# best EMT-B scope of practice



## jedi88 (Mar 4, 2012)

Hi! I am just curious as to which state has the best scope of practice for EMT-B and allows them to do the most skills. I am not saying I agree with EMT doing something like intubation but just want to know what states allow things in addition to what is normally considered BLS.


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## medicdan (Mar 4, 2012)

How do you define "best"? Number of hours of mandated training? Number of toys on the truck? Number of people killed by these toys?


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## bw2529 (Mar 4, 2012)

It sounds like NYS is moving to a "super B" scope of practice. They are eliminating AEMT-I and AEMT-CC so the only levels remaining will be Certified First Responder, EMT-B, and AEMT-P. Word is that EMT-Bs will be getting King Airways, and possibly even IVs. This will make them much closer in scope of practice to the current AEMT-I.

How exactly that'll all work and exactly what skills will come down at the state level remains to be seen, and then of those skills what your agency will allow...*shrug*


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## rwik123 (Mar 4, 2012)

bw2529 said:


> It sounds like NYS is moving to a "super B" scope of practice. They are eliminating AEMT-I and AEMT-CC so the only levels remaining will be Certified First Responder, EMT-B, and AEMT-P. Word is that EMT-Bs will be getting King Airways, and possibly even IVs. This will make them much closer in scope of practice to the current AEMT-I.
> 
> How exactly that'll all work and exactly what skills will come down at the state level remains to be seen, and then of those skills what your agency will allow...*shrug*



Will the B curriculum be replaced by the intermediate one? So basically I's will become basics by label?

If the classroom hours equal a basic class that teaches to the intermediate level, I have a problem with it.


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## jjesusfreak01 (Mar 4, 2012)

rwik123 said:


> Will the B curriculum be replaced by the intermediate one? So basically I's will become basics by label?
> 
> If the classroom hours equal a basic class that teaches to the intermediate level, I have a problem with it.



Kings are in the EMT-B scope where I live. IVs can be taught in a few hours, plus a few more for clinicals. As long as they are making the EMTs skill monkeys (to help the medics) and not actually letting them administer meds I don't really have a problem with it. This actually makes sense if you are going to get rid of EMT-Is, since it turns EMT-Bs into slightly more helpful medic assistants without giving them more responsibility.


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## bw2529 (Mar 4, 2012)

rwik123 said:


> Will the B curriculum be replaced by the intermediate one? So basically I's will become basics by label?



That is my understanding, yes. Additional hours (both classroom/lab and clinical) will be added.


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## jedi88 (Mar 5, 2012)

Which state allows them to do the most skills such as combitube, IV, manual defib, EKG? Do they have special training for that?


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## rwik123 (Mar 5, 2012)

jedi88 said:


> Which state allows them to do the most skills such as combitube, IV, manual defib, EKG? Do they have special training for that?



For these super advanced things its probably region specific in rural areas. Under medical direction w/training, a basic could do anything the supervising physician seems fit.


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## nwhitney (Mar 5, 2012)

jedi88 said:


> Which state allows them to do the most skills such as combitube, IV, manual defib, EKG? Do they have special training for that?



In Oregon we do Combitube, King LT, BGL, and can administer epinephrine via SQ.


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## Tigger (Mar 5, 2012)

jedi88 said:


> Which state allows them to do the most skills such as combitube, IV, manual defib, EKG? Do they have special training for that?



In Colorado we have an IV add-on class that is 20-22 hours long plus clinical time. Not much really, usually it's taught to be more of a "medic's helper" course. With completion of the course one can ask their medical director to be approved for IV initiation, NS, LR, D5W, D50, and Narcan IV/IN. There is one ambulance district that has their EMT-IVs doing IOs as well, and my course included practice with the EZIO as well. We also have supraglottic airways, albuterol nebs, and CPAP in our basic scope (CPAP is a bit a location dependent). 

There is a separate EKG course but it is more directed at placing 12 leads and very basic interpretation (i.e. this is a normal sinus rhythm, this is not). Manual debilitation is an I-99 skill and above.


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## EpiEMS (Mar 5, 2012)

New Hampshire allows Basics to drop Kings and Combitubes, I believe.

Those IV-helper classes sound great.


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## jjesusfreak01 (Mar 8, 2012)

Tigger said:


> We also have supraglottic airways, albuterol nebs, and CPAP in our basic scope (CPAP is a bit a location dependent).
> 
> There is a separate EKG course but it is more directed at placing 12 leads and very basic interpretation (i.e. this is a normal sinus rhythm, this is not). Manual debilitation is an I-99 skill and above.



While CPAP is fairly easy to apply (though tricky to assemble for some), I would have a problem with basics being able to make the clinical determination for whether a patient actually needs CPAP.



nwhitney said:


> In Oregon we do Combitube, King LT, BGL, and can administer epinephrine via SQ.



I am always annoyed when I hear about protocols that allow SQ administration of Epi.


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## WolfmanHarris (Mar 8, 2012)

jjesusfreak01 said:


> IVs can be taught in a few hours, plus a few more for clinicals.



Autonomous IV for Primary Care Paramedics (BLS) is four full days in Ontario. Two full days theory and then two full days clinical. Autonomous IV is not yet a skill organic to the PCP scope. I'm not sure whether we've got the overkill putting that on top of two years schooling or whether short little training sessions are woefully inadequate.


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## Medic Tim (Mar 9, 2012)

WolfmanHarris said:


> Autonomous IV for Primary Care Paramedics (BLS) is four full days in Ontario. Two full days theory and then two full days clinical. Autonomous IV is not yet a skill organic to the PCP scope. I'm not sure whether we've got the overkill putting that on top of two years schooling or whether short little training sessions are woefully inadequate.



IVs are in the most recent NOCP PCP skillset. Not that that matters much in some places.


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## nwhitney (Mar 9, 2012)

[/QUOTE]I am always annoyed when I hear about protocols that allow SQ administration of Epi.[/QUOTE]

Why is that?


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## medic417 (Mar 9, 2012)

I am always annoyed when I hear about protocols that allow SQ administration of Epi.[/QUOTE]

Why is that?[/QUOTE]

Study what takes place in a persons body when a person needs epi and you will find SQ is worthless.


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## jjesusfreak01 (Mar 9, 2012)

WolfmanHarris said:


> Autonomous IV for Primary Care Paramedics (BLS) is four full days in Ontario. Two full days theory and then two full days clinical. Autonomous IV is not yet a skill organic to the PCP scope. I'm not sure whether we've got the overkill putting that on top of two years schooling or whether short little training sessions are woefully inadequate.



Overall, it makes sense that the training surrounding IV administration would amount to multiple days, as i'm sure it covers how you do IVs as well as when they are indicated, possible complications, and what you can give through them. That said, I believe that it could be taught as an ALS assist monkey skill in a few hours with associated clinical time to get some practice with sticks before going into the field.


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## Tigger (Mar 11, 2012)

jjesusfreak01 said:


> While CPAP is fairly easy to apply (though tricky to assemble for some), I would have a problem with basics being able to make the clinical determination for whether a patient actually needs CPAP.



I'm yet to find a place where a straight BLS service carries CPAP, most of the time there is an intermediate or medic on board. I imagine it's oh I'm the basic scope so that a basic can apply it under a medics direction.

We can start IVs on our own accord though, given that the class does teach their indications.


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## Christopher (Mar 14, 2012)

jedi88 said:


> Hi! I am just curious as to which state has the best scope of practice for EMT-B and allows them to do the most skills. I am not saying I agree with EMT doing something like intubation but just want to know what states allow things in addition to what is normally considered BLS.



North Carolina has fairly broad EMT protocols including BIADs, EpiPens, albuterol, nitro, colorimetric/waveform capnography, 12-lead acquisition/transmission. I wish they had CPAP though.


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## WolfmanHarris (Mar 14, 2012)

jjesusfreak01 said:


> Overall, it makes sense that the training surrounding IV administration would amount to multiple days, as i'm sure it covers how you do IVs as well as when they are indicated, possible complications, and what you can give through them. That said, I believe that it could be taught as an ALS assist monkey skill in a few hours with associated clinical time to get some practice with sticks before going into the field.



That's why I find it a bit of an anachronism. We cover all of that in two years of PCP school. Fluid balance, tonicity of solutions, the anatomy of the vasculature, the equipment, calculating drip rates and starts on dummies. But because it's still not included in the provincial scope of practice a PCP must cover this material again in a four day auxiliary course. This is frustrating because it actually holds back advancing practice since a service must decide they wish to add this enhancement and invest in the additional education. Thankfully my service decided this year to add the enhanced scope to all current PCP's who wish to and all new hires from here forward, but there's no reason it shouldn't be included.

For us it's not just about IV starts btw. Certainly bolus is nice to have once in awhile, but having the IV starts lets PCP's give D50 over glucagon, first time nitro, 0.8mg over 0.4mg SL in cardiogenic pulmonary edema. It's a worthwhile expansion to our scope and cuts down on calls for ALS back-up while increasing the contribution a PCP can make to their ACP partner.


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