# O2 admin in cases of ETOH and AMS



## medicdan (Feb 2, 2010)

I have a clinical question I have been pondering for some time, have spoken to my supervisors about, but would still like to hear more opinions about. I'm presenting the thoughts and ideas in no apparent order, just the order of my decision-making, and it's likely I answer my own questions, but I'd like feedback on the decision-making tree.

The point of view I am taking is that of an EMT-B, functioning as a first responder under a conservative Med. Director on a college campus. 

We call nearby ALS for transport, but this scenario discusses our decision making and treatments in the intervening minutes before ALS arrives.

Hypothetical Case:
Called to a 22 yom, ca&oX2, who consumed somewhere between 5 and 15 shots of assorted liquors within the last 2.5 hours, last drank just before we arrived, s/p regular dinner 5 hours PTOA. Able to speak, but poor historian, and walked quite a distance from where he first drank. Vomited 2x PTOA, and 2x on scene. Pt unable to sit up straight, unable to stand straight or ambulate much.
We are going to send this patient ALS.

I understand that O2 is indicated-- AMS of unknown or unconfirmed etiology. Not doubting that. My question lies more in delivery device and effectiveness in short period of time. I argue that a n/c is indicated, due to the continuing vomiting, and necessity to get more information out of the patient. Admittedly, a  n/c is "bull:censored::censored::censored::censored:" oxygen, and provides little clinical benefit... but its better then nothing...? Should this patient receive an NRB (already going ALS) just because the textbook says that is best-- and because we can?

What true benefit will this patient receive (no matter the underlying cause) from just a few minutes of O2 therapy (with either delivery method, knowing the medics will rip it off anyway)? We know, based on the ammt consumed, and the last consumption, that this patient will deteriorate in mental status, and eventually pass out (unconscious). In that case, is the O2 indicated?

I disagree with cookbook medicine-- or in saying "textbook"-- AMS=O2. As a BLS provider, especially on this campus, I dont have the tools to rule anything else out... Should this become a policy (ETOH intox requiring the ER should always get O2)? That takes away the judgment of the provider...? Clearly, partially because of the fact this patient is a poor historian, and partially because of the long walk (with no present bystanders), we know nothing about a fall or TBI...but in cases where we know the parameters, is it appropriate not to provide O2...?

Is it worth the trouble of setting up the delivery method, getting it to stay on, making it stay with the patient as we move them? Vomiting pts with a NRB can cause an airway issue, so we must be ever vigilant that the mask doesn't become, ahem, clogged. 

Please forgive this rant. Ultimately, I think, it boils down to a judgment call, and "gut" instinct. I often make "textbook" treatments, partially to CYA, partially because my Med. Dir. wants to see it...

What do you all think?


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## CAOX3 (Feb 2, 2010)

Sometime nothing is better.

If the guy isnt having any difficulty breathing why would you apply oxygen?  Its possible he aspirated but again you would have to assess him, what are his lungs sounds.

We dont do things to look busy we do things to benefit the pt if O2 isnt beneficial why use it?  If your going to transport him BLS place him on his side in case he vomits again monitor his airway and mental status, check his BS to rule out any diabetic issues if possible and bring him to the hospital.


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## Shishkabob (Feb 2, 2010)

Do you have access to a pulseox? 

If they aren't SoB, satting ok, and no other signs of possible hypoxia / hypoxemia aside from AMS which an be caused by a multitude of things, I'd tend to agree that a NC is appropriate.  I've had drunks on NRBs vomit in to the mask, and it seems rather counter-intuitive to have something that prohibits easy escape of the vomit. 

22-44% oxygen via NC never hurt the average person that I know of.  



On the same token, it'd be ok to not give oxygen as well, if your assessment determines it's unnecessary.   


 Use your judgment, and be able to back it up if asked why or why not.


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## VentMedic (Feb 2, 2010)

Alcohol can affect cerebral blood flow in the acute heavy intoxication as well as the chronic. This can also impair cerebral oxygen utilization. The vomiting rids the body of excess undigested alcohol but can also trigger other physiological events. If the patient is a chronic alcoholic, their electrolyes and total body chemistry will be affected setting them up for a critical medical incident. Usually you can get these patients to the hospital before they crash if they are still conscious when you pick them up. 

If severe enough we will monitor SjvO2, calculate cerebral perfusion pressure (CPP) and titrate O2 and pressors accordingly in the hospital. The SpO2 will not tell much about this level.

Alcoholics or the street "drunks" may have several cerebral events occur before they ever get a CT Scan or MRI even with many ED admissions.  There are also many other chronic changes that occur through the years that precipitate a major event later.  Younger heavy binge drinkers also can experience these changes which are not always noticeable until later.  It is like what was described in the articles about the repeated head trauma from football or boxing.  

I would not suggest a mask but O2 by NC would be appropriate to raise the PaO2.


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## reaper (Feb 2, 2010)

emt.dan said:


> I have a clinical question I have been pondering for some time, have spoken to my supervisors about, but would still like to hear more opinions about. I'm presenting the thoughts and ideas in no apparent order, just the order of my decision-making, and it's likely I answer my own questions, but I'd like feedback on the decision-making tree.
> 
> The point of view I am taking is that of an EMT-B, functioning as a first responder under a conservative Med. Director on a college campus.
> 
> ...



Just wondering which instructor put that into your head?


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## VentMedic (Feb 2, 2010)

emt.dan said:


> Admittedly, a n/c is "bull:censored::censored::censored::censored:" oxygen, and provides little clinical benefit... but its better then nothing...?


 


reaper said:


> Just wondering which instructor put that into your head?


 
I would say that is an instructor who needs a little Respiratory 101 or  should have at least taken a college level A&P course.


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## MrBrown (Feb 2, 2010)

emt.dan said:


> Admittedly, a  n/c ... provides little clinical benefit... but its better then nothing...?



Unless hypoxemic, oxygen generally provides little clinical benefit!

There is nothing magic about oxygen and slapping your patient on fifteen litres by non-rebreather doesn't cure what ailes them!

See the new UK guidelines (which includes reference to the BTS study) *here*http://www2.warwick.ac.uk/fac/med/r...ombined_final_published_version_22apr09sb.pdf

Note that for severe trauma the JRCALC/BTS guideline is fifteen litres while we use a much lower dose at 6-10.


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## VentMedic (Feb 2, 2010)

MrBrown said:


> Unless hypoxemic, oxygen generally provides little clinical benefit!
> 
> There is nothing magic about oxygen and slapping your patient on fifteen litres by non-rebreather doesn't cure what ailes them!
> 
> ...


 

It is good to see the U.K. has raised the lower SpO2 level ot 94% where as some still use 92% for hypoxemia. Other than that, 10 -15 liters seem to be the recommendation for many conditions.

One also has to remember there are different types of hypoxia.

1. Hypoxic Hypoxia

2. Anemic (Hypemic) Hypoxia

3. Stagnant Hypoxia

4. Histoxic (histologic) Hypoxia (*Alcohol consumption falls into this categoy.)*

*Good Slide Presentation:*
www.rcsw.org/Download/Other_Power_Point/*Hypoxia*.ppt

Note that a NRB mask is not a "high flow" device by true definition.

Another presentation on Hypoxic Drive:

www.idasrc.org/Hypoxic_Drive.ppt


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## Melclin (Feb 2, 2010)

Bloke needs to quit the drink I reckon. Doesn't suit him.

Assuming this is your standard 22M out for a Friday night with his mates and he's a drink too many, I don't see that he realistically needs any O2. But as a campus basic (or any ambo for that matter) I suppose you can't really make those kinds of judgements, what with a lack of equipment, time with the pt, training, scope and especially a lack of an accurate hx of the pts condition/consumption. 

A nasal cannula would be just dandy. Now somebody tell our state service that will you.


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## medicdan (Feb 2, 2010)

The comment about use of a n/c being useless came from one of my supervisors. At least in this area, the medics rip any O2 we admin off... so the question is of effect in the first few minutes.

From my point of view, on a college campus, there are 4 MAIN causes of AMS 1) ETOH/Drugs, 2) Head injury/TBI, 3) DM and other metabolic conditions, and 4) hypoxia or hypoperfussion of different forms. 

In my first few mintes on scene, I like ruling out conditions my patient doen't have. Right  now, I dont have a glucometer, but use my physical exam/skin assessment. I know that ETOH/Drugs are involved, I can't rule out TBI, can determine the lack of hypo/hyperglycemia based on PE, and can look for s/s of hypoperfusion. 
Lets say we have pulseox, and it is normal, 99%.


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## VentMedic (Feb 2, 2010)

emt.dan said:


> Lets say we have pulseox, and it is normal, 99%.


 
Cerebral oxyimetry would tell you more.

If you ever go on to some type of critical care medicine (if the U.S. Paramedic even advances that far or in another profession), you will notice that we utilize the pulse ox as only one guide and in sick patients, it must be correlated with other lab work including an ABG.   If a very ill patient has an SpO2 of 99% while on a NRB mask but is still short of breath, that SpO2 means little as the gas exchange may be impaired to where the level in the blood never reached what it should with a higher FiO2.    The PaO2 may be very low and gas exchange must be improved or the patient can decompensate very quickly without the oxygen.  

Likewise, if we have a septic patient with a lactate level of > 4 mmol/L we will keep that patient on oxygen until the level starts declining.  If they are sick enough to require a ventilator, they will remain on 100% and we will monitor ScvO2.  If the ScvO2 number drops out of range, we will add fluids or pressor to increase it.  We may also have to make adjustments to the ventilator to either back up on the airway MAP (Mean Airway Pressure) or even consider adding Nitric Oxide.  The same for some neuro patients as we may be monitoring SjvO2, ICP and CPP as a guide for oxygen delivery.

For head trauma, each patient will have a different guideline for O2 depending on injury sight, extent of injury, pneumocephalus, pre-existing conditions and pulmonary complications.  

If the hemoglobin is fully saturated,  other treatments will have to be relied upon to improve oxygenation at the tissue level.   

What I am trying to say is there is no easy recipe especially with all the possibilities.  You are on the right track for recognizing a lot of different things that could be happening.  At 22 y/o, he could have been binge drinking  2- 3x per week for 4 years of college...not good.   He could also have been assaulted while drinking and now has a subdural hematoma.   It is also difficult in the field to know many of these things even with a thorough examine but if you at least look for these things you may not be caught off guard at the hospital.  You'd be surprised what we find in the ED with young weekend warriors or college students who drink too much as well as the street alcoholics that someone failed to do a thorough assessment and just took the obvious diagnosis. 

But, prehospital you will have to just rely on your M.D.'s protocols based on what you can assess. 

In the hospital, the "over educated" (see the locked thread) RNs and RRTs will be titrating meds and technology based on an ongoing bedside assessment for their entire shift.


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## medicdan (Feb 2, 2010)

Thank you, Vent, this is very helpful. I didnt include the field pulse ox in the original description, because I dont consider it significant in my assessment or treatment. 
I am interested in other assessments or critical thinking skills I can utilize for "under-educated" EMTs in the field, while waiting for the "trained professional" paramedics to arrive. 
I'd like to say I administer oxygen (or any other medication/treatment) for more significant reasons then "protocol says", or "because my Med. Director says", so am looking for deeper meaning.

Thanks again.


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## VentMedic (Feb 2, 2010)

emt.dan said:


> for "under-educated" EMTs in the field, while waiting for the "trained professional" paramedics to arrive.


 
Unfortunately in the U.S., oxygenation and ventilation are barely covered in the Paramedic curriculum.

Too often someone will read a JEMS article and take it to heart as being a statement on how to treat all patients. This may be why you have seen some Paramedics ripping off the O2 from your patients.  They don't pull up the articles discussed in the references to see exactly what patient population was studied or even how many were studied.   This is essentially how the "COPD and hypoxic drive" issue has stayed in the mainstream.  What some fail to realize is that COPD is a very broad term and only about 5% will actually be CO2 retainers. 

One could pull up literally thousands of articles about alcohol and oxygenation that have been studied over the past century.  

Also, whatever treatment you see in the ED for the patient may differ greatly from what will be done in the ICU.  Quite often as soon as it is determined the patient needs an ICU, the ED doctor steps aside and an intensivist takes over or their protocols are initiated.   That is of course provided the RNs have some ICU education and training.


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## Jon (Feb 2, 2010)

Dan,

We sometimes get called BLS to the local University Public Safety for similar patients. I assume your role is First Responder?

Often I'll BLS them. We have a ~5 minute, 1.5 mile transport, non-emergent. If I had a longer transport, I'd also be thinking more along the lines of ALS. ALSO, if I'm on a ALS ambulance, I'd likely ride the patient in. (Note - I ride with a service that is BLS only, even though I'm a medic).

Why?
I question what an ALS provider will do for the patient during the short transport, and what they really could do for the patient?


Now, if they are unconscious/unresponsive and/or unable to control their airway, They get ALS and whatever I need to do BLS until they get there.


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## VentMedic (Feb 2, 2010)

Jon said:


> Dan,
> 
> We sometimes get called BLS to the local University Public Safety for similar patients. I assume your role is First Responder?
> 
> ...


 
This is what is so wrong about the American EMS system.

If you are a Paramedic, you should be thinking and assessing as an advanced provider regardless of whether you are on an ALS or BLS truck.    If you fail to recognize important signs and symptoms because you are only on a "BLS" truck then you may not be anticipating some very important situations.  You may also fail to recognize that a different hospital might be needed rather than just the local little general and dump.  

As an ALS provider, you most definitiely can do than just airway even for the short term.  If you have done your assessment properly, you may find HR and BP situations that may need intervention.   One should NEVER assume a patient is just a drunk by first appearance without some type of assessment and hopefully more than just one that is just  "BLS" if you are capable of doing a more advanced assessment. 

Never do patient care or at least not the assessment just by "the truck you are on".  Even if you have limited equipment, that patient is still entitled to the full abilities of your patch and training regardless of whether you want to call your ride in "BLS" or "ALS".   Someday in the very distant future,  U.S. EMS will be about patient care and not the "truck".


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## medichopeful (Feb 2, 2010)

I'm interested in this subject too, as our situations (work environments) are the same (college campuses).


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## FLEMTP (Feb 2, 2010)

Short or long transports I ALS ETOH patients. I figure they can use the IV fluids and the sooner I start giving them fluids and get them closer to discharge, the quicker the ER can get them out the door. I also will go the extra step and contact someone who is sober to meet the patient at the ER. The ER staff love this and it helps them get things moving, especially on a friday or saturday night when ER beds are at a premuim!


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## MrBrown (Feb 2, 2010)

> Short or long transports I ALS ETOH patients.



Meaning what exactly, a bag of fluid? Yes that is truly advanced prehospital care, perhaps performing rapid sequence intubation or thrombolysing them based upon one's 12 lead findings I might call providing "advanced" care.

Now that is mildly unfair because that's not aimed at you specifically and I know Lee County EMS is a good setup.

That aside this "ALS" vs "BLS" thing just drives me absolutely up the wall and across the roof, down the other wall and back up again.

I suppose the biggest factor is that "BLS" in your system includes oh yes, oxygen and everything else is "advanced" so the education and mental conditioning covers just enough to enable you to do this, take some vitals and strap somebody to a board.  Let's not get cute and say you can "assist" with GTN because that's not really something you can do medically, you can call and ask to help give somebody a tablet.  Not the same thing.


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## Melclin (Feb 2, 2010)

Jon said:


> Often I'll BLS them. We have a ~5 minute, 1.5 mile transport, non-emergent. If I had a longer transport, I'd also be thinking more along the lines of ALS.
> .



I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures 

But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?


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## 46Young (Feb 2, 2010)

Melclin said:


> I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures
> 
> But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?



It's just the culture here, I suppose. Where I come from, NYC, to "BLS" them means to only treat within BLS protocols. To "ALS" someone means to perform one or more ALS only interventions. When we would give notifications to the hospital, the driver would give a radio report to the dispatcher such as: Male, 38, A&O3, R/O MI, 178/112, 108 regular, 24, ALS established, ETA 10 mins to the ED. ALS established typically means (in general) whatever interventions would be normally assosciated with the pt's condition, whatever matches that protocol.

Here's NYC's BLS and ALS protocols if you care to glance:

http://www.nycremsco.org/

To deviate from protocol, you need to call OLMC and get clearance to deviate. I believe this is due to the many different agencies providing 911 MS in NYC. Too many different agencies to place trust in any one crew without MD consult.


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## VentMedic (Feb 2, 2010)

It is the mentality behind the "ALS" and "BLS" that has made EMS here so ridiculous.   

If a doctor places a nasal cannula on a patient does that make it "BLS" even if the patient is headed for the ICU?    If the patient is brought in by "BLS" does that make them less sick because less or no "ALS" procedures were done on them?  If a BLS truck brings in an acute stroke patient does that make the patient less sick?   If an ALS truck rushes a patient in cardiac arrest to the ED that they have not established any "ALS" interventions on, is that patient "BLS" and less sick? 

In the U.S. we tend to get more hung up on labeling the patient by a skill or procedure rather than the knowledge of the provider or the actual patient care where assessment is concerned or whether that patient might actually be sick.  If the Paramedic does not see where they can or want to do a "skill" the patient  becomes "BLS".   Thus, it is then assumed the patient is "less sick".    

We can take a severely injured trauma patient as an example since the BLS vs ALS is argued.   The fact that only "BLS" procedures are done does not make that patient less sick.  It should be the fact that an ALS assessment determined less is best rather than stay and play.  Either way the patient needs Advanced Patient Care regardless of whether it is initiated in the field or in the ED.  They may not need "ALS" skills but they are entitled to an assessment by someone capable of determining if immediate intervention is required and one that can do that procedure be it "BLS" or "ALS".


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## FLEMTP (Feb 2, 2010)

MrBrown said:


> Meaning what exactly, a bag of fluid? Yes that is truly advanced prehospital care, perhaps performing rapid sequence intubation or thrombolysing them based upon one's 12 lead findings I might call providing "advanced" care.
> 
> Now that is mildly unfair because that's not aimed at you specifically and I know Lee County EMS is a good setup.
> 
> ...



well something i want to point out.. my agency is different from most, in that our EMT's are expected to perform skills above what most EMT's perform. here our EMT"s start IV lines, perform 12 leads, and are able to place any advanced airway with the exception of an ET tube. They are also expected to be able to draw up any medication we call for, with the exception of narcotics, and depending on the level of comfort of the medic, push the medication in certain circumstances. They also are expected to set up and apply CPAP and set up and apply a simple tranport ventilator. Most of this is much more than most typical EMT's are allowed to do on the BLS level... so with us, BLS is a skewed concept from most.


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## MrBrown (Feb 2, 2010)

VentMedic said:


> It is the mentality behind the "ALS" and "BLS" that has made EMS here so ridiculous.



Aw dude seriously I am picturing an ambulance pulling up and a bunch of people in clown getup with the funny pants and face paint and the hillarious sound effects getting out.

That is so wrong but I'm almost having some sort of hypoxic event laughing so hard.  Sorry guys but that was pretty funny.

Problem is with the whole terms of "basic" and "advanced life support" is that they are used internationally but in every country they mean different things.

Ambo does way more than "life support" and I think that terminology stopped being relevant long ago.

New Zealand attempted to move beyond that nomanclature when we developed our new Ambulance Standard however there wasn't a consensus on what to replace it with.

Something that seemed to be the most supported was

Primary Care [Paramedic] - the old "basic life support"
Advanced Care [Paramedic] - the old "intermediate life support"
Intensive Care [Paramedic] - the old "advanced life support"
Extended Care [Paramedic] - Paramedic Practitioner

The problem was around "primary care" because well, it's not true primary care as the GP sees it; "basic care" sounds really bad and we couldn't think up a reasonable alternative to that.  There was also some resistance to calling those at the basic level "Paramedic".

Canada uses this set (PCP/ACP) but they also have CCP but that's more critical care flight and IFT, lots of meds and pumps.  

Queensland and Victoria in Australia use Advanced and Intensive Care Paramedic.  

New Zealand used to used to have "intermedite" and "advanced care officer" in the 80s and mid 90s but the application was quite poorly designed and led to a lot of public confusion because patches and nomanclature did not match the terms.


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## VentMedic (Feb 2, 2010)

FLEMTP said:


> well something i want to point out.. my agency is different from most, in that our EMT's are expected to perform skills above what most EMT's perform. here our EMT"s start IV lines, perform 12 leads, and are able to place any advanced airway with the exception of an ET tube. They are also expected to be able to draw up any medication we call for, with the exception of narcotics, and depending on the level of comfort of the medic, push the medication in certain circumstances. They also are expected to set up and apply CPAP and set up and apply a simple tranport ventilator. Most of this is much more than most typical EMT's are allowed to do on the BLS level... so with us, BLS is a skewed concept from most.


 
Those are still "skills" that can be done, unfortunately, with very little education or knowledge. Thus, we still can associate EMT with "BLS" even in the areas that allow EMTs to do ETI. We have had many threads about "EMT-Bs intubating" or "BLS and intubating". What is missing is the "patient care" as it pertains to assessment, knowledge and the level of care of the provider as it relates to the seriousness of the illness/injury and not just a "skill".

At least in FL, there should always be a Paramedic directly supervising the EMT doing these skills. Without that Paramedic, this would be a "BLS" patient because of the level of the provider regardless of how sick that patient is.


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## FLEMTP (Feb 2, 2010)

VentMedic said:


> They may not need "ALS" skills but they are entitled to an assessment by someone capable of determining if immediate intervention is required and one that can do that procedure be it "BLS" or "ALS".



Exactly... anyone in EMS, be an EMT or a paramedic, should be able to look at a patient and very quickly determine if the patient needs ALS intervetion, BLS intervention, or any intervention at all. 

As an EMT on a BLS 911 unit, working in a county with only 2 medic flycars in the entire county, I became very good very quickly at determining who needed a medic and who doesnt. Any EMT should be the best they can at doing the same thing, and should be even better at managing that patient at a BLS level until that higher level of care is available, whether it be a paramedic, or an ER.


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## FLEMTP (Feb 2, 2010)

VentMedic said:


> Those are still "skills" that can be done, unfortunately, with very little education or knowledge. Thus, we still can associate EMT with "BLS" even in the areas that allow EMTs to do ETI. We have had many threads about "EMT-Bs intubating" or "BLS and intubating". What is missing is the "patient care" as it pertains to assessment, knowledge and the level of care of the provider as it relates to the seriousness of the illness/injury and not just a "skill".
> 
> At least in FL, there should always be a Paramedic directly supervising the EMT doing these skills. Without that Paramedic, this would be a "BLS" patient because of the level of the provider regardless of how sick that patient is.



True, as far as the simple hands on of the skills goes, they are very simple and any EMT could be trained to do those. THe difference is here we try and educate our EMT's as to the why behind the how. And yes, they must be directly supervised by a county credentialed paramedic. It works out quite well for the paramedic in charge though, because they can focus on overall scene management without being tied to doing one specific task, or it also makes it easier to manage the care of the more critically ill patients.

Also keep in mind, we have quite a few state licensed paramedics that work in an EMT capacity because there are not open paramedic positions, or because they feel overwhelmed working in a system with such liberal protocols as ours, and want to learn the system a step at a time. Certainly no shame in it, and I applaud them for knowing their own limitations and recognize the need to educate themsevles and gain experience. They are able to perform ANY paramedic level skill as long as they are being supervised directly by a county credentialed paramedic.


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## VentMedic (Feb 2, 2010)

FLEMTP said:


> Exactly... anyone in EMS, be an EMT or a paramedic, should be able to look at a patient and very quickly determine if the patient needs ALS intervetion, BLS intervention, or any intervention at all.


 
Yet, we hear comments from EMTs about dialysis patients very often as being BLS or "BS" even though they are the sickest patients they may see on their truck. Dialysis is an "advanced" procedure required for supporting life. Even if the patient can go by a "BLS" truck because they do not require an IV or ETI, they should in no way be considered not sick which is unfortunately what happens with the "BLS" label.

Trauma and the obviously ill are one set of examples which require very little assessing to determine there is a problem. Unfortunately there are many other medical and some trauma situations that should require a more thorough assessment especially when it comes to determining appropriate facility. Example: we have also had Paramedics that assumed "BLS", some even before they see the patient, only to take a STEMI to a hospital with no cath lab. They did a "BLS" assessment. We have also had similar patients where the stroke or whatever neuro event was not immediately obvious or masked by alcohol. Thus, in their eagerness to determine the label "BLS" vs "ALS" they overlooked some very serious signs and symptoms which cost valuable time getting a CCT to move the patient to another facility.


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## VentMedic (Feb 2, 2010)

FLEMTP said:


> True, as far as the simple hands on of the skills goes, they are very simple and any EMT could be trained to do those. THe difference is here we try and educate our EMT's as to the why behind the how. And yes, they must be directly supervised by a county credentialed paramedic. It works out quite well for the paramedic in charge though, because they can focus on overall scene management without being tied to doing one specific task, or it also makes it easier to manage the care of the more critically ill patients.
> 
> Also keep in mind, we have quite a few state licensed paramedics that work in an EMT capacity because there are not open paramedic positions, or because they feel overwhelmed working in a system with such liberal protocols as ours, and want to learn the system a step at a time. Certainly no shame in it, and I applaud them for knowing their own limitations and recognize the need to educate themsevles and gain experience. They are able to perform ANY paramedic level skill as long as they are being supervised directly by a county credentialed paramedic.


 
Essentially your service has created an Intermediate level which is the ALS skills but not the same depth of knowledge as the Paramedic level.


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## FLEMTP (Feb 2, 2010)

VentMedic said:


> Essentially your service has created an Intermediate level which is the ALS skills but not the same depth of knowledge as the Paramedic level.



More or less yes. It works well for our system, and every EMT and paramedic that works in our system sits for a rather rigorous oral board exam with our training captain, training chief, a Lieutenant, and our medical director, who ultimately has responsibility for what we do as EMS providers.


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## VentMedic (Feb 2, 2010)

FLEMTP said:


> More or less yes. It works well for our system, and every EMT and paramedic that works in our system sits for a rather rigorous oral board exam with our training captain, training chief, a Lieutenant, and our medical director, who ultimately has responsibility for what we do as EMS providers.


 
The Paramedic and EMT team is also cheaper than two Paramedics.  It isn't like Florida has a shortage of Paramedics although many are waiting for the FD which is more stable form of employment for many areas in this state.

Even for CCT, Specialty and Flight that does primarily IFT the Paramedic can be viewed as the "Intermediate" as they are hired for "skills" and lack indepth critical care knowledge.  Their use as an RN/Paramedic team is also cheaper than RN/RN.   California uses RN/2 EMTs with a few extra skills for its CCTs.   But again, EMS providers are viewed for their "skills" rather than actual knowledge just as the determination for "ALS" might be the difference of one skill.


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## MrBrown (Feb 2, 2010)

"Advanced" skills here are considered:

Endotracheal intubation and RSI
Cricothyrotomy
Turkel chest decompression
Atropine
Ketamine
Midaz (may change in  the future for seizures)
Frusemide
Pacing
Hydrocortisone
Thrombolysis
IV salbutamol
IV magnesium

Everything else is either a Paramedic or Technician skill


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## johnrsemt (Feb 3, 2010)

To go back to the original poster (OP):   I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m.  it gives them some relief  (it does for me anyway).  and I have had multiple patients tell me that it gives them relief too.

   As a preceptor told me back 13 years ago, when I was on a BLS FD;  putting someone on O2 does multiple things:  
   1:  makes the patient feel better
   2:  makes the patients family feel better
   3:  gives you something to do while you are trying to figure out 'what the ____ ' to do for your patient, without making you look like a moron.
   4:  gives the Fire fighters something to do,  to make them look useful.


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## FLEMTP (Feb 3, 2010)

VentMedic said:


> Even for CCT, Specialty and Flight that does primarily IFT the Paramedic can be viewed as the "Intermediate" as they are hired for "skills" and lack indepth critical care knowledge.  Their use as an RN/Paramedic team is also cheaper than RN/RN.   California uses RN/2 EMTs with a few extra skills for its CCTs.   But again, EMS providers are viewed for their "skills" rather than actual knowledge just as the determination for "ALS" might be the difference of one skill.



Im not quite sure where you are getting the assumption that we as EMS providers are viewed for skills and not actual knowledge....if it was just about skills we would go back to the day where we were taught to read protocols out of a book and follow instructions without thinking. I was taught to think for myself and use my KNOWLEDGE to assess my patient, form a differential diagnosis and treat my patient based on that diagnosis.

Also, im glad you can cite what california does, but our helicoptor crews consist of 2 CCEMTP level providers who have attended a formal critical care course, and complete daily rounds in the ICU with the medical staff, and routinely demonstrate actual KNOWLEDGE and use that knowledge to form a treatment plan, and use that knowledge to perform skills well beyond what a ground paramedic (or a RRT with an EMT license ) would perform.

Maybe you have a different view of EMS providers, since you really dont function as one, and you work in the hospital instead of in the same enviroment we (paramedics and emt's) face, but please dont imply that we are just skill driven technicians that dont know what we are doing or why


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## VentMedic (Feb 3, 2010)

FLEMTP said:


> Im not quite sure where you are getting the assumption that we as EMS providers are viewed for skills and not actual knowledge....if it was just about skills we would go back to the day where we were taught to read protocols out of a book and follow instructions without thinking. I was taught to think for myself and use my KNOWLEDGE to assess my patient, form a differential diagnosis and treat my patient based on that diagnosis.
> 
> Also, im glad you can cite what california does, but our helicoptor crews consist of 2 CCEMTP level providers who have attended a formal critical care course, and *complete daily rounds* in the ICU with the medical staff, and routinely demonstrate actual KNOWLEDGE and use that knowledge to form a treatment plan, and use that knowledge to perform skills well beyond what a ground paramedic (or a RRT with an EMT license) would perform.
> 
> Maybe you have a different view of EMS providers, since you really dont function as one, and you work in the hospital instead of in the same enviroment we (paramedics and emt's) face, but please dont imply that we are just skill driven technicians that dont know what we are doing or why


 
You are only talking about one service in Florida and not every HEMS, CCT or ALS in the state or every EMS in this country.    You seem very reluctant to see that EMS still has a long way to go to achieve the same level that other countries have.  

Since you used the CCEMTP letters, which is a trademark of UMBC, that is a very limited overview of a few critical care concepts consisting of about 80 hours.  It is also open to just about any health care professional that wants to take it and requires no prior experience.  It is vastly different from what is required to do "critical care" as a Paramedic in other countries.  

As for as my RRT credential, it is very difficult for a Paramedic or EMT in this country to gain much hands on hospital experience and definitely not in a critical care unit.   Doing "rounds" is vastly different than actually doing the patient care in an ICU.  Thus, some of us have chosen to obtain other credentials such as RN or RRT to get hands on experience and further our education. 

And no, I haven't been on a helicopter since last year.   Fortunately, now working in a hospital and doing Specialty transport by many means of transportation, I can expand both my skills, knowledge and experience to a level that is not available for most EMS providers.  Thus, I encourage people to not stop at one level of their education and if they are serious about advancing either as a Paramedic, RN or RRT, they should continue their education and seek out an area for growth in their chosen profession.


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## CAOX3 (Feb 3, 2010)

johnrsemt said:


> To go back to the original poster (OP):   I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m.  it gives them some relief  (it does for me anyway).  and I have had multiple patients tell me that it gives them relief too.
> 
> As a preceptor told me back 13 years ago, when I was on a BLS FD;  putting someone on O2 does multiple things:
> 1:  makes the patient feel better
> ...



Ok not trying to be difficult here.....But why is everyone under the impression if your not doing something then your failing your patient?  We dont do things to look busy or because we need something to do, if they all need is an ice pack and a ride thats what they get.

Oxygen is a medication and should be treated as one and not handed out to make yourself look "busy", it has specific uses and should be administerd in those situations.

You wouldnt do it with morphine or albuterol.

I feel much better now, Thanks


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## Melclin (Feb 3, 2010)

johnrsemt said:


> To go back to the original poster (OP):   I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m.  it gives them some relief  (it does for me anyway).  and I have had multiple patients tell me that it gives them relief too.
> 
> As a preceptor told me back 13 years ago, when I was on a BLS FD;  putting someone on O2 does multiple things:
> 1:  makes the patient feel better
> ...



Oh dear. 

1 & 2:First of all it doesn't necessarily do either of the first two things. The presence of a mask on someones face often seems to make them quite uncomfortable, and the appearance is (in my obviously limited experience) often upsetting for family and friends, because they look like a sick person.

3: There is no harm in spending a little time considering your care options. It doesn't make you look like a moron, it makes you look like a calm, collected ambulance provider who is obviously putting thought into their pts treatment and who is not worried enough to be rushing around doing random and unhelpful busy work.

4: Another boon for FD based medical services. <_< You guys over there need to realise that having a bunch of FFs barrel in the door in their bloody turnout gear for some nanna who's been a bit crook for a few days, (or for just about anything really) is simply absurd.

EDIT: This is separate to the obvious and excellent point made by CAOX3. Plus 1 too that, old chap.


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## MrBrown (Feb 3, 2010)

I have put one or two old's ladies on one litre via a nasal cannula when they seem quite worried and we're going to take a long time extricating them, made them feel a bit better; even if it's just psychosamatic.

Small white lie really.


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## Jon (Feb 4, 2010)

Melclin said:


> I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures
> 
> But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?


Here's my point. If I'm dispatched BLS, and I get there and they have a patent airway... even if they are somewhat altered, what is a medic going to do.

One of the pertinent negatives I usually rule out is Hx. of diabetes...unfortunately I don't even have a glucometer.

Vent - I do the same H&P exam of my patient... it doesn't matter if I'm on a BLS or ALS truck... but if I'm on a BLS truck, I don't have a glucometer, cardiac monitor, advanced airway equipment, or IV and drugs. Thats what makes the difference for me.


My thinking on this, with the short transport time... by the time I get a medic to me, I can be almost at the ER... why should I wait for a medic, or meet one around the corner from the ER. What is the medic going to do for my patient.


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## MrBrown (Feb 4, 2010)

Jon said:


> ... but if I'm on a BLS truck, I don't have a glucometer, cardiac monitor, advanced airway equipment, or IV and drugs. Thats what makes the difference for me.



This really suprises me, well, not really.  If you are working on a "basic" truck can you not grab your ALS bag and make it an "ALS" trucK? 

By contrast our vehicles are all the same; they may be crewed by two Technicians (BLS) but if you look at the equipment on that vehicle vs one crewed by an Intensive Care Paramedic it's all the same except for one green bag for the Intensive Care Paramedic.

That bag will contain intubation and advanced drug rolls and chest decompression kit.  By "advanced" drugs I mean amiodarone, atropine, ketmainze and midaz.  Stuff like salbutamol, glucagon, glucomonitor, GTN, Lifepak, general resus kit and extrication gear etc is common to all vehicles regardless of crew level. 

So what happens if you are called to intercept with a "basic" unit? Do you change vehicles or do you make the patient change vehicles?



Jon said:


> My thinking on this, with the short transport time... by the time I get a medic to me, I can be almost at the ER... why should I wait for a medic, or meet one around the corner from the ER. What is the medic going to do for my patient.



That's a good point; the general consensus here is that if your backup can locate you "significantly faster" than you can deliver the patient to hospital then call for it.  

No longer is it acceptable to wait on-scene for backup unless they are only a few minutes away or if you are moving farther away from them to begin transport.


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## medicdan (Feb 4, 2010)

MrBrown, in the US care is very fragmented, and each department or region treats their ambulance service differently. I believe the company Jon is describing working for is ONLY BLS, that is, they do not have authorization from the state to provide ALS-level care, and when they employ paramedics, they do so understanding they have a BLS SOP.


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## MrBrown (Feb 4, 2010)

emt.dan said:


> MrBrown, in the US care is very fragmented, and each department or region treats their ambulance service differently. I believe the company Jon is describing working for is ONLY BLS, that is, they do not have authorization from the state to provide ALS-level care, and when they employ paramedics, they do so understanding they have a BLS SOP.



Ah nationalisation how I love thee ^_^

Every vehicle here has the same equipment, so, if an Intensive Care Paramedic jumps onboard all he has to take is his ICP bag which has his airway gear and drug roll.  A vehicle crewed by two Technicians will have at least one IV kit, for example, even though they cannot use it per-se.

I did have a look at the *PA Ambo licensing manual*http://www.portal.state.pa.us/portal/server.pt?open=18&objID=445337&mode=2 and it looks like the only difference is in the equipment carried, which, is really the same here as an Intensive Care Paramedic will carry intubation gear (for example) whereas a vehicle crewed by say, a Paramedic and a Technician will not.

Not to judge a system I have no experience in, but, it does seem a little odd to me.


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## 46Young (Feb 4, 2010)

VentMedic said:


> It is the mentality behind the "ALS" and "BLS" that has made EMS here so ridiculous.
> 
> If a doctor places a nasal cannula on a patient does that make it "BLS" even if the patient is headed for the ICU?    If the patient is brought in by "BLS" does that make them less sick because less or no "ALS" procedures were done on them?  If a BLS truck brings in an acute stroke patient does that make the patient less sick?   If an ALS truck rushes a patient in cardiac arrest to the ED that they have not established any "ALS" interventions on, is that patient "BLS" and less sick?
> 
> ...



Where I work now, virtually every unit its a medic unit. So, there's no "BLS or ALS", just the crew's assessment and treatments. When I worked in NYC , there were both BLS and ALS units. If the BLS assesses the pt and determines that their limited diagnostic capabilities are inadequate for the pt, then they will call for ALS. As medics, our PCR's had a section for treatment codes. The first code, every time, is "ALS Assessment", regardless of the pt's condition. "BLSing or ALSing" a pt is more to say if the pt required any interventions that BLS would not be able to provide. This is after proper diagnostics, such as pulse ox, ECG, 12 lead, BGL, and a paramedic level physical assessment/interview, of course.

If the paramedic level was entry level, BLS and ALS categories would be unnecessary.

Bottom line, when we, the double medic unit in the city would advise the pt is BLS, that means that the we decided that the pt didn't require any further Tx under ALS protocols other than those diagnostics already provided. In the city, when giving a note to the hosp, we would say "ALS in progress" rather than "ALS established" if interventions were in progress. As far as what interventions were established were left intentionally vague, as the medics need to work, not answer a plethora of questions during transit. The advised R/O along with the pt's mental status, vitals and general condition would suggest the actual "ALS" established or in progress. That's how it works in NY. Also, the stubbed toe wouldn't require a 12 and a BGL, and the diff breather with significant Hx needs more than air and chair.

I don't understand why some ED's need to know every detail during transit (when we need to work and also watch the pt), when they've already been advised of the pt condition, suspected Dx, diagnostics, interventions, and applicable reassessments. That's what the pt transfer portion of the call is for.


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## MrBrown (Feb 4, 2010)

46Young said:


> If the paramedic level was entry level, BLS and ALS categories would be unnecessary.



Sounds like a plan



46Young said:


> when giving a note to the hosp, we would say "ALS in progress" rather than "ALS established" if interventions were in progress. As far as what interventions were established were left intentionally vague, as the medics need to work, not answer a plethora of questions during transit.



Does the hospital actually care about what you've done for the patient or understand the difference? I think the hospital staff here are a little niave about what an Officers' skill set is but that's not thier fault!

Here a radio message to the hospital is very brief; it is specifically directed to report only abnormal routine vital signs or non-standard treatment.

Example might be "City 3 bringing to you a 63 year old male, moderately short of breath speaking 3-4 words of breath, extremely wheezy, has not responded well to salbutamol, saturation is 91%, status two (unstable), be with you in 6 minutes"


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## JPINFV (Feb 4, 2010)

It really depends. For example the base hospital report (the one filled out by the RN manning the radio) is essentially the same as the paramedic PCR. For base hospital contact calls (essentially any real emergency), the form is supposed to be filled out completely, even if it means that the paramedic calls the base hospital after turning over care to finish reporting the information. 

http://ochealthinfo.com/docs/medical/ems/P&P/390.10.pdf


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## FLEMTP (Feb 4, 2010)

MrBrown said:


> Sounds like a plan
> 
> 
> 
> ...



I keep my reports short sweet and to the point... just like yours posted above... here we call the ER directly to give report.. and we dont have to ever ask for orders.. all of our protocols are standing orders for anything we do.. meds or procedures... and those ER nurses are just too busy to wait for you to tell them every med.. every allergy and what the patient had for breakfast last tuesday


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## Jon (Feb 5, 2010)

MrBrown said:


> Ah nationalisation how I love thee ^_^
> 
> Every vehicle here has the same equipment, so, if an Intensive Care Paramedic jumps onboard all he has to take is his ICP bag which has his airway gear and drug roll. A vehicle crewed by two Technicians will have at least one IV kit, for example, even though they cannot use it per-se....
> Not to judge a system I have no experience in, but, it does seem a little odd to me.



Mr. Brown - Exactly right. Remember how I said that your system was much LESS confusing than ours?

All "my" ALS gear is actually my employers, and is shared among all employees. The transport job I have works somehow like yours does - when I'm on the truck, I pull all the ALS gear out of a closet and use it for the shift, and if I'm not relived by a medic, it gets locked up again. Lots of schlepping when I'm the 2nd daytime medic.

I currently spend at least 16 hours a week on a BLS truck to pay my "rent" - I live in an apartment at a BLS company and my roommates and I trade time on the truck for rent. Not a bad deal for all involved. It's allowed them to still be staffed by all volunteers from 6p-6a all week.



MrBrown said:


> ...Here a radio message to the hospital is very brief; it is specifically directed to report only abnormal routine vital signs or non-standard treatment.
> 
> Example might be "City 3 bringing to you a 63 year old male, moderately short of breath speaking 3-4 words of breath, extremely wheezy, has not responded well to salbutamol, saturation is 91%, status two (unstable), be with you in 6 minutes"



Nice. We need to call in for orders for some things, but not every call requires a command call.



JPINFV said:


> It really depends. For example the base hospital report (the one filled out by the RN manning the radio) is essentially the same as the paramedic PCR. For base hospital contact calls (essentially any real emergency), the form is supposed to be filled out completely, even if it means that the paramedic calls the base hospital after turning over care to finish reporting the information.
> 
> http://ochealthinfo.com/docs/medical/ems/P&P/390.10.pdf



JP - Has anything changed since Emergency! in CA?
Has it changed for the BETTER?


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## JPINFV (Feb 5, 2010)

I never really enjoyed Emergency (I watched 3/4s of the pilot), but from what I've heard... no.


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