# New NRP bridge and scope



## ExpatMedic0 (Dec 16, 2012)

I am in the process of signing up for the new NREMT-P to NRP bridge and I was quite surprised at the new minimum standard skill set for Paramedics. Some of it many people have been doing, but not everything. I have included it below. Does anyone know if new a Paramedics education has been extended by a lot to incorporate this stuff? 

 For a current 1998 EMT-Paramedic (based on 1998 EMT-P National Standard Curriculum) transitioning to 2009 Paramedic, the following skills are new:
Use of BiPAP/CPAP
Waveform capnography
Monitoring and management of a chest tube
Assist in the insertion of a chest tube
Performing a percutaneous cricothyrotomy
Accessing indwelling catheters and implanted central IV ports
Central line monitoring
Initiation of intraosseous infusion in all patients (previously used IOs on children only)
Intranasal medication administration (1998 Paramedic limited to intranasal decongestants)
Eye irrigation with the Morgan® lens
Initiation and monitoring of thrombolytic medication
Blood chemistry analysis (includes psychomotor skills involved with collection of blood for analysis [point of care testing] and the cognitive material necessary to understand implications of results)


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## lightsandsirens5 (Dec 16, 2012)

I was taught all of those in medic school and am currently allowed to do all except for thrombolytics.


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## ExpatMedic0 (Dec 16, 2012)

I have been outside the U.S. for a few years, but I see a few items that would be new for me


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## medic417 (Dec 16, 2012)

I was taught and did many of those as an Intermediate and the rest as a Paramedic. Not really anything that is new in my area.


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## Christopher (Dec 16, 2012)

schulz said:


> I am in the process of signing up for the new NREMT-P to NRP bridge and I was quite surprised at the new minimum standard skill set for Paramedics. Some of it many people have been doing, but not everything. I have included it below. Does anyone know if new a Paramedics education has been extended by a lot to incorporate this stuff?
> 
> For a current 1998 EMT-Paramedic (based on 1998 EMT-P National Standard Curriculum) transitioning to 2009 Paramedic, the following skills are new:
> Use of BiPAP/CPAP
> ...



None of those are outside of my current protocols. We just never see chest tubes (crit care services typically do those transfers), are too close to pPCI centers for lytics, and need MC orders for central line access.

I should add we're mandated to use waveform capno in our area, or you don't practice as a medic.


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## Veneficus (Dec 16, 2012)

Officially no program is mandated to increase their time, but the two programs I am familiar with have found they have had to in order to incorperate the changes.

The same thing happened in 2000. Officially from the State, paramedic class has to be a minimum of 750 hours.

Some places still stick to this as the maximum, but there are one or two students here that are in those programs. It doesn't seem to be working out for them.


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## DrankTheKoolaid (Dec 16, 2012)

Have been doing them all already except for initiation of thromobolytics. Only 1 EMS system in California starts thromobolytics in the field that I'm aware of.


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## NomadicMedic (Dec 16, 2012)

None of this is new for me. Monitored and transported chest tubes, placed central lines and my old fire department had protocols for lytics in a STEMI. Nothing new here. 

Apparently, our medical directors and education department are building the bridge course now to cover the next round of reverts.


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## CANMAN (Dec 17, 2012)

n7lxi said:


> None of this is new for me. Monitored and transported chest tubes, placed central lines and my old fire department had protocols for lytics in a STEMI. Nothing new here.
> 
> Apparently, our medical directors and education department are building the bridge course now to cover the next round of reverts.



When you are saying "placed central lines" are you talking about accessing existing lines, because thats what the guidelines are talking about? I know of no services, EMS wise, that are placing central lines, with the exception of Flight Programs.


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## Christopher (Dec 17, 2012)

CANMAN13 said:


> When you are saying "placed central lines" are you talking about accessing existing lines, because thats what the guidelines are talking about? I know of no services, EMS wise, that are placing central lines, with the exception of Flight Programs.



Technically our Crit Care Medics folks can do fem lines by scope...but I'm unaware of any service allowing it.


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## CANMAN (Dec 17, 2012)

Right, that was my point, if you are functioning in a true Critical Care Ground or Flight Program and have the additional training, which is normally coupled with an aggressive medical director..... However I was saying I know of no 911 programs doing such things.


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## Veneficus (Dec 17, 2012)

CANMAN13 said:


> Right, that was my point, if you are functioning in a true Critical Care Ground or Flight Program and have the additional training, which is normally coupled with an aggressive medical director..... However I was saying I know of no 911 programs doing such things.



and considering an IO is faster, easier, has less complications, and often just as good unless you are transfusing or reinfusing, there probably is not valid reason for anyone to be doing this in EMS.


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## Outbac1 (Dec 17, 2012)

Use of BiPAP/CPAP
Waveform capnography
Monitoring and management of a chest tube
Assist in the insertion of a chest tube
Performing a percutaneous cricothyrotomy
Accessing indwelling catheters and implanted central IV ports
Central line monitoring
Initiation of intraosseous infusion in all patients (previously used IOs on children only)
Intranasal medication administration (1998 Paramedic limited to intranasal decongestants)
Eye irrigation with the Morgan® lens
Initiation and monitoring of thrombolytic medication
Blood chemistry analysis (includes psychomotor skills involved with collection of blood for analysis [point of care testing said:
			
		

> and the cognitive material necessary to understand implications of results)



For our ACP  I believe we were taught  everything but the Morgan lens. I remember discussing blood chemistry results but we were not taught the actual testing of it. 
 At my service I wish we had capnography but we do initiate thrombolytics. 
 Time wise it wasn't an issue as there is about 1000 hrs of class and lab time in the course. Plus about 900 more in the hospital and as a student on an ambulance. The prerequiste PCP course is almost as long. 

 This leads me to a question:

There has been much discussion here about the length of time for both the EMT -B and the EMT-P courses. The education requirements for Austrailia and New Zealand have moved to a four year degree. (We, Canada, are not quite there yet). If it means bringing up the standard of EMS care in the US how many of you are willing to do either the four yr degree or Canada's model?

 Canada's model costs about $30,000.00 and 23 months in full time school to be an  "Paramedic". 
(Full time is 7 hrs /day 5 days a week for 15 months and 560 hrs hospital time and 1000 hrs as student on an ambulance. Combined PCP and ACP.)


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## Akulahawk (Dec 17, 2012)

schulz said:


> I am in the process of signing up for the new NREMT-P to NRP bridge and I was quite surprised at the new minimum standard skill set for Paramedics. Some of it many people have been doing, but not everything. I have included it below. Does anyone know if new a Paramedics education has been extended by a lot to incorporate this stuff?
> 
> For a current 1998 EMT-Paramedic (based on 1998 EMT-P National Standard Curriculum) transitioning to 2009 Paramedic, the following skills are new:
> Use of BiPAP/CPAP
> ...



The only things that I and the list above that are new to me are: none of the above. The paramedic program that I attended back in 2000 – 2001 included all of those subjects above. In the intervening years, it has only been relatively recently that some of that information has actually reached the field. In my current County, to the best of my knowledge, we are still unable to monitor central lines, chest tubes, initiate or monitor thrombolytics, do blood chemistry analysis beyond blood glucose levels, and the like. Outside of some individually authorized companies, paramedics are not even authorized to monitor IV solutions containing potassium. Those that _are _authorized can monitor up to 20 mEq/L at a rate that is predetermined by the facility. Of course, this was approximately 10 years ago, it is unknown if they are still using dial-a-flow devices or if they have upgraded to using pumps. This is because I have not had a chance to work in the field out here for several years.

Eventually, I will end up taking the transition course and upgrade/regain my NR EMT certificate as a paramedic. The process will not be horribly difficult for me as I still maintain my paramedic license. The only thing that I worry about with the new postnomial letters "NRP" is that in addition to standing for "Nationally Registered Paramedic" it also stands for "Neonatal Resuscitation Program" and it could be confusing.


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## medic417 (Dec 18, 2012)

Outbac1 said:


> For our ACP  I believe we were taught  everything but the Morgan lens..)



Morgan lens is a basic skill.


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## ExpatMedic0 (Dec 18, 2012)

wait... I thought everyone got bilateral 18G in the AC wide open, 15L O2 and titrate everything to effect? If in doubt call Rampart ?
:unsure::unsure:


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## NomadicMedic (Dec 18, 2012)

CANMAN13 said:


> When you are saying "placed central lines" are you talking about accessing existing lines, because thats what the guidelines are talking about? I know of no services, EMS wise, that are placing central lines, with the exception of Flight Programs.



I am talking about reaching into the ALS bag, pulling out a central line kit and placing a subclavian central line. 

Now, we don't do it at my current service, but in Washington it's taught in the paramedic program and some services still use them. I worked in Jefferson County and was told the doc preferred a central line over an IO!

I've done two in my life. I always just placed an IO, but it was in my scope, the same as a pericardiocentesis.


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## medicdan (Dec 18, 2012)

n7lxi said:


> I am talking about reaching into the ALS bag, pulling out a central line kit and placing a subclavian central line.
> 
> Now, we don't do it at my current service, but in Washington it's taught in the paramedic program and some services still use them. I worked in Jefferson County and was told the doc preferred a central line over an IO!
> 
> I've done two in my life. I always just placed an IO, but it was in my scope, the same as a pericardiocentesis.



I have no doubt central lines are taught in many programs, and within protocol in states, but doesn't External Jugular access function as central venous access? That is certainly taught in all paramedic programs...


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## ExpatMedic0 (Dec 18, 2012)

n7lxi said:


> I am talking about reaching into the ALS bag, pulling out a central line kit and placing a subclavian central line.
> 
> Now, we don't do it at my current service, but in Washington it's taught in the paramedic program and some services still use them.


I am took my medic in Washington state, Clark county in 2006 and I do not recall being taught this.


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## NomadicMedic (Dec 18, 2012)

schulz said:


> I am took my medic in Washington state, Clark county in 2006 and I do not recall being taught this.



I just looked at the updated Northwest region protocols and central lines are no longer included. I'll look for my old copy of the protocols and post it. 

We were taught the placement of subclavian central lines in the TCC paramedic program, and in 2010, had a Jeff County base station skills night where we had to demonstrate competency on a manikin. 

If you were not taught this skill, that's fine. However, I was, and I was expected to know how to do it. 

As I said, I usually just drilled an IO, as it was easier and a lot less messy.


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## NomadicMedic (Dec 18, 2012)

I must have tossed the binder with the protocols, but if you're really doubting that we did place central lines, Dr Smith-Poling is still the medical director and I'm sure she can corroborate my claims. 

Also, King County Medic One doesn't have an IO device. They, last I knew, still place central lines.


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## Fox800 (Jan 7, 2013)

n7lxi said:


> Also, King County Medic One doesn't have an IO device. They, last I knew, still place central lines.



Interesting, but kind of silly. Especially since EZ-IO's are becoming very commonplace in emergency departments. It sure was nice to have a catheter in place while my EMT was still finishing flushing out the bag...


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## CANMAN (Jan 7, 2013)

I am not doubting your honesty in the least, but hopefully with the introduction of the EZ I.O. they have gone away from this. The outta hospital infection rate alone would be a huge concern, gained you have gotten access pre-hospital but now the pt. is going to die of a overwhelming sepsis. The hospitals around my way will not even keep a field I.V. start over 24hrs.


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## Fox800 (Jan 7, 2013)

CANMAN13 said:


> I am not doubting your honesty in the least, but hopefully with the introduction of the EZ I.O. they have gone away from this. The outta hospital infection rate alone would be a huge concern, gained you have gotten access pre-hospital but now the pt. is going to die of a overwhelming sepsis. The hospitals around my way will not even keep a field I.V. start over 24hrs.



Well said. Central line placement is supposed to be a sterile technique. There's no way you can say that's going to happen in a Wal-Mart, parking lot, bathroom, etc. Especially not in an ambulance.


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## reaper (Jan 7, 2013)

Funny thing is, back in early 90's when we still did chest tubes in the field. There was a big study that showed the infection rate for chest tubes were twice as high in the ED, then in the field. The reason they found was that in the field we would try harder to keep it clean and sterile, because we were worried more about it then the drs in the ED.

So the sterile issue on ivs gets old. I know I clean the sites better then the ED does. Tegaderm placed right away keep things pretty clean. Just takes having caution in your procedures. Btw, our hospitals will use field ivs up to 48hrs. They change all ivs at 48hr intervals.


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## Dwindlin (Jan 7, 2013)

My old service placed subclavian lines in the field. Went away with mainstream introduction of EZ-IO.


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## FLdoc2011 (Jan 7, 2013)

Dwindlin said:


> My old service placed subclavian lines in the field. Went away with mainstream introduction of EZ-IO.



Were y'all able to do chest tubes as well, or at least needle decompression?  If you're going to be doing procedures then you need to be able to handle the complications.   

From a prehospital standpoint I don't see the need of central lines being put in in the field, especially with the IO if you just can not get peripheral access.   You're not going to be able to push fluids any faster through a typical 8Fr multi-lumen central line as opposed to a good large bore peripheral line, with something like a cordis being an exception.   

When I use an IJ or subclavian,  I'm also using it for measuring CVP and/or ScVO2 which isn't done prehospital.


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## Dwindlin (Jan 8, 2013)

FLdoc2011 said:


> Were y'all able to do chest tubes as well, or at least needle decompression?  If you're going to be doing procedures then you need to be able to handle the complications.
> 
> From a prehospital standpoint I don't see the need of central lines being put in in the field, especially with the IO if you just can not get peripheral access.   You're not going to be able to push fluids any faster through a typical 8Fr multi-lumen central line as opposed to a good large bore peripheral line, with something like a cordis being an exception.
> 
> When I use an IJ or subclavian,  I'm also using it for measuring CVP and/or ScVO2 which isn't done prehospital.



We did needle decompression. And I happen to agree with you about pre-hospital CVL's but again this was before IO's were easily available for adults.  Also we placed a cordis, not a multilumen line.


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## Fox800 (Jan 9, 2013)

I'd like to see data on the efficacy of needle decompression vs. chest tube placement.


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## Action942Jackson (Feb 6, 2013)

Central lines take too much time in an emergent situation. Just grab the IO gun and drill baby, drill.  Two finger widths below the bony notch on the shoulder and drill.  Humoral head IOs are larger and more effective then a central line, much larger fluid volumes can be pushed through vs a CL.  The only thing I can see with CLs is the monitoring aspect.  If you have one in place you can thread additional lines for PWP, MAP, Etc. through them without having to redo the line.


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## Action942Jackson (Feb 6, 2013)

Unless of course, you've got a double upper extremity amputee.  Then well.... Whatever works! Lol.


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## usalsfyre (Feb 6, 2013)

Action942Jackson said:


> Central lines take too much time in an emergent situation. Just grab the IO gun and drill baby, drill.  Two finger widths below the bony notch on the shoulder and drill.  Humoral head IOs are larger and more effective then a central line, much larger fluid volumes can be pushed through vs a CL.  The only thing I can see with CLs is the monitoring aspect.  If you have one in place you can thread additional lines for PWP, MAP, Etc. through them without having to redo the line.



Errr, the only thing you can monitor off a normal central line is CVP....I REALLY don't think any program is going to float a PA cath....

The situation where central line placement is useful is CCT, some smaller (esp NP/PA or FM covered) EDs aren't real comfortable placing them. Useful to throw in a central prior to transport rather than manage multiple pressors in peripheral lines. Outside that, kinda pointless.


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## DrankTheKoolaid (Feb 6, 2013)

Fox800 said:


> I'd like to see data on the efficacy of needle decompression vs. chest tube placement.



Even better, give us finger thoracostomy.


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## Action942Jackson (Feb 6, 2013)

Err my bad.  I was talking CC sense with swan ganz caths through the EJ.  Got the two confused.  Still trying to get the CC stuff down pat.


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## Action942Jackson (Feb 6, 2013)

Any I don't see any service doing it.  I was referring to the ED and ICU care after EMS.


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