaken some BLS units in our area do have Life Pacs and send rhythms to hospitals before their arrival. That and setting up for medics are the only things I can imagine them being used for.


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## firemoose0827 (Jul 14, 2009)

gicts said:


> If I am not mistaken some BLS units in our area do have Life Pacs and send rhythms to hospitals before their arrival. That and setting up for medics are the only things I can imagine them being used for.




This, and another reason.  Im my squad we are volunteer, but we are ALS certified and only have 3-4 ALS providers.  If they dont show, we ask for the County Medics to respond.  My squad trains all of the members in the set up of certain things like ECG, and IV's so we can assist the medics.  This helps.  So when we respond as a BLS crew with a county medic responding from 10 minutes out, we can be on scene and have the monitor attached and strip printed out for the medic.  When they get there we grab a bag of fluid and spike it for the medic too, so when they get the IV the bag is ready to go.  It helps.  We are here to help.  Whats wrong with Basics helping Medics?  Good topic.


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## akflightmedic (Jul 14, 2009)

firemoose0827 said:


> This, and another reason.  Im my squad we are volunteer, but we are ALS certified and only have 3-4 ALS providers.  If they dont show, we ask for the County Medics to respond.  My squad trains all of the members in the set up of certain things like ECG, and IV's so we can assist the medics.  This helps.  So when we respond as a BLS crew with a county medic responding from 10 minutes out, we can be on scene and have the monitor attached and strip printed out for the medic.  When they get there we grab a bag of fluid and spike it for the medic too, so when they get the IV the bag is ready to go.  It helps.  We are here to help.  Whats wrong with Basics helping Medics?  Good topic.



Before I respond, and hopefully some of the other ALS providers will follow my lead...would you please take the time to explain how and what you teach the BLS providers i n order for them to do a 12 lead?

Please go into detail regarding everything you cover or give a very thorough outline with the important highlights noted.


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## firemoose0827 (Jul 14, 2009)

akflightmedic said:


> Before I respond, and hopefully some of the other ALS providers will follow my lead...would you please take the time to explain how and what you teach the BLS providers i n order for them to do a 12 lead?
> 
> Please go into detail regarding everything you cover or give a very thorough outline with the important highlights noted.



Sure...Ill try.  First off, we dont do anything with the 12 leads, just 3 lead.  But regardless of what I explain here there will be the ones that just tear it apart and be the usual monday morning quarterback, just like in every discussion that has something that someone is not sure of, or has never seen before.

Medics from both the squad and the County come to drill night.  They take the monitor we have in both of our rigs.  They show the Basics where the leads are placed (Isnt hard, a monkey can do it.)  Than show how to turn on the monitor, and than how to print out a strip...Is that realy hard?  They are not reading the rhythm, they are not making any diagnoses, just simply printing a strip to show the medics what the rhythms were when the BLS crew arrived.  The medics here have no problems with that and I dont see why some here cant grasp that...The doctors know of it, the nurses know of it and they all agree and help whenever possible.

IV's.  We take the drip set (the appropriate one) and go through the steps of spiking a bag of IV fluid, filling the chamber, and bleeding the line to prepare it for hooking it to the IV catheter.  We than are instructed on arranging the various other supplies like blood tubes, tape strips, tegaderms, saline flushes, etc etc so the Medic has all they need at their finger tips when they need it.  The county medics love doing calls with us because they know all of this will be done for them and they can worry about patient care.

We checked our SOP's and by-laws, we checked with our med control director, and we checked with the State EMS office about the legalities of this and it all checks out OK.  The County EMS Coordinators, who are also ALS fly cars, are involved with the training of the basics, hell, they are the instructors who teach Basic EMT in our county to begin with, and they agree with it.

Dont know what the issue is.  Hope this helps you.  Stay Safe.

[RANT]An after thought here as I read through my post.  I see where you might be potentially headed with this and I will intervene before it gets there...if I am correct in my guess that is.
We do not tunnel vision and forget the basic BLS skills we should be performing.  We arrive on scene, do an assessment, render treatment as needed like O2 and bandaging and what not, get a full set of vitals and history, THAN...and only than do we hook up the monitor and print a strip for the arriving medics.  Ninety percent of the time we are doing this with the medic present as he/she gets their assessment done and renders any other treatments anyway.  So no...we do not forget what our BLS skills are and we do not forget them.  We dont run in to the house with monitor in hand and run up to the patient and immediately slap the electrodes on and print a strip than sit there and wait...(something reminiscent of a Steve Berry Cartoon.)  We do our jobs than we assist where we can. [END OF RANT/]


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## daedalus (Jul 14, 2009)

What if the patient is in need of cardioversion, and an enterprising EMT recognizes the strip he just printed out. The monitor is there, but no medic. Should they for the good of the patient go ahead and zap him? Or do you tell the family of the dying patient you cannot use your own equipment until other personnel arrive?


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## Shishkabob (Jul 14, 2009)

daedalus said:


> Or do you tell the family of the dying patient you cannot use your own equipment until other personnel arrive?



Yes.  That's exactly what you do.  Or just keep doing the primary assessment without even letting them know that it CAN be used for more.

Chances are a civilian won't know that you can cardiovert using the monitor, and the ones that DO realize, will most likely undertsand the differences in cert levels as well.


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## MMiz (Jul 14, 2009)

daedalus said:


> What if the patient is in need of cardioversion, and an enterprising EMT recognizes the strip he just printed out. The monitor is there, but no medic. Should they for the good of the patient go ahead and zap him? Or do you tell the family of the dying patient you cannot use your own equipment until other personnel arrive?


Where I worked we had EMT-Paramedics that acted as first responders or "Echo" units.  They would literally master the city/locations, and would arrive on scene to help an ALS crew.  Each call got an ALS rig (Paramedic/Paramedic) and a Paramedic First Responder.  They carried all of the ALS gear, but could only operate at the BLS level until the ALS unit arrived.

They would hook the patient up to the monitor, even run a 12 lead if necessary, but any treatment from the defib. was in AED mode until ALS arrived.  They also had full airway equipment, but they would not insert an ET tube until the ALS unit arrived.  They would prep for an IV, but again, not put one in until ALS arrived.  

At the time our ALS arrive average time was just over three minutes, so it wasn't a big deal.


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## Shishkabob (Jul 14, 2009)

What was the logic behind such a plan?


You're an ALS provider, with ALS gear, but can't do anything until you have more ALS personnel?


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## Summit (Jul 14, 2009)

In CO, EKG is offered as a 2 credit hour (24-32 classroom hours) for Basics. 3 lead interpretation is the main emphasis as well as cardio A&P is covered, 1st line cardiac drugs, and how to hook up a 12 lead. Basics are allowed by the state to capture strips and transmit data. The state does not allow Basics to interpret 3 lead etc.


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## MMiz (Jul 14, 2009)

Linuss said:


> What was the logic behind such a plan?
> 
> 
> You're an ALS provider, with ALS gear, but can't do anything until you have more ALS personnel?


1.  It guaranteed the city several Paramedic first responders in vehicles dedicated to the city.  They would not get called way to other areas.  
2.  Now you had a crew of three working ALS calls instead of two

I worked for a private service, and like many private services, we served multiple cities.  The idea was that one of our most highly trained Paramedics would arrive on scene first and initiate care, while a fully staffed ALS ambulance also arrived.  Once the ALS crew arrived they would immediately "upgrade" to ALS and continue with ALS interventions.  If the call was truly an emergency then you had two Paramedics working in the back of an ambulance instead of only one.

The hope was that the county would recognize our program and allow the single Paramedic to start ALS treatments alone, but that never happened.


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## Shishkabob (Jul 14, 2009)

That's why I'm wondering their reasoning.


I totally get the fly-car idea.  I don't get forcing a medic to act as strictly BLS because there isn't another medic there, when they obviously have the tools, training, and other items required to be ALS.


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## emtjack02 (Jul 14, 2009)

daedalus said:


> What if the patient is in need of cardioversion, and an enterprising EMT recognizes the strip he just printed out. The monitor is there, but no medic. Should they for the good of the patient go ahead and zap him? Or do you tell the family of the dying patient you cannot use your own equipment until other personnel arrive?



Are you referring to a coding pt or one that is conscious?


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## akflightmedic (Jul 14, 2009)

firemoose0827 said:


> Sure...Ill try.  First off, we dont do anything with the 12 leads, just 3 lead.  But regardless of what I explain here there will be the ones that just tear it apart and be the usual monday morning quarterback, just like in every discussion that has something that someone is not sure of, or has never seen before.
> 
> Medics from both the squad and the County come to drill night.  They take the monitor we have in both of our rigs.  They show the Basics where the leads are placed (Isnt hard, a monkey can do it.)  Than show how to turn on the monitor, and than how to print out a strip...Is that realy hard?  They are not reading the rhythm, they are not making any diagnoses, just simply printing a strip to show the medics what the rhythms were when the BLS crew arrived.  The medics here have no problems with that and I dont see why some here cant grasp that...The doctors know of it, the nurses know of it and they all agree and help whenever possible.
> 
> ...



Thanks for replying. Since it is limited to a 3 lead only, I have no further comment as I thought you were implying you perform 12 leads prior to medic arrival. I was going to get into placement, positioning of patient, etc, because there are a lot of medics that do not even know that stuff and do it incorrectly every time.

My only issue with the way you do it, is someone already mentioned it. The thought of having equipment on scene, knowledge of a problem, but no licensure or true education to fix the problem. It is like 2 basics arriving in an ambulance that says Advanced Life Support or MICU or whatever language your area uses...it is false representation.

I think it is potentially bad juju and there will be fallout somewhere, sometime, eventually.


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## daedalus (Jul 14, 2009)

emtjack02 said:


> Are you referring to a coding pt or one that is conscious?



Ether or. Doesn't matter. My post was to demonstrate the stupidity of EMTs carrying around a machine that they cannot use, where there will be people pressuring them to use it.


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## MMiz (Jul 14, 2009)

daedalus said:


> Ether or. Doesn't matter. My post was to demonstrate the stupidity of EMTs carrying around a machine that they cannot use, where there will be people pressuring them to use it.


I love working in an ALS truck.  We don't have to mess around with switching cots and missing equipment.  ALS hops in and we take off, and everything they need is where it should be.


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## Medic744 (Jul 14, 2009)

My main pondering on this was that I would like a 12 lead EKG as a baseline from a BLS crew when I get there.  A large amount of services in our area allow Basics to admin ASA and NTG and if they are going to allow it (which is fine with me) then I would like to know what the inital EKG looks like before I start giving anything else. I used to be one of the Basics that had everything ready when the Paramedic arrived on scene including 12 leads.  I was trained in lead placement for 2 diff Dr offices I worked for long before joining EMS. God Bless every Basic out there that gets my stuff ready in the back of the truck, I am greatly appreciative of it. We were all Basics once.


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## chadwick (Jul 15, 2009)

*I wouldn't do it*

My old partner brought his mom in, hooked her up on the cardiac monitor, ran the 12 lead, and then while she was on it, she started complaining of chest discomfort and we called for a paramedic. 

Because I was present at the station and read what the ECG printed out as a diagnosis before the paramedic got there, I was written up by a third EMT, investigated by the state board of emergency medical services, put on probation for a year, and forced to take 4 hours of continuing education in the roles and responsibilities of EMT-B. 

I was watching him do it just the same as the guy that wrote me up and when she began having discomfort began asking her OPQRST and SAMPLE questions. They said I should have stopped him from touching the monitor without the paramedic present. The EMT-B curriculum in Kentucky teaches EMTs to hook up the monitor only if they are working on an ALS truck with a paramedic present. 

I would not under any circumstances recommend to any EMT to use the cardiac monitor before the medic gets on scene. If someone at the station doesn't like you, like this old fart who wrote me up did, you could get in a heap of trouble.


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## TransportJockey (Jul 15, 2009)

In NM I think expanding education to include monitor usage might not be a bad thing. As a basic here I can run 4-lead strips for facilities/medics, I just can't interpret.

All NM ambulances, as far as I know, are required to carry a monitor.


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## firemoose0827 (Jul 15, 2009)

akflightmedic said:


> Thanks for replying. Since it is limited to a 3 lead only, I have no further comment as I thought you were implying you perform 12 leads prior to medic arrival. I was going to get into placement, positioning of patient, etc, because there are a lot of medics that do not even know that stuff and do it incorrectly every time.



Understood.  I was once an EMT-CC and know of this too.  But we just learn the basics of getting a picture to the ALS provider of what things looked like before they got there, which helps them get a bigger timeline.  Thanks.



> My only issue with the way you do it, is someone already mentioned it. The thought of having equipment on scene, knowledge of a problem, but no licensure or true education to fix the problem.



I guess this is the same as any other EMT arriving on scene of a code, knowing what is needed but cant help because they don't have a little piece of paper that says they can...Especially for those of us who were ALS providers once and than let it drop and became BLS providers...we know what is needed, and how to go about doing it, but without that tiny piece of paper...:sad: we cant do anything but what our BLS protocols tell us to do, which is use the AED, CPR, O2 and hope ALS gets there or you can get to a decent level ED quick.  In my view, BLS providers trained in applying the heart monitor and printing a strip is just another diagnostic tool to aid in the overall treatment and care of the prehospital patient.  Good discussion, thanks!





> It is like 2 basics arriving in an ambulance that says Advanced Life Support or MICU or whatever language your area uses...it is false representation.
> 
> I think it is potentially bad juju and there will be fallout somewhere, sometime, eventually.



Well, our rigs simply say "Cobleskill Fire & Rescue" on the side.  We do not feel the need to label them with ALS signs or Paramedic symbols.  We keep track of resources in our county at the dispatch level, they know where the ALS is located, and the EMS Captains know it as well, so we do not need to plaster the bus with the decals.  That helps some.

Stay Safe


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## VentMedic (Jul 15, 2009)

firemoose0827 said:


> Well, our rigs simply say "Cobleskill Fire & Rescue" on the side. We do not feel the need to label them with ALS signs or Paramedic symbols.


 
So the public has no idea what or who they are getting? You could be running all EMTs who just happen to carry some equipment that people believe to be standard on a Paramedic truck? 



> Especially for those of us who were ALS providers once and than *let it drop and became BLS providers*...we know what is needed, and how to go about doing it, but without that *tiny piece of paper*...:sad: we cant do anything but what our BLS protocols tell us to do, which is use the AED, CPR, O2 and hope ALS gets there or you can get to a decent level ED quick.


 
The EMS providers let their ALS certs drop but still want to be like one? If one did not have the ambition to maintain their advanced cert, what is to say they can maintain proficiency at the very basic skills of an EMT? 

I do know this is a practice with some of our FDs once you achieve a certain number of years but those FFs are also now running where there will be little patient care contact. They don't pretend to be something they no longer hold a license for but do maintain EMT proficiencies.


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## firemoose0827 (Jul 15, 2009)

VentMedic said:


> So the public has no idea what or who they are getting? You could be running all EMTs who just happen to carry some equipment that people believe to be standard on a Paramedic truck?
> 
> 
> 
> ...



Wow...Ouch.  Thanks for the insult.
I let my ALS drop because I was a FT EMT-CC and had no issues getting my CME's.  When I left my FT Job for better pay, I could not continue to get my CME's, work 2 jobs and support a family, so I went to a Basic EMT again to help my volunteer squad.  Some people are not as fortunate as others I guess to have all the free time in the world to keep up their certs and still come on these web sites and belittle others.  Where I come from we work as a team and support each other, and thats the way I like it.


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## VentMedic (Jul 15, 2009)

firemoose0827 said:


> Wow...Ouch. Thanks for the insult.
> I let my ALS drop because I was a FT EMT-CC and had no issues getting my CME's. When I left my FT Job for better pay, I could not continue to get my CME's, work 2 jobs and support a family, so I went to a Basic EMT again to help my volunteer squad. Some people are not as fortunate as others I guess to have all the free time in the world to keep up their certs and still come on these web sites and belittle others. Where I come from we work as a team and support each other, and thats the way I like it.


 
You believe that lowering the stanards serves your community better?  Maybe if they had someone who promoted higher standards they would see a way to accomplish that for the community.  If you real the EMS newswires, you will find that many small communities are now developing ways to get ALS service.  

BTW, many of us have families also when we were getting our education.  You are not the only one.  I just saw how my education could benefit my family even if I had to make a few adjustments for a couple of years.


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## Level1pedstech (Jul 15, 2009)

Linuss said:


> What was the logic behind such a plan?
> 
> 
> You're an ALS provider, with ALS gear, but can't do anything until you have more ALS personnel?



 My former department was a combination department with ALS engines. If we did not have a medic in the company we ran BLS. All meds were kept in a lock box with access only available to those authorized to use them.


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## firemoose0827 (Jul 15, 2009)

VentMedic said:


> You believe that lowering the stanards serves your community better?  Maybe if they had someone who promoted higher standards they would see a way to accomplish that for the community.  If you real the EMS newswires, you will find that many small communities are now developing ways to get ALS service.
> 
> BTW, many of us have families also when we were getting our education.  You are not the only one.  I just saw how my education could benefit my family even if I had to make a few adjustments for a couple of years.



I am glad for you and your desire to remain in EMS.  And obviously your pay scale is better than mine.  Can you raise your family on $14/hour as a medic??  As a basic I started with $7.50/hour...sorry, but that is not enough to raise a family.  I did make adjustments to suit my family.  I got a better paying job and I still help my community as an EMT, nothing wrong with that sir.  

But you digress from the original content of the post, so can we get back on track?  You have your opinions and values and I have mine, thats what makes us different people, and there is nothing wrong with that.  So we should stop the highjacking of this thread and get it back on track.
Sorry everyone! lol

Back to the BLS members armed with monitors...


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## VentMedic (Jul 15, 2009)

firemoose0827 said:


> I am glad for you and your desire to remain in EMS. And obviously your pay scale is better than mine. Can you raise your family on $14/hour as a medic?? As a basic I started with $7.50/hour...sorry, but that is not enough to raise a family. I did make adjustments to suit my family. I got a better paying job and I still help my community as an EMT, nothing wrong with that sir.


 
We all make choices.  However, it is when you use your own personal choices at arguments for what is best for your community it becomes an issue.  If you read the arguments pro volunteer, you will also hear these same ones at the town meetings when it is debated.  Too often people can not differentiate whether they are arguing for the good of the community or they are wanting to hang on to the way things are for their own selfish reasons.  

Imagine how much better a community would be with a paid employee who put their career in EMS first and not their "other" job.   

As far as $14/hr, it all depends on where you live and the lifestyle you have chosen.  Many do survive much less and still have a quality life. 

Back to the topic:
Handing out extra skills just to keep EMTs satisfied and to give them more reason not to advance their education should not be condoned nor should it be used as an excuse for a service to remain BLS and hire cheap labor.  EMS has ended up with 50+ different certs by trying to keep the lowest level provider happy.   BLS truck employers are happy because they can offer a nickel more for a "skill" and the EMTs will keep applying because they can do 1 more "skill".


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## firecoins (Jul 15, 2009)

VentMedic said:


> So the public has no idea what or who they are getting?


what makes you think they know what they are getting either way?  Most members of the public have no idea the difference between BLS and ALS.  If someone shows up and takes them to the hospital, they be none the wiser.



> Handing out extra skills just to keep EMTs satisfied and to give them more reason not to advance their education should not be condoned nor should it be used as an excuse for a service to remain BLS and hire cheap labor. EMS has ended up with 50+ different certs by trying to keep the lowest level provider happy. BLS truck employers are happy because they can offer a nickel more for a "skill" and the EMTs will keep applying because they can do 1 more "skill".


That is correct.


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## VentMedic (Jul 15, 2009)

firecoins said:


> what makes you think they know what they are getting either way? Most members of the public have no idea the difference between BLS and ALS. If someone shows up and takes them to the hospital, they be none the wiser.
> 
> That is correct.


 
That depends on where you live. In Florida, they know they are getting Paramedics. 

Of course, in services as described in some of these posts, it is to the advantage of that EMS system if the public doesn't know what is really going on. 

Can you imagine in a hospital if they didn't have enough RNs so they had CNAs appear to be doing what an RN would normally do?

While CNAs do put on monitor electrodes, they know it is only for assistance and do not give any pretense otherwise.


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## firecoins (Jul 15, 2009)

VentMedic said:


> That depends on where you live. In Florida, they know they are getting Paramedics.


 Do they know that really means?


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## VentMedic (Jul 15, 2009)

firecoins said:


> Do they know that really means?


 
Yes the majority of them do. Many attend meetings in their city halls or condo associations, read newspapers, subscribe to AARP which does a great job of explaining EMS, read what they are paying taxes for especially at election time and attend local health fairs to get more information. As well, the FDs (yes, Fire Based EMS) make their rounds doing public safety inspections and distributing useful information at various locations. The FDs do a great PR job with informing people what "ALS" and Paramedics are. It is also hard to walk more than a 100 yards in Florida without meeting a Paramedic either working for the FD or working at Burger King waiting to get on at the FD. So there is always someone around to tell you what a Paramedic is.

One more little thing to add, many of our tourists and citizens are from other countries where EMS is advanced.  Many probably wouldn't be familar with or would be shocked at our "BLS" or EMT-B level.


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## firemoose0827 (Jul 15, 2009)

VentMedic said:


> We all make choices.  However, it is when you use your own personal choices at arguments for what is best for your community it becomes an issue.  If you read the arguments pro volunteer, you will also hear these same ones at the town meetings when it is debated.  Too often people can not differentiate whether they are arguing for the good of the community or they are wanting to hang on to the way things are for their own selfish reasons.
> 
> Imagine how much better a community would be with a paid employee who put their career in EMS first and not their "other" job.
> 
> ...



Well, we agree on one thing.  I believe that a paid system needs to be started in every community.  The service to the patient is what is priority, and the timely delivery of this service is key.  Most volunteer based services, especially rural areas, have extremely high response times.  This is not acceptable any more.  We all need to think about the patient first, everything else second.  If I had a decent paying job as an EMT I would still be there, but my family comes first.  Does this mean I do not want to help anymore?  No.  Does this make me a bad person? No.  I still want to be able to use any free time I may have to help my community as a Firefighter/EMT.  Back to my idea in my original post, I believe that EMT's having the knowledge to attach a monitor to a patient and get a strip for the medic is a way to help both the medic and the patient.  Im here to help others any way I can.  If that means going to a paid EMS system supplemented with volunteer staff, I would be the first to vote yes.
For now, in my community, what we have been practicing is working fine for us as EMT's and the service we provide to our residents.  I work for the local private EMS agency PT and I am the one in front at the volunteer meeting telling everyone to turn our calls over to the paid service for weekday calls, and have them be primary mutual aid nights and weekends.

Look at that...lots of different people with different opinions able to share them in an open forum.


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## emtjack02 (Jul 15, 2009)

daedalus said:


> Ether or. Doesn't matter. My post was to demonstrate the stupidity of EMTs carrying around a machine that they cannot use, where there will be people pressuring them to use it.



Well I believe it does matter to an extent because if they BLS service is using a LP12 or another unit that has an AED function they would be able to use it.  I will not argue the point of a BLS having a monitor like the LP12 because I am sure each service has their reasons...plus I guess if you have the money..wow.

I do enjoy the help I can get from a basic.  If they put electrodes on wrong then fix it, educate, and move on.  I think there have been many good points about not giving basics things to do just because they want to do more w/o an advance cert but I think we should be evaluating this on a case by case basis.  I would love to have one uniform thing but I dont know if that will be happening anytime soon.


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## firespec35 (Jul 16, 2009)

why can't basics just do basix stuff. you wanna do als go to medic school


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## Shishkabob (Jul 16, 2009)

firespec35 said:


> why can't basics just do basix stuff. you wanna do als go to medic school



I suggest actually reading this thread before you make a comment.


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## MrBrown (Jul 19, 2009)

VentMedic said:


> One more little thing to add, many of our tourists and citizens are from other countries where EMS is advanced.  Many probably wouldn't be familar with or would be shocked at our "BLS" or EMT-B level.



I would have to agree.  Our "basic" providers (called an Ambulance Officer or "AO") are able to administer GTN, aspirin, acetaminophen, glucagon PO/IM, methoxyflurane and entonox (although nox is being withdrawn) and nebulize salbutamol.  They are also able to insert NPAs, OPAs and the LMA (laryngeal mask airway) as well as obtain (but not interpret) a 3 lead ECG and soon, a 12 lead ECG.

Now I was going to make the argument in support of EMT-Basic's being allowed to obtain a 12 lead ECG for the reason that it provides basis for serial ECG comparison by hospital/ALS and that it could potentially assist ALS if they do an intercept by having a 12 lead already done for the Advanced Paramedic.

Having reviewed the DOT/NHTSA EMT-Basic national standard cirricula it does not mention anything about rhythm monitoring or ECG acqiusition (which honestly suprises me, even our most basic volunteer officers (analouge to Fire Responders) are taught to acqurie a 3 lead ECG) ... so on that basis  I would have to be against it.



akflightmedic said:


> Before I respond, and hopefully some of the other ALS providers will follow my lead...would you please take the time to explain how and what you teach the BLS providers i n order for them to do a 12 lead?
> 
> Please go into detail regarding everything you cover or give a very thorough outline with the important highlights noted.



Before being able to acquire a 3 lead we are taught the following at the BLS level:

- cardiac anatomy (position, chambers, layers, valves and vascularization)
- cardiac physiology (systole, diastole, systemic/pulmonary circulation)
- cardiac electrical structure/function (origins and path of electrical circut)
- placement of LA/LL/RA/RL leads
- ECG waveforms and intervals (PQRST, PR and QT)
- interpretation of NSR, VT, VF, asystole 

Once 12 leads become a BLS skill they will be included into the cardiac education; I don't know exactly WHAT will be taught but for interest here is what our Paramedics (ILS) are taught before they can obtain one (granted this will also allow use of manual defibrillator and cardioversion):

- advanced cardiac anatomy and electrophysiology (cellular anatomy, electrolytes/action potential physiology etc)
- to identify who should/should not have a 12 lead performed
- to be able to competently acquire one
- to link the 12 lead back to rationale of treatment (published evidence)
- interpretation of atrial, ventricular, supraventricular, junctional and sinus rhythms (MAT, WAP, VT, VF, SVT, blocks, IVR etc)
- manual defibrillation and cardioversion

Hope this provides an international perspective; we are also trialling thrombolytics prehospitally at the moment with, from what I have seen, some very pleasing results.


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## Melclin (Jul 19, 2009)

Welcome to the forum MrBrown,

What are the educational requirements for AO and Paramedics?


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## MrBrown (Jul 19, 2009)

Melclin said:


> Welcome to the forum MrBrown,
> 
> What are the educational requirements for AO and Paramedics?



Well, it depeneds which track you take.  Like Australia we are transitioning away from the in-service "on the job" trade school type education model towards a pre-employment university degree system.  I don't know how much of your transition was supported by MAS but St John has been OK but somewhat less than accepting of the graduates.

There are currently three education streams being offered in New Zealand; Bachelors, paid in-service and volunteer in-service.

Bachelors degree is three years and graduates are employed autonomusly as an AO but can practice up to the skill level of thier partner (AO, Paramedic, Upskilled Paramedic or Advanced Paramedic) while they go through the 18 month internship.  

If you are a volunteer or a new paid member of staff (employment of ab-initio zero qualifications paid staff is declining as the service begins to recognize the value of the Bachelors degree students) you have to complete the National Diploma in Ambulance Practice (NDAP) to become an AO.  This is a new qualification introduced last year.  It's a very broad qualification that has had some fundamental changes from the old National Certificate in Ambulance (NCA).  the NCA had more book based theory in anatomy and physiology (e.g. cells and tissues), laws, ethics and mushy grief handling.  These have been removed from the new Diploma and everything is now specifically geared towards "...an ambulance context" so for A&P it shifts the focus towards system level "form and function" rather than "can you describe the cellular membrane and selective permiability?" which I personally take an issue with.  

Besides the "form and function" based A&P you have to do basic pharmacology, cardiology (which I must say the ECG components I was quite impressed with), a core skills module (scoop stretcher, vital signs, scene management etc), medical module and a trauma module.  This part of the course is done over 12 weeks online and with 12 days in the classroom doing practical skills.

You then have to document 20 calls (assessment, treatment, rationale, evidence based practice etc) and pass an end-of-course assessment with your mentor and somebody from Clinical Standards.  If they are happy, you can become an AO.

To become a Paramedic (ILS) which adds 3 lead interpretation, 12 lead acquisition, manual defibrillation, cardioversion, IV cannulation and IV fluids (NS and D10) to your scope you need to complete 6 written assignments, 6 days in class, a logbook of at least 50 (preferably 100) IV cannulations and 20 rhythm strips in ED and a shift with your mentor on road.  The written assignments are 4 cardiac and 2 shock/fluids/trauma but also include some pharmacology and awareness/knowledge of hospital based treatment/continuim of care; they are fairly comprehensive with about 30 rhythms strips you have to identify and questions such as ...

- Explain why fluid tends to shift from the interstitial to intravascular space in the early stages of shock.
- Explain the difference between the injuries (and thier MOI) commonly encountered in and the management of shock caused by both blunt trauma and penetrating trauma.
-List 15 causes of chest pain other than an MI and 10 symptoms of an MI other than chest pain 
- Describe the difference between an interpolated PVC and a PVC with a compensatory pause.

Upskilled Paramedic is a wishy-washy level mostly introduced to remove demand on ALS for adrenaline /pain relief and give rural patients access to treatment they would not otherwise have avaliable.  It requires the completion of 4 written assignments (I haven't seen them), a viva with a medical director and some more days in class.  You can then administer adrenaline IM/IV, naloxon IM/IV/IN, metaclopramide IV and naloxone IM/IN/IV.  

From there the final step is Advanced Paramedic (ALS) which requires completion of the Bachelors Degree.


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## TomB (Jul 20, 2009)

There are some areas in the country where BLS providers can capture a 12 lead ECG and transmit it for physician interpretation. In some cases, this allows the BLS provider to bypass a non-PCI hospital, which is a good thing!

Tom


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## VentMedic (Jul 20, 2009)

TomB said:


> There are some areas in the country where BLS providers can capture a 12 lead ECG and transmit it for physician interpretation. In some cases, this allows the BLS provider to bypass a non-PCI hospital, which is a good thing!
> 
> Tom


 
That could be a good thing provided the other hospital is within a very reasonable distance.  I would hate to think of the bad outcomes if this is a BLS truck that can only rely on speed when the BP is dropping or the rhythm changes to VT/VF while bypassing another hospital and is at the point of no return.   It is one thing to bypass hospitals if you are ALS and have similar capabilities as to what would be initially done in an ED but it is a whole other pandora's box to tell a crew with nothing more than first-aid training and an 12 - lead EKG skill to bypass and keep going just by a transmitted piece of paper and a BLS assessment.  Would they also be trained to recognize rhythm changes that might require immediate attention?   They would also be speeding into the further ED with no IV access (not that they should be taking more time at scene to do that either at a BLS level) and probably a very sick patient if nothing else from a very scary ride.


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## MrBrown (Jul 20, 2009)

VentMedic said:


> That could be a good thing provided the other hospital is within a very reasonable distance.  I would hate to think of the bad outcomes if this is a BLS truck that can only rely on speed when the BP is dropping or the rhythm changes to VT/VF while bypassing another hospital and is at the point of no return.   It is one thing to bypass hospitals if you are ALS and have similar capabilities as to what would be initially done in an ED but it is a whole other pandora's box to tell a crew with nothing more than first-aid training and an 12 - lead EKG skill to bypass and keep going just by a transmitted piece of paper and a BLS assessment.  Would they also be trained to recognize rhythm changes that might require immediate attention?   They would also be speeding into the further ED with no IV access (not that they should be taking more time at scene to do that either at a BLS level) and probably a very sick patient if nothing else from a very scary ride.



No it's not a good thing.  My experience with American basic life support is not first hand but I understand it to be somewhat archaic and totally inappropriate for this sort of procedure.  Even here where our BLS is a mix of BLS and ILS, I would advocate it inappropriate for bypassing a facility with a suspected STEMI patient onboard.

If the transport time was LESS than a defined margin (say 15 minutes) and the patient was fairly stable in terms of cardiac rhythm (not throwing PVcs, runs of VT etc) I may consider entertaining the idea.


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## VentMedic (Jul 20, 2009)

I often refer to the OPALS study in Ontario as an example of misinterpretation amongst American providers.   It was done using the equivalent of Ontario's BLS education which is almost a year and not the 120 hours of the U.S. EMT-B.   However, some in the U.S. have continued using that study for the BLS vs ALS arguments when the meaning of BLS of the study did not exclude assessment from a more educated level.


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## MrBrown (Jul 20, 2009)

VentMedic said:


> I often refer to the OPALS study in Ontario as an example of misinterpretation amongst American providers.   It was done using the equivalent of Ontario's BLS education which is almost a year and not the 120 hours of the U.S. EMT-B.   However, some in the U.S. have continued using that study for the BLS vs ALS arguments when the meaning of BLS of the study did not exclude assessment from a more educated level.



I just skimmed that OPALS report, seems very interesting, will have to read it later.

While I think the US is doing some positive things in prehospital medicine such as the introduction of rapid sequence intubation (mind you we have that, and the US have used it since the war in Vietnam), thrombolytics (but we have that too), corticosteriods for asthma/anaphylaxis and despite the "EMS agenda for the future: a systems approach" the distinction between BLS and ALS is still very clear cut.

As much as I'd like to work on the streets of NYC, Los Angeles or San Francisco (those are systems I have first-hand experience in visiting) I just couldn't work in the United States -- at your equivalent level (BLS) anyway!


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## TomB (Jul 20, 2009)

I'll take my chances! I'd rather have a BLS ride and primary PCI in 60 min than a BLS ride and fibrinolysis in 30 min (or transfer PCI), but that's just me! 50% of STEMI patients self-report to the hospital anyway, and BLS can defibrillate. In a perfect world, all STEMI patients would get ALS transport to a PCI center. Regardless of your view, it is happening in some areas of the country, so we should have some real data to help support our opinions soon enough.

Tom



VentMedic said:


> That could be a good thing provided the other hospital is within a very reasonable distance.  I would hate to think of the bad outcomes if this is a BLS truck that can only rely on speed when the BP is dropping or the rhythm changes to VT/VF while bypassing another hospital and is at the point of no return.   It is one thing to bypass hospitals if you are ALS and have similar capabilities as to what would be initially done in an ED but it is a whole other pandora's box to tell a crew with nothing more than first-aid training and an 12 - lead EKG skill to bypass and keep going just by a transmitted piece of paper and a BLS assessment.  Would they also be trained to recognize rhythm changes that might require immediate attention?   They would also be speeding into the further ED with no IV access (not that they should be taking more time at scene to do that either at a BLS level) and probably a very sick patient if nothing else from a very scary ride.


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## VentMedic (Jul 20, 2009)

One more argument for BLS only and EMT-Bs to not advance to the next level. 

It is all fine provided you survive to the hospital.


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## bstone (Jul 20, 2009)

When I worked BLS we carried no EKG. As an Intermediate 3-lead EKG is standard. We were not trained in 12, but learned it from the medics we work with.


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