# States and EMT-B Morphine Administration



## Hal9000

Having recently received an email on the matter, I began to wonder how many states in the US allow EMT-Bs to administer morphine.  I imagine that the number is low—in the single digits—but I'm not really sure.

If your state does it, what are your thoughts on the practice?


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## exodus

No state allows EMT-B to push anything.


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## Hal9000

exodus said:


> No state allows EMT-B to push anything.



Ok, not "push," then, but auto-inject.

Sorry for using such a broad term.  Didn't mean to cause any confusion.


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## JPINFV

Even auto-inject I highly doubt it. In fact, I highly doubt that any states allow EMT-Bs to administer any schedule controlled drug, little less a schedule 2. Ignoring the psychomotor and assessment aspect of autoinjection, once you start involving narcotics, you start playing with legal fire.


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## Hal9000

JPINFV said:


> Even auto-inject I highly doubt it. In fact, I highly doubt that any states allow EMT-Bs to administer any schedule controlled drug, little less a schedule 2



Yeah, that's why I went with just single digits.  I thought that perhaps such rural areas as WY, AK, etc. might.  

According to the Montanan Board of Medical Examiners, EMT-Bs can now utilize Morphine 2.5mg auto after contacting medical control and with BP systolic >100; further admin requires further medical control direction.  

However, these "partial-ALS" units are mostly EMT-B (with endorsements) + EMT-B, or FR+ EMT-B, so there is not really much supervision.  Currently, EMT-Bs can perform unsupervised IOs, administer Glucagon, etc.

I was curious to know if there were any other states like that, but perhaps MT is just rogue.   


From the MT protocol book:


> *
> EMT-B (medication endorsement)*
> 
> Administer 2.5 mg Morphine (auto-injector only) in cases of isolated injury to prevent pain induced during patient movement and transport ONLY if blood pressure is above 100 systolic, and with direct communication from medical control
> 
> Can be repeated only with direct communication from medical control




I am myself somewhat uncomfortable with EMT-Bs doing ET tubes, IOs, and morphine, but I do understand the theory behind it, and a board of people much more intelligent and well-versed than I made the decisions. 

Regardless, it's above my pay grade, and not within my current degree.  I'd have to defer to any comments made by ALS providers.  What are your thoughts on the practice, keeping in mind that this is probably aimed at areas that are superrural?


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## JPINFV

There's a big difference between communities that can't afford and communities that won't afford the $20/person extra a month for paramedic service. In those (really rare on a per-capita basis) locations, I'm somewhat more comfortable with expanded scopes for EMTs. However, I'd rather see blind airways than ET tubes, IVs than IO, and something a little further down the schedule list than morphine. There's a big difference between someone screwing up or losing a tube or oral glucose and an auto injector of morphine, and I'd hate to be the medical director the first time an audit comes up with a missing auto injector  of morphine.


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## Hal9000

Those are very valid concerns, not that you need me to confirm that.  I have witnessed a certain naivety among rural providers.  It's sometimes easy to forget that their are meth labs around, but out of sight, out of mind.  What would you suggest instead of morphine, if you don't mind my inquisitiveness?

This will almost certainly become something of an ordeal for some medical directors in the future, especially the superrural types.    I can't really see this being viable on the East Coast, but there are many places in MT that have >45 minutes until arrival of HEMS, even, and with less than 300 calls/year.  In such cases, it seems somewhat cruel to deny pain management to a patient, but it's a catch-22. 

Back to the original subject, I suppose that there may only be one state that does allow -B morphine.  I was assuming that they were following a model from some other state.  I may have been incorrect.


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## rhan101277

Well 2.5mg IM Morphine for isolated extremity trauma may be better than no pain management at all, certainly better than distraction procedures.  Even 2.5mg IVP is not really that much pain management but better than IM.

Giving 2.5mg IM will absorb slow and take time to onset.  Pain management will not be maximized but better than nothing.

IM dosages need to be higher to achieve effect, here medics can give up to 10mg IM if unable to establish IV.  IV dosages are only allowed in 2mg increments q 3-5


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## Hal9000

rhan101277 said:


> Well 2.5mg IM Morphine for isolated extremity trauma may be better than no pain management at all, certainly better than distraction procedures.  Even 2.5mg IVP is not really that much pain management but better than IM.
> 
> Giving 2.5mg IM will absorb slow and take time to onset.  Pain management will not be maximized but better than nothing.
> 
> IM dosages need to be higher to achieve effect, here medics can give up to 10mg IM if unable to establish IV.  IV dosages are only allowed in 2mg increments q 3-5




I suppose that will come down to whoever is on the other end of the radio/phone in consultation with the EMT-B in the field.  Many of the physicians in the rural areas are of course familiar with the resources they (don't) have, so I imagine that they'll authorize higher doses, in this case done by utilizing more auto-injectors.  

Keeping better inventory of items will become a necessity for those BLS units which begin using morphine.


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## Shishkabob

Severe pain + 2mg morphine = severe pain.


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## MrBrown

Brown is very worried about all of this :unsure:


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## rhan101277

Linuss said:


> Severe pain + 2mg morphine = severe pain.



Yeah I agree, here we can't give the whole 10mg at one time due to a bad reaction or maybe they just don't want us zonking people out.

I can give 2mg morphine q 3 min, so some on scene, some in ambulance, some upon arrival at ER.  How are your protocols.

Well I say that but I am starting work for a new service maybe we can give up to 10mg, I think they are worried about blood pressure w/ high dosages in the emergency setting.


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## Hal9000

MrBrown said:


> Brown is very worried about all of this :unsure:



I cannot express my apprehension as a function of my arms, Mr. Brown.  




Linuss said:


> Severe pain + 2mg morphine = severe pain.



The number of auto-injectors is limited only to the number the physician online says may be used.


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## MrBrown

rhan101277 said:


> Yeah I agree, here we can't give the whole 10mg at one time due to a bad reaction or maybe they just don't want us zonking people out.
> 
> I can give 2mg morphine q 3 min, so some on scene, some in ambulance, some upon arrival at ER.  How are your protocols.
> 
> Well I say that but I am starting work for a new service maybe we can give up to 10mg, I think they are worried about blood pressure w/ high dosages in the emergency setting.



Gah! Please tell your Medical Director that it is no longer 1990.

We have unlimited morphine plus midaz and ketamine.


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## ERMedic

Hal9000 said:


> What would you suggest instead of morphine, if you don't mind my inquisitiveness?
> QUOTE]
> 
> 
> Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.


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## MrBrown

ERMedic said:


> Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.



Nitrous is great stuff, it's sometimes called Nitronox or entonox and we have used it here for by george .... well since the seventies at least with excellent effect.

Interestingly we are replacing it with methoxyflurane


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## Melclin

Hal9000 said:


> What would you suggest instead of morphine, if you don't mind my inquisitiveness?.



What about IN fentanyl. Faster onset, no sharps, probably cheaper than a couple of auto-injectors and less likely to cause BP problems.


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## Hal9000

ERMedic said:


> Some sqauds here in PA allow their EMTs to adminster nitrous oxide depending on their medical director and protocols. It's been succesful and the patient's just need to inhale it with a mask.






Melclin said:


> What about IN fentanyl. Faster onset, no sharps, probably cheaper than a couple of auto-injectors and less likely to cause BP problems.




I'd personally like either of those options better.  Nitrous would be nice because I believe is not on the Schedule, and fentanyl because I prefer its use.  The medic system in which I work has moved to almost exclusive use of fentanyl.  Your mention of no sharps is also very important, as many rural services have no Shuttles, instead carrying sharps to whatever bins they have in their ambulances.  

Interestingly, medical directors can petition for their own expanded protocols, including drug administration, so it wouldn't be impossible for a director to submit his proposal and have it accepted, for his system.


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## medicRob

exodus said:


> No state allows EMT-B to push anything.



Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan. TN also allows D5w, Glucagon, and is about to allow Nitrous since we train our lowest level (The EMT-IV not B with IV at I/85). 


@OP

EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.


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## Hal9000

medicRob said:


> Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan. TN also allows D5w, Glucagon, and is about to allow Nitrous since we train our lowest level (The EMT-IV not B with IV at I/85).
> 
> 
> @OP
> 
> EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.




MT also has glucagon and dextrose, but not Narcan.  Of course, most of these are EMT-B plus a couple hours for an endorsement here and there.  I'm not familiar with the levels in TN.

Regarding 





> EMT-B and Morphine won't happen, as it shouldn't. They have nowhere near the training to carry out such actions.


, would you elaborate?


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## JPINFV

An important distinction needs to be made regarding terminology. Is "push" in the concept of medical interventions the administration of anything outside of the classic EMT scope of oxygen, activated charcoal, and oral glucose (so any other oral medications, sub-Q, intramuscular, intranasal, IV, or various other routes), or does "push" mean only the administration of a bolus of medication through an IV ("IV push")? In terms of the latter, intranasal naloxone or IM glucagone are not "pushed" in the sense of an IV bolus.


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## Hal9000

For the sake of the EMT-B part of this thread, I suppose we should simply consider medications regardless of route.  While fentanyl IN may be easier, I'm somewhat more interested in the concept of EMT-Bs being given the ability to give the medication sans direct ALS supervision, regardless of how they get it there.  The TN deal sounds a lot more advanced, relatively, than what MT does.  

Glucagon is given unit dose in the standard quick-syringe layout, and morphine is being put forth as auto-injector, much like the Epi-Pens that -Bs use.  

However, any specifications for the method of delivery are given to minimize the chance of a trained (not educated) EMT-B hurting a patient.  Thus auto-injector.


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## BLSBoy

Linuss said:


> Severe pain + 2mg morphine = severe pain.



Win...........


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## medicRob

Hal9000 said:


> MT also has glucagon and dextrose, but not Narcan.  Of course, most of these are EMT-B plus a couple hours for an endorsement here and there.  I'm not familiar with the levels in TN.
> 
> Regarding , would you elaborate?



I assume we are speaking of EMT-B, not i/85 trained B's but rather EMT-B. Can an EMT-B explain the pharmacodynamics and kinetics of morphine? Have they had enough physiology to understand the mechanisms at play at the cellular and molecular level? Some of the EMT-B programs mentioned on here do not even require clinicals. There is no way in hell an EMT-B should be allowed to administer morphine. Is the EMT-B ACLS certified and an ALS provider? What if something goes wrong? What if they accidentally give too much are they prepared to handle that? What if the patient goes into respiratory arrest?


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## Hal9000

medicRob said:


> I assume we are speaking of EMT-B, not i/85 trained B's but rather EMT-B. Can an EMT-B explain the pharmacodynamics and kinetics of morphine? Have they had enough physiology to understand the mechanisms at play at the cellular and molecular level? Some of the EMT-B programs mentioned on here do not even require clinicals. There is no way in hell an EMT-B should be allowed to administer morphine. Is the EMT-B ACLS certified and an ALS provider? What if something goes wrong? What if they accidentally give too much are they prepared to handle that? What if the patient goes into respiratory arrest?





Yes, very Basic EMTs.  

And I concur with all your points, and believe that the safety levels (BLS units suddenly keeping narcotics with little or no training as to security procedures) will be diminished as well.

However, a group of physicians determines these protocols, so my opinion means little, in the end.  

On the other hand, I don't think that MT will be starting a trend by doing this...


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## medicRob

Hal9000 said:


> Yes, very Basic EMTs.
> 
> And I concur with all your points, and believe that the safety levels (BLS units suddenly keeping narcotics with little or no training as to security procedures) will be diminished as well.
> 
> However, a group of physicians determines these protocols, so my opinion means little, in the end.
> 
> On the other hand, I don't think that MT will be starting a trend by doing this...



I am not against EMT-B pushing medications as a whole. Some medications can be pushed by the EMT effectively, I don't think EMT-B would be prepared for this, However EMT's trained at the i/85 level should have no problem with some of the meds. However, morphine is not one of these meds.


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## clibb

medicRob said:


> I am not against EMT-B pushing medications as a whole. Some medications can be pushed by the EMT effectively, I don't think EMT-B would be prepared for this, However EMT's trained at the i/85 level should have no problem with some of the meds. However, morphine is not one of these meds.





medicRob said:


> I assume we are speaking of EMT-B, not i/85 trained B's but rather EMT-B. Can an EMT-B explain the pharmacodynamics and kinetics of morphine? Have they had enough physiology to understand the mechanisms at play at the cellular and molecular level? Some of the EMT-B programs mentioned on here do not even require clinicals. There is no way in hell an EMT-B should be allowed to administer morphine. Is the EMT-B ACLS certified and an ALS provider? What if something goes wrong? What if they accidentally give too much are they prepared to handle that? What if the patient goes into respiratory arrest?



I agree with this. You can argue all about the extra training and all that, but that's what makes you a Paramedic compared to an EMT-B. I would never want to administer someone Morphine even if the doctor gave me the go ahead. I don't have the training on what to do if someone goes south from me administering Morphine.


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## LonghornMedic

Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.


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## medicRob

LonghornMedic said:


> Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.



TN doesnt even license EMT-B anymore. The lowest level is trained to the i/85 curriculum.


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## Shishkabob

BLSBoy said:


> Win...........



Not my saying (That credit goes to the Rogue Medic) but alas it holds true.


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## clibb

LonghornMedic said:


> Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.



In Colorado we have EMT-B who are allowed to start IV and administer D-50, Saline, and other medications.


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## fortsmithman

LonghornMedic said:


> Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.



Why not have a Paramedic only system.


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## Shishkabob

fortsmithman said:


> Why not have a Paramedic only system.



Because more isn't always better.


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## Ridryder911

Linuss said:


> Because more isn't always better.



True.. look at Florida.. BUT... we need quality not quanity! Making multiple levels in lieu of the true gold standard is not nor will ever fix the problem. 

R/r 911


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## the_negro_puppy

fortsmithman said:


> Why not have a Paramedic only system.



Which is what we have here. Having said that, you dont get to use your ALS skills as much as many jobs/calls are BLS only


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## JPINFV

I wonder how physicians keep their "ALS" skills up when they see all of the "BLS" patients that either show up on their own or is transported by EMS.


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## CAOX3

JPINFV said:


> I wonder how physicians keep their "ALS" skills up when they see all of the "BLS" patients that either show up on their own or is transported by EMS.



Its called fast track, where I get to see a PA in twenty-minutes or less.


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## LonghornMedic

fortsmithman said:


> Why not have a Paramedic only system.



We do here. Keeps burnout down. When you are a Medic working with a EMT, there are days where you tech all the calls. That gets old. In a dual Medic system, the work load is shared evenly.


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## LonghornMedic

Linuss said:


> Because more isn't always better.



Works well here. But we don't have to deal with FF/Paramedics. Having worked in a system where everyone and their brother on scene was a Paramedic, it was a real pain in the ***.


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## JPINFV

Linuss said:


> Because more isn't always better.



There's a difference between a medic or two on every ambulance and a medic or two on every vehicle that has emergency lights and siren.


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## LonghornMedic

Amen!!


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## Melclin

I don't really agree with the EMT-B level, but having said that you can't have every provider as top tier. You've guys over there have your skill levels arse up. Its so all or nothing. Everyone being a 'paramedic' dilutes the skill levels. 

"But everyone should be educated to the paramedic level, EMT isn't good enough". No its not. Neither is you "paramedic" level in most cases. 

Every provider should have an excellent base of education. Then specialize if that's what floats their boat. Just like nursing or medicine. Everyone has the same good basic education (an EMT-B is not a good basic education). Every div one nurse here has a degree, but if we just randomly allocated nurses to any job, you'd dilute the skills you need for the specialty rolls. If you only had to look after one guy in ICU every 12 months, you'd bugger it up more than if you did it everyday. The same could be said for rehab or cardiac care. 

I don't see it being any different for the prehospital world.


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## Hockey

Here's my uneducated .02


What if they say they aren't allergic to Morphine but turns out they are?  I can't really say what sorts of reaction you may have via IM with only 2, but I'd rather not find out (since everyone is different).  I feel comfortable knowing I could counteract the Morphine if needed


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## Shishkabob

Hockey said:


> What if they say they aren't allergic to Morphine but turns out they are?  I can't really say what sorts of reaction you may have via IM with only 2, but I'd rather not find out (since everyone is different).  I feel comfortable knowing I could counteract the Morphine if needed



To be fair, EMTs have Epi-Pens.


Granted that's a stop-gap...


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## Hal9000

Linuss said:


> To be fair, EMTs have Epi-Pens.
> 
> 
> Granted that's a stop-gap...





And seeing as how I think the purpose of this is to help with long transports/time to ALS or definitive care, I can see EMTs requesting to use a few auto-injectors of morphine...and then getting to go all the way to the hospital with their one or two Epi-Pens.

Anyway, good point.


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## jjesusfreak01

I don't think there should be a problem with EMTs giving a few IM medications using syringes and auto-injectors. Just stuff like Glucagon and Epinephrine that can reverse life threatening conditions.


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## Veneficus

Hockey said:


> I feel comfortable knowing I could counteract the Morphine if needed



could I just inquire what you would be planning to counteract it with?


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## medic417

Heck lets give them narcan.  Then we need fent but then we need to ad it's reversal agent.  Then because they might cause them to arrest we need to give them cardiac drugs and .............   So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level.  Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused.  But I digress 120 hours is plenty to kill I mean help someone.


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## Veneficus

medic417 said:


> Heck lets give them narcan.  Then we need fent but then we need to ad it's reversal agent.  Then because they might cause them to arrest we need to give them cardiac drugs and .............   So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level.  Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused.  But I digress 120 hours is plenty to kill I mean help someone.



fentanyl ↔ naloxone
Applies to:fentanyl and Narcan (naloxone) 

MONITOR CLOSELY: This warning does not apply to the naloxone component in oral pentazocine/naloxone tablets. Naloxone injection is an antagonist that will reverse the actions of opiates. This reversal can occur when the opiate drug is being used clinically and when it is being abused. Physically dependent patients may experience withdrawal symptoms. Abrupt postoperative opioid reversal has resulted in hypotension, ventricular tachycardia and fibrillation, pulmonary edema, cardiac arrest, encephalopathy, and death. 

MANAGEMENT: Patients receiving naloxone injection should be monitored for changes in vital signs, nausea, vomiting, diarrhea, aches, fever, runny nose, sneezing, nervousness, irritability, shivering, abdominal cramps.


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## Phlipper

jjesusfreak01 said:


> I don't think there should be a problem with EMTs giving a few IM medications using syringes and auto-injectors. Just stuff like Glucagon and Epinephrine that can reverse life threatening conditions.



I agree.  I think this makes sense.

But morphine or dilaudid?  No way.  I don't want that responsibility.  I am proud to be an EMT, but just being in the A&P class for the Paramedic cert I'm learning how superficial the EMT-B really is.  Paramedic is a whole different can o' worms.  Until I have that level of knowledge and experience I'm content to leave the drugs to the pros.  As Clint Eastwood says ...

"A man's gotta know his limitations."


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## CAOX3

medic417 said:


> Heck lets give them narcan.  Then we need fent but then we need to ad it's reversal agent.  Then because they might cause them to arrest we need to give them cardiac drugs and .............   So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level.  Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused.  But I digress 120 hours is plenty to kill I mean help someone.



We're you beat by an angry mob of EMTs at some point in your life?  Your hostility is getting a little ridiculous, you seem to hold the EMT personally responsible for the lack of education that is included in the curriculum.

We're all well aware of your opinions on the education level of the EMT, must you regurgitate at every oppurtunity?

You were once an informative poster but you've grown quite tiresome.

By the way some EMTs have been carrying nasal narcan for years.


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## reaper

They should carry one drug, Oxygen!

They are so worried about helping their Pts, then get an education. Plain and simple.


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## JPINFV

CAOX3 said:


> Your hostility is getting a little ridiculous, you seem to hold the EMT personally responsible for the lack of education that is included in the curriculum.


Is it fair to blame them for the lack of education, especially foundational education, required to become an EMT? No.

Is it fair to blame them for not understanding the limits of the limited education required for EMTs? Yes. 

Is this a thread where, at this point, people are advocating allowing EMTs to administer opioid based on a limited foundational education? Yes. 


> By the way some EMTs have been carrying nasal narcan for years.



The question isn't whether some EMTs are administering naloxone IN. The question is both 'from an education standpoint, should they?' and 'why wasn't the system able to provide enough paramedics so that the situation exists where it was needed.'


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## CAOX3

reaper said:


> They should carry one drug, Oxygen!
> 
> They are so worried about helping their Pts, then get an education. Plain and simple.



Who's worried?  

I have an education.


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## CAOX3

JPINFV said:


> The question isn't whether some EMTs are administering naloxone IN. The question is both 'from an education standpoint, should they?' and 'why wasn't the system able to provide enough paramedics so that the situation exists where it was needed.'



As far as I know every EMS system has a medical control MD who has the ability to set treatment protocols as he see's fit, correct?

Those would be questions best answered by them.

And no I dont believe in expanded scope at the EMT level.


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## Veneficus

*the practical perspective:*

How could EMT-Bs with morphine or other opioid analgesics play out?

Well on the positive side, it would bring faster reduction/elimination of pain in areas that had prolonged response from ALS. 

Let us not forget that until the 1900s laudanum was available OTC. More modern formulation available by perscription is still PO self admnistered. Opiod analgesics have been used for centuries, prior to the development of reversal agents.

( I will intentionally leave out any discussion on uses for other conditions so as not to get into the education of EMT-B debate again, we are all very much aware of that topic even if we don't always agree)

Patients may also have various opioid prescriptions for a variety of ailments. An EMT-B can "assist" a patient in taking their own prescribed medication. Practically speaking what is the difference between an EMT-B assisting somebody with putting on the fent patch and administering an opioid by another route approved by their medical direction?

Let us consider for a second some down sides though. (purposefully leaving out the 1980s theory that it might mask a dx and leaving a pt in pain is somehow beneficial)

What happens if respiratory drive is depressed? an EMT-B can certainly manage an airway with simple adjuncts and ventilate. However, what about a potential drop in BP? reactions to other medications including synergies of which they do not have a strong background in? What if a patients physician purposefully didn't prescribe them opioids?

What if an EMT-B is permitted to start an IV and administer NS in a service?
With the ability to ventilate and increase vascular volume, almost all of the adverse effects can be at least managed during transport. Mental status should come around when the effects start declining.

Here are some of my more opinionated thoughts. 

If you are going to use analgesia, then you should use it properly. As was pointed out, giving inadequete doses serves absolutely no purpose. (American medicine is also rather conservative with analgesia. I think they are taught to fear it and never get over that.) If EMS administers an opioid, the receiving facility may be reluctant to add to it despite the patients subjective pain. 

An autoinjector is not a great idea. Because of the absolute dose an autoinjector delivers, it cannot be adjusted to the patient need or response. If you start with a low dose, are you planning to stab somebody 5 or 6 times to respolve their pain? How are they going to respond to that? If you start with a high dose, say 10mg, what if you have a frail elderly person? A child? Previous self opioid administration in the patient's normal med list?

Are you planning on writing a protocol excuding all these things? If so who would get the medication administered except perfectly healthy people?

Which brings me to reversal agents. As far as I am concerned reversal agents should be stricken from EMS. If a patient is ODing or hypersensitive to what you gave, then manage the symptoms and take them to the hospital. 

Reversal of an OD can have consequences. agitated patient, withdrawl, etc.

Reveral of hypersensitivity can remove the ability to treat pain (think about it, you narcan a person and how does the hospital control the pain until narcan wears off?) and as endorphines can be mitigated as well you could actually increase the pain of the patient. 

As for the skill, drug abusers use all forms of opioids all the time. Certainly if they can, an EMT-B can? 

Just to touch on the education issue, once more, it is the knowledge a paramedic brings, not a skill, a drug, or a toy, that makes them superior to the EMT-B. The issue here isn't if EMT Bs can administer opioids, the issue are when, how, and how much?

Without proper education, the EMT B cannot make those decisions with any accuracy. A few hours training on a drug is not going to be enough to make up for the background of diverse knowledge the EMT B is undisputadly lacking.

However, it is only fair to point out, in very rural or austere environments, an EMT B administering a medication without any background would be no more harmful than doing nothing at all.

I think it is a bit premature to give this idea the thumbs up or down without having at least some idea of the likely circumstances EMTs in a specific system would be likely to administer the medication.


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## LonghornMedic

jjesusfreak01 said:


> I don't think there should be a problem with EMTs giving a few IM medications using syringes and auto-injectors. Just stuff like Glucagon and Epinephrine that can reverse life threatening conditions.



Then be a EMT-Intermediate. I know in some systems EMT-B's can't even use a glucometer. But if you want to give meds, IM is the least preferred method. Go to school and be an Intermediate or Paramedic where you can start IV's and give meds.


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## Hal9000

Some great points, and thanks, Veneficus, for giving such a detailed answer—you and JPINFV will be the ones who can make these decisions, anyhow.

In some situations, I can see it being used wisely.  Given that medical directors have to authorize the trainings to allow the autoinjectors, and then someone has to be on line to give the OK, it's probably not going to cause sweeping deaths across rural areas. 

On the other hand, there are a lot of naive EMT-Bs in the rural areas that believe they know a great deal—I've seen this first hand—which could lead to problems.  That's an issue of personnel.  I know some places where the EMTs will not ask for orders to use the morphine, and the medical directors exist in name only, but a bad system is a bad system, and that will have to work out in the wash.

Some small BLS groups could easily attract the local methheads (small towns can be big for huge meth operations) or other cretins if they're not vigilant. Many EMTs will develop puffed chests over the ability, and the knowledge will spread quickly that narcs are onboard.  

As far as pain management, many of the calls areas where I volunteer (paid service is a large city, and the calls vary quite a good deal, obviously) are miles from ALS, at least 30-60 minutes for HEMS.  However, due to the nature of the topography and roads, MVCs have a proclivity for producing some nasty results, with pain management often an hour away.  The closest Trauma II is 80 miles, and for some services, it's almost 160, with the closest hospital a 60-80 miles.  

Still, some areas have advanced providers acting as EMT-Bs (CRNAs, RNs, etc., though I have witnessed many quit over having to "deal" with the adrenaline-junky, uneducated lot that gravitates toward lights and sirens), mostly due to time and budget constraints preventing services from going past BLS.  One CRNA I know has his doctorate and has performed anesthesia for many years, so giving him an autoinjector is fine, as he has the education to back its use.

The issue then is rather complicated, and it's hard to make sweeping generalizations with any accuracy, which is a perturbing characteristic inherent to them.  

With that said, this thread has been enlightening to me.  Perhaps the morphine is OK, given the nature of MT (still under one million people in the whole state, and it's large), but is it the best of choices?  Is fentanyl IN better?  How about nitrous?  Will stabbing a patient five times be OK?  Will patients report better pain outcomes, or will mortality rates stupidly change?  

I don't know.  I'd like to see systems improve their educational levels, but I doubt that will happen.  It would be nice if current providers, such as RNs,  volunteered more often, even at the -B level, in the rural areas in which they reside.  However, it often seems to me that rural EMTs are like politicians—the best one will be the one that doesn't want to be involved.  (That adrenaline fixation I've mentioned.) 



Anyway, the state made it a state protocol, so it will be up the the providers and medical directors to utilize it well.  We'll see the result.

EMS in America has many concerning areas, at least to me, but it's a low-level job (again, at least to me, and given the current requirements) that I've passed educationally for another career.  While I'm involved, I'll still do what I can to advocate for and improve safety (including attempted culls of those with phenomenally poor judgment), so this topic will remain of interest to me.


----------



## Hal9000

LonghornMedic said:


> Then be a EMT-Intermediate. I know in some systems EMT-B's can't even use a glucometer. But if you want to give meds, IM is the least preferred method. Go to school and be an Intermediate or Paramedic where you can start IV's and give meds.



This reminds me of my previous post, where I mentioned the CRNA.  It's sad, but I've seen such professionals not volunteer because they didn't want the hassle of "wasting" 120 hours of their lives listening to an uneducated EMT-B lecture them as a "lead instructor."  I understand that the upcoming changes will alleviate this problem to a degree, at least from the NASEMSO literature and webcasts to which I've read and listened.


----------



## LonghornMedic

Hal9000 said:


> This reminds me of my previous post, where I mentioned the CRNA.  It's sad, but I've seen such professionals not volunteer because they didn't want the hassle of "wasting" 120 hours of their lives listening to an uneducated EMT-B lecture them as a "lead instructor."  I understand that the upcoming changes will alleviate this problem to a degree, at least from the NASEMSO literature and webcasts to which I've read and listened.



I guess I read some of these "EMT-B's should be able to do more" posts and think to myself- GO TO SCHOOL! EMT-Basics are just that...BASICS. I think it's admirable that people explore the whys and whens of BLS. Personally, I think EMT-Basics should be phased out and replaced by Intermediates. EMT-B is nothing more than glorified First Aid. All it teaches you to do is a proper assessment. Intermediate school isn't very hard and only requires another few months of part time classroom. But the end result is that ILS in place of BLS results in far superior treatment skills and patient outcomes. In more rural areas, ILS is going to save more lives than BLS ever could. And for those Intermediates who want to push the boundaries and desire Paramedic skills- GO TO SCHOOL! 

When a practitioner starts blurring the lines of their respective skill sets and education, then go get the required education and to move to the next level.


----------



## JPINFV

LonghornMedic said:


> Then be a EMT-Intermediate. I know in some systems EMT-B's can't even use a glucometer. But if you want to give meds, IM is the least preferred method. Go to school and be an Intermediate or Paramedic where you can start IV's and give meds.



I think that's the big issue right there. In my perfect world, EMS would diverge from IFTs (who would be free to develop their own curriculum which better matches the needs of people with chronic illness not experiencing a medical emergency) and the entry level would be something, scope wise however with a proper education, between an I/85 and a I/99.


----------



## Veneficus

LonghornMedic said:


> But the end result is that ILS in place of BLS results in far superior treatment skills and patient outcomes. In more rural areas, ILS is going to save more lives than BLS ever could..



I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.


----------



## JPINFV

Veneficus said:


> I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.



The question, though, is "lives saved" the only metric that EMS should be concerned with? What about reduction of pain and suffering?


----------



## BLSBoy

Veneficus said:


> I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.



Where are these alleged "studies"? 
They are obviously flawed. 
Lets think here, CHF pt.... CPAP, NTG. Those alone can turn around a bad CHFer in 10-15 min, avoiding a tube in the hospital. 

STEMIs, early detection and transport to a cath lab saves lives. 

Prehospital hypothermia. My Dept had DOUBLE DIGIT percentages of people walking out of the hospital, NEUROLOGICALLY INTACT, not some vegetable that will eat our MCR and MCD money up, costing the taxpayers and insurance companies more money then they are worth. 

You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.


----------



## Veneficus

JPINFV said:


> The question, though, is "lives saved" the only metric that EMS should be concerned with? What about reduction of pain and suffering?



I think we should get away from the "lives saved" metric entirely. It is difficult to actually prove and only a very small portion of what EMS does on a regular basis. 

I am not sure what a better metric would be under the current version of US EMS. Response times are just as bad. I would like it to be money saved by being a relatively inexpensive way to get into the heathcare system, not necessarily an emergency dept. 

"we gave grandma jones a ride to her doctor's appointment this month at a cost of $100 and saved medicare a cost of X1000's for an ED visit when she goes into extremis."

"after 5 years of our community and school outreach programs, we have cut 911 calls by 60% saved the municipality millions in emergency response, and increased the quality of healthcare as demonstrated by the increase of x years of productive life."

"our community CPR outreach program has decreased the time from sudden cardiac arrest to quality cpr from 8 minutes to nearly 2"

"Our senior outreach program has helped our population over age X remain in their homes an average of Y years longer, reducing emergency calls by Z a year saving a cost of N in both emergency in longterm care"

"On average we identify X medical emergencies which get prompt transport to an emergency department, thereby reducing the number of out of hospital cardiac arrests by Z%"

"Our community health screen as well as adult health and wellness education has led to the referral and counciling of X people for earlier identification and preventative care which improves the quality of life for said population, keeps them producing longer, and saves W costs in long term care compared to last year's total of R"

Would be some things I would like to see.


----------



## medic417

Veneficus said:


> fentanyl ↔ naloxone
> Applies to:fentanyl and Narcan (naloxone)
> 
> .



LOL I was wanting one of the basics to catch it since they now know everything.  No point in wasting time with education.  Heck I think we can do an auto injector stent in the field so no need for cardiologists.


----------



## medic417

CAOX3 said:


> We're you beat by an angry mob of EMTs at some point in your life?  Your hostility is getting a little ridiculous, you seem to hold the EMT personally responsible for the lack of education that is included in the curriculum.
> 
> We're all well aware of your opinions on the education level of the EMT, must you regurgitate at every oppurtunity?
> 
> You were once an informative poster but you've grown quite tiresome.
> 
> By the way some EMTs have been carrying nasal narcan for years.



Yes see I told you guys I was an informative poster.  Now I have proof.  Thanks.  

Just because a system allows mediocrity does not mean one must settle for it.


----------



## JPINFV

medic417 said:


> LOL I was wanting one of the basics to catch it since they now know everything.  No point in wasting time with education.  Heck I think we can do an auto injector stent in the field so no need for cardiologists.



Well... if the EMTs can do it, so can the ED, which would be an additional billable procedure so... sure!


----------



## medic417

JPINFV said:


> Well... if the EMTs can do it, so can the ED, which would be an additional billable procedure so... sure!



Why stop there?  Let the janitor do it.  Yay more toys with no more education. :wacko:


----------



## Shishkabob

I want toys :unsure:


----------



## Veneficus

*Oh for shame*



BLSBoy said:


> Where are these alleged "studies"?



There have been several OPALS studies for medical emergencies, trauma, and pediatrics. As these and other smaller studies have called into question the cost effectiveness of ALS response, I would hope that EMS providers become aware of them and attempt to demonstrate a less flawed method with a more accurate study. Until such a time, this is what there is to go by.




BLSBoy said:


> They are obviously flawed.



I don't dispute the metrics they used to measure ALS effectiveness are always representative of service provided, they are compiled in an ALS system that has higher standards than the current and past US system.



BLSBoy said:


> Lets think here, CHF pt.... CPAP, NTG. Those alone can turn around a bad CHFer in 10-15 min, avoiding a tube in the hospital.



CPAP manages an acute symptom of CHF, it is not a definitive treatment for it. It in no way reverses the disease process. It does not allow people to walk around like Darth Vader enjoying scaring the daylights of of the younger relatives when they ask them for a hug. Maybe EMS could doll out some welbutrin or prozac for that too. 

Would that be the emergent 0.04 mg of NTG that lasts 3-5 minutes or the 12 hour patch that allows the unstable angina patient with CHF sit a few more days in their cardiac chair?

Avoiding a tube in the hospital for how long? A DNR avoids a tube. So does end of life care. If these patients are so turned around, why do they still need to go to the hospital? Aside from intervening in one acute crisis, which often sets off a sequely of ED, CICU, SNF, Hospice, or ED, CICU, mortgage forclosure, recurrent acute episode refer to earlier sequely, exactly how many lives would you call a save? 

In strict protocol driven systems, both CPAP and NTG are basic skills. A basic is much cheaper to field than a medic.



BLSBoy said:


> STEMIs, early detection and transport to a cath lab saves lives.



Would it save more lives than a Basic with a LP 12 or 15 that puts on the 12 lead and takes the pt to a cathlab when it reads "possible STEMI" while they give the pt NTG and ASA?



BLSBoy said:


> Prehospital hypothermia. My Dept had DOUBLE DIGIT percentages of people walking out of the hospital, NEUROLOGICALLY INTACT,



Probably the only thing here that EMS does that actually saves lives in a measurable quantity.




BLSBoy said:


> not some vegetable that will eat our MCR and MCD money up, costing the taxpayers and insurance companies more money then they are worth.



I don't think it is accurate to say that a arge percentage of these people wind up in a SNF on a vent. I see a considerable number of them die within a few days in the ICU,  DNR orders, and even a few who get "the plug pulled."

Wouldn't hurt insurance companies to lose a few bucks, and while I agree it does save a tube and those complications, it does not save a few days in the unit, so the actual savings is rather small. The fact the patient didn't die also means considerable spending for the chronic care. Ask any insurance company if they would rather fork over the cash for a few days in the ICU for a patient who dies or the 20 or 30 years of chronic care of those who survive with multiple decompensating pathology? Good death panel argument though with the cost comparison at the end compared to the earlier human argument.

If I am not mistaken the OPALS or similar study did show a slight reduction in hospitalization time in a few specific emergencies, which is a much better argument than "saving lives." 



BLSBoy said:


> You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.



A good twist on the Mark Twain quote. But I am afraid that EMS uses equally flawed stats to demonstrate the lives they save. I have seen many over the years. From ROSC at the ED to response times, to superior/cheaper care provided by various agencies. Now the OPALS lies are cancelled out.


----------



## medic417

Linuss said:


> I want toys :unsure:



Well go look around the doctors area and tell them you can do what they do.  Then take it.  No education required.  Have fun with your new toys.


----------



## Shishkabob

medic417 said:


> Well go look around the doctors area and tell them you can do what they do.  Then take it.  No education required.  Have fun with your new toys.




But I'd still get some funny looks, and I don't have the self-esteem for those looks.


----------



## medic417

Linuss said:


> But I'd still get some funny looks, and I don't have the self-esteem for those looks.



Just a minute let me find it.  Yes here it is self esteem auto injector.  Now who needs a shrink?  Wow you really don't need education.


----------



## Hal9000

medic417 said:


> LOL I was wanting one of the basics to catch it since they now know everything.  No point in wasting time with education.  Heck I think we can do an auto injector stent in the field so no need for cardiologists.




I do not believe that many Basics have posted in this thread.  However, since it involved Basics, I did put in the BLS section, though it irked me to do so.  

It seems safe to say that only one state is allowing Basics to give morphine.


----------



## Meursault

BLSBoy said:


> Where are these alleged "studies"?
> They are obviously flawed.





BLSBoy said:


> You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.



I'm tempted to tape my epidemiology textbook to a Clue Bat and start driving south.

Are you really arguing that massive clinical trials are either useless or in any way equivalent to your handful of stories about patients walking out of the hospital?

Here's the OPALS executive summary: http://www.chsrf.ca/final_research/ogc/pdf/stiell_e.pdf

And here's the portion dealing with trauma, which suggests that ALS is actually worsening outcomes in a subset of trauma patients: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/

Here's a separate publication on respiratory distress from the OPALS study, which shows some benefits, including a significant reduction in in-hospital mortality, during the ALS phase (though ALS providers only responded to about 60% of the relevant calls during this phase)
http://www.nejm.org/doi/full/10.1056/NEJMoa060334
Interestingly, what we consider "ALS interventions" were used in only a small number of patients and the biggest change was appreciably and significantly greater use of albuterol ("salbutamol"), which the authors say was the result of a different program.

Explain the problems you have with the study designs or shut up and stop reflexively criticizing evidence that challenges your beliefs.


----------



## CAOX3

Everyone needs more education I am not arguing that point.

That being said I love when people preach evidence based medicine, hold it as gospel and then dismiss it when it doesn't support their argument  or personal agenda.


----------



## Hal9000

As it turns out, the state officials say that currently no company makes an autoinjector in 2.5mg for morphine, though there is one 10mg version that is somewhat common.

The state says that a company that makes the 10mg version will cave to demand and produce a 2.5mg one.  Given that the entirety of MT has less than one million people, and also knowing that probably 200,000 of them are served by prehospital ALS, I do not see much demand for this product.  I can't find a 2.5mg version myself, so perhaps it's not to be found. 

Interestingly stupid or stupidly interesting, it's your pick.


----------



## BLSBoy

MrConspiracy said:


> I'm tempted to tape my epidemiology textbook to a Clue Bat and start driving south.


Please, start driving. I'll meet you at the state border to show you a little, "Southern Hospitality". 




MrConspiracy said:


> Explain the problems you have with the study designs or shut up and stop reflexively criticizing evidence that challenges your beliefs.


The "Holy Grail" that you and everyone else clinging to it is all, "no shiite, Sherlock" stuff. ALS gets focused in on ALS procedures, and forgets all about good, high quality CPR, same with trauma. They don't need me, they need hot lights and cold steel. 

MIs, respiratory distress, seizures, (to include eclamptic ones as well), and cardiac arrests with short downtimes and ROSC with good CPR, followed through with aggressive post rescusitation care (hypothermia, RSI, transport to a cath facility). 

ALS doesn't save codes or trauma. 
That is where we are going to be saving lives with ALS


----------



## boingo

Veneficus said:


> There have been several OPALS studies for medical emergencies, trauma, and pediatrics. As these and other smaller studies have called into question the cost effectiveness of ALS response, I would hope that EMS providers become aware of them and attempt to demonstrate a less flawed method with a more accurate study. Until such a time, this is what there is to go by.
> 
> 
> 
> 
> I don't dispute the metrics they used to measure ALS effectiveness are always representative of service provided, they are compiled in an ALS system that has higher standards than the current and past US system.
> 
> 
> 
> CPAP manages an acute symptom of CHF, it is not a definitive treatment for it. It in no way reverses the disease process. It does not allow people to walk around like Darth Vader enjoying scaring the daylights of of the younger relatives when they ask them for a hug. Maybe EMS could doll out some welbutrin or prozac for that too.
> 
> Would that be the emergent 0.04 mg of NTG that lasts 3-5 minutes or the 12 hour patch that allows the unstable angina patient with CHF sit a few more days in their cardiac chair?
> 
> Avoiding a tube in the hospital for how long? A DNR avoids a tube. So does end of life care. If these patients are so turned around, why do they still need to go to the hospital? Aside from intervening in one acute crisis, which often sets off a sequely of ED, CICU, SNF, Hospice, or ED, CICU, mortgage forclosure, recurrent acute episode refer to earlier sequely, exactly how many lives would you call a save?
> 
> In strict protocol driven systems, both CPAP and NTG are basic skills. A basic is much cheaper to field than a medic.
> 
> 
> 
> Would it save more lives than a Basic with a LP 12 or 15 that puts on the 12 lead and takes the pt to a cathlab when it reads "possible STEMI" while they give the pt NTG and ASA?
> 
> 
> 
> Probably the only thing here that EMS does that actually saves lives in a measurable quantity.
> 
> 
> 
> 
> I don't think it is accurate to say that a arge percentage of these people wind up in a SNF on a vent. I see a considerable number of them die within a few days in the ICU,  DNR orders, and even a few who get "the plug pulled."
> 
> Wouldn't hurt insurance companies to lose a few bucks, and while I agree it does save a tube and those complications, it does not save a few days in the unit, so the actual savings is rather small. The fact the patient didn't die also means considerable spending for the chronic care. Ask any insurance company if they would rather fork over the cash for a few days in the ICU for a patient who dies or the 20 or 30 years of chronic care of those who survive with multiple decompensating pathology? Good death panel argument though with the cost comparison at the end compared to the earlier human argument.
> 
> If I am not mistaken the OPALS or similar study did show a slight reduction in hospitalization time in a few specific emergencies, which is a much better argument than "saving lives."
> 
> 
> 
> A good twist on the Mark Twain quote. But I am afraid that EMS uses equally flawed stats to demonstrate the lives they save. I have seen many over the years. From ROSC at the ED to response times, to superior/cheaper care provided by various agencies. Now the OPALS lies are cancelled out.



If EMS just prolongs the inevitable, what exactly does the ED do?  The ED does not fix the pathology leading to CHF either, or reverse STEMI unless they are not equiped with a cath lab.  They stabilize and refer to a specialist.  There is a continuem of care, from the scene, to the hospital, to home or admission with expert consultation and definitive care.  I don't buy into the "ALS saves lives" crap, but nor do I dismiss the fact that without it several people wouldn't make the ED.  You can argue that these interventions just prolongs the inevitable, but that arguement extends right into your hospital as well.


----------



## Veneficus

boingo said:


> If EMS just prolongs the inevitable, what exactly does the ED do?  The ED does not fix the pathology leading to CHF either, or reverse STEMI unless they are not equiped with a cath lab.  They stabilize and refer to a specialist.  There is a continuem of care, from the scene, to the hospital, to home or admission with expert consultation and definitive care.  I don't buy into the "ALS saves lives" crap, but nor do I dismiss the fact that without it several people wouldn't make the ED.  You can argue that these interventions just prolongs the inevitable, *but that arguement extends right into your hospital as well*.



Not denying that at all. My point is that advanced care doesn't equal better outcome.

But I would also like to point out data from the AHA. 

Between 2000 and 2005 (according to the AHA numbers) ACLS providers put priority in advanced life support skills.

The number of unsuccesful resuscitations increased from 300,000/year to 350,000 a year. (now I understand there are some confounders to these numbers, but please bear with me) 

in the 2005 guidlines, there was a refocusing on BLS (cpr) as the primary ntervention in both bystander an ACLS interventons. I cannot remember the exact number, but if I am remebering the right number, think it was an increase ~14-18%

which means that resucutation of cardiac arrest went back to near the 2000 baseline.

With the advent of AEDs and a renewed focus on CPR, (all of which are basic life support skills) it could be concluded that the BLS skills have a greater impact than ALS skills.

Now correlate that to the OPALS studies, which do point out a decrease in hospital stay from ALS in certain conditions. (respiratory and hypoglycemic again if memory serves me) 

What can be logically concluded is that ALS does have a positive outcome in certain conditions. 

I think we have both argued the position that there is benefit to ALS particularly in cases like pain control. My position is that it is not "life saving" in any appreciable number compared to BLS. (that also includes in the hospital)

I think we need to start being realistic about the value that ALS provides, not keep clinging to some romantic fantasy.

I would also like to point out something that was said without directing it at the person who brought it up. 

Trauma does not equate to surgical intervention anymore. Those days have been over for about 20 years. It does equate to care from a trauma specialist. That can include Emergency Physicians, Surgeons (all appropriate disciplines), Interventional Radiologists, and Intensivists.

Surgical trauma requiring emergency damage control surgery in the western world is actually decreasing and has been for some time. as is our ability to nonsurgically manage injuries that once automatically meant damage control surgery. (emergent, and without regard to return to function or aesthetic value.)

Some patients in western countries will still require a surgeon to be sure, but less for life threatening injuries and more for return to near normal function.

Would all parties please stop perpetuating the dogma.


----------



## LonghornMedic

Boy, this thread sure went sideways. As far as patient outcomes in BLS versus ALS systems, I'm convinced they are better in ALS. I've worked as a Basic when I first started in a BLS system, an Intermediate in a ALS system and now as a Paramedic. Both ALS systems I've worked in were far superior to the BLS system I worked in. All EMS systems are different. It's like the old saying- "If you've seen one EMS system, you've seen one EMS system." So my experience may differ from another person's experience. My one complaint about ALS is that some Medics spend WAY too much time on scene. Especially on medical calls. Everyone seems to understand the Golden Hour when it comes to trauma calls, but medical calls seem to bring out a different perspective. I've worked with partners who just love to start everything on scene. I do everything en route. My philosophy is I am not a doctor or a ER. My job is to get them to the next highest care ASAP.


----------



## JPINFV

Golden hour as a time matrix is bunk. Your patient doesn't magically expire at 60 minutes post insult.


----------



## LonghornMedic

JPINFV said:


> Golden hour as a time matrix is bunk. Your patient doesn't magically expire at 60 minutes post insult.



No. But ****ing around on scene doesn't do your patient any good either.


----------



## JPINFV

Depending on what exactly you're ****ing around doing. Not all emergencies are load and go, do everything enroute emergencies. For example, if you're going to intubate, why make the intubation harder by adding extra external noises and movement? However, if you're just sitting on scene for the sake of sitting on scene, then I agree.


----------



## reaper

Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.

Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?

No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.


----------



## LonghornMedic

reaper said:


> Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.
> 
> Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?
> 
> No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.



Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.


----------



## reaper

LonghornMedic said:


> Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.



You could have chose a better example to make! Why transport a working code? What will they do in the ER that is any different then what you are providing? Why not sit on scene for 30 minutes providing quality CPR and work the pt. If you do not get a change by then, think about calling it!

Does not matter if you can do it en route. If there is no need to rush, why rush? Do you know the anxiety to a pt that an IV while moving causes? I can do an IV in 30 secs. Why wait till you bouncing down the road?

Point is, the majority of medical pt's are not time sensitive, so why rush them off to the ER? Take your time, treat your pt, keep them calm and explain everything. Even if I take 10 minutes extra on scene. It will not change the out come for my pt.


----------



## JPINFV

LonghornMedic said:


> Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.



...except you can't provide continuous good quality compressions while the ambulance is moving any faster than a crawl to the hospital.


----------



## LonghornMedic

reaper said:


> You could have chose a better example to make! Why transport a working code? What will they do in the ER that is any different then what you are providing? Why not sit on scene for 30 minutes providing quality CPR and work the pt. If you do not get a change by then, think about calling it!
> 
> Does not matter if you can do it en route. If there is no need to rush, why rush? Do you know the anxiety to a pt that an IV while moving causes? I can do an IV in 30 secs. Why wait till you bouncing down the road?
> 
> Point is, the majority of medical pt's are not time sensitive, so why rush them off to the ER? Take your time, treat your pt, keep them calm and explain everything. Even if I take 10 minutes extra on scene. It will not change the out come for my pt.



Again, I'm not rushing them. I just choose to do stuff en route. My preference. The majority of the people who call us get transported. We don't turf too many. So I do an initial assessment on scene. If it's something like hypoglycemia, then we'll obviously do an IV and D-50 there. 

Again, my method may vary from yours. I prefer not to sit around and do stuff when I can do it on the way. Shortens my scene time and allows me to go available for calls sooner. I've worked with guys who take an hour and a half to tech a kidney stone from call origination to available for calls. When I do it, we'll be available in 30-45 minutes. Again, that's just me.


----------



## LonghornMedic

reaper said:


> Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.
> 
> Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?
> 
> No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.



A calm controlled setting is in the back of my ambulance, even if we're on scene. In a critical emergency, with panicked family, co-workers or other bystanders milling around I'd rather be in the rig doing what I need to do. Believe me, I've worked codes with hysterical family members screaming and crying. If given the choice, I just as soon be in the rig with all my equipment within reach instead of fishing through a jump bag. Just my preference.


----------



## Jay

medicRob said:


> Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan.



Narcan/Naloxone should really be a "common sense" drug that can be used if the proper protocols allow along with adequate training at any level. I just got done replying to another post on here where rwik123 was unsure given the following scenario:

http://emtlife.com/showthread.php?p=249067#post249067

I for the most part immediately saw the opiate OD as a possibility along with perhaps hypoglycemia as another strong possibility, but this is because I immediately recognized two of three pieces of the opioid triad. Now, granted if there was adequate training explaining the opioid, especially the "why's" than an OD that would require naloxone would be easy to treat at any level, it goes back to recognizing the symptoms and treating your patient and not just the numbers.

Now, on that note, training would also have to include what NOT to do, e.g. NOT to push narcan for a non-opiate overdose, e.g. benzos or antidepressants; teaching the theory on this would be extremely beneficial. Also, there are certain "opiates" such as Tramadol where narcan would not have a very powerful (if any) effect (due to the way it acts on two receptors and its pseudo-opiate makeup) so training on contraindications would be beneficial. This could be a 4 hour class. Or even combined with some other BLS-ALS hybrid drug administration could be a day or two even that could really make common sense situations a lot easier because they could be defused at a lower level in much less time.


----------



## Basermedic159

exodus said:


> No state allows EMT-B to push anything.



That's not totally accurate. I'm an EMT-B in NC and I can draw up and administer EPI sq for anaphylaxis. Not auto injector.

Also Narcan via MAD device...


----------



## Basermedic159

JPINFV said:


> There's a big difference between communities that can't afford and communities that won't afford the $20/person extra a month for paramedic service. In those (really rare on a per-capita basis) locations, I'm somewhat more comfortable with expanded scopes for EMTs. However, I'd rather see blind airways than ET tubes, IVs than IO, and something a little further down the schedule list than morphine. There's a big difference between someone screwing up or losing a tube or oral glucose and an auto injector of morphine, and I'd hate to be the medical director the first time an audit comes up with a missing auto injector  of morphine.



Medics can steal medications just as fast as basics can. As a matter of fact, the news that i've have seen/read about, only showed medics stealing narcs. In my opinion, it is easier for a medic to snatch a drug quicker than a basic, due to the simple fact of medic being able to access narcotics more easy than a basic.


----------



## Basermedic159

Linuss said:


> Severe pain + 2mg morphine = severe pain.



What does Severe pain + nothing for pain =?


----------



## Basermedic159

LonghornMedic said:


> Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.



Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.

You should remember whats infront of your patch Mr. *EMT*-paramedic


----------



## JPINFV

Basermedic159 said:


> Medics can steal medications just as fast as basics can. As a matter of fact, the news that i've have seen/read about, only showed medics stealing narcs. In my opinion, it is easier for a medic to snatch a drug quicker than a basic, due to the simple fact of medic being able to access narcotics more easy than a basic.




Where in my post did I bring up theft?


----------



## triemal04

Basermedic159 said:


> Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there.* Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.*
> 
> You should remember whats infront of your patch Mr. *EMT*-paramedic


I don't think that at all.  I *know* that in the vast majority of cases it doesn't matter medically if an EMT get's to the patient before me.  Of course, in many cases it also doesn't matter if *I* get to the patient either; the number and types of calls where we (paramedics) will have an effect on patient mortality and final outcome are not as high as you think.  

There are plenty of cases where we will be able to help with the patient's comfort and resolving some symptoms/conditions.  But...there aren't many times you can say that, can you?

Before you get to pissy, think about what I'm actually saying.  It isn't that EMT's and paramedics aren't needed, just that your (and my) skill set and education are often woofully inadequate to have any meaningful medical impact.

This doesn't mean that we never do; don't bother bringing up examples, everyone knows they exist, it's just that more often than not...we could take the patient to the hospital while doing absolutely nothing, and the outcome wouldn't change.


----------



## RocketMedic

exodus said:


> No state allows EMT-B to push anything.



Not entirely true, the armed forces count as states to the NR and FedGov and allow poorly-trained EMT-Bs (68W10/20s) to administer quite a bit. Big ones on this list are morphine, fentanyl, and valium/versed.


----------



## RocketMedic

Hal9000 said:


> As it turns out, the state officials say that currently no company makes an autoinjector in 2.5mg for morphine, though there is one 10mg version that is somewhat common.
> 
> The state says that a company that makes the 10mg version will cave to demand and produce a 2.5mg one.  Given that the entirety of MT has less than one million people, and also knowing that probably 200,000 of them are served by prehospital ALS, I do not see much demand for this product.  I can't find a 2.5mg version myself, so perhaps it's not to be found.
> 
> Interestingly stupid or stupidly interesting, it's your pick.



We've got 2.5mg autoinjectors, but I haven't seen them in ages.


----------



## RocketMedic

Basermedic159 said:


> Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.
> 
> You should remember whats infront of your patch Mr. *EMT*-paramedic



You seem a bit...bitter.

I don't think a _good_ EMT or EMT-I is any _worse_ than a good paramedic, but all things considered, I'd prefer to have a paramedic who can actually do what is indicated as opposed to someone who can follow orders well and blindly. 

Competence isn't tied to a patch, but in general terms, I'd rather have more training.


----------



## Basermedic159

JPINFV said:


> Where in my post did I bring up theft?



If youll look, someone stated something about EMT's administering morphine "until an auto injector comes up missing"


----------



## Handsome Robb

Basermedic159 said:


> Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.
> 
> You should remember whats infront of your patch Mr. *EMT*-paramedic



So make the firefighters upgrade to intermediate. It's not that difficult. Since the fire service seems to be justifying much of their funding with response to EMS calls why not make them more capable to provide comfort to the patients in those situations where the FD is on scene first and have an extended wait for an ALS crew?

99% of the time a basic isn't going to be able to do a whole lot medically for the patient and as someone else said, that is true of medics as well. 

It's not EMT-Paramedic anymore boss, it's Nationally Registered Paramedic under the new national guidelines. As a new member it's not great practice to come in and start scolding and harassing people who have been around this place longer than you. There's lots of info hear and sources of education but no one is going to be nice to you if you come in guns blazing.


----------



## Basermedic159

JPINFV said:


> There's a big difference between someone screwing up or losing a tube or oral glucose and an auto injector of morphine, and I'd hate to be the medical director the first time an audit comes up with a missing auto injector  of morphine.



There ya go


----------



## JPINFV

...because theft is the only way to lose something?


----------



## Handsome Robb

JP :nosoupfortroll:


----------



## Basermedic159

NVRob said:


> So make the firefighters upgrade to intermediate. It's not that difficult. Since the fire service seems to be justifying much of their funding with response to EMS calls why not make them more capable to provide comfort to the patients in those situations where the FD is on scene first and have an extended wait for an ALS crew?
> 
> 99% of the time a basic isn't going to be able to do a whole lot medically for the patient and as someone else said, that is true of medics as well.
> 
> It's not EMT-Paramedic anymore boss, it's Nationally Registered Paramedic under the new national guidelines. As a new member it's not great practice to come in and start scolding and harassing people who have been around this place longer than you. There's lots of info hear and sources of education but no one is going to be nice to you if you come in guns blazing.



Alot of fire departments are going to ALS, atleast around here they are. If OEMS would combine EMT-B and Intermediate together like they have been talking about for years, they wouldn't have to. 

Not EMT-Paramedic anymore? Um yeah it is, all Paramedics are not nationally reistered? Your not a Nationally Registered Paramedic until you take the NR test...boss.

I may be new but I only "scolded" on the things I thought where incorrect,stupid etc. Im not coming in "guns blazing" I have also commented on other stuff. Just because I am new and said something you didnt like dosnt mean Im scolding anyone or have " my guns blazing" I may be new but I haven't broken any rules.h34r:


----------



## Basermedic159

JPINFV said:


> ...because theft is the only way to lose something?



Not at all, but now it seems you are insinuating that Basics can loose something more easily than Intermediates or Paramedics?


----------



## RocketMedic

Yes, because there's more of y'all, and as much as I hate to say it, there's less to lose. Paramedics aren't perfect, but they have sunk time into career advancement, and there's fewer of us than EMTs. Basics may be more mature as individuals, but as a group, y'all needs to meet our (relatively low) standard before the rest of the world trusts you with real medication.

Baser, your argument is weak. Our title is mere semantics. I don't care if I'm called a paramedic or an emt-p or an AD(RGIB). The point is that EMT-B needs more education or special circumstances to have drugs in their protocols.


----------



## Flight-LP

Basermedic159 said:


> Alot of fire departments are going to ALS, atleast around here they are. If OEMS would combine EMT-B and Intermediate together like they have been talking about for years, they wouldn't have to.
> 
> Not EMT-Paramedic anymore? Um yeah it is, all Paramedics are not nationally reistered? Your not a Nationally Registered Paramedic until you take the NR test...boss.
> 
> I may be new but I only "scolded" on the things I thought where incorrect,stupid etc. Im not coming in "guns blazing" I have also commented on other stuff. Just because I am new and said something you didnt like dosnt mean Im scolding anyone or have " my guns blazing" I may be new but I haven't broken any rules.h34r:



OK, since we are going to play on the semantics....................

I am not a Nationally Registered Paramedic, I only currently hold a Texas License. No where in my title or licensure does it say EMT.

Why am I being an ***? Simple.........

You come in here with your smart a$$ attitude waving around unsubstantiated statements and then have the audacity to say you are "new" and only complaining about things that you "think are incorrect or stupid". Who are you and on what grounds does your inexperienced opinion hold any validation of fact? MY friend, everyone is entitled to an opinion. But remember the old saying about opinions?

I believe if you altered your approach a bit and became more inquisitive instead of confrontational, you may get farther with this crowd. You may also learn something along the way...........................


----------



## Flight-LP

Rocketmedic40 said:


> Basics may be more mature as individuals........



The proof isn't in the pudding here lately in some of these posts...........


----------



## JPINFV

Basermedic159 said:


> Not at all, but now it seems you are insinuating that Basics can loose something more easily than Intermediates or Paramedics?


The majority of EMTs I've worked were not as particular when it came to things like truck checkout and filling out the supplies used section of the PCR as they probably should have been. I'll fully admit to being anal bordering on OCD when it comes to checking out my ambulance and filling out my PCRs, but I've seen a lot of people who left more than a little to be desired for.


----------



## ffemt8978

Basermedic159 said:


> I may be new but I haven't broken any rules.h34r:


Only because I haven't spent the time checking all off your posts yet.


----------



## paradoqs

Although I agree that the basic curriculum leaves alot to be desired, I think they can bring alot of value to the ems system. I think it is shortsited to say that basics are worthless because of their education. A bsn could say the same to a medic with only a diploma. First, how many pts do we run on would have no change in outcome if they got a taxi to the ed? Alot. In my system, there are no intermediates and you have to be a basiic for atleast a year before p school, and they are highly competitive. No one here wants to hire a medic with no exp as a basic.  Also, my company charges alot less for a bls transport. Cost savings alone is a great argument for basics. Any good basic is going to know when als needs to be called in so why not start with bls atleast in ift systems. Educatiin shouldnt be the only thing that defines provider level anyway. Experience, judgement, and maturity are important too. And acting as a basic in an ems system can help achieve those things.  I dont know about other systems, but emts are indespensible in mine. There arent enough medics to go around and not enough money to pay them with. Saying basics dont have a good education is true, but discounting their value in ems is condescending and falacious.

On another note, if an emt is acting with online med control to give opiods, he/she is really just acting as the eyes and ears of the md. So, any screw up unrelated to the med admin i.e. Dosage or route is the md' problem. And its pretty hard to screw up an autoinjector.


----------



## AMF

paradoqs said:


> Although I agree that the basic curriculum leaves alot to be desired, I think they can bring alot of value to the ems system. I think it is shortsited to say that basics are worthless because of their education. A bsn could say the same to a medic with only a diploma. First, how many pts do we run on would have no change in outcome if they got a taxi to the ed? Alot. In my system, there are no intermediates and you have to be a basiic for atleast a year before p school, and they are highly competitive. No one here wants to hire a medic with no exp as a basic.  Also, my company charges alot less for a bls transport. Cost savings alone is a great argument for basics. Any good basic is going to know when als needs to be called in so why not start with bls atleast in ift systems. Educatiin shouldnt be the only thing that defines provider level anyway. Experience, judgement, and maturity are important too. And acting as a basic in an ems system can help achieve those things.  I dont know about other systems, but emts are indespensible in mine. There arent enough medics to go around and not enough money to pay them with. Saying basics dont have a good education is true, but discounting their value in ems is condescending and falacious.
> 
> On another note, if an emt is acting with online med control to give opiods, he/she is really just acting as the eyes and ears of the md. So, any screw up unrelated to the med admin i.e. Dosage or route is the md' problem. And its pretty hard to screw up an autoinjector.



+1.  P/P systems are very hard to maintain.  They are possible here in Maine, because our health care is subsidized, but the patients' bills can get pretty ridiculous.  Basics make the US EMS system feasible (I don't fit into this category, if you're wondering) and, as a method of giving paramedic students field experience, are an invaluable part of paramedic training.
    This does not really apply to paramedics themselves, however, in that higher trained paramedics would be a distinct advantage to the public health system, even if there were less of them.  I've heard the phrase "enough rope to hand yourself" come up in conversations about PIFT, which allows a medical control-based scope of ~ a PA (minus procedures).  There are a bunch of arguments for dealing with this, all of which make sense and none of which seem to work, but the fact that ALS providers find themselves woefully unprepared to deal with critical care patients speaks to the unreasonableness of giving basics the responsibility of administering pain medication without sufficient physiological and clinical background.
You might want to use spell check, though


----------



## Tigger

Basermedic159 said:


> What does Severe pain + nothing for pain =?


Ever needed narcotic pain management? 2mg of morphine is not going to touch most patient's pain. What's the point of a procedure if it does nothing and also adds a significant degree of liability to the service.


Basermedic159 said:


> Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.
> 
> You should remember whats infront of your patch Mr. *EMT*-paramedic


The whole "we're all EMTs at heart" line of thinking is a total load of crap. A competent EMT-B (or EMT-B/IV) should know full well how massive the difference between them and and paramedics. It's not even the difference in skills and scope, it's the massive dichotomy in human body knowledge and assessment between the two provider levels that makes the difference here. Even crappy medics still have a tremendously greater amount of schooling than most basics.


Basermedic159 said:


> Alot of fire departments are going to ALS, atleast around here they are. If OEMS would combine EMT-B and Intermediate together like they have been talking about for years, they wouldn't have to.
> 
> Not EMT-Paramedic anymore? Um yeah it is, all Paramedics are not nationally reistered? Your not a Nationally Registered Paramedic until you take the NR test...boss.
> 
> I may be new but I only "scolded" on the things I thought where incorrect,stupid etc. Im not coming in "guns blazing" I have also commented on other stuff. Just because I am new and said something you didnt like dosnt mean Im scolding anyone or have " my guns blazing" I may be new but I haven't broken any rules.h34r:


But whatever OEMS you speak of has not done so, these FDs are doing what they can do provide the best possible pre-hospital care that they can deliver to their citizens. Face it, unless you're city is full of trauma centers, a BLS EMS service is not providing the best care to the citizens.

What is the purpose in digging up old threads and saying you disagree with them? I just don't get the point.


----------



## Tigger

paradoqs said:


> Although I agree that the basic curriculum leaves alot to be desired, I think they can bring alot of value to the ems system. I think it is shortsited to say that basics are worthless because of their education. A bsn could say the same to a medic with only a diploma. First, how many pts do we run on would have no change in outcome if they got a taxi to the ed? Alot. In my system, there are no intermediates and you have to be a basiic for atleast a year before p school, and they are highly competitive. No one here wants to hire a medic with no exp as a basic.  Also, my company charges alot less for a bls transport. Cost savings alone is a great argument for basics. Any good basic is going to know when als needs to be called in so why not start with bls atleast in ift systems. Educatiin shouldnt be the only thing that defines provider level anyway. Experience, judgement, and maturity are important too. And acting as a basic in an ems system can help achieve those things.  I dont know about other systems, but emts are indespensible in mine. There arent enough medics to go around and not enough money to pay them with. Saying basics dont have a good education is true, but discounting their value in ems is condescending and falacious.
> 
> On another note, if an emt is acting with online med control to give opiods, he/she is really just acting as the eyes and ears of the md. So, any screw up unrelated to the med admin i.e. Dosage or route is the md' problem. And its pretty hard to screw up an autoinjector.



Not trying to be that guy, but spell check will do a lot to make your point clearer. That said, I see no reason why anyone needs to work as a basic before being a medic. Especially if they're going to be working for an IFT company where they will not be exposed to a lot of acutely sick and complex patients. It takes about two days to become competent with ambulance operations, and not much longer to become comfortable speaking to patients (at least for many of the people I've worked with). Will these medics be behind the 8 ball a bit when starting clinicals? Yes, but I don't a competent student couldn't overcome this.

While EMS providers are the eyes and ears of the ED docs, those eyes and ears need to be well educated to provide a clear picture to the doc. Not to mention that morphine is not a benign drug (is there such thing anyway?) and basics in most places have no way to reverse the effects of morphine.

While I agree that maturity and experience can help measure the quality of a provider, there is no way to objectively measure either of these qualities, while it is possible to do this with education.


----------



## Tigger

AMF said:


> +1.  P/P systems are very hard to maintain.  They are possible here in Maine, because our health care is subsidized, but the patients' bills can get pretty ridiculous.  Basics make the US EMS system feasible (I don't fit into this category, if you're wondering) and, as a method of giving paramedic students field experience, are an invaluable part of paramedic training.
> This does not really apply to paramedics themselves, however, in that higher trained paramedics would be a distinct advantage to the public health system, even if there were less of them.  I've heard the phrase "enough rope to hand yourself" come up in conversations about PIFT, which allows a medical control-based scope of ~ a PA (minus procedures).  There are a bunch of arguments for dealing with this, all of which make sense and none of which seem to work, but the fact that ALS providers find themselves woefully unprepared to deal with critical care patients speaks to the unreasonableness of giving basics the responsibility of administering pain medication without sufficient physiological and clinical background.
> You might want to use spell check, though



Much of Massachusetts has P/P 911 trucks because it was once a legal requirement and many towns wish to keep it that way despite the law being repealed to allow P/B. Personally I don't care either way, I think every patient deserves to be assessed initially by a paramedic and then care and transport decisions can be made after that. 

I don't see how working as BLS provider helps anyone be a better medic. I think it took me a week to get the hang of working a BLS truck, and while I enjoy working with my patients, I think anyone with some degree of social skills would not struggle if there first patient contacts were as a medic student.


----------



## paradoqs

Tigger, sorry, posting from my phone in the back of a moving ambulance while our 3rd rider drives around town is rough on my spelling ability. Most of the cars in our system do ift and emergent calls and thus see the whole range of patients. The fi process for medics is a couple of weeks and once they are cleared its sink or swim. For this reason and the ones I stated earlier, no one I know would agree with your assertion that one needs no basic experience to become a good medic. And although I can give narcan as a basic, I would be very uncomfortable if someone put morphine in my protocol.

I dont know why we need to objectively measure traits. You can be great in p school and still suck as a medic. And I can work with someone for a couple weeks and have a good idea of their maturity and professionalism without needing to see their diploma for it.

I should add that the basic in my system can start iv's and are allowed to give als drugs such as morphine when directed by the medic. So, in a sense they get alot of experience performing als skills which helps prepare them to become medics. In a system that only allows basics to drive, backboard and give 02 I could see basic exp being less helpful.


----------



## Tigger

paradoqs said:


> Tigger, sorry, posting from my phone in the back of a moving ambulance while our 3rd rider drives around town is rough on my spelling ability. Most of the cars in our system do ift and emergent calls and thus see the whole range of patients. The fi process for medics is a couple of weeks and once they are cleared its sink or swim. For this reason and the ones I stated earlier, no one I know would agree with your assertion that one needs no basic experience to become a good medic. And although I can give narcan as a basic, I would be very uncomfortable if someone put morphine in my protocol.
> 
> I dont know why we need to objectively measure traits. You can be great in p school and still suck as a medic. And I can work with someone for a couple weeks and have a good idea of their maturity and professionalism without needing to see their diploma for it.
> 
> I should add that the basic in my system can start iv's and are allowed to give als drugs such as morphine when directed by the medic. So, in a sense they get alot of experience performing als skills which helps prepare them to become medics. In a system that only allows basics to drive, backboard and give 02 I could see basic exp being less helpful.



I have the same CO certification as you as you and work in a similar system in a different state. Even with the mix of calls, let's be honest, there's not a whole a true (non-IV) basic can do in non-immediately life threatening emergency besides get a good history, make the patient comfortable, and take the patient to the hospital. 

I also do not mean that new medics should be learning basic patient contact skills once they're new medics, I mean that this can happen during their internship if they work at it. 

My point about education being quantifiable was to respond to your point that 





> Educatiin shouldnt be the only thing that defines provider level anyway. Experience, judgement, and maturity are important too.


 I agree that these are important traits, but you can classify a provider in terms of their scope of practice with these traits, this is only possible with education because you can actively test the provider's knowledge base. A mature and experienced basic might make a good medic or intermediate, but they are going to be awful if they cannot hack the education component. Education must always come first.

Also as far as I can tell, you're basics should not be giving Morphine, regardless even if it is under a medic's direction. Under the current 6 CCR 1015-3 - Chapter 2 – Practice and Medical Director Oversight 
Rules Pertaining To The State Emergency Medical And Trauma Care System  
(effective June 2011):



> 5.6  An EMT-IV may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications which exceed those listed in Appendices B and D of these rules for an EMT-IV under the direct visual supervision of an AEMT, EMT-I or
> Paramedic when the following conditions have been established:
> *5.6.1  The patient must be in cardiac arrest or in extremis. *
> 5.6.2  Drugs administered must be limited to those authorized by these rules for an AEMT, EMT-I  or Paramedic as stated in Appendices B and D.
> 5.6.3  The medical director(s) shall amend the appropriate protocols and medical continuous quality improvement program used to supervise the EMS Providers to reflect this change in patient care. The medical director(s) and the protocol(s) of the EMT-IV and the AEMT, EMT-I or Paramedic, shall all be in agreement.



Based on this, EMT-IVs are permitted to give drugs out of their scope under a higher level provider's direction provided that the patient is *in extremis*, I'm not sure what use morphine would have for a patient in extremis. I am also unaware of any services having a waiver that changes this aspect of the state protocols.


----------



## paradoqs

Tigger, do you have a url for that site pertaining to emt_iv scope? Funnily, in practice emt's push whatever they are told regardless of pt condition, and I bet alot of people dont even know about the rule you mentioned. I have a waiver for iv and odt zofran although its nowhere near as serious as morphine. If all basics do is get a good history, make pts comfortable and transport, how many calls do we get where thats all that is needed? A lot

Nevermind, i found the website


----------



## Tigger

paradoqs said:


> Tigger, do you have a url for that site pertaining to emt_iv scope? Funnily, in practice emt's push whatever they are told regardless of pt condition, and I bet alot of people dont even know about the rule you mentioned. I have a waiver for iv and odt zofran although its nowhere near as serious as morphine. If all basics do is get a good history, make pts comfortable and transport, how many calls do we get where thats all that is needed? Alot



Try http://www.cdphe.state.co.us/regulations/ems/index.html. Then look at "Chapter 1 - Rules Pertaining to EMS Education and Certification." It's in section 5, located on page 7. 

I will willingly agree that many of the emergencies that are handled by EMS can be handled by BLS without any detriment to the patient's condition. However, having a an advanced level provider available can improve the patient's condition. Pain and nausea management isn't going to save the patient's life but surely you agree that it is beneficial to the patient? I'm just arguing that EMS can do more than just make sure the patient is any worse by the time they arrive at the hospital. I'd have done a lot for some pain meds the last time I was in an ambulance, sadly the truck was non-narcotic ILS.


----------



## Basermedic159

ffemt8978 said:


> Only because I haven't spent the time checking all off your posts yet.



Check them. I haven't done anything wrong other than state my opinion, just as everyone else here is doing. I'm rubbing people the wrong way because I disagree with some things, and state my opinion. Isn't that what this site is for?

What am I supposed to do? Not comment on things I disagree with or have a different method and or opinion, just because "I'm new"?

But check my posts, you'll see I haven't done anything wrong. I read the CR and T&C


----------



## Basermedic159

Flight-LP said:


> OK, since we are going to play on the semantics....................
> 
> I am not a Nationally Registered Paramedic, I only currently hold a Texas License. No where in my title or licensure does it say EMT.
> 
> Why am I being an ***? Simple.........
> 
> You come in here with your smart a$$ attitude waving around unsubstantiated statements and then have the audacity to say you are "new" and only complaining about things that you "think are incorrect or stupid". Who are you and on what grounds does your inexperienced opinion hold any validation of fact? MY friend, everyone is entitled to an opinion. But remember the old saying about opinions?
> 
> I believe if you altered your approach a bit and became more inquisitive instead of confrontational, you may get farther with this crowd. You may also learn something along the way...........................



Inexperienced? You don't know me or my level. What grounds does my "inexperienced" opinion hold any validation? - I imagine it's the same as everyone else.


----------



## Basermedic159

Flight-LP said:


> OK, since we are going to play on the semantics....................
> 
> I am not a Nationally Registered Paramedic, I only currently hold a Texas License. No where in my title or licensure does it say EMT.
> 
> Why am I being an ***? Simple.........
> 
> You come in here with your smart a$$ attitude waving around unsubstantiated statements and then have the audacity to say you are "new" and only complaining about things that you "think are incorrect or stupid". Who are you and on what grounds does your inexperienced opinion hold any validation of fact? MY friend, everyone is entitled to an opinion. But remember the old saying about opinions?
> 
> I believe if you altered your approach a bit and became more inquisitive instead of confrontational, you may get farther with this crowd. You may also learn something along the way...........................



Also, Who says I'm not here to learn? Appearantly thats not going to be the case because you can't contradict or question anyone w/o being accused of an altered approach or "guns blazing".....


----------



## Flight-LP

Perhaps it's the approach instead of the intent?


----------



## Basermedic159

Flight-LP said:


> Perhaps it's the approach instead of the intent?



I really think thats it and I cam off as being an A$$ but i'm not, time will tell.


----------



## RocketMedic

Basermedic159 said:


> Inexperienced? You don't know me or my level. What grounds does my "inexperienced" opinion hold any validation? - I imagine it's the same as everyone else.



By your attitude, you're either new or don't want to learn to interact professionally.


----------



## STXmedic

From baser's most recent posts, he seems like he's making an effort to come off as less of an a$$... Let's ease up and give him more of a chance... Just sayin'


----------



## Basermedic159

PoeticInjustice said:


> From baser's most recent posts, he seems like he's making an effort to come off as less of an a$$... Let's ease up and give him more of a chance... Just sayin'



I am. Like I said I just went about things the wrong way. I understand people being pissed off about the way I went about things, but all I can do is learn from it and move forward.


----------



## ffemt8978

That is enough about the attitude of certain members, especially since it appears to have changed.

So lets get this back on topic before the dancing lock makes an appearance


----------



## RipCity

Rocketmedic40 said:


> Not entirely true, the armed forces count as states to the NR and FedGov and allow poorly-trained EMT-Bs (68W10/20s) to administer quite a bit. Big ones on this list are morphine, fentanyl, and valium/versed.



Who says army medics are "poorly trained EMT-b's"?? Thats quite an insult and i hope you have some proof to back it up.


----------



## STXmedic

RipCity said:


> Who says army medics are "poorly trained EMT-b's"?? Thats quite an insult and i hope you have some proof to back it up.



Pretty sure Rocket is 68W...


----------



## RocketMedic

RipCity said:


> Who says army medics are "poorly trained EMT-b's"?? Thats quite an insult and i hope you have some proof to back it up.



I am an active-duty 68w and I'm saying it. The average 68w is a poorly trained EMT-Basic. Later on that may change, but every new medic in the Army starts like that.


----------



## medic417

Basermedic159 said:


> Check them. I haven't done anything wrong other than state my opinion, just as everyone else here is doing. I'm rubbing people the wrong way because I disagree with some things, and state my opinion. Isn't that what this site is for?
> 
> What am I supposed to do? Not comment on things I disagree with or have a different method and or opinion, just because "I'm new"?
> 
> But check my posts, you'll see I haven't done anything wrong. I read the CR and T&C



Are your statements rude or attacking?  If so that makes them rules violation.


----------



## bw2529

medic417 said:


> Are your statements rude or attacking?  If so that makes them rules violation.



Ironic considering your avatar.

I'm just yanking your chain, but you see my point.


----------



## Maine iac

Who here has seen the TV show Trauma? It was on a few years ago and is floating around on Hulu. If you have not seen it is is great, well worth rotting your brain in front of the TV for that level of entertainment.

In one of the episodes the new basic on the team loads up a guy complaining of chest pain with nitro, and the pt hits the floor completely out. The medic rushes over and magically runs a 12-lead and says something about RVI causing the guy to collapse... The basic had no idea that the simple nitro which is given to everybody could be very dangerous.

Why do I bring that up? The entire premise around advancing ones skill level is the amount of education involved with moving through the ranks. Medics are trusted with giving medications because they are taught about them, the side affects, what to watch out for, what questions to ask.... Basics are not typically taught this.

IMHO if you as a basic want to give medications show that you have an understanding of the medication. This argument is way larger than "well.. .just give them preloaded syringes", or "only give them 2mg of MS," or any of the other useless answers that people are giving. WFT is 2mg of MS going to do? Nothing. The loading dose for somebody 100kg+ is 10mg MS... 

Why are we not teaching BLS providers EKG interpretation (rural areas, long ALS intercept times)? Don't you want to save somebodies life by DIAGNOSING an MI? That is way more important than MS, and EKG interpretation is much easier to learn than even the basic pharmacology.

End of long rant- you want MS? Show me you know what you are doing with it.


----------



## Mountain Res-Q

Maine iac said:


> Who here has seen the TV show Trauma? It was on a few years ago and is floating around on Hulu. If you have not seen it is is great, well worth rotting your brain in front of the TV for that level of entertainment.
> 
> In one of the episodes the new basic on the team loads up a guy complaining of chest pain with nitro, and the pt hits the floor completely out. The medic rushes over and magically runs a 12-lead and says something about RVI causing the guy to collapse... The basic had no idea that the simple nitro which is given to everybody could be very dangerous.
> 
> Why do I bring that up? The entire premise around advancing ones skill level is the amount of education involved with moving through the ranks. Medics are trusted with giving medications because they are taught about them, the side affects, what to watch out for, what questions to ask.... Basics are not typically taught this.
> 
> IMHO if you as a basic want to give medications show that you have an understanding of the medication. This argument is way larger than "well.. .just give them preloaded syringes", or "only give them 2mg of MS," or any of the other useless answers that people are giving. WFT is 2mg of MS going to do? Nothing. The loading dose for somebody 100kg+ is 10mg MS...
> 
> Why are we not teaching BLS providers EKG interpretation (rural areas, long ALS intercept times)? Don't you want to save somebodies life by DIAGNOSING an MI? That is way more important than MS, and EKG interpretation is much easier to learn than even the basic pharmacology.
> 
> End of long rant- you want MS? Show me you know what you are doing with it.



Basing an argument on Trauma?  LMAO.  It sparked a number of debates when it was on and the general consensus was that it was crap and a disservice to EMS.  There is a reason why it never even completed a single season.

That said, I agree with you general reasoning for the average EMT (maybe not as it pertains to nitro; every FR should know that).  Solution: keep the scope small or increase EMT standards for education.  IMO, the EMTs that think they should have more drugs in their box are either new and do not understand the validity of you statements regarding pharmacological knowledge.  Or they are old and seasoned, not recognizing that while they may be at a knowledge level to have their drug box expanded, the certification is what must be judged, not the person.


----------



## Basermedic159

medic417 said:


> Are your statements rude or attacking?  If so that makes them rules violation.



Dude, your only about 2 days late... I've already talked to someone about it.
Plus if you read the community leaders post, I think he said thats enough about members attitudes...Like the other guy said look at your avatar, and your other posts:lol:


----------



## ffemt8978

medic417 said:


> Are your statements rude or attacking?  If so that makes them rules violation.





bw2529 said:


> Ironic considering your avatar.
> 
> I'm just yanking your chain, but you see my point.



That whole topic was handled via PM, so that's enough of it.  Let's get back on topic, please.


----------



## RocketMedic

RipCity said:


> Who says army medics are "poorly trained EMT-b's"?? Thats quite an insult and i hope you have some proof to back it up.



Do you disagree?


----------



## paradoqs

Why are they poorly trained? I would imagine there are alot if opportunities to get experience, especially trauma.


----------



## RipCity

Rocketmedic40 said:


> Do you disagree?


I would totally disagree. How can you say that after 5 months of training they are merely "poorly trained emt-b's"? Even brand new cherry medics have have a huge amount of knowelage compared to a civilian trained basic. IV/IO access, needle decompression, cric, morphine/antibiotics, chest tubes just to name a few skills.


----------



## JPINFV

Because dealing primarily with traumatic injuries, and the corresponding infection, in generally healthy and young patients is totally a similar patient population and presentation as found in civilian EMS.


----------



## Tigger

paradoqs said:


> Why are they poorly trained? I would imagine there are alot if opportunities to get experience, especially trauma.


Plenty of experience in dealing with trauma I am sure. However how much significant trauma is the average EMT-B dealing with? Not that much...


RipCity said:


> I would totally disagree. How can you say that after 5 months of training they are merely "poorly trained emt-b's"? Even brand new cherry medics have have a huge amount of knowelage compared to a civilian trained basic. IV/IO access, needle decompression, cric, morphine/antibiotics, chest tubes just to name a few skills.



You don't judge a provider's competency by their list of skills. If my dog was a touch smarter, I'd teach him to crich too.


----------



## RipCity

JPINFV said:


> Because dealing primarily with traumatic injuries, and the corresponding infection, in generally healthy and young patients is totally a similar patient population and presentation as found in civilian EMS.



Was that sarcasm? Deal primarily with traumatic injuries? Well there arent many GSW's and blast injuries back on base in the states. So what do medics do? They run sick call. They write soap notes on anything from chronic pn, injuries and illness. I cant even remember how many times some of the older soldiers came in after physical training with dizziness and chest pn. Who does the immunizations for the whole unit of 300 soldiers? Medics. Blood draws? Medics. In iraq i had to deal with civilian medical problems when out on patrol, all through in interpreter. I can go on all day. As long as were comparing military EMS to Civilian EMS, almost everything a medic does in the field is out of a aid bag the size of a normal backpack. They dont have the luxury of a fully stocked ambulance. So to merely give them the title "poorly trained emt-b's" to me is BS. Thats all im sayin.


----------



## JPINFV

Oh, immunizations and blood draws? Wow, SOAP notes too! [sarcasm]Oh, impressive. [/sarcasm] So, how many antibiotics do you have access to and to treat which diseases, or are you simply shotgunning everything with a second generation cephalosporin? Do you get a culture before throwing antibiotics at the situation, or is this more of a "does it burn when you pee? Oh, look, positive for leukocyte esterase and nitrates, here's some trimethoprim-sulfoximide" style straight up clinical diagnoses?


----------



## Handsome Robb

RipCity said:


> I would totally disagree. How can you say that after 5 months of training they are merely "poorly trained emt-b's"? Even brand new cherry medics have have a huge amount of knowelage compared to a civilian trained basic. IV/IO access, needle decompression, cric, morphine/antibiotics, chest tubes just to name a few skills.



Can your average 68W explain the physiology about what's happening? Or is it a "monkey see, monkey do" type thing? None of those skills are really _that_ difficult to perform...It's the knowing when and why that becomes the more complex part. 

Not an attack, I truly am wondering.


----------



## ffemt8978

NVRob said:


> It's the knowing when and why that becomes the more complex part.
> 
> Not an attack, I truly am wondering.


I'd argue that even more important than that is when NOT to do them.


----------



## Handsome Robb

ffemt8978 said:


> I'd argue that even more important than that is when NOT to do them.



Touche salesman.


----------



## RocketMedic

RipCity said:


> I would totally disagree. How can you say that after 5 months of training they are merely "poorly trained emt-b's"? Even brand new cherry medics have have a huge amount of knowelage compared to a civilian trained basic. IV/IO access, needle decompression, cric, morphine/antibiotics, chest tubes just to name a few skills.



68w's are trained to recognize and apply initial aid to massive life threats. They aren't taught how those interventions work, why they work, or what to do next. They are not trained as to what medications they commonly carry, what those medications do, or how to give them. They are not trained on medical assessments or on focused exams. They are not trained to think beyond a nine-line. Their charts are simplified nearly to the TC3 card. Their "sick call" consists of following algorithms or taking vitals and a spoomfed history and asking a PA or NCO. They are not trained at triage, treatment of non-typical wounds, or most medical maladies.

A 68w is trained to CLS+. They are taught a few skills and sent out. The burden of training is on the individual and the receiving unit.

If I have a limb amputated or a penetrating chest wound, a 68w can provide good BLS care and mediocre ALS. Anything else is a crapshoot.

Before you ask, I am an exception to the rule. I'm an active E4, a paramedic, and I work part time outside. IIlve also been a line medic downrange in Hawkish Province, Iraq


----------



## RipCity

NVRob said:


> Can your average 68W explain the physiology about what's happening? Or is it a "monkey see, monkey do" type thing? None of those skills are really _that_ difficult to perform...It's the knowing when and why that becomes the more complex part.
> 
> Not an attack, I truly am wondering.



Well they can be difficult to do while only wearing NODS(night vision) or after you just got shot at, or after a mortar landed 20 meters from you and you have been in 120 degree heat with 120 pounds of gear on all day... so yea id say a bit more difficult. And yes combat medics learn alot of anatomy and physiology. They dont just hand you equipment without explaining indications/contraindications. Im not here to try and convince you all that army medics are the most BA MF medical personell walking the earth, but when someone casually refers to something i spent 4 years working my *** off doing as just a "poortly trained EMT-Basic", then i get a bit offended.


----------



## RocketMedic

paradoqs said:


> Why are they poorly trained? I would imagine there are alot if opportunities to get experience, especially trauma.



This is highly unit dependent. A medic assigned to a hospital will quickly become, at a minimum, technically competent. A line or support medic will not receive much musical training, and what training they do get will often be either tied to TC3 point of injury care or EFMB memorization.

Some units are exceptions, and some medics are far better trained.


----------



## RocketMedic

RipCity said:


> Well they can be difficult to do while only wearing NODS(night vision) or after you just got shot at, or after a mortar landed 20 meters from you and you have been in 120 degree heat with 120 pounds of gear on all day... so yea id say a bit more difficult. And yes combat medics learn alot of anatomy and physiology. They dont just hand you equipment without explaining indications/contraindications. Im not here to try and convince you all that army medics are the most BA MF medical personell walking the earth, but when someone casually refers to something i spent 4 years working my *** off doing as just a "poortly trained EMT-Basic", then i get a bit offended.



That's what a 68w is. To pretend anything otherwise is dishonest. That being said, there are exceptions. My last PA handed out medications and never bothered to explain much of anything, and somehow expected his treatment squad to understand EKGs with no instruction. My new PA is much better.

Dude, 68ws have NCOs who don't know what 10mg of MS is, much less how to give it or why/what it does. Asking what it is is a whole new level of pointless.


----------



## ffemt8978

Rocketmedic40 said:


> A line or support medic will not receive much *musical* training,



That's a good thing.  I don't want my medic serenading me with the blues.


----------



## RocketMedic

RipCity said:


> Well they can be difficult to do while only wearing NODS(night vision) or after you just got shot at, or after a mortar landed 20 meters from you and you have been in 120 degree heat with 120 pounds of gear on all day... so yea id say a bit more difficult. And yes combat medics learn alot of anatomy and physiology. They dont just hand you equipment without explaining indications/contraindications. Im not here to try and convince you all that army medics are the most BA MF medical personell walking the earth, but when someone casually refers to something i spent 4 years working my *** off doing as just a "poortly trained EMT-Basic", then i get a bit offended.




Adverse conditions are not an acceptable excuse for poor education and shouldn't be an excuse for poor care. Besides, even in an infantry role, those situations are uncommon, and the interventions are CLS-level.

I have new medics who can't tell me what an IV IS, much less how/why it works, when or where to start one, and what can be done with it. Theuly literally only know for volume replacement and dehydration, and can't even explain how fluids correct those.


----------



## RipCity

Rocketmedic40 said:


> 68w's are trained to recognize and apply initial aid to massive life threats. They aren't taught how those interventions work, why they work, or what to do next. They are not trained as to what medications they commonly carry, what those medications do, or how to give them. They are not trained on medical assessments or on focused exams. They are not trained to think beyond a nine-line. Their charts are simplified nearly to the TC3 card. Their "sick call" consists of following algorithms or taking vitals and a spoomfed history and asking a PA or NCO. They are not trained at triage, treatment of non-typical wounds, or most medical maladies.
> 
> A 68w is trained to CLS+. They are taught a few skills and sent out. The burden of training is on the individual and the receiving unit.
> 
> If I have a limb amputated or a penetrating chest wound, a 68w can provide good BLS care and mediocre ALS. Anything else is a crapshoot.
> 
> Before you ask, I am an exception to the rule. I'm an active E4, a paramedic, and I work part time outside. IIlve also been a line medic downrange in Hawkish Province, Iraq



I dont know know when you went through medic school, but i went through in 2005 and it was the complete opposite. Maybe they have relaxed the standards since then, i dont know. Anyways i wasnt just a "poorly trained emt-b" so thats why i said what i did.


----------



## RocketMedic

RipCity said:


> Was that sarcasm? Deal primarily with traumatic injuries? Well there arent many GSW's and blast injuries back on base in the states. So what do medics do? They run sick call. They write soap notes on anything from chronic pn, injuries and illness. I cant even remember how many times some of the older soldiers came in after physical training with dizziness and chest pn. Who does the immunizations for the whole unit of 300 soldiers? Medics. Blood draws? Medics. In iraq i had to deal with civilian medical problems when out on patrol, all through in interpreter. I can go on all day. As long as were comparing military EMS to Civilian EMS, almost everything a medic does in the field is out of a aid bag the size of a normal backpack. They dont have the luxury of a fully stocked ambulance. So to merely give them the title "poorly trained emt-b's" to me is BS. Thats all im sayin.



Blood draws and SRP immunization drives are about as cookie cutter as it gets. Screen patients,  prep injections, inject and chart. I can do those in my sleep.


----------



## ffemt8978

Why don't you two take this discussion of military medics to the Military/Tactical/Wilderness Forum, where it would be more appropriate for it's own thread.

Otherwise, you two will create more work for me here.


----------



## RocketMedic

RipCity said:


> I dont know know when you went through medic school, but i went through in 2005 and it was the complete opposite. Maybe they have relaxed the standards since then, i dont know. Anyways i wasnt just a "poorly trained emt-b" so thats why i said what i did.



There's a rumor from our new guys that the NR will be optional as of this month. We get our next crop in March, so Ill know then if standards have further slipped.

Did you and/or your peers really understand what y'all were doing?


----------



## RocketMedic

Can do.

Back on topic, I'd agree with one of the other replies. If you want to be given the ability to provide medication, earn that ability with knowledge and education. Don't be a Basic wanting loose protocols without education.


----------



## RipCity

Rocketmedic40 said:


> Adverse conditions are not an acceptable excuse for poor education and shouldn't be an excuse for poor care. Besides, even in an infantry role, those situations are uncommon, and the interventions are CLS-level.
> 
> I have new medics who can't tell me what an IV IS, much less how/why it works, when or where to start one, and what can be done with it. Theuly literally only know for volume replacement and dehydration, and can't even explain how fluids correct those.



I never said they were an excuse. I dont know what to tell you brother it sounds like Ft Sam is pumping out crap medics or your in a crap unit does doesnt put a big emphasis on the "why?" of medicine. Our PA held classes 2 or 3 times a week and made tests for us about A&P, pharmacology etc. they even had EMT-B refreshers with mock scenarios just so we stayed current on the knowelage. He would never just hand us random drugs to give.


----------



## RocketMedic

RipCity said:


> I never said they were an excuse. I dont know what to tell you brother it sounds like Ft Sam is pumping out crap medics or your in a crap unit does doesnt put a big emphasis on the "why?" of medicine. Our PA held classes 2 or 3 times a week and made tests for us about A&P, pharmacology etc. they even had EMT-B refreshers with mock scenarios just so we stayed current on the knowelage. He would never just hand us random drugs to give.



Nailed it on both counts I think. New 68w is pretty much untrained.


----------



## ffemt8978

Last warning...stop the threadjacking and stay on topic.


----------



## DHFD402

Morphine is in no way, shape, or form able to be administered by an EMT Basic...


----------



## Basermedic159

I hope this is not too off topic, but I think the drug formulary/skills of an EMT and an Intermediate should be combined. OEMS has been talking about consolidating them for about 5 years now. Instead of EMT-B, EMT-I, EMT-P It would just be Advanced EMT and EMT-Paramedic. I think its a great idea. Of course the basics would need to have additional training, but I think this is what needs to happen.


----------



## Tigger

DHFD402 said:


> Morphine is in no way, shape, or form able to be administered by an EMT Basic...



Not sure about now, but I have read on this forum of basics in Montana (I think) administering morphine via autoinjector following OLMC approval.



Basermedic159 said:


> I hope this is not too off topic, but I think the drug formulary/skills of an EMT and an Intermediate should be combined. OEMS has been talking about consolidating them for about 5 years now. Instead of EMT-B, EMT-I, EMT-P It would just be Advanced EMT and EMT-Paramedic. I think its a great idea. Of course the basics would need to have additional training, but I think this is what needs to happen.


I would support such an idea, the death of the BLS emergency ambulance needs to be hastened in many areas.


----------



## JPINFV

Tigger said:


> I would support such an idea, the death of the BLS emergency ambulance needs to be hastened in many areas.



Not according to a Facebook EMS group discussion. Those poor brave heroic EMTs are the only thing racing the reaper, armed only with an oxygen tank and compassion. 


Ever write something that almost makes you vomit because you have to actually think about the words as you write it? Yea, that just happened to me.


----------



## Handsome Robb

Basermedic159 said:


> I hope this is not too off topic, but I think the drug formulary/skills of an EMT and an Intermediate should be combined. OEMS has been talking about consolidating them for about 5 years now. Instead of EMT-B, EMT-I, EMT-P It would just be Advanced EMT and EMT-Paramedic. I think its a great idea. Of course the basics would need to have additional training, but I think this is what needs to happen.



The thing I don't understand is if there are only two levels why it has to be "Advanced EMT"? Why not just EMT and Paramedic? ILS and ALS. Maybe a BLS designation in certain rural areas but limit it to that. 

But that's another argument all together. 

I still stand by my stance that BLS providers and even some ILS providers have no business dealing with and administering narcotics until the education standard increases. 

The autoinjector idea is cool but then you are pretty limited on your decision for dosing. Especially in weight based pediatric dosages.


----------



## JPINFV

Why not "Basic Paramedic" and "Advanced Paramedic" or something similar. After all, until we can provide a single unified name do we really have a foot to stand on when a news article calls us "ambulance drivers"?


----------



## Handsome Robb

JPINFV said:


> Why not "Basic Paramedic" and "Advanced Paramedic" or something similar. After all, until we can provide a single unified name do we really have a foot to stand on when a news article calls us "ambulance drivers"?



You make a very good point sir. 

Here even though we ride I/P all the firefighters always tell people "Sir/Ma'am the Paramedics are here."


----------



## JPINFV

NVRob said:


> You make a very good point sir.
> 
> Here even though we ride I/P all the firefighters always tell people "Sir/Ma'am the Paramedics are here."




To be fair, it was my very first blog post...

http://emtmedicalstudent.wordpress.com/2010/10/31/whatarewe/


----------



## RocketMedic

As ling as I'm not "Jeeves"...


----------



## Medic Tim

JPINFV said:


> Why not "Basic Paramedic" and "Advanced Paramedic" or something similar. After all, until we can provide a single unified name do we really have a foot to stand on when a news article calls us "ambulance drivers"?



Most of Canada switched to Paramedic levels years ago. It is a much more understood term to the public. Primary Care Paramedic- PCP is in line with an Intermediate, Advanced Cara Paramedic- ACP is in line with the paramedic, and Critical Care Paramedic -CCP is mostly hospital based. very few of them skill set closer to a PA than anything else. In alot of areas the PCP is the minimum to run on a truck.


----------



## R99

JPINFV said:


> Why not "Basic Paramedic" and "Advanced Paramedic" or something similar. After all, until we can provide a single unified name do we really have a foot to stand on when a news article calls us "ambulance drivers"?



We've changed titles a bunch of times 

1972 paramedic trial in auckland
1975 ambulance officer level formally established
early 1980s intermediate care officers introduced
mid 1980s advanced care officer (paramedic) established

1980s to 2002 ambulance officer, intermediate care officer, paramedic

2002 to 2009 ambulance officer, paramedic, advanced paramedic

2009 onward emergency medical technician, paramedic, intensive care paramedic

in US you use EMT and Paramedic no?


----------



## JPINFV

Medic Tim said:


> Most of Canada switched to Paramedic levels years ago. It is a much more understood term to the public. Primary Care Paramedic- PCP is in line with an Intermediate, Advanced Cara Paramedic- ACP is in line with the paramedic, and Critical Care Paramedic -CCP is mostly hospital based. very few of them skill set closer to a PA than anything else. In alot of areas the PCP is the minimum to run on a truck.




That's basically where I got [stole] the idea from...


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## triemal04

Medic Tim said:


> Most of Canada switched to Paramedic levels years ago. It is a much more understood term to the public. Primary Care Paramedic- PCP is in line with an Intermediate, Advanced Cara Paramedic- ACP is in line with the paramedic, and Critical Care Paramedic -CCP is mostly hospital based. very few of them skill set closer to a PA than anything else. In alot of areas the PCP is the minimum to run on a truck.


How has that worked out as far as public perception goes?  I'm guessing the difference in healthcare systems and how EMS is run will make a difference, don't know about any difference in media coverage/accuracy, but I've been curious for awhile.

The problem I can see with any designator that is designed as either XXX-paramedic or EMT-XXX is that, even though there are different level's, they still sound very much alike.  And in the US at least, it is much more common for people to assume that everyone is an EMT with the same skillset; either guessing that to much or to little will be done.  My guess would be it's the same in Canada; most people assume that every PCP, ACP and maybe CCP are all going to do/know the same things because they can't see the difference.  But you can answer that better than me.

The NREMT seems to have caught on to this; EMT, Advanced EMT (still could be a problem) and Paramedic.  Makes sense.


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## Tigger

NVRob said:


> You make a very good point sir.
> 
> Here even though we ride I/P all the firefighters always tell people "Sir/Ma'am the Paramedics are here."



Where I work at school the AMR crews made up "Colorado Springs Paramedics" hoodies and hats. They work P/B, yet you can be sure that the basics are all wearing the same stuff. I don't like it.


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## docmoods

R99 said:


> in US you use EMT and Paramedic no?



Yea, depending on what state your in depends on the level of care, for instance in New Jersey there's only EMT-B (Basic only first aid with very little difference to first responder) and Paramedic. In most other states they recognize EMT-I (Intermediate) and they can perform higher medical treatment (IV, Combitube, Narcan ect.).


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## MontanaEMT

Montana EMT B's can do Morphine injecotr if they have the Medication endorsment


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