# NYC EMTs get EpiPens



## bstone (Apr 7, 2009)

http://www.jems.com/news_and_articl...UCH1@MAC.COM&utm_campaign=JEMS+eNews+04-07-09

I think it's about time, but I just demand that the level of education be on par with the level of care. A mandatory 4 hour ConEd, exam and check off should be required before just giving the an EpiPen.


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## AJ Hidell (Apr 7, 2009)

> Although an FDNY ALS ambulance is typically dispatched to 9-1-1 calls for suspected anaphylactic shock, BLS crews could be asked to respond if caller information is inaccurate or in the rare case that ALS resources will be delayed.


What a joke.  I notice they FAIL to provide any statistics that would support this move.  That's because there probably are none.  Most medics go through an entire career without ever seeing a true anaphylaxis.  And those that do usually find that SQ epi is inadequate to make a difference.

This is going to cost the bankrupt City of New York a lot of money for zero return.


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## PapaBear434 (Apr 7, 2009)

AJ Hidell said:


> What a joke.  I notice they FAIL to provide any statistics that would support this move.  That's because there probably are none.  Most medics go through an entire career without ever seeing a true anaphylaxis.  And those that do usually find that SQ epi is inadequate to make a difference.
> 
> This is going to cost the bankrupt City of New York a lot of money for zero return.



Think so?  Were do you run, AJ?  Rural, city, or suburban?  Because in my run area (suburban and city) we see a true anaphylatic emergency at least once a week.  By the time we show up, the person is unconscious or barely there, obvious difficulty breathing (a few arrests too) and all the other symptoms with it.  Maybe city folks are too stupid to avoid peanuts, I don't know.

Either way, we deal with this a lot.  Usually it's the Benadryl treatment that does the most good, and the epi injection buys time to get the IV in.  This is always done by ALS, obviously.

But as Epi-pens are an BLS skill, provided you have medical control of course, I see no reason not to have them available so long as they still require medical control to administer.  When I was still running as BLS, we had a couple cases of a major reaction where our unit showed up before ALS, and they even said they wished we could have dropped an Epi-Pen to stave off the reaction a bit until they were able to make it.

Besides the reasoning you usually have of wanting everyone to get mediced up instead of passing more and more down to the Basic level (a valid complaint, but not pertinent to the current discussion), what don't you like about this prospect?  You worried people are going to be too eager to use it and do it needlessly?  I wouldn't want to trust basics with that call either, necessarily, because you would be putting a lot of responsibility into a very little education.  But as I said, so long as Medical Control authorization is still required and it would be their call and their call alone, I don't see why it wouldn't be a bad idea to have them on hand just in case.


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## bstone (Apr 7, 2009)

As long as the level of skill is at the level of education (and vice-versa) I have no problem with this.


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## AJ Hidell (Apr 7, 2009)

PapaBear434 said:


> Maybe city folks are too stupid to avoid peanuts, I don't know.


LOL!  Well, most of the patients you describe would not benefit from SQ epi because they have already shut down peripherally.  The ones that have not shut down peripherally are usually not bad enough off to need it.  So what you are left with is a very few cases where it is actually indicated.  Popping in a couple of SQ epis in a peripherally compromised patient is not a benign intervention.  When the medics get there and give them IM or IV epi, the patient is going to also receive those two SQ doses that have been sitting in the SQ fat, just waiting to be picked up by a returning circulation.  Now you have someone with a heart rate (and possibly BP too) of 220, which isn't a whole lot better off than they were!



> You worried people are going to be too eager to use it and do it needlessly?  I wouldn't want to trust basics with that call either, necessarily, because you would be putting a lot of responsibility into a very little education.


That is definitely a huge concern.  It results in the same problem we have with EMT-Is, where there is a lot of doing things just because their protocols "allow" them to.  The invasive skills that are allowed of EMTs and Is are so very rarely actually indicated that the tech looks for any excuse to perform them, resulting in improper care.  If you've got time to explain it all to a physician online, then you've got time for your medics to arrive.

Ask any system that carries Epi Pens how much they spend a year on them, and how many of them actually get used.  The number is miniscule.  Then QA the times they were used and narrow that down to the ones that were truly indicated and beneficial to the patient, and the number gets even lower.  It's just almost impossible to justify this in an urban system.


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## bstone (Apr 7, 2009)

As an Intermediate my protocols allow SC/IM Epi with offline protocol.


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## firecoins (Apr 7, 2009)

bstone said:


> As long as the level of skill is at the level of education (and vice-versa) I have no problem with this.




The title of the thread is wrong.  FDNY EMTs carry epi pens.  Other NYC emts already had it.  FDNY EMS is not the only agency that provides 911.

NYC EMTs get more than 4 CMEs on it.  

NY State has allowed BLS agencies to carry EPI Pens on their ambulance with permission from their medical director. Many agencies have carried them for years.


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## AJ Hidell (Apr 7, 2009)

By the way, minus 5 for posting in the wrong forum.  Prescription drug administration is ADVANCED Life Support.


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## bstone (Apr 7, 2009)

firecoins said:


> NYC EMTs get more than 4 CMEs on it.
> 
> NY State has allowed BLS agencies to carry EPI Pens on their ambulance with permission from their medical director. Many agencies have carried them for years.



The more the ConEd the merrier!


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## firecoins (Apr 7, 2009)

AJ Hidell said:


> By the way, minus 5 for posting in the wrong forum.  Prescription drug administration is ADVANCED Life Support.



It might be but its being carried on BLS busses.


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## bstone (Apr 7, 2009)

AJ Hidell said:


> By the way, minus 5 for posting in the wrong forum.  Prescription drug administration is ADVANCED Life Support.



Oxygen is a drug. I think they carry it on BLS buses.


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## AJ Hidell (Apr 7, 2009)

Oxygen can also be administered by a lay person without medical training.  Different case.


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## bstone (Apr 7, 2009)

AJ Hidell said:


> Oxygen can also be administered by a lay person without medical training.  Different case.



But it is a prescription drug. Do you disagree?


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## AJ Hidell (Apr 7, 2009)

firecoins said:


> It might be but its being carried on BLS busses.


EMT and BLS are not synonymous.  It doesn't matter whether it is an EMT or a brain surgeon administering it, drug administration is still ADVANCED Life Support.


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## firecoins (Apr 7, 2009)

AJ Hidell said:


> EMT and BLS are not synonymous.  It doesn't matter whether it is an EMT or a brain surgeon administering it, drug administration is still ADVANCED Life Support.



FDNY EMS put epi pens on BLS busses.  FDNY EMS paramedics do not man the BLS busses. NYS allows epi bens to be carried on BLS busses. NY paramedics do not carry epi pens but draw up more exact doses.  
Could EMT-B not discuss items in their scope of practise in the BLS forum?

I don't think FDNY EMS BLS units need it.


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## silver (Apr 7, 2009)

AJ Hidell said:


> LOL!  Well, most of the patients you describe would not benefit from SQ epi because they have already shut down peripherally.  The ones that have not shut down peripherally are usually not bad enough off to need it.  So what you are left with is a very few cases where it is actually indicated.  Popping in a couple of SQ epis in a peripherally compromised patient is not a benign intervention.  When the medics get there and give them IM or IV epi, the patient is going to also receive those two SQ doses that have been sitting in the SQ fat, just waiting to be picked up by a returning circulation.



I may be confused but don't epipens deliver IM not SQ?


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## AJ Hidell (Apr 7, 2009)

firecoins said:


> FDNY EMS put epi pens on BLS busses.  FDNY EMS paramedics do not man the BLS busses. NYS allows epi bens to be carried on BLS busses. NY paramedics do not carry epi pens but draw it up.
> 
> Why would an EMT-B giving an epipen qualify for the ALS forum?


You're talking semantics.  You're just playing with the silly words that FDNY uses to label their ambulances.  This isn't about FDNY.  This is about medical care.  What I am talking about is the reality that, no matter who is performing it, prescription drug administration is ADVANCED care.  I'm not saying EMTs shouldn't be doing it. I'm not saying that doing it makes them paramedics.  I'm not saying that FDNY should re-label their "buses".  I am simply noting the fact that, if a lay person cannot legally do it, then it is ADVANCED Life Support.  How are you not getting this?


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## Juxel (Apr 7, 2009)

I'm highly embarrassed to admit that my ALS service carries EPI-pens instead of a multi-use vial of epi because they are that terrified of a lawsuit.  We never made the mistake of using 1:1000 when we should have used 1:10000, but we still made the switch.

Just for reference:  Epi-pens cost about $50 for one dose whereas a multi-use vial costs less than $1 per dose.


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## firecoins (Apr 7, 2009)

AJ Hidell said:


> EMT and BLS are not synonymous.  It doesn't matter whether it is an EMT or a brain surgeon administering it, drug administration is still ADVANCED Life Support.



are basic EMT-Bs not allowed to discuss items in their scope fo practise in the BLS forum?


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## AJ Hidell (Apr 7, 2009)

firecoins said:


> are basic EMT-Bs not allowed to discuss items in their scope fo practise in the BLS forum?


In this forum, you can discuss anything you want, anywhere you want.  The moderators obviously don't care.  I'm just making the point that their scope of practice is not limited to BLS, so they shouldn't limit their discussion to the BLS forum.  Why not step outside of that confining box and embrace the ALS that is within your scope?


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## exodus (Apr 7, 2009)

AJ Hidell said:


> By the way, minus 5 for posting in the wrong forum.  Prescription drug administration is ADVANCED Life Support.



Not always....

NTG is prescription, and basics can assist with it. Albuetoral inhalers are prescription, and basics can assist...


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## PapaBear434 (Apr 7, 2009)

AJ Hidell said:


> Ask any system that carries Epi Pens how much they spend a year on them, and how many of them actually get used.  The number is miniscule.  Then QA the times they were used and narrow that down to the ones that were truly indicated and beneficial to the patient, and the number gets even lower.  It's just almost impossible to justify this in an urban system.



Huh.  Because my system has been batting around the prospect of putting an Epi-Pen on board our BLS units for the very reasons I mentioned.  It's true that giving a report to a MD takes time, but it's not guaranteed an ALS interceptor is going to make it in time.  

It makes little difference to me at this time, as EMT-E's in Virginia are allowed to drop SQ epi when warranted and are considered ALS (in the "shock/trauma" capacity), but having it on hand for BLS with medical advisory still doesn't seem like a bad idea...

Until you rightly point out the peripheral circulatory shut down, of course.  I would hope that an ALS wouldn't be stupid enough to then administer a SQ epi in addition to the pen injection before getting the IV access and Benadryl drop.  Though a lot of that epi wouldn't make it to where it needs to go, wouldn't enough of it make it in order to buy time?  Isn't that why Epi-Pens are prescribed in the first place?  

I'm speaking for the early caught reactions, of course, but even a more advanced case seems like you'd want to say "A little is better than nothing."

Abuse with any new item is always a warranted with a new item or treatment, but I think the Docs would be able to keep the overly zealous among us from going crazy and dosing everyone with adrenaline.


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## AJ Hidell (Apr 7, 2009)

exodus said:


> Not always....
> 
> NTG is prescription, and basics can assist with it. Albuetoral inhalers are prescription, and basics can assist...


So how does that contradict anything I said?  :unsure:


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## AJ Hidell (Apr 7, 2009)

PapaBear434 said:


> Huh.  Because my system has been batting around the prospect of putting an Epi-Pen on board our BLS units for the very reasons I mentioned.  It's true that giving a report to a MD takes time, but it's not guaranteed an ALS interceptor is going to make it in time.


Right.  But we're talking about NYC, not wherever you are.


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## trevor1189 (Apr 7, 2009)

AJ Hidell said:


> You're talking semantics.  You're just playing with the silly words that FDNY uses to label their ambulances.  This isn't about FDNY.  This is about medical care.  What I am talking about is the reality that, no matter who is performing it, prescription drug administration is ADVANCED care.  I'm not saying EMTs shouldn't be doing it. I'm not saying that doing it makes them paramedics.  I'm not saying that FDNY should re-label their "buses".  *I am simply noting the fact that, if a lay person cannot legally do it, then it is ADVANCED Life Support.*  How are you not getting this?



I think you picked the wrong battle in this thread AJ... But when you pick battles to fight all the time, I guess you are bound to get it wrong every once in a while. ^_^ There are a lot of EMT-*BASICS* that can do way more than a lay person and they are not considered ALS.

Side note, my towns BLS rigs carry both regular and junior dose Epi pens.


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## trevor1189 (Apr 7, 2009)

AJ Hidell said:


> So how does that contradict anything I said?  :unsure:


Because you said administering prescription drugs is an ALS procedure... :unsure:


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## AJ Hidell (Apr 7, 2009)

Trevor, as an EMT-B student, you are about the least qualified person here to tell me when I am right or wrong.  And you have proven that with this last post.

EMT-B is not synonymous with BLS.  They are not the same thing.  One is a title.  The other is an intervention.  Whether or not you are an EMT-B or not, if you are performing an ADVANCED intervention, you are performing ADVANCED Life Support.  Dr. Bledsoe, who wrote the paramedic textbook, says the very same thing.  You have to pull your head out of the semantic games and understand that your certification level does not define the level of an intervention.  If your system allows an EMT to intubate, that does not make intubation BLS.  It simply makes your EMT's ALS.


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## nomofica (Apr 7, 2009)

/bursts into room all cheery!


/gets stared at by AJ


/backs out of room very slowly


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## trevor1189 (Apr 7, 2009)

AJ Hidell said:


> Trevor, as an EMT-B student, you are about the least qualified person here to tell me when I am right or wrong.  And you have proven that with this last post.
> 
> EMT-B is not synonymous with BLS.  They are not the same thing.  One is a title.  The other is an intervention.  Whether or not you are an EMT-B or not, if you are performing an ADVANCED intervention, you are performing ADVANCED Life Support.  Dr. Bledsoe, who wrote the paramedic textbook, says the very same thing.  You have to pull your head out of the semantic games and understand that your certification level does not define the level of an intervention.  If your system allows an EMT to intubate, that does not make intubation BLS.  It simply makes your EMT's ALS.


If an Epi Pen is in the BLS Scope of Practice then it is not an ALS intervention. It is considered BLS intervention... You can't just lump prescription drug administration as ALS like you did.


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## firecoins (Apr 7, 2009)

AJ Hidell said:


> In this forum, you can discuss anything you want, anywhere you want.  The moderators obviously don't care.  I'm just making the point that their scope of practice is not limited to BLS, so they shouldn't limit their discussion to the BLS forum.  Why not step outside of that confining box and embrace the ALS that is within your scope?



EMT-B discussing their scope of practise in the BLS forum is not a "limit"  Maybe we shouldn't break it down to BLS and ALS. Both EMTs and medics take C-Spine precautions.  We should just consider it medical care.


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## EMT271WNY (Apr 7, 2009)

As a NY EMT-B, who has seen a bonafide save with an eppipen, I cthink I can speak for rural EMTs all over.  MANY of the tx in my district are 20 to 30 minutes AFTER we get the patient to the unit.  Getting them out of the woods is another story.  
The call we had was a logger, in the woods, stung with ALS further away that the closest hospital (20 min).  We have been able to carry Epi at the BLS level for about 5 years with Medical directors approval, and an inservice.  I know this rubs the advanced guys the wrong way when basics horn in on the lifesaving but it sure was a wonderful thing to have on board that day.  I'm sure the guys wife and kids think so too!


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## PapaBear434 (Apr 7, 2009)

AJ Hidell said:


> Right.  But we're talking about NYC, not wherever you are.



True enough.  I'm just trying to relate it to my system, as they are thinking of doing this too.


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## Aidey (Apr 8, 2009)

AJ Hidell said:


> Oxygen can also be administered by a lay person without medical training.  Different case.



EpiPens can be administered by laypeople without any training. That is why there are pictures and instructions on the sides.


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## nomofica (Apr 8, 2009)

Aidey said:


> EpiPens can be administered by laypeople without any training. That is why there are pictures and instructions on the sides.



I'm going to add another thing here: Public AED's.

Yes, better used by somebody who is trained BUT AED's placed for access by the general public should need arise have verbal, written and illustrated instructions.

My city is implementing these all downtown and I believe in our city transit centres.


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## 281mustang (Apr 8, 2009)

Good, more BLS rigs should start carrying EpiPens.


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## PapaBear434 (Apr 8, 2009)

nomofica said:


> I'm going to add another thing here: Public AED's.
> 
> Yes, better used by somebody who is trained BUT AED's placed for access by the general public should need arise have verbal, written and illustrated instructions.
> 
> My city is implementing these all downtown and I believe in our city transit centres.



We have them everywhere.  Public parks, stadiums, marinas, pet stores...


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## nomofica (Apr 8, 2009)

PapaBear434 said:


> We have them everywhere.  Public parks, stadiums, marinas, pet stores...



I believe our city has them in the majority of our high-traffic locations. I think it's bloody good to have them, too. Some people need to be defibbed before we get to them. At the same time I believe everyone should have CPR and AED training to at least some degree.


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## AJ Hidell (Apr 8, 2009)

Aidey said:


> EpiPens can be administered by laypeople without any training. That is why there are pictures and instructions on the sides.


These word games are above you, Aidey.  They require a physicians order.  Therefore, they are ALS.  Period.

Again, we're not labelling the people administering the intervention.  We are labelling the intervention itself.  You are neither ALS nor BLS.  You are an EMT.  The interventions you provide are both ALS and BLS.

The problem with attempting to label advanced interventions as "BLS" is that it cheapens the seriousness of that intervention, causing way too many providers to take them for granted with the typical EMT attitude of, "Well, it's just BLS, so it's not really that dangerous", which could not be farther from the truth.  Instead of reclassifying Epi as BLS, why don't you reclassify yourself as ALS, take pride in that privilege, and accept it in a professional manner rather than arguing with the people who have spent three decades paving the way for you to have that privilege?


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## bstone (Apr 8, 2009)

I've seen real saves using SC/IM Epi. The stupid 26 year old kid decided not to take his EpiPen with him on a caming trip. If it wasn't for the BLS administration of the Epi the kid would have surely died.

Here's another one in favor of BLS EpiPens. Just make sure there is plenty of ConEd, test and checkoff to go with it.


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## AJ Hidell (Apr 8, 2009)

bstone said:


> If it wasn't for the BLS administration of the Epi the kid would have surely died.


It wasn't BLS administration.  It was ALS administration by an EMT.


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## bstone (Apr 8, 2009)

AJ Hidell said:


> It wasn't BLS administration.  It was ALS administration by an EMT.



I love how you are splitting hairs. You do realize that every intervention I provide is ILS, correct?


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## AJ Hidell (Apr 8, 2009)

bstone said:


> I love how you are splitting hairs. You do realize that every intervention I provide is ILS, correct?


It is not hair splitting.  It is applying the proper terms to what you are doing.

Would you rather me tell you that you're not really ALS?  I don't get why someone who is practicing ALS would go out of their way to deny it, as if there is some shame in that.


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## bstone (Apr 8, 2009)

AJ Hidell said:


> It is not hair splitting.  It is applying the proper terms to what you are doing.
> 
> Would you rather me tell you that you're not really ALS?  I don't get why someone who is practicing ALS would go out of their way to deny it, as if there is some shame in that.



 Ok dude. Have a great day!


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## CAOX3 (Apr 8, 2009)

I would agree any med administration would be considered an advanced skill


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## Airwaygoddess (Apr 8, 2009)

*Patient care from BLS to ALS*

With the proper education and trainning, an Epi-pen can be given to the patient that requires it.  Now I strongly believe that certain skills and medications must be kept to the paramedic scope of practice. Proper education, theory, and skills must be taught and maintained, from the EMT-B level to the paramedic.  The ultimate goal is to provide great patient care from the BLS level to the ALS level and working together as a team. 

  Respectfully submitted.


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## trevor1189 (Apr 8, 2009)

AJ Hidell said:


> These word games are above you, Aidey.  *They require a physicians order.  Therefore, they are ALS.*  Period.
> 
> Again, we're not labelling the people administering the intervention.  We are labelling the intervention itself.  You are neither ALS nor BLS.  You are an EMT.  The interventions you provide are both ALS and BLS.
> 
> The problem with attempting to label advanced interventions as "BLS" is that it cheapens the seriousness of that intervention, causing way too many providers to take them for granted with the typical EMT attitude of, "Well, it's just BLS, so it's not really that dangerous", which could not be farther from the truth.  *Instead of reclassifying Epi as BLS, why don't you reclassify yourself as ALS,* take pride in that privilege, and accept it in a professional manner rather than arguing with the people who have spent three decades paving the way for you to have that privilege?



1. EMTs using Basic life support interventions are working off of a physicians orders as well... Just because a physician ordered it doesn't make it ALS. 

2. Because I have seen the difference in what is carried on an ALS ambulance and a BLS ambulance. An epi pen certainly doesn't qualify one as an Advanced Life Support Rig.


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## CAOX3 (Apr 8, 2009)

Its not about the method of delivery, its about the fact that you are administering a medication for a desired effect.  Which would constitue and advanced procedure.


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## Ridryder911 (Apr 8, 2009)

trevor1189 said:


> 1. EMTs using Basic life support interventions are working off of a physicians orders as well... Just because a physician ordered it doesn't make it ALS.
> 
> 2. Because I have seen the difference in what is carried on an ALS ambulance and a BLS ambulance. An epi pen certainly doesn't qualify one as an Advanced Life Support Rig.



And exactly what expertise do you have to determine such? What formal education and experience do you have to make such judgements? Did you serve on medical research committees to the differential of what limited skills and those that can interpret medical findings and outcomes are? 

You have seen how many ALS EMS units? Have you reviewed each State or even the State of New York requirement and medical definition of what ALS services requires to make and define them as such? 

Do you really know what the "legal" definition of ALS is (what resources) even or even what the legality of _Medical Practice Act _ you were implying? 

Not just picking on you, but there are so many self acclaimed experts that have never formally studied or acted upon these roles that only offer their self opinion and are not based upon facts, just only false information. 

p.s. yes, I have the formal education and experience. 

R/r 911


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## Scott33 (Apr 8, 2009)

CAOX3 said:


> Its not about the method of delivery, its about the fact that you are administering a medication for a desired effect.  Which would constitue and advanced procedure.



Agreed :beerchug:


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## Shishkabob (Apr 8, 2009)

Just so we're all on the same page;

Aj
Is providing someone with oxygen Advanced Life Support?


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## bstone (Apr 8, 2009)

Linuss said:


> Just so we're all on the same page;
> 
> Aj
> Is providing someone with oxygen Advanced Life Support?



I asked Aj this question. As O2 is my Rx only, then by Aj's definition it's an ALS intervention being done by an EMT-Basic. 

Am I wrong?


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## rhan101277 (Apr 8, 2009)

I think that EMT-B's should be trained at the minimum to be able to administer EPI-Pens and albuterol via nebulizer.  It may take more training but if you are on a basic truck there is a chance you could go on a call.  

I mean you can bag the patient if needed and treat for shock.  That is still time when the organs aren't getting perfused as well as they could have been with proper medications.  Certain life or death issues we need to be trained to give proper medication for.  Maybe they should include A&P I and II for all EMT-Basic training nationwide and add a couple of meds.


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## bstone (Apr 8, 2009)

rhan101277 said:


> I think that EMT-B's should be trained at the minimum to be able to administer EPI-Pens and albuterol via nebulizer.  It may take more training but if you are on a basic truck there is a chance you could go on a call.
> 
> I mean you can bag the patient if needed and treat for shock.  That is still time when the organs aren't getting perfused as well as they could have been with proper medications.  Certain life or death issues we need to be trained to give proper medication for.  Maybe they should include A&P I and II for all EMT-Basic training nationwide and add a couple of meds.



I am always in favor of adding more education and skills to match that education.


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## AJ Hidell (Apr 8, 2009)

bstone said:


> I asked Aj this question. As O2 is my Rx only, then by Aj's definition it's an ALS intervention being done by an EMT-Basic.
> 
> Am I wrong?


No, you are correct.  ALS being performed by an EMT is still ALS, just like BLS being performed by a paramedic is still BLS.  There is really no intelligent way to dispute that.



rhan101277 said:


> I think that EMT-B's should be trained at the minimum to be able to administer EPI-Pens and albuterol via nebulizer.  It may take more training but if you are on a basic truck there is a chance you could go on a call.


I totally agree.  And that "more training" should take about two years.


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## Ridryder911 (Apr 8, 2009)

Actually, medical care is medical care and only EMS has the divisions of identification of separation. Agreed, medical care (such as medications) should not be administered from anyone with less than an associate degree. 

R/r 911


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## daedalus (Apr 8, 2009)

trevor1189 said:


> If an Epi Pen is in the BLS Scope of Practice then it is not an ALS intervention. It is considered BLS intervention... You can't just lump prescription drug administration as ALS like you did.



Trevor, you are very very wrong. Medical care is medical care. Drug administration, esp epinephrine, is ADVANCED life support. I agree with Rid/ryder, only EMS separates and defines different levels of care.


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## daedalus (Apr 8, 2009)

bstone said:


> I love how you are splitting hairs. You do realize that every intervention I provide is ILS, correct?



AJ is not splitting hairs. There is a important lesson to be learned here, and a lot of you are missing it. Administering medication is an ALS "skill". Oxygen does not count because lay people are allowed its use. However, medication administration is a very serious responsibility, and one only has to watch new RN student's terrified faces as they are lectured about med errors the day before their first hospital clinical to realize that. It is an advanced intervention that takes a solid knowledge in chemistry, anatomy, physiology, and pharmacology to safely preform.


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## nomofica (Apr 9, 2009)

I agree with the people who say that it is an ALS intervention.

Any drug administration, save Oxygen, is considered advanced intervention. Just because a BLS knows how to administer and its in the BLS scope of practice doesn't mean that it is now a basic intervention. *It is just a BLS who has that specific ALS skill.*


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## rmellish (Apr 9, 2009)

daedalus said:


> It is an advanced intervention that takes a solid knowledge in chemistry, anatomy, physiology, and pharmacology to safely preform.



Agreed, unfortunately it is also performed by plenty of folks with a solid knowledge of label reading....


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## DavethetrainWreck (May 13, 2009)

We can carry them on the rig in NJ if all the EMTs are trained in their use and have permission from our medical director. We do get trained in how to use them in our basic class because before we could carry them on the rig we were allowed to administer a patient's own EpiPen if available.


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## CAOX3 (May 13, 2009)

Just for  discussion.

Ten year olds administer epi pens, insulin and glugagon usually without incident.

So would that be a ten-year old performing a ALS skill?  Yet we should restrict the EMTs from a beneficial treatment because they operate in a system that was provided to them

Im all for education, until that changes what are the options? Every one has opinions but no reasonable solutions on how to get there.  In the present economy laying off a million EMTs isnt a option.


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## ResTech (May 13, 2009)

Epi-Pens are very beneficial and in terms of severe allergic reactions/anaphylaxis, time is not on the patients side. A patient should not have to wait for a Paramedic unit to arrive to administer this life saving medication when it can be administered relatively safe by BLS. In some locales, ALS may be at least 30mins away. I know in the upper most portion of the county i used to live you were looking at a good 20-30mins for ALS and if one of my kids had allergy issues and was in anaphylaxis I would rather have the BLS unit 5mins away arrive and administer Epi then have my son or daughter deteriorate and suffer in the 20-30mins it takes for an ALS unit to arrive.

Epi-Pens by BLS are based on a benefit vs risk assessment. When Epi is indicated, something very, very bad is going on with the patient and the benefits of having Epi administered by BLS far outweigh the potential risks of not being fully ALS capable. These patients dont have time to wait. Its a need it and need it now situation. And I think its important that we consider the epidemiology of anaphylaxis and the age populations most greatly affected. These are young to middle aged people who most often can handle the adrenergic effects of the epinephrine without any problem. And lets throw in the short half-life of Epinephrine. Overall, the risks of patients not getting the medication is MUCH GREATER then if patients do get it by BLS. I'm not seeing much of a realistic argument here.  

Granted, EPi-Pens may be cost prohibitive for some EMS services as 99% expire and get tossed prior to use. However, in rural areas serviced primarily by BLS with ALS coming from a chase unit from a hospital, Epi-Pens are a very worthwhile expenditure and the few hundred dollars spent every year or so on Epi is worth the security and potential life saving ability of that BLS unit. 

In PA, it is required for BLS units that choose to carry Epi-Pens to have two adult dose and two pedi doses. So multiply that by two EMS units its roughly about $400 to have that medication on both units. 

Sorry for being long winded but this is a subject that really irks me. Just because a treatment modality has traditionally been reserved for an advanced level practitioner, does not mean it cannot be permitted by a lesser level provider. Through history and research, we can determine that some modalities can be safely administered by basic level providers with great benefit. Not only Epi, but also ASA and albuterol.

For example, traditionally prescription-only medications are now OTC meds available at Wal-Mart. Im not interested in joining in the argument so just read my opinion and take it for what its worth.


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## medic417 (May 13, 2009)

CAOX3 said:


> In the present economy laying off a million EMTs isnt a option.



Why not?  Would open more positions for Paramedics that could provide some actual medical care.


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## whizkid1 (May 13, 2009)

We are a basic service,but we can give Epi.We are trained in it yearly as refreshers. We can also give nitro,albuteral,glutose,glucose,MDI's and start IV's for NS and LR.


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## rmellish (May 13, 2009)

whizkid1 said:


> We are a basic service,but we can give Epi.We are trained in it yearly as refreshers. We can also give nitro,albuteral,glutose,glucose,MDI's and start IV's for NS and LR.



give epi as a autoinjector? Or actually drawing up the desired dose from a 1:1000 vial or 1mg preload for arrests?


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## whizkid1 (May 13, 2009)

Auto injectors.


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## FieldMedic2007 (May 15, 2009)

I dont have an issue with the use of epi pens to emts do to the fact that I am a military medic and carry one even without a provider over me. I am aware that military medicine is totally different than civilian medicine and we get to carry a bit more than regular emt-b'b. I also agree that should they issue out epi pens to emt's that they definately need to make sure there is proper training and knowledge because we all know that there will be one person out there to make somethin so simple and totally mess it up Haha, but yeah, thats my thought on it.


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## 46Young (May 15, 2009)

In NYC, BLS respond for the allergic reaction, and ALS respond for the anaphylaxis. Medic back is usually not more than 3-5 minutes away in most cases if needed. EMT B's are allowed to admin albuterol, and assist with pt's ntg. When I left NY in 10/07, there were two asthma call types, one for BLS, and one for ALS. The BLS asthma calls would be for younger pts, with asthma Hx only, and a mild severity on pt's self assessment. Oftentimes these pts would have run out of their meds, and needed a free Tx and maybe a ride to the hosp if they refuse after Tx. A cardiac condition will always be an ALS call, with BLS back if medics give a greater than 10 eta. When I was BLS, we would give O2, proper positioning, and stair chair txp to the front door to make things move quicker for the medics. As such, BLS really shouldn't be messing aroung with ntg admin in lieu of packaging/moving the pt. Epi, on the other hand, can potentially kill. In a resource rich area, there's no reason BLS should need to carry epi, as they're ill equipped to treat any untoward reactions. You can study as many medical texts as you want, but having an attending emergency room MD's knowledge base is useless unless you have the tools to properly diagnose, administer the intervention, and be able to treat any side effects. Really, the previous sentence pretty sums up this entire thread.


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## 46Young (May 15, 2009)

Also, I became a medic out of desire to be able to do more for my pt's. I remember as a basic I would get a sense of fufillment and excitement after being able to give albuterol, oral glucose, or assist with ntg. If this describes you, and/or you want to do more for your pt's, become a medic.


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## Melbourne MICA (May 16, 2009)

*Epi Pens*

A logical addition to an EMT's skillset. Yet there must be cost issues and the EMT's would surely benefit from having to draw up Epi instead - valuable practice in assisting ALS types with IV med adminisatration. 

Besides, with Epi's short half life, rebound anaphylaxis is a definite probablity porportional to distance to the nearest ED. The ability to give follow-up doses may be life saving for guys on the periphery or in rural areas in particular.

Having Epi as part of the kit will also provide a visual cue to their bosses to think about expanding their skill set to include Epi beyond just anaphyaxis and perhaps even looking at where education can (must) go beyond just bean counting and litigation issues. Every life saved or med-long term illness problem nullified has cost and health benefits for all stakeholders.

Our BLS guys have had Epi for over four years now. They can apply it in arrests (IV and IM), anaphylaxis (IM), croup (neb) and asthma (IV and IM). So far no major dramas with competencies though some of the guys tend to be a bit timid sticking pts especially if inexperienced (not such a bad thing anyway). Sometimes they will wait till the MICA unit arrives to hold their hand. The good ones don't baulk.

A great drug used for the right purpose.

MM


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## 46Young (May 16, 2009)

Melbourne MICA said:


> A logical addition to an EMT's skillset. Yet there must be cost issues and the EMT's would surely benefit from having to draw up Epi instead - valuable practice in assisting ALS types with IV med adminisatration.
> 
> Besides, with Epi's short half life, rebound anaphylaxis is a definite probablity porportional to distance to the nearest ED. The ability to give follow-up doses may be life saving for guys on the periphery or in rural areas in particular.
> 
> ...



You say education can (must) go beyond just bean counting and litigation issues. I agree. That's why there's a paramedic program to properly educate, and provide the tools to administer advanced procedures. When one of your basics eventually kills someone via an epi admin, how will you fend off the inevitable litigation? What tools do your BLS providers have to treat any untoward reactions resulting from epi admin? I don't mean an AED and epi IV for an arrest after epi IV/IM admin for asthma. So, you mean to tell me that your basics administer IV/IM pharmocological intervention without intubation capabilities or cardiac monitoring/12 lead? What training have your basics received past the BLS level to fully understand the effects of their procedures? Epi IM for an arrest? I don't recall seing that on any ACLS algorithms.


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## Melbourne MICA (May 16, 2009)

*Ah you may well ask!!!*



> 46Young said:
> 
> 
> > You say education can (must) go beyond just bean counting and litigation issues. I agree. That's why there's a paramedic program to properly educate, and provide the tools to administer advanced procedures. When one of your basics eventually kills someone via an epi admin, how will you fend off the inevitable litigation?
> ...


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## High Speed Chaser (May 16, 2009)

I'm trained to use Epi-Pens and I'm not an EMT. Even before I joined St John Ambulance, I was taught to use them. If some one who isn't an EMT can be trained to use them, why shouldn't EMTs, who are trained more than a First Aider, be able to carry them?

St John Ambulance doesn't carry them for various reasons as I have previously stated in another Thread. However sometimes I wished we did because often at a sports events, people are more likely to find and get help quickly from SJA then Ambulance Victoria who are more spread out. 

A nurse I spoke with outside SJA said its better to administer an Epi-Pen then to not. Is this true? 

Correct me if I'm wrong but the basic units are refered to as Paramedics and ALS are refered to as MICA. 

Found the CPG (Scope of Practice) here http://www.ambulance-vic.com.au/media/docs/index.htm


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## Melbourne MICA (May 16, 2009)

*Als*



High Speed Chaser said:


> I'm trained to use Epi-Pens and I'm not an EMT. Even before I joined St John Ambulance, I was taught to use them. If some one who isn't an EMT can be trained to use them, why shouldn't EMTs, who are trained more than a First Aider, be able to carry them?
> 
> St John Ambulance doesn't carry them for various reasons as I have previously stated in another Thread. However sometimes I wished we did because often at a sports events, people are more likely to find and get help quickly from SJA then Ambulance Victoria who are more spread out.
> 
> A nurse I spoke with outside SJA said its better to administer an Epi-Pen then to not. Is this true?


Found the CPG (Scope of Practice) here http://www.ambulance-vic.com.au/media/docs/index.htm
[/QUOTE]



> Correct me if I'm wrong but the basic units are refered to as Paramedics and ALS are refered to as MICA.



Correct though the training is not equivalent between EMT basics in the US and our "ALS" (BLS) road units.

MM


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## 46Young (May 17, 2009)

Yes, Melboure, that cover it pretty well. Things make more sense now. What you describe is roughly equivalent to the american EMT-I scope of practice.


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## SauceyEMT (May 17, 2009)

AJ Hidell said:


> Trevor, as an EMT-B student, you are about the least qualified person here to tell me when I am right or wrong. And you have proven that with this last post.
> 
> EMT-B is not synonymous with BLS.  They are not the same thing.  One is a title.  The other is an intervention.  *Whether or not you are an EMT-B or not, if you are performing an ADVANCED intervention, you are performing ADVANCED Life Support. * Dr. Bledsoe, who wrote the paramedic textbook, says the very same thing.  You have to pull your head out of the semantic games and understand that your certification level does not define the level of an intervention.  *If your system allows an EMT to intubate, that does not make intubation BLS.  It simply makes your EMT's ALS*.



While I may also be one of the "least qualified" (read: inexperienced) to interject here, I'm going to do so because I can. 

I think you're exactly correct in this above post. With that said, this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS? 

Just my $0.02


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## 46Young (May 17, 2009)

SauceyEMT said:


> While I may also be one of the "least qualified" (read: inexperienced) to interject here, I'm going to do so because I can.
> 
> I think you're exactly correct in this above post. With that said, this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS?
> 
> Just my $0.02



When I worked in NY, I relied heavily on BLS back, and counted on them to be competent. They've helped by knowing when to call ALS, report, O2 and package, do a decent assessment/Hx, good L/S, good trauma/immobilization skills, giving cric and tube confirmation L/S, good ongoing assessment including mental status, airway/resps, accurate BP/pulse, and a smooth, safe ride to the hosp. I'm disappointed in systems that use an exclusive "one and one" medic/emt crew. Things differ by agency, but from my personal experience, the medic will dominate pt care, with the emt doing a BP, pulse/resp count, O2, BGL, monitor placement, immobilization, and that's about it. The basic never develops strong assessment skills or pt care decisions. Advanced skills are just that, advanced, and require proper education/training, and the tools to properly implement/manage such skills. It's not meant as a knock towards basics, it's just reality. Every medication has the potential to kill, and should be respected as such. When you go through the training, you'll understand the importance having full ALS capabilities to properly perform your skills.


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## AJ Hidell (May 20, 2009)

SauceyEMT said:


> ...this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS?


I won't presume to define what this battle is about for everyone here.  But, as for what it is about for me, yes, you are off base.  It has nothing to do with who is performing what.  It's about only what I said it is about, which is correctly categorizing the facets of our profession.  But I certainly appreciate your efforts to intelligently analyze and understand the issue.  I just wouldn't get too hung up trying to determine the motivations behind anyone's argument.  This isn't a criminal case.  Culpable mental states are not a relevant factor.


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## Afflixion (May 20, 2009)

First off I don't know what EpiPens some of you guys are looking at but the acctual EpiPen brand one is IM says right on it "Delivers one 0.3mg intramuscular dose of epinephrine 1:1000" Second some of you may have been going to some crackpot basic school because the NREMT standard and TESTS the use of assisting Pts with the use of their EpiPens so there should be NO reaon why a basic rig shouldn't carry it. I also aggree with AJ that it is not BLS as any invasive proceedure is catagorized as ALS. Why do you basics have to put yourselves down and insist it is BLS? just because your a EMT-B doesn't mean your limited to BLS... in AZ our basics can initiate peripheral IV therapy is that not considered an ALS skill as well?


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## AJ Hidell (May 20, 2009)

Afflixion said:


> Why do you basics have to put yourselves down and insist it is BLS?


So they can play the victim and blame it on me.

But I have to say there is a major difference between "assisting" someone with their prescribed medication and prescribing it for them.  Major, major difference.  A protocol for the former does not necessarily qualify you for the latter.


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## Afflixion (May 20, 2009)

AJ Hidell said:


> So they can play the victim and blame it on me.
> 
> But I have to say there is a major difference between "assisting" someone with their prescribed medication and prescribing it for them.  Major, major difference.  A protocol for the former does not necessarily qualify you for the latter.



This is true. Though it is saying that they should be able to open a tube, twist off a grey cap and stab it into someones leg. The only concern left is when to use said EpiPens.


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## Ridryder911 (May 20, 2009)

The main concern is not the device but rather the ability to differentiate anaphylaxis and just a reaction or in other simple terms making the right diagnosis when to really administer it. 

A monkey could utilize an Epi pen as they have thumbs also, so carrying the device is a mute point. 

R/r 911


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## CAOX3 (May 20, 2009)

If your just throwing them on the truck without the neccesary information. Yes there could be a problem.   We have been giving them for over ten years now, before that we drew it up from a multi dose.

We have a signifigant CQI department and I dont believe we have had an issue.  Its a low risk high reward medication if the educatin and knowledge is there.


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## Afflixion (May 20, 2009)

As I said when to use...Another thing to consider if one lived in a more hot environment is epi rapidly degrades in heat so one would have to put a med fridge in the unit of a bls truck...


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