# ALS for the BLS Provider -- Assisting ALS



## EpiEMS (Jan 6, 2013)

As I gained experience with routine BLS care, I found that the ALS providers I worked with would let me help with ALS procedures more and more. I'll do BGLs, spike bags, place 4 and 12 lead EKGs, and occasionally apply cricoid pressure.

As BLS providers, what ALS procedures are you expected to assist with? What ALS procedures will ALS folks let you do under their supervision?


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## VFlutter (Jan 6, 2013)

Delegation is a great tool for a provider, especially in EMS when resources are limited, but it is important to understand what can safely and legally be delegated. All the things you mentioned are good examples of what can and should be done by BLS providers under ALS supervision. That being said the ALS provider is ultimately responsible so if the 12 lead looks funky it would be prudent to double check lead placement. If you call a STEMI alert on a patient with reversed leads you can't say "well my EMT placed the leads". BLS providers should also be familiar with the steps and equipment for various ALS procedures so they can anticipate what the medic may need or understand what they are asking for.


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## DesertMedic66 (Jan 6, 2013)

All the ones you listed plus setting up pre loaded meds and some other stuff I'm not going to say on the forum. Set up for intubation. Set up for IV. Get recordings from the 12-lead and transmit them.


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## Clare (Jan 6, 2013)

First Responders complete an "Assistant to Ambulance" module which covers how to do things delegated to them by somebody with an Authority to Practice; including 

- cervical collars
- SpO2 
- nebulisation of salbutamol, ipratropium and adrenaline
- use of KED
- combat application tourniquet 
- ECG acquisition 
- Entonox and methoxyflurane
- Use of automatic suctioning
- How to set up for IV cannulation

Everything listed above can be performed by an Emergency Medical Technician (BLS) or above, and all levels are also taught how to assist with intubation.


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## EpiEMS (Jan 6, 2013)

firefite said:


> and some other stuff I'm not going to say on the forum



Yep, me too. It strikes me as fairly common that once the ALS folks get to know your capabilities they delegate more (or even expect an EMT to do something that isn't *technically* in scope).

I'd like to see BLS transmission of 12-leads in my area, but I doubt it'll happen -- we have lots of medics (some, like me, argue that there could quite possibly be so many that their skills are diluted).


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## JDub (Jan 6, 2013)

Around here ALS assist skills are:

Spiking a bag of fluids
Setup for an IV
Secure an IV
Setup for an Intubation
Secure ETT
12 lead placement
Setup nebulizers with Albuterol and Atrovent
Help with administration of Nitro and Aspirin.
Combitube insertion.

I think that is about it for skills that are only ALS assists. I can check BGLs, use KEDs, and do some of the other things mentioned in this thread on BLS calls.




Chase said:


> Delegation is a great tool for a provider, especially in EMS when resources are limited, but it is important to understand what can safely and legally be delegated. All the things you mentioned are good examples of what can and should be done by BLS providers under ALS supervision. That being said the ALS provider is ultimately responsible so if the 12 lead looks funky it would be prudent to double check lead placement. If you call a STEMI alert on a patient with reversed leads you can't say "well my EMT placed the leads". BLS providers should also be familiar with the steps and equipment for various ALS procedures so they can anticipate what the medic may need or understand what they are asking for.



You bring up a good question on the legality of delegation. I understand that it is the medic's responsibility to cover his own butt, but what constitutes crossing the legal line on delegation? (Ignoring obvious things like allowing an EMT to intubate or perform a chest decompression.)


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## EpiEMS (Jan 6, 2013)

JDub said:


> You bring up a good question on the legality of delegation. I understand that it is the medic's responsibility to cover his own butt, but what constitutes crossing the legal line on delegation? (Ignoring obvious things like allowing an EMT to intubate or perform a chest decompression.)



Assuming the EMT doesn't mess up, probably doesn't matter very much 

That's a good question -- I'd bet that it's state-by-state. Looks like (in NYS at least) doing something out of your scope constitutes reason for them to pull your license: "Any certification issued pursuant to this Part may be suspended for a fixed period, revoked or annulled, or the certificate holder may be censured, reprimanded, or fined in accordance with section 12 of the Public Health Law, after a hearing conducted pursuant to section 12-a of the Public Health Law, the department determines that the certificate holder:...(g) has held him or herself out as being certified at a higher level than actually certified, or has used skills restricted to individuals holding a higher level of certification."

Granted, if you don't screw up, and nobody writes up the PCR saying that EMT X started a line while Medic Y intubated or something of the sort then nobody would be the wiser. This is illegal and I wouldn't do it, though I cannot imagine that it doesn't happen.


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## Tigger (Jan 6, 2013)

As an aside, just because you can properly setup some part of the medic's gear, that doesn't mean you should be the one testing it at the start of the shift. If you miss something, the medic is going to be hung to dry twice, once for the equipment failure (if preventable), and once for not doing his own checkout. In Mass the state "ALS interface" guidelines don't even want basics setting up airway equipment prior to its use. OEMS provides a table of what is allowable and what is not, and those working with a medic are to be given an interface class, which I'll admit is probably not quite the norm. 

In Colorado with the expanded scope add on things are a little different. A BLS provider may be expected to get the IV, and then administer fluids, nalaxone, or D50 if indicated. For a patient in extremis, the first line code drugs can be given by the basic under the medic.

Other more common things like EKG acquisition, nebs, give nitro carried on board as well.


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## Tigger (Jan 6, 2013)

Regulations for Massachusetts, as referenced above.


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## Aidey (Jan 6, 2013)

Tigger said:


> As an aside, just because you can properly setup some part of the medic's gear, that doesn't mean you should be the one testing it at the start of the shift. If you miss something, the medic is going to be hung to dry twice, once for the equipment failure (if preventable), and once for not doing his own checkout.



The closest I have ever come to committing murder was when my EMT B partner checked out the bus and found one of the laryngascope blades wasn't working. He deliberately didn't tell me about it because he figured he would just take care of it himself. He couldn't, and I only found out because he told the oncoming medic, who told me.


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## systemet (Jan 6, 2013)

My local BLS can already start IVs, place 4-lead, most can do an ok job of placing 12-lead, and give a small number of meds.

Depending on how well I know the person I'm working with, I may ask them to draw up meds, or pass them something to push, like an epi preload during a code, if I'm tied up with something else.  But because they're not legally allowed to do this, I make sure I know who's on scene before I ask them to do something that might get them into trouble.

If I work with a medic student towards the end of their second year, working in a paid EMT spot (i.e. not currently on practicum), I'll let themm do a lot.  But usually while giving some sort of direct oversight.

I like it if the EMTs I'm working with are familiar with most of the skills that I can do, so that they can help me if we feel the need to move quickly.  If they're willing to learn, I'll happily teach them.


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## Brandon O (Jan 6, 2013)

Tigger said:


> OEMS provides a table of what is allowable and what is not, and those working with a medic are to be given an interface class, which I'll admit is probably not quite the norm.



Well, it is a state requirement.


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## NomadicMedic (Jan 6, 2013)

We teach a "medic assist" class to the BLS providers here. It teaches simple skills that allow the EMT to act as a medic's second set of hands and familiarizes them with the location and function of a lot of our equipment.

The majority of the EMTs take a medic assist class, but you quickly learn which EMTs can actually help you… And which EMTs just get in your way.


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## EpiEMS (Jan 6, 2013)

Tigger said:


> Regulations for Massachusetts, as referenced above.



We don't have regulations, per-se, but that's pretty much what I do. Though they do let me assemble the capnography equipment, as well as CPAP.
And I'll never touch the medic's gear before he/she checks it -- no way, no how.


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## Tigger (Jan 6, 2013)

Brandon Oto said:


> Well, it is a state requirement.



I've never taken it (should I even be admitting this...), and I know people who work elsewhere who have not been offered it either. Regrettable, no doubt but at least I have been "trained" to do all that is mentioned elsewhere.


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## medicdan (Jan 6, 2013)

Brandon Oto said:


> Well, it is a state requirement.



The ambulance service needs to provide the class to both the medics and EMTs if they sure going its be functioning PB, but many companies offer it during orientation, so new EMTs lose the skills fairly quickly. Every private in MA has specifically "PB cleared" EMTs and Medics to make sure both are actually up to it.


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## RustyShackleford (Jan 6, 2013)

All of the things you mentioned are bls or sub bls skills here, als assistance is more along the lines of prepping io hanging meds etc


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## Tigger (Jan 6, 2013)

emt.dan said:


> The ambulance service needs to provide the class to both the medics and EMTs if they sure going its be functioning PB, but many companies offer it during orientation, so new EMTs lose the skills fairly quickly. Every private in MA has specifically "PB cleared" EMTs and Medics to make sure both are actually up to it.



We do not operate P/B units in a traditional sense where I work (which you both may know already), which is how they get around "mandatory compliance" I reckon. The only time we run P/B is on _all_ vent calls, where a basic drives the medic truck and both medics ride in back. This is silly most of the time, but that's what has been decided. No rhyme or reason to who gets called to drive the medic truck, though they are nice enough to send a crew with two qualified drivers. Usually.


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## medicdan (Jan 6, 2013)

Tigger said:


> We do not operate P/B units in a traditional sense where I work (which you both may know already), which is how they get around "mandatory compliance" I reckon. The only time we run P/B is on _all_ vent calls, where a basic drives the medic truck and both medics ride in back. This is silly most of the time, but that's what has been decided. No rhyme or reason to who gets called to drive the medic truck, though they are nice enough to send a crew with two qualified drivers. Usually.



In the eyes of the state, that isn't PB at all... there are two medics on the truck (somewhere), it would even be double medic if one medic was driving, with or without a basic in the back. As long as the expertise exists somewhere a time when the defecation hits the ventilation... 
All of that does not mean proper PB training shouldn't be available, but its more often best provided OTJ by competent FTOs/Preceptors.


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## Bullets (Jan 6, 2013)

Set up LP15 and attach to patient
Set up IV locks and such
Spike and hang NS/LR
Set up D50, NaHCO3, and other prefilled meds
Set up Nebulizer

Pretty much everything but stick the patient, push the drugs, or insert the tube

Ive heard some medics who are very familiar with the BLS who work 5-6 days a week together have drawn meds like prednisone and other vial-and-syringe drugs, Or so ive heard


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## Anjel (Jan 7, 2013)

When I first started in EMS, I hated the medics calling me their basic. I think I even argued with someone on here about it. 

But now that I run in a busy 911 system, I see what my role is. I do everything in my power to help the medics. And to make their job a little easier. I am their best friend on scene.

I get the stretcher, bag, monitor, backboard, etc. I have them on the monitor, pulse ox, and BP cuff as soon as we walk in and I get the Glucometer ready. 

In return they trust me, respect me, and teach me. They print me interesting strips so I can look and learn. Since I am a medic student they let me do other things.

We have a really good relationship. And each crew likes different things. It's all about learning what is expected, and getting it done. 

I should say we run double medic double basic. A BLS and an ALS unit go on every 911.


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## Handsome Robb (Jan 7, 2013)

I've never worked with a basic partner except when taking handoff reports from a special event crew or occasionally a ski patroller although usually we get reports from the ALS patrollers.

My partner does everything that's listed in this thread plus a little more but he's an Intermediate. He has his own, albeit small, list of IV/IM meds he can administer and attend the patient as well as assist me with things like code drugs and respiratory treatments "under direct supervision". With another little class and test while working alone or with a BLS partner at a special event their scope gets even larger after requesting an ALS intercept. There's a new-hire academy for equipment and procedure familiarization. The intermediates at the agency I work for are trained to assist in surgical crichs as well as bougie intubations. We run P/I with the occasional P/P truck mixed in. Every field employee goes through an annual skill re-certification as well. 

The only thing I'm particular about that I always do myself is airway equipment. We do a required bag check at the beginning of every month that must be turned in to our logistics supervisor. My partner helps me with everything including the drug kit, except for my ALS airway kit. He knows not to go into it unless I directly ask him too. That's my only no-no that'll make me really mad except for endangering us or the patient and arguing with me on scene, otherwise I let my partner do a lot because he's asked me if he can do the majority of the skills, which is fine by me because he's proven himself to not be an idiot.


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## Clare (Jan 7, 2013)

Tigger said:


> In Mass the state "ALS interface" guidelines don't even want basics setting up airway equipment prior to its use. OEMS provides a table of what is allowable and what is not, and those working with a medic are to be given an interface class, which I'll admit is probably not quite the norm.



So, the list you provided says an Emergency Medical Technician is not able to do any of the following things:

-- Insert LMA
-- Auscultate breath sounds for tube placement 
-- Assemble capnography device or equipment
-- Retrieve or prepare drugs for administration
-- Apply tourniquet
-- Handle or dispose of needles
-- Cleanse the IV site
-- Operate or charge manual defibrillator

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!

I mean maybe, maybe the only thing in that list that I would consider being unreasonable is preparation of drugs for administration by which I mean diluting drugs; if you're doing something simple like drawing 1 mg of adrenaline into a 1 ml syringe or something then that is different.


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## Meursault (Jan 7, 2013)

Clare said:


> I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!



You just have to remember to think like the protocol committee. Basics, not having sat through multiple state-sanctioned training courses on each subject, are to be presumed too dumb not to:

Jam the LMA in unlubricated and upside down
Misidentify air in the stomach as breath sounds (not a mistake unique to unskilled providers, and one of the more defensible entries here)
Somehow assemble a capno sensor in such a way that it gives plausible but incorrect numbers
Confuse clearly-labeled color-coded boxes and deceive the paramedic into doing the same. (Okay, not _preparing_ meds seems like a sensible restriction)
I can't for the life of me imagine how you can screw up a tourniquet. Moving on...
Hurt themselves with pointy things,
Lick the site clean.
Fail to recognize numbers and/or press the wrong button.
And mind you, these are the basics who underwent a few hours of extra training on the subject. Presumably, basics who haven't been through the interface course are to stand very still and wait for the medics to explain what they need slowly and with small words.

Seriously, most of these entries, like breath sounds and capnography, are meant to ensure that a paramedic is responsible for every critical step of an intervention they perform. The alternative, educating and training EMTs to the point where they're somewhat trustworthy, is apparently unacceptable.


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## Milla3P (Jan 7, 2013)

Clare said:


> I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!.



Welcome to the US of A. 

Would you expect anything different considering our national EMS standards are regulated by the Department of Transportation?

'Merica!


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## Tigger (Jan 7, 2013)

emt.dan said:


> In the eyes of the state, that isn't PB at all... there are two medics on the truck (somewhere), it would even be double medic if one medic was driving, with or without a basic in the back. As long as the expertise exists somewhere a time when the defecation hits the ventilation...
> All of that does not mean proper PB training shouldn't be available, but its more often best provided OTJ by competent FTOs/Preceptors.



They do teach a course, but I am never around when they do it. It's the same with EVOC, but apparently I don't need that either.



Clare said:


> I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!
> 
> I mean maybe, maybe the only thing in that list that I would consider being unreasonable is preparation of drugs for administration by which I mean diluting drugs; if you're doing something simple like drawing 1 mg of adrenaline into a 1 ml syringe or something then that is different.



You're preaching to the quire here. Massachusetts limits its EMTs significantly, for better or for worse. In the other state I work in (Colorado), things are much different. I can start IVs and things like that as an EMT, but under no circumstances would this be allowed in Massachusetts. Clear as mud?


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## mycrofft (Jan 7, 2013)

Milla3P said:


> Welcome to the US of A.
> 
> Would you expect anything different considering our national EMS standards are regulated by the Department of Transportation?
> 
> 'Merica!



AH, someone's reading me!!!! Except I feel the too-loose NHTSA lets various EMSA's and States/Commonwealths dilute their EMT ratings with additional skills despite inadequate control or education, as a sop to employers.


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## Brandon O (Jan 8, 2013)

Tigger said:


> Massachusetts limits its EMTs significantly



I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.


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## Trashtruck (Jan 8, 2013)

Aidey said:


> The closest I have ever come to committing murder was when my EMT B partner checked out the bus and found one of the laryngascope blades wasn't working. He deliberately didn't tell me about it because he figured he would just take care of it himself. He couldn't, and I only found out because he told the oncoming medic, who told me.



This is exactly why I check out my own gear, regardless if somebody said that they just checked it and 'it's fine'. 
Not good enough in my book. I have to know it's good for myself for my own peace of mind.

As for when the EMT's assist, I let them do whatever they want, but I watch and if they screw something up(spiking a micro drip instead of a macro drip comes to mind), I don't yell or scold or demean them like I'm so awesome and have never done the same thing. I fix it, or they do, and explain after the call how to do X, Y, or Z. I like the extra set of hands.
If they really suck, I tell them to sit up front and I'll tell them when I'm ready to go.


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## Trashtruck (Jan 8, 2013)

Clare said:


> So, the list you provided says an Emergency Medical Technician is not able to do any of the following things:
> 
> -- Insert LMA
> -- Auscultate breath sounds for tube placement
> ...



And we wonder where 'ambulance driver' comes from...


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## Christopher (Jan 9, 2013)

"Every patient requires BLS care, few patients require ALS care." This is what I tell EMT's who ride with me.

The biggest help to me is a competent EMT who can completely manage the BLS aspects of patient care while I add on any additional ALS care as necessary. In our area BLS providers have a broad scope, so this effectively means I'm only necessary to start a line and read a 12-Lead (maybe push a drug or two, ultimately I don't add much to the truck).


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## Christopher (Jan 9, 2013)

Meursault said:


> You just have to remember to think like the protocol committee. Basics, not having sat through multiple state-sanctioned training courses on each subject, are to be presumed too dumb not to:
> 
> Jam the LMA in unlubricated and upside down
> Misidentify air in the stomach as breath sounds (not a mistake unique to unskilled providers, and one of the more defensible entries here)
> ...



Our basics are entrusted with those skills...and I live in a state where Algebra is considered "advanced".


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## Christopher (Jan 9, 2013)

Brandon Oto said:


> I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.



One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.


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## Brandon O (Jan 9, 2013)

Christopher said:


> One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.



Yes, well. All things be relative, you lucky bastid.


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## Christopher (Jan 9, 2013)

Brandon Oto said:


> Yes, well. All things be relative, you lucky bastid.



They thought it was wicked ahhsome we could place KingLT's and nebulize albuterol.


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## Milla3P (Jan 9, 2013)

Christopher said:


> One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.



I'm sure it was the "lower educational standards" and "restricted scope"

I doubt OEMS wanted the testing and licensing fees.


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## Christopher (Jan 9, 2013)

Milla3P said:


> I'm sure it was the "lower educational standards" and "restricted scope"
> 
> I doubt OEMS wanted the testing and licensing fees.



No cost to test or get your certification (outside of any classes or background checks) in NC. I don't pay to recertify.


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## VFlutter (Jan 9, 2013)

Christopher said:


> "Every patient requires BLS care, few patients require ALS care." This is what I tell EMT's who ride with me.



I totally agree with that statement however IMO every patient deserves an ALS assessment. (Outside the obvious like "I need to get to the ER for a script refill)


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## EpiEMS (Jan 9, 2013)

Chase said:


> I totally agree with that statement however IMO every patient deserves an ALS assessment. (Outside the obvious like "I need to get to the ER for a script refill)



To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.

Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.


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## Brandon O (Jan 9, 2013)

EpiEMS said:


> To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.
> 
> Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.



This, a thousand times. Any non-invasive assessment and diagnostic techniques that use nothing more than BLS equipment (i.e. H&P) are open game. Granted, if you make a ridiculous treatment decision based on your misunderstanding of Cullen's sign, you're probably on your own, but ridiculous decisions are always off the reservation.

To me, an "ALS assessment" includes diagnostic devices only a medic carries and is trained to use, such as the ECG. When people use it to mean "a competent assessment," I understand what they mean, but I find it vexing.


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## Christopher (Jan 9, 2013)

EpiEMS said:


> To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.
> 
> Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.



Agreed, most paramedic textbooks repeat the same chapters as the EMT textbooks for Patient Assessment.

I provide no advantage in patient assessment outside my ability to read a 12-Lead and having had more education.


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## Brandon O (Jan 9, 2013)

Christopher said:


> I provide no advantage in patient assessment outside my ability to read a 12-Lead and having had more education.



Capnography?


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## Christopher (Jan 9, 2013)

Brandon Oto said:


> Capnography?



EMT-B skill in my state


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## Brandon O (Jan 9, 2013)

Christopher said:


> EMT-B skill in my state



Fine... then my reply is:

You can read 12-leads?


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## EpiEMS (Jan 9, 2013)

Brandon Oto said:


> To me, an "ALS assessment" includes diagnostic devices only a medic carries and is trained to use, such as the ECG. When people use it to mean "a competent assessment," I understand what they mean, but I find it vexing.



I have to say, though, in full disclosure, my thoughts on this matter have been shaped a lot by the EMS Basics posts. Always great stuff on the blog!


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## Brandon O (Jan 9, 2013)

EpiEMS said:


> I have to say, though, in full disclosure, my thoughts on this matter have been shaped a lot by the EMS Basics posts. Always great stuff on the blog!



Hey! Thanks a ton.


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## Tigger (Jan 10, 2013)

Brandon Oto said:


> I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.



Much of which is done through waivers, or at least till recently. The basic state scope is no better than most.


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## Brandon O (Jan 10, 2013)

Tigger said:


> Much of which is done through waivers, or at least till recently. The basic state scope is no better than most.



The mere fact that there are many urban systems here running a truly tiered response (BLS 911 units with ALS available per EMD or BLS unit request) is more and more unusual in the current era of all-ALS-all-the-time.


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## Tigger (Jan 10, 2013)

Brandon Oto said:


> The mere fact that there are many urban systems here running a truly tiered response (BLS 911 units with ALS available per EMD or BLS unit request) is more and more unusual in the current era of all-ALS-all-the-time.



I would rather see ALS all the time frankly. 

The only reason the metro Boston area system can be be considered less of detriment to patients than other tiered systems is that there are so many hospitals around. My thought is that everyone is entitled to an assessment better than that of the average EMT (not you certainly), so at least they are getting it in about 15 minutes after we show up.

I would much prefer to run P/B, but that's not going to happen where I am.


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## Brandon O (Jan 10, 2013)

Tigger said:


> I would rather see ALS all the time frankly.
> 
> The only reason the metro Boston area system can be be considered less of detriment to patients than other tiered systems is that there are so many hospitals around. My thought is that everyone is entitled to an assessment better than that of the average EMT (not you certainly), so at least they are getting it in about 15 minutes after we show up.
> 
> I would much prefer to run P/B, but that's not going to happen where I am.



I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.

I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.

In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).


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## Tigger (Jan 10, 2013)

Brandon Oto said:


> I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.
> 
> I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.
> 
> In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).



I would much prefer to see the way Boston EMS trains its EMTs move into the rest of EMS. Until then however...

At least in the city where I go to school (Colorado Springs), AMR runs all P/B and from what I understand they have few issues with burnout. They also properly split calls, and most shifts the basic can expect to attend at least half of the calls.


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## Brandon O (Jan 10, 2013)

Tigger said:


> I would much prefer to see the way Boston EMS trains its EMTs move into the rest of EMS. Until then however...
> 
> At least in the city where I go to school (Colorado Springs), AMR runs all P/B and from what I understand they have few issues with burnout. They also properly split calls, and most shifts the basic can expect to attend at least half of the calls.



I think that's a reasonable approach as well, as long as the BLS scope is adequate that the medics don't feel like they need twelve hands to get everything done when a patient actually needs it.

I started in an all-PB system in California where the medic had to tech all calls. The EMTs were glorified drivers and didn't need to practice any clinical decision-making, the medics spent all the time managing BLS patients... not good. Even that seemingly small difference is significant.


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## medicdan (Jan 10, 2013)

Brandon Oto said:


> I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.
> 
> I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.
> 
> In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).



Couldn't agree more. I think we all need to understand that Boston is truly unique-- not many urban systems can get away with having 3ALS trucks for a city this size. Not many systems can justify doing the training they do with their EMTs (again, realizing many are actually medics). For all the ribbing it gets, I like the Cambridge system. Highly trained basics, higher trained Medics, a few ALS trucks supported by ALS first responders. There are enough skills to go around that all the Pro medics get a tube or two a month, and the fire medics get a few a year each. The PB trucks can quickly become double medic by taking fire along, and there is support on scene if necessary. 

The city is augmented by a few BLS trucks, who's patients often get an ALS assessment from fire, and can become ALS quickly by taking fire along. 

100% of calls are QA'd, interesting or difficult calls are replayed in sim lab monthly for all staff. Education takes a front burner, as does infrequently used skill retention and clinical decision making. 

This seems to be a system where PB EMS works well, BLS care is well delivered, and ALS care is always available. 

Thoughts? I know I drink the Kool-Aid, but this seems to meet all the system efficiency and care delivery end points we've talked about.


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## Brandon O (Jan 10, 2013)

emt.dan said:


> Couldn't agree more. I think we all need to understand that Boston is truly unique-- not many urban systems can get away with having 3ALS trucks for a city this size. Not many systems can justify doing the training they do with their EMTs (again, realizing many are actually medics). For all the ribbing it gets, I like the Cambridge system. Highly trained basics, higher trained Medics, a few ALS trucks supported by ALS first responders. There are enough skills to go around that all the Pro medics get a tube or two a month, and the fire medics get a few a year each. The PB trucks can quickly become double medic by taking fire along, and there is support on scene if necessary.
> 
> The city is augmented by a few BLS trucks, who's patients often get an ALS assessment from fire, and can become ALS quickly by taking fire along.
> 
> ...



I haven't directly dealt with them much, but in principle I think it works. My only concern is that making first responders a truly integral part of the system, particularly as ALS, needs some special attention toward creating the right relationship and culture. There's potential for antagonism and cross-talk if it's not clear who's in charge on scene; for BLS transporting units to feel like taxi drivers ("the nice firemen came and took care of me, then an ambulance showed up to give me a ride"); conflicts between transporting and fire medics; and so forth. And you need to make sure that the local protocols/policies, both explicit and implicit, say it's okay for patients to get an ALS assessment but to get down-triaged to BLS.

It may work better in places where EMS already has a good relationship with fire (or other first responders); if they're somewhat hostile that's a deeper problem that needs to be addressed first. Probably over the course of about ten years...


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## medicdan (Jan 10, 2013)

Brandon Oto said:


> I haven't directly dealt with them much, but in principle I think it works. My only concern is that making first responders a truly integral part of the system, particularly as ALS, needs some special attention toward creating the right relationship and culture. There's potential for antagonism and cross-talk if it's not clear who's in charge on scene; for BLS transporting units to feel like taxi drivers ("the nice firemen came and took care of me, then an ambulance showed up to give me a ride"); conflicts between transporting and fire medics; and so forth. And you need to make sure that the local protocols/policies, both explicit and implicit, say it's okay for patients to get an ALS assessment but to get down-triaged to BLS.
> 
> It may work better in places where EMS already has a good relationship with fire (or other first responders); if they're somewhat hostile that's a deeper problem that needs to be addressed first. Probably over the course of about ten years...



Agreed. It takes the coordination of working together for 30+years, and sharing a medical director, equipment, training, and common goals. Certainly not possible for cities with a different private provider every 3 years, or a turnover of medics every 6 months. What I'm saying is that PB 911 response can work, albeit rarely, perhaps as rarely as a system with as few ALS resources as Boston does, it just takes special circumstances.


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## EpiEMS (Jan 10, 2013)

I'd bet that Boston has better ALS, though, as a function of how few ALS providers they have: at peak staffing, they have 3.8 BLS units for each ALS unit, and, in total, they have  3.44 medics for every EMT (http://www.cityofboston.gov/Images_Documents/2011_Boston_EMS_Vital_Stats[1]_tcm3-31009.pdf). This probably means more chances for the medics to practice real ALS skills, leading to more experienced (hopefully, better) medics.


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## medicdan (Jan 10, 2013)

EpiEMS said:


> I'd bet that Boston has better ALS, though, as a function of how few ALS providers they have: at peak staffing, they have 3.8 BLS units for each ALS unit, and, in total, they have  3.44 medics for every EMT (http://www.cityofboston.gov/Images_Documents/2011_Boston_EMS_Vital_Stats[1]_tcm3-31009.pdf). This probably means more chances for the medics to practice real ALS skills, leading to more experienced (hopefully, better) medics.



I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly. 
Skill degradation is real, as you note, and it appears is not a problem for Boston medics.


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## Brandon O (Jan 10, 2013)

emt.dan said:


> I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly.
> Skill degradation is real, as you note, and it appears is not a problem for Boston medics.



Actually, I don't think I'm saying that. Having a lot of high-quality hospitals nearby may mean you can have less ALS, but it also means you can do almost anything for EMS; it's a panacea, you could be running a taxi service and people will still get care reasonably quickly.

It's more that -- as you said -- "BLS can handle so much." That's not a function of being close to hospitals, it's a result of putting out competent EMTs with an adequate scope. If you have that, you can acknowledge the reality that most patients don't need anything more than BLS, and then you don't need much ALS on the road. No calling ALS just because a patient is sick, or calling to cover your butt, or calling because the protocol says you can't be trusted -- you call only when a patient needs something they can provide but you cannot.

The only concerns I have with such a system (particularly when transport times are longer) are: 1) BLS usually can't provide much symptomatic relief for pain, nausea, anxiety, etc (of course, in many areas ALS is also reluctant to crack their drugbox for such "wussy" reasons); and 2) It raises the threshold for an ECG, since some patients with ambiguous complaints may initially receive a BLS crew who won't ask for an intercept, whereas an initial ALS crew may have done the "just in case" 12-lead and perhaps caught a STEMI. That's why I like to fantasize about BLS with 12-lead capability (available in some places) and IM/IN analgesia, antiemetics, etc (probably never going to happen).


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## EpiEMS (Jan 10, 2013)

emt.dan said:


> I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly.
> Skill degradation is real, as you note, and it appears is not a problem for Boston medics.



Makes good sense. Though, as one of my favorite blogs says (and I don't 100% agree), the life-threatening problems caused by opioid overdose can be managed without Naloxone. Or, to quote: "If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation. Manage the airway first, then, if you have naloxone and desire to use appropriately titrated naloxone, go ahead." (http://roguemedic.com/2010/07/current-drug-shortages-2/) Lots of other problems can be adequately managed by BLS, conditional on prompt transport and short transport times.




Brandon Oto said:


> That's why I like to fantasize about BLS with 12-lead capability (available in some places) and IM/IN analgesia, antiemetics, etc (probably never going to happen).



BLS should be transmitting 12 leads, for sure. IM/IN medications are tougher...but they're done in some places. Heck, Montana lets EMTs with an "endorsement" give morphine with an autoinjector. Admittedly, they can only give 2.5mg, but, still, they are EMTs and giving a narcotic. Viz.: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf


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## Brandon O (Jan 10, 2013)

EpiEMS said:


> Heck, Montana lets EMTs with an "endorsement" give morphine with an autoinjector. Admittedly, they can only give 2.5mg, but, still, they are EMTs and giving a narcotic. Viz.: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf



Awesome.

This would help address the issue of narc control.


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## Clare (Jan 10, 2013)

Brandon Oto said:


> Awesome.
> 
> This would help address the issue of narc control.



Um, entonox would be a better idea?


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## Brandon O (Jan 10, 2013)

Clare said:


> Um, entonox would be a better idea?



I was gonna mention that... I know it's popular overseas. How do you guys deal with controlling the stuff? Or do you just figure the occasional medic is huffing gas during his shifts and it's no big deal (sorta how most other supplies are treated here)?


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## Christopher (Jan 10, 2013)

Brandon Oto said:


> I was gonna mention that... I know it's popular overseas. How do you guys deal with controlling the stuff? Or do you just figure the occasional medic is huffing gas during his shifts and it's no big deal (sorta how most other supplies are treated here)?



I'm wondering the same thing, it is now in our protocols.


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## systemet (Jan 10, 2013)

Entonox is a tool, and one that can't adequately replace morphine or other opiods, or ketamine / toradol in a proper pain management regimen.

It's relatively safe, provided it's used properly.  If for some reason the patient is unusually sensitive to its effects (copharmacy?) then they will stop administering it, as their arm falls away from their face and the mask drops off.  It has some specific contradindications in terms of disease processes exhibiting air-filled spaces, e.g. pneumothoraces, bowel obstruction, emphysema.  If you don't invert the tank properly, or expose it to low temperatures, there can be issues with FiN20.

But it has some limitations.  It's simply not as effective at controlling severe pain as other agents, e.g. fentanyl / morphine.  The patient has to be conscious, and capable of following instruction and using at least one arm to self-administer.  It causes a lot of nausea and dysphoria, which are limiting for some patients, even those in severe pain, as often a mild reduction in pain + dysphoria is a no sale.  It's not commonly used outside of obstetrics in-hospital -- so supposing it works, and you get acceptable analgesia -- you now arrive at the hospital, and have to either wait for the hospital to give other meds (usually opiates, that you could have given yourself earlier), so that you can get your tank / regulator back.  Or you need spares, and a mechanism to recover your equipment left with the patient.  Ultimately this will eventually run out, and create a problem after you leave.  The ER staff may well be unfamiliar with entonox, and not know what to do with it.

I like it, usually as an adjunct to morphine, for short painful periods.  It can help for moving someone to the ambulance, providing its not too cold outside.  It can be ok if there's a bouncy ride. But it's not a wonder drug.

The area I live in has much laxer narcotic control laws than in the US.  We usually check tank pressure periodically, during unit checks, then record start and end PSI when it's used.  Typically it's primarily used by BLS, due to the limitations mentioned above, and a general preference for opiates in most situations by ALS.  It's a good option for services that have a long distance for ALS intercept or no ALS.

There have been historical issues with abuse, but it's a lot harder to divert than other controlled substances.  There have been incidents where tanks and regs have been stolen, but this is a little like stealing a D tank out of the airway kit --- if it's gone, someone should notice quickly.  It could be taken from a stock cupboard, but this should be caught by an inventory process, or increased use of tanks caught by ordering.  The only incidents I know of with prolonged abuse have centered around small services where the person ordering the tanks is diverting them themselves.  

As a drug of abuse the effects are also very short-lived, so unless your provider is huffing the second a call comes in, and there's a very short response, any intoxication is going to be long gone by the time they get on scene.  I would think that while the potential for abuse exists, the potential for serious consequences are minimal.

Don't get me wrong, it's not a bad option for BLS, but it's not a morphine replacement.


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