# Biggest problem at the EMT(BLS) Level?



## EMT856 (Dec 13, 2013)

Just wondering what the biggest problems my fellow EMTs feel affect the EMT level of care.

Personally I feel that EMT-Basic has too basic of a scope.

Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.


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## DesertMedic66 (Dec 13, 2013)

A lot of services already allow most if not all of the items mentioned to be used at the EMT level. 

More skills = more time in the classroom.


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## EMT856 (Dec 13, 2013)

I know that EMTs in NJ as well as a lot of other states do not.


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## DesertMedic66 (Dec 13, 2013)

I work for a very restrictive system in SoCal and can hang NS, obtain a 12-lead, and do BGL testing. 

The major issue is lack of education. The EMT level is less than 200 hours of training (more around 120 hours). With more education come more skills.


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## DrParasite (Dec 13, 2013)

EMT856 said:


> Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.


Narcan yes, ASA yes, BGL testing, yes, the rest no.

remember, you need to think about the lowest common denominator.  many EMTs would be able to both do the skills you describe, but I know too many dumb people in EMS that i wouldn't trust with a band aid, let along administering d50.

Also remember, drugs do expire, especially if they aren't used frequently.  the cost will play a factor


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## EMT856 (Dec 13, 2013)

What if there was a separate class you could take to expand your scope by a little bit? And supraglottic airways are almost foolproof.


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## medicdan (Dec 13, 2013)

EMT856 said:


> What if there was a separate class you could take to expand your scope by a little bit? And supraglottic airways are almost foolproof.



Become an Advanced EMT, and lobby for your state to incorporate that SOP. More time in the classroom + a verifiable certification = more "skills".


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## TransportJockey (Dec 13, 2013)

Almsot everything you mentioned is in the SOP for EMT-Bs here in NM... that being said, I think ya'll in most areas have too BROAD of a scope for what you actually get in the classroom. EMT-B is advanced first aid. Nothing more. You need more time in the classroom before I would feel comfortable giving basics a broader scope.


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## SixEightWhiskey (Dec 13, 2013)

EMT856 said:


> Just wondering what the biggest problems my fellow EMTs feel affect the EMT level of care.
> 
> Personally I feel that EMT-Basic has too basic of a scope.
> 
> Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.



In NH, state protocol allows EMTs to do 12-leads, narcan, ASA, nitro and 7 other meds, do glucose testing, drop King LTs/Combitubes, and perform advanced spinal assessments/clear c-spine under strict protocol so we don't have to backboard every single MVA or fall pt just based on MOI. Having moved here from a different state and also being an EMT in MA (where the protocol for 99% of situations is 'initiate transport, call ALS'), working in NH is very refreshing.

I agree with what some of the other posts have said about people in EMS who you wouldn't trust to even take a set of vitals correctly, which is why NH requires an additional scope of practice course (including practicals) in order to do these more advanced skills.


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## EMT856 (Dec 13, 2013)

SixEightWhiskey said:


> In NH, state protocol allows EMTs to do 12-leads, narcan, ASA, nitro and 7 other meds, do glucose testing, drop King LTs/Combitubes, and perform advanced spinal assessments/clear c-spine under strict protocol so we don't have to backboard every single MVA or fall pt just based on MOI. Having moved here from a different state and also being an EMT in MA (where the protocol for 99% of situations is 'initiate transport, call ALS'), working in NH is very refreshing.
> 
> I agree with what some of the other posts have said about people in EMS who you wouldn't trust to even take a set of vitals correctly, which is why NH requires an additional scope of practice course (including practicals) in order to do these more advanced skills.




I am not saying lets just give everyone a wider scope with no additional training, I am saying we should be getting this training to begin with.


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## TransportJockey (Dec 13, 2013)

EMT856 said:


> I am not saying lets just give everyone a wider scope with no additional training, I am saying we should be getting this training to begin with.



So how long do you think initial training should be?


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## EMT856 (Dec 13, 2013)

TransportJockey said:


> So how long do you think initial training should be?



the original 220, plus at least an additional 100-150. However long is needed in order to teach these skills effectively.


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## TransportJockey (Dec 13, 2013)

EMT856 said:


> the original 220, plus at least an additional 100-150. However long is needed in order to teach these skills effectively.



The skills a monkey can be trained how to do. What about more pathophys and pharmacology to teach them what they actually are doing. And to help teach them when to NOT do the fancy skills. 
We are one of the only vocations in medicine that is so proud of themselves based on what skills we can do. And not what knowledge we have. Hence we we are a technical vocation and not a profession or a career.


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## JPINFV (Dec 13, 2013)

EMT856 said:


> What if there was a separate class you could take to expand your scope by a little bit? And supraglottic airways are almost foolproof.



Like a paramedic class?

The problem with limited tools with limited education is that you end up with providers who both only have a hammer and only know about hammers... and when that occurs, everything looks like a nail, including screws.


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## Tigger (Dec 13, 2013)

EMT856 said:


> Just wondering what the biggest problems my fellow EMTs feel affect the EMT level of care.
> 
> Personally I feel that EMT-Basic has too basic of a scope.
> 
> Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.



We have all of this in Colorado with an extra 24 hour course. Which is not nearly enough time, but the point is that it exists. CPAP requires a waiver. 

The purpose of course is really to become a better "paramedic assistant," and that's all it should be. It does not teach a better assessment or anything of that nature, and frankly I have seen plenty inappropriate interventions performed by our BLS volunteers that were done only "because we can so we did." Everyone forgets to actually assess the patient and instead concentrates on getting an IV, which misses the point of you know, patient care. 


DesertEMT66 said:


> I work for a very restrictive system in SoCal and can hang NS, obtain a 12-lead, and do BGL testing.
> 
> The major issue is lack of education. The EMT level is less than 200 hours of training (more around 120 hours). With more education come more skills.



How do you hang NS if you can't start IVs?


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## DesertMedic66 (Dec 13, 2013)

Tigger said:


> We have all of this in Colorado with an extra 24 hour course. Which is not nearly enough time, but the point is that it exists. CPAP requires a waiver.
> 
> The purpose of course is really to become a better "paramedic assistant," and that's all it should be. It does not teach a better assessment or anything of that nature, and frankly I have seen plenty inappropriate interventions performed by our BLS volunteers that were done only "because we can so we did." Everyone forgets to actually assess the patient and instead concentrates on getting an IV, which misses the point of you know, patient care.
> 
> ...



BLS units don't run 911 calls in my area. So as the medic is getting the IV we can hang NS or get a saline lock. We are able to monitor NS during BLS transports including changing bags of NS if a new on is needed.


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## mycrofft (Dec 13, 2013)

Basic means basic. Want more, then train higher. 
At any level, the first lesson is know what not to do!


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## jpregulman (Dec 13, 2013)

I would agree, the basic level should be a more advanced level (with more training of course).

There is progress however. Under my protocols in OH EMTs can now give Narcan w/o online med control, give their own ASA, drop kings/LMAs, glucose testing, apply and transit 12 leads and CPAP


CO lets their EMTs give d5w and NS as well as start lines with extra training.


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## NomadicMedic (Dec 13, 2013)

It's my belief that the focus in EMT class should be on how to perform high performance CPR, moving patients safely, driving the vehicle safely and developing interpersonal relationship skills. 

Those are the 4 most important skills an EMT can have, yet they're glossed over, if they're covered at all.


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## TransportJockey (Dec 13, 2013)

DEmedic said:


> It's my belief that the focus in EMT class should be on how to perform high performance CPR, moving patients safely, driving the vehicle safely and developing interpersonal relationship skills.
> 
> Those are the 4 most important skills an EMT can have, yet they're glossed over, if they're covered at all.



Sounds like a good plan to me


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## Rockies (Dec 14, 2013)

EMT856 said:


> I am not saying lets just give everyone a wider scope with no additional training, I am saying we should be getting this training to begin with.



Good luck cramming that into the semester long course to begin with.


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## Wheel (Dec 14, 2013)

EMT856 said:


> Just wondering what the biggest problems my fellow EMTs feel affect the EMT level of care.
> 
> Personally I feel that EMT-Basic has too basic of a scope.
> 
> Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.



What kind of serious stuff would you be freeing up ALS for? If they aren't going to respiratory calls (you have CPAP and supra glottic airways), chest pain (you have ASA, nitro, 12 leads), diabetic emergencies (you have D50 and IV access), then what are they going for?

My opinion is that BLS doesn't need a wider scope. They need a more thorough education in assessment and physiology. Skills are simple. The knowledge of when to use them is not. Frankly there are too many BLS providers giving oxygen willy nilly for no reason other than "because my protocols say so", that I can't see giving them a bunch of cool toys to play with without having a better knowledge base to back it up.


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## Christopher (Dec 17, 2013)

EMT856 said:


> Just wondering what the biggest problems my fellow EMTs feel affect the EMT level of care.
> 
> Personally I feel that EMT-Basic has too basic of a scope.
> 
> Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, along with glucose testing, and d50... We would keep ALS free for the serious crap.



Come join us in North Carolina and you can do just about all of that (no IV's). I know our politicians make us look like we're a bunch of toothless, shirtless, moronic rednecks...but in spite of all of that we're actually really good at EMS.

If your EMT scope is too basic it is your State or medical director's fault.


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## Christopher (Dec 17, 2013)

Rockies said:


> Good luck cramming that into the semester long course to begin with.



If North Carolina can do it, your State can too. We're _literally _the bottom of the barrel in education and manage to do it.


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## cprted (Dec 17, 2013)

EMT856 said:


> Personally I feel that EMT-Basic has too basic of a scope.


  Well, it is called EMT-_Basic_



EMT856 said:


> *Shouldn't we be able to use CPAP, pull 12 leads, give Narcan, have our own supply of NTG and ASA, drop Kings/LMAs, *amongst other things? I honestly think we should also be able to hang a bag of NS and grab peripheral IV access for certain C/Cs? With that, if we had the above, *along with glucose testing, and d50... We would keep ALS free for the serious crap.*



You think that patients requiring CPAP, Nitro, Narcan, a King, D50 etc don't qualify as serious?


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## toxik153 (Dec 17, 2013)

My EMT hours are 252...not under 200.


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## emt11 (Dec 19, 2013)

EMT856 said:


> the original 220, plus at least an additional 100-150. However long is needed in order to teach these skills effectively.



At that point your somewhere around 100 hours shy of the AEMT, so why not tack that on and boom you have a wider scope.


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## DesertMedic66 (Dec 19, 2013)

toxik153 said:


> My EMT hours are 252...not under 200.



Not all EMT programs are that long. There are many that are in the 126 hour range.


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## Greywind (Dec 19, 2013)

I'm currently in rural Montana and am able to do many of these skills as an EMT-Bl all the way up to and including ET intubation and administering morphine for some patients. My scope is quite advanced. I believe that basics should be allowed to do these skills withe proper training. Take your class, get your practice, do your competency skills test and have a certain number of patients in which you performed these tasks and I would think you should be cleared to perform the tasks without supervision.


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## NomadicMedic (Dec 19, 2013)

Or, you could just take the extra education, learn the WHY as opposed to just the HOW and voila! You're a paramedic. 

Basics are called basics for a reason. Because the initial education was enough to teach basic life support. If you want a wide scope, get more education.


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## TransportJockey (Dec 19, 2013)

Greywind said:


> I'm currently in rural Montana and am able to do many of these skills as an EMT-Bl all the way up to and including ET intubation and administering morphine for some patients. My scope is quite advanced. I believe that basics should be allowed to do these skills withe proper training. Take your class, get your practice, do your competency skills test and have a certain number of patients in which you performed these tasks and I would think you should be cleared to perform the tasks without supervision.



You're in the land of the merit badge courses. How many 'additional certifications' are there for basics up there? Four or five? Unless those courses were 50+ hours each then I don't see how you were taught the pathophys behind why you are doing that and why you shouldn't do it


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## VFlutter (Dec 19, 2013)

Basics intubating? Screw CRNA school, I'm moving to Montana!!


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## Greywind (Dec 19, 2013)

Yes, I am in the land of merit badge courses. My scope allows me to do all of these things but I don't do them as I have not had the need to yet. I have myself closely monitored by a paramedic mentor and also a basic mentor. I strive to be the best EMT that I can be and will not do something just because I can do it.


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## Carlos Danger (Dec 19, 2013)

> I'm currently in rural Montana and am able to do many of these skills as an EMT-Bl all the way up to and including ET intubation and administering morphine for some patients. My scope is quite advanced. *I believe that basics should be allowed to do these skills withe proper training.* Take your class, get your practice, do your competency skills test and have a certain number of patients in which you performed these tasks and I would think you should be cleared to perform the tasks without supervision.



I completely agree that people should be allowed to perform these skills with the proper training. Anyone can learn anything with the proper training. Afer all, physicians are just laypersons who obtained "the proper training" to do what they do.

The problem is, three hours is not "proper training" to learn advanced airway management. You could quadruple those hours and it wouldn't be nearly enough.

I honestly can't believe that any medical director would sign off on that.


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## triemal04 (Dec 19, 2013)

You have to remember that Montana is different than almost all other states.  There are still large areas that are truly "frontier" areas, and, as in Alaska, there are places that, weather dependent, may be days away from a hospital, not just minutes or hours.  While I don't neccasarily agree with how this type of thing usually get's done, I can see the reasoning behind it.  And let's be honest...giving someone morphine (or a fentanyl lozenge, or narcotic patch, or any of the multitude of ways to give a pain reliever other than an injection), especially if you have access to narcan, is relatively benign.

Intubation is a bit different, and probably just a throw back to a time when there weren't as many supraglottic airways available as there are now; to be honest I'm surprised it hasn't been removed in favor of one of those.

If people are going to do/give something they absolutely need to be properly taught how to do it, I'm not saying anything at all against that.  What I am suggesting it that, in certain very specific situations, there may be exceptions to that.

Now, if this guy lives in any type of population center with even somewhat easy access to advanced care, then all bets are off.


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## emt11 (Dec 21, 2013)

triemal04 said:


> You have to remember that Montana is different than almost all other states.  There are still large areas that are truly "frontier" areas, and, as in Alaska, there are places that, weather dependent, may be days away from a hospital, not just minutes or hours.  While I don't neccasarily agree with how this type of thing usually get's done, I can see the reasoning behind it.  And let's be honest...giving someone morphine (or a fentanyl lozenge, or narcotic patch, or any of the multitude of ways to give a pain reliever other than an injection), especially if you have access to narcan, is relatively benign.
> 
> Intubation is a bit different, and probably just a throw back to a time when there weren't as many supraglottic airways available as there are now; to be honest I'm surprised it hasn't been removed in favor of one of those.
> 
> ...



Having some of my wife's family living in Montana, and looking at possibly moving there one day. From my understanding, the classes are recognized state wide and the only thing stopping you at that point is the medical director.


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## triemal04 (Dec 21, 2013)

emt11 said:


> Having some of my wife's family living in Montana, and looking at possibly moving there one day. From my understanding, the classes are recognized state wide and the only thing stopping you at that point is the medical director.


I know.  I have no clue how widely all the little extra certs are used, but it wouldn't surprise me at all if they were misused, even to the point of places that should have paramedics not having them in favor of an EMT with XYZ extra tacked on.

This is probably one of those things that started out with the best of intentions and as an appropriate idea...and then fell flat.  Kinda common for that to happen unfortunately.


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## Carlos Danger (Dec 21, 2013)

triemal04 said:


> If people are going to do/give something they absolutely need to be properly taught how to do it, I'm not saying anything at all against that.  *What I am suggesting it that, in certain very specific situations, there may be exceptions to that.*



"First, do no harm". 

When it comes to invasive airway management, the threat of harm from someone not knowing what they are doing is very high. Probably _always_ higher than just sticking to skilled BLS airway management. Frontier or not, there is never a justification for handing a complete layperson (which is exactly what an EMT-B is after a 3-hour intubation course) an ETT and blade and telling them to go to work.

Paramedics get at least 30 hours of airway training in the classroom alone - plus manikin time, OR clinical, and ride time - and there are still a lot of people who think as a group paramedics suck at airway management because they don't get nearly enough education in it.

I would love to see the statewide QI data on EMT-B intubation.


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## TheLocalMedic (Dec 22, 2013)

Seems like the general consensus is:  if you want a bigger scope, become a paramedic.  I agree wholeheartedly.  EMT-basics simply lack the depth of knowledge (and often experience) to be given much more than they currently have.  

That being said, there are a few things that I feel ought to be added to the EMT scope here in Northern Cal.  The three big ones are ASA, Narcan and blood glucose determination.  

But then again, most 911 providers here are all ALS, so the only areas lacking these things are the rural, outlying departments that staff BLS ambulances.  And I don't really see a need for all those EMTs running around with the IFT companies to have anything more than they do now.  Most are, sadly, glorified taxi drivers.


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## triemal04 (Dec 22, 2013)

Halothane said:


> "First, do no harm".
> 
> When it comes to invasive airway management, the threat of harm from someone not knowing what they are doing is very high. Probably _always_ higher than just sticking to skilled BLS airway management. Frontier or not, there is never a justification for handing a complete layperson (which is exactly what an EMT-B is after a 3-hour intubation course) an ETT and blade and telling them to go to work.
> 
> ...


I was actually thinking more along the lines of narcotics, not airway management.  As I said that's probably a throwback to when there weren't any good SGA's around and the thinking was along the lines of "well, the patient's already dead, so where's the harm?"  Ignoring that even in dead people improper intubation attempts can be harmful.  Best intentions don't always work out for the best...

And I'm one of the people that thinks that paramedics as a group suck at intubation because we don't get enough education and practice at it.


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## Carlos Danger (Dec 22, 2013)

triemal04 said:


> I was actually thinking more along the lines of narcotics, not airway management.  As I said that's probably a throwback to when there weren't any good SGA's around and the thinking was along the lines of "well, the patient's already dead, so where's the harm?"  Ignoring that even in dead people improper intubation attempts can be harmful.  Best intentions don't always work out for the best...
> 
> And I'm one of the people that thinks that paramedics as a group suck at intubation because we don't get enough education and practice at it.



Yeah, narcs are another animal. Probably very little chance of harm from a conservative dosing protocol, especially if the agonist/antagonists like butorphanol or nalbuphine are used. And there's always nitrous....


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## TheLocalMedic (Dec 24, 2013)

Halothane said:


> Yeah, narcs are another animal. Probably very little chance of harm from a conservative dosing protocol, especially if the agonist/antagonists like butorphanol or nalbuphine are used. And there's always nitrous....



I have a hard time believing that any medical director would be comfortable letting basics give out any form of narcotic.  Waaaayyyyy too much liability for the amount of schooling basics have.


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## Carlos Danger (Dec 24, 2013)

TheLocalMedic said:


> I have a hard time believing that any medical director would be comfortable letting basics give out any form of narcotic.  Waaaayyyyy too much liability for the amount of schooling basics have.



Don't get me wrong, I'm not a big fan of basics giving them without education and a solid, reasonable protocol to follow, but I can envision unusual scenarios in remote or austere settings where it may be deemed appropriate for BLS to administer opioids. Opioids are generally safe and forgiving meds, as long as you aren't using really large doses or giving them concomitantly with benzos or other sedatives. 

I have a different view of what BLS should / can be than most do. I think about what the really important and effective prehospital interventions are, like epi pens, defibrillation, IM seizure meds, SGA's, etc, maybe even opioids in some cases, and I don't see much that is outside of the scope of basics. With some better education I don't see why basics can't do all those things and therefore be able to manage most prehospital situations quite well. But that's another discussion, I guess.


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## TransportJockey (Dec 24, 2013)

TheLocalMedic said:


> I have a hard time believing that any medical director would be comfortable letting basics give out any form of narcotic.  Waaaayyyyy too much liability for the amount of schooling basics have.



I know of at least one frontier service in Texas with basics giving toradol and Nubain. Texas has some odd systems due to sheer size


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## TheLocalMedic (Dec 24, 2013)

Halothane said:


> Don't get me wrong, I'm not a big fan of basics giving them without education and a solid, reasonable protocol to follow, but I can envision unusual scenarios in remote or austere settings where it may be deemed appropriate for BLS to administer opioids. Opioids are generally safe and forgiving meds, as long as you aren't using really large doses or giving them concomitantly with benzos or other sedatives.
> 
> I have a different view of what BLS should / can be than most do. I think about what the really important and effective prehospital interventions are, like epi pens, defibrillation, IM seizure meds, SGA's, etc, maybe even opioids in some cases, and I don't see much that is outside of the scope of basics. *With some better education I don't see why basics can't do all those things *and therefore be able to manage most prehospital situations quite well. But that's another discussion, I guess.



That highlighted bit?  Yeah, that's the problem.  Basics need more education before they can do these things.  Like, say, a paramedic program?


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## Carlos Danger (Dec 24, 2013)

TheLocalMedic said:


> That highlighted bit?  Yeah, that's the problem.  Basics need more education before they can do these things.  Like, say, a paramedic program?



Most of those things are currently being done by basics already.

How much education does it take to give an IM injection to a seizing patient?


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## VFlutter (Dec 24, 2013)

Halothane said:


> Most of those things are currently being done by basics already.
> 
> How much education does it take to give an IM injection to a seizing patient?



Ever play lawn darts? Same difference


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