# BLS Skills -- What Should We Add?



## EpiEMS

What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?

As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.

I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):

  - Glucometry
  - 3- and 12-lead placement and transmission
  - Blind insertion airway devices
  - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
  - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
  - Rectal diazepam (carried on ambulance -- not just prescribed)
  - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
  - IN naloxone

Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.


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## bahnrokt

EpiEMS said:


> - Glucometry
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - IN naloxone



We already do these with few issues as a BLS squad in NYS.  Just started the pilot program for narcan last month.

I would love to see BLS squads trained to use a monitor.  Aside from monitors with a manual shock mode, it is a non invasive tool that is hard to do damage with. 

IM morphine would be usefull but it would be abused, so I don't see that catching on. It would be nice to have something to give legit trauma pts for pain.  But seekers would ruin in.


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## truetiger

EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.


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## firetender

*You mean for the actual job?*

What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.


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## EpiEMS

bahnrokt said:


> Just started the pilot program for narcan last month.
> 
> IM morphine would be usefull but it would be abused, so I don't see that catching on. It would be nice to have something to give legit trauma pts for pain.  But seekers would ruin in.



How's the Narcan worked out so far?

I like the idea of additional pain control -- maybe IN Fentanyl, or ActiQ (Fentanyl lollipops), or, heck, nitrous?



firetender said:


> What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.



Completely agree. Completely. More geriatric medicine education, more pharmacology, and more psych (inclusive of drug abuse, suicide, and behavioral crises) should be included in the curriculum. Social services should be covered by agencies, surely.

Then again, with some of the drug abuse patients and attempted suicides, I'd really like access to IN Narcan.

I'd like to know more about local social services and local non-ER facilities to help triage patients who want to refuse (or have been assessed and have no medical need to go to the ED, but should be seen within 24-48 hours or so).




truetiger said:


> EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.



I understand your perspective. EMTs, as it stands today, do give drugs. SQ Epinephrine (I carry it on the ambulance), oral glucose (even though it's OTC), activated charcoal, etc. You know this better than I do, surely. I use the monitor –:censored:I place leads, I use the NIBP, pulse oximetry, and capnography. Of course, I'm not *technically* allowed to -- but the paramedics damn well expect it (so let's put it in the protocols, please).

I've no problem with additional education. However, I think that considering my baseline level of education, I am more than capable of learning these additional skills. I don't want to -- nor would it really be helpful for me to -- start IVs. I don't usually have a need to do so -- I've selected the skills above (and CPAP, too) because those are the evidence-based, non-invasive skills that I see used most often by EMT-Ps (who so often tell me that I ought to be doing them as an EMT).


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## DrankTheKoolaid

While I agree with BLS providers having more options, I dont think it should be a blanket for all.  That is exactly why there is such thing expanded scope.   

If you truely want to expand your scope get involved with your LEMSA MAC meetings and provide input.  Be warned that if you do you had better of done your homework and be able to show a documented need for it.

Ill tackle them 1 by one to get you started

CPAP, no for BLS providers and I say this because at some point a patient will be put on CPAP in the field by a non transport EMT FR only to find an extended ETA on the ambulance and run out of O2.... Then what do they do.

Narcan......... Hell its hard enough to train ALS personel when it should and should not be given.  BLS can just bag them until ALS arrives.  Because im sure you know its not given simply because someone is altered.   It is for respiratory depression only.. 

Supraglottic airways...........    Emerging science is showing they may not be all they were cracked up to have been in the wrong hands.   Will withold on that one. 

Epi pens........ Sure

Glucometer for what. Pale Cool and Clammy needs candy dont need a glucometer for that, and if they are hot and dry give it to them anyways to rule out hypo and it wont hurt them.

Rectal Valium. No.     Do you realllllllly have that many pedi seizures and als out of position to justify narcotics in the hands of the unlicensed.

MDI only when they are skilled enough to be able to rule out other reasons for wheezing such as cardiac asthma and pulmonary edema.

3 lead placement - why would you bother with no Paramedic at scene to intepret what is going on.

12 Lead placement and transmission I could get behind though.


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## DrankTheKoolaid

Asa and NTG i can get behind once documented training and testing on indications contraindications etc etc.  That would included performing a C/P exam to include being able to rule out cardiac and identify non cardiac causes


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## the_negro_puppy

truetiger said:


> EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.



Granted I don't have first hand experience with US EMS but I think that your Basic level can't really do a whole lot without calling for a medic.

What if they increased the education level for x number of hours and added-


Glucometer- Speeds up diagnosis, sure its easy to know if its hypo-hyper by presentation but when you call for ALS intercept the medic will already know what the BSL/BGL is and can start treatment straight away. Diabetics do this to themselves every day lol. Basic goes to call 60 y.o F confused. hx reveals IDDM BSL reveals low BGL. Pt able to have oral glucose, ALS intercept and transport not required.

Cardiac monitor with 3 lead- + interpretation of  basic arrhythmias. Again pretty basic and will speed up diagnosis and treatment.

300mcg Epi Pens for Anaphylaxis + asthma

Nebulised albuterol- for sure. You guys already use oxygen, and patients give themselves ventolin every day. Put two and two together and you have effective treatment. Extra training obviously given as part of education.

Narcan- maybe. I guess it depends if you have large scale opioid abuse in your area. I've never used Narcan in 2.5 years on an Ambulance. Been to 1 narc overdose that came up swinging after 1 min of ventilation.

These really are basic interventions that every day civilians perform on themselves with little training or education. Would also free up ALS units with Basics doing and treating more things


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## Handsome Robb

I'm not a huge fan of EMTs getting more skills unless we increase education as well. That doesn't mean in-services... "This is your new toy, this is how it works, alright sweet go have fun." That's not going to cut it. 

NTG...not a fan, I want to see the 12-lead before any NTG is given, I know it's not always possible especially if the patient has their own, that's just my opinion. My coworker called a STEMI the other day and after NTG x 3 there was no elevation and the ER doc cancelled the STEMI only to have to reactivate the cath lab later.  I know, n=1.

Epi pens I can agree with, I don't agree with letting them do the math and draw it themselves. There are plenty of EMTs out there that are more than capable of doing so but there are plenty that can/will mess it up and could end up in a very bad situation because of it. 

Monitor, no. You can't interpret it, why do you need it? Transmitting 12-leads I can see if you are in an area without good ALS coverage other than that I don't see the point. There is no reason you can't place the leads for an ALS provider but you can't interpret  the rhythm so unless you are in the presence of a paramedic who is attending the patient there is no point. 

Supraglottic airways I will agree with but like Corky said, there's evidence that they aren't as great as originally thought. 

Rectal Diazepam, nope sorry. Wont agree with that. 

Narcan - maybe provided there is proper education about it's use so we don't end up having BLS providers slam 2 mgs and making things more difficult for providers and that patient throughout the rest of their care while the narcan is metabolized.

Pain management - there's a pretty extensive thread around here somewhere about it at the ILS level. Maybe nitronox for isolated extremity injuries but like it was stated in the other thread, there is no current manufacturer of a system that will work in the EMS environment. From what I hear one may be popping up soon but until then it just isn't practical. I'm a huge fan of nitrous, our special events crews have it and our ALS ski patrollers do as well and it has always worked when we were taking a patient from one of them and they were using it. 

Glucometry - sure why not. Our BLS special events crews can do it already.

Inhaled beta agonists - I'm on the fence about this one. For the same reasons stated by Corky.

When it comes down to it if you want to have more tools available to you go to medic school and further your education.


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## Veneficus

firetender said:


> What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.



this, without caviat or condition.


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## DrParasite

Corky said:


> Glucometer for what. Pale Cool and Clammy needs candy dont need a glucometer for that, and if they are hot and dry give it to them anyways to rule out hypo and it wont hurt them.


because if they are showing all the signs of a CVA (left sided weakness, altered mental status, etc), they are either having a stroke or a diabetic emergency.  Let me check the BGL, if it's low, we can wait for ALS to arrive, shoot them full of sugar, and they can RMA once all the symptoms subside.  If the BGL is normal, than I have a high index of suspicion that the patient is having a stroke, than I can (and have) cancelled the ALS due to their ETA, had the patient loaded up in the ambulance and be enroute to the stroke center (not that ALS is going to do much for a CVA in the field anyway).  And depending on where I am, I can activate the stroke/brain attack team on my own.

ditto for an unresponsive, esp with a diabetic history. sugar drops, raise it up, and they are good to go (after they become AOx3 and eat a sandwich).  normal BGL, something else is going on, load and go to the ER.

I would also like to see intranasal narcan on the BLS truck.  minimal contraindications when used on a non-opiade overdose, and can restore the breathing drive of a heroin OD.  always good when your 300 lb accidental narcotic OD gets woken up, and can walk down 3 flights of stairs, instead of having to carry him and bag him on the way to the cot.

Maybe nitrous for pain management, or some other pain management drug that isn't invasive.  too much or certain paint meds can go wrong if you give too much, and i don't think EMTs are educated enough for give stronger stuff.

The biggest thing EMTs need as BLS skills is the ability to recognize sick/need ALS vs sick/need ER but no ALS vs not sick / needs to go to the ER because the patient needs to go.  Some people don't recognize a sick patient because they never see one, and others see a sick patient, panic, and don't know what do to except wait for the ALS to arrive and hold their hand.  Also EMTs need to understand the limitations of what they can do, both in their POV and  in the ambulance.  Sometimes there is nothing you can do to help the patient in the field, and can just take them to the ER for the ER docs to do their thing.


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## DrankTheKoolaid

I like your rational DrP, and that is exactly the kind of thing I was trying to get out of the OP so he would understand and bring to his MAC commitee. 

Gotta say I would / will fight against narcan in BLS hands tooth and nail though.  I said it before and Ill say it again. Its hard enough to teach Medics when to give it appropriately.  Ive watched / QA'ed new and old medics alike give it simply because someone was altered as im sure most of you have also.  Simply not a reason to give it, so what makes you think as a whole, the BLS personel are more trainable then the ALS personel? 

BLS should master one of the hardest and most life saving skills in all of EMS.... BVM ventilations 

Pain control, maybe someday something safe to be given that works can be identified. 


OP great discussion starter I must say.  I think this thread has the opportunity to help alot of others that are also interested in trying to expand their local/optional scopes and the information that will need to be presented / and questions answered upon asking for it.   Remember you have to not only pitch it to your Medical Director, but the whole MAC commitee.


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## bahnrokt

EpiEMS said:


> How's the Narcan worked out so far?



No uses so far, I had one that was borderline but decided Id rather bag than wrestle.   Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.


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## Handsome Robb

bahnrokt said:


> No uses so far, I had one that was borderline but decided Id rather bag than wrestle.   Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.



What's your dosing?

The whole point of naloxone is to titrate it to respiratory effect, not to wake them up. 

Not trying to use you as an example but the whole wrestling comment is exactly why I don't think BLS providers should have naloxone.


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## DrankTheKoolaid

Forgot to address this in my last post.  

Never and I mean never have I had any diabetic patient present as a stroke.  Ive had BGL's of 10 F(BGL) full on decorticate posturing to 1700 (number from ED Labs) with a complaint of weakness and everywhere in between.   Sure they may have global weakness and slurred speech, but they have also always been pale cool and wet (low obviously).  But I have never seen unilateral weakness caused by hypoglycemia.  Academic theory, sure it is probably possible but that does not equate to real life argument for glucometer use.  Its still an unneeded procedure in BLS hands.  Give em all sugar and let the ALS/ED sort it out

And sure they both could have been strokes, but its all about a good solid patient history


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## bahnrokt

NVRob said:


> What's your dosing?
> 
> The whole point of naloxone is to titrate it to respiratory effect, not to wake them up.
> 
> Not trying to use you as an example but the whole wrestling comment is exactly why I don't think BLS providers should have naloxone.



.02

Aside from a 35min CME I had no experience with narcan and the guy was just coming into the range of where my protocols allow me to administer it.  So rather than whipping out a new toy just for the sake of playing with it, I waited 4 minutes to intercept with a fly car.


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## Tigger

EpiEMS said:


> What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?
> 
> As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.
> 
> I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):
> 
> - Glucometry
> We do this already. I think giving everyone sugar and letting ALS settle it out is terrible medicine. Everyone talks about administering 02 only when appropriate. We should be doing the same with sugar. Any AMS patient is getting their sugar checked especially if they're a diabetic or have another problem with regulating their sugar. I am not going to give patients anything until I get a glucometery reading. I have no idea why anyone thinks basics should not be doing this, it takes about a minute and does have value.
> 
> - 3- and 12-lead placement and transmission
> If you have no ALS or hospital in the area, fine. If you're in the sticks of Colorado and your ALS comes from a helicopter, yea this could be a good idea. For most though I don't think it's beneficial.
> 
> - Blind insertion airway devices
> Also doing this already, if properly trained in their insertion and placement it makes BVM use considerably easier and the airway can be managed by one instead of two providers. The AHA wants two providers doing mask ventilation and I agree, the "anesthetist's grip" is too difficult for many, even those with experience.
> 
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> Also doing this already. No reason why not, one of the few ways BLS can actually save a life. Just don't do this.
> 
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> I don't agree with this one without a significant increase in education. If a patient is prescribed it that's one thing, but as stated ideally a 12 lead will be completed prior to administration. In Colorado I can give it without med control, but the reasoning is that if dumps the patients pressure I can start an IV to bring it back. Not sure how I feel about that...
> 
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> Absolutely not. BLS should not be carrying, much less administering benzos. Not to mention the massive increase in regulation needed for every service to start to manage and carry a controlled substance.
> 
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> Already done here as well, and should be expanded everywhere. Asthma attacks are a fairly common EMS call and BLS can do very little for them especially if the patient can no longer properly use an MDI.
> 
> - IN naloxone
> Done here and I'm ok with it provided that it is given slowly and only to correct respiratory depression.
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.





bahnrokt said:


> No uses so far, I had one that was borderline but decided Id rather bag than wrestle.   Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.



Proper administration of Naloxone should not end in wrestling. Even at 0.2mg you do not have to give the entire dose. If you push it slowly and notice a change after half the dose, just stop.


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## DrankTheKoolaid

Giving a glucometer to BLS will change nothing.  If they are that altered they should not be receiving PO glucose paste to begin with.  So you now have a mg/dL reading you can do nothing with since you cant start lines to give IV Dextrose.  

And generally i agree that blind blanket treatments have no business in EMS.  But in the case of a known or suspected diabetic who is symptomatic I feel this is a good exception to the rule.  As it truely is benign with a few exceptions such as with alcoholics or if the BLS provider misses the fact that they do not have an intact gag reflex and the patient aspirates


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## DrankTheKoolaid

Now giving BLS Glucagon i can get behind for unconscious known diabetics


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## Tigger

Corky said:


> Giving a glucometer to BLS will change nothing.  If they are that altered they should not be receiving PO glucose paste to begin with.  So you now have a mg/dL reading you can do nothing with since you cant start lines to give IV Dextrose.
> 
> And generally i agree that blind blanket treatments have no business in EMS.  But in the case of a known or suspected diabetic who is symptomatic I feel this is a good exception to the rule.  As it truely is benign with a few exceptions such as with alcoholics or if the BLS provider misses the fact that they do not have an intact gag reflex and the patient aspirates



As already mentioned, if I get a low reading I'll call ALS, have them come and give some D50 or glucagon and then if needed, RMA the patient. Otherwise the patient is going to the hospital, which is needed. Oral glucose takes at least 15 minutes to have the same effect, which would you want? Also if someone can protect their airway and clearly needs sugar, and says I need sugar, they are going to get it. Wouldn't it be nice to you know, quantify and measure your treatments?

I know how you feel about basics, but honestly considering that lay people do it all the time, there is no excuse for an incomplete assessment. I can't do anything with a high BP either, maybe I should just not take those either?


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## Tigger

Corky said:


> I like your rational DrP, and that is exactly the kind of thing I was trying to get out of the OP so he would understand and bring to his MAC commitee.
> 
> Gotta say I would / will fight against narcan in BLS hands tooth and nail though.  I said it before and Ill say it again. Its hard enough to teach Medics when to give it appropriately.  Ive watched / QA'ed new and old medics alike give it simply because someone was altered as im sure most of you have also.  Simply not a reason to give it, so what makes you think as a whole, the BLS personel are more trainable then the ALS personel?


 
There is very little correlation between the education someone already has and their ability be educated in something new.


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## DrankTheKoolaid

I absolutely agree tigger.  But that will not convince your Medical Director or other MAC members to allow a new skill/medication.  You will have to present it in a methodical manner with all research available to show a need.  Just because you feel your entitled to do something because you feel it is a mundane act is not a valid argument


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## NYMedic828

Corky said:


> Now giving BLS Glucagon i can get behind for unconscious known diabetics



Pretty hard to do damage with 1mg of glucagon.

Its better than people drowning an unconscious diabetic with glucose paste, and expecting it to work to begin with let alone in any timely manner.


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## shiroun

In my district (nassau county, NY) a very big name in our area is pushing for intranasal administration of narcan for BLS


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## Tigger

Corky said:


> I absolutely agree tigger.  But that will not convince your Medical Director or other MAC members to allow a new skill/medication.  You will have to present it in a methodical manner with all research available to show a need.  Just because you feel your entitled to do something because you feel it is a mundane act is not a valid argument



My medical director already agrees that basics should be doing glucometry, and we have glucometers per his instructions. He also supported us having combitubes, nasal narcan, and nebs. However these were not implemented due to cost apparently. I don't feel entitled to do any of these things, I feel they are beneficial to BLS patient care for the reasons I have outlined above and my company, medical directors, and area hospitals agree as well. If they had a problem, I don't think they would have implemented them.


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## DrankTheKoolaid

Oh trust me where i am we have expended scope for BLS.  That is not the point of my posting to the OP.  The point of my posting in here, as a member of a MAC commitee myself is to show him what he will be up against and to give him an oppotunity to try to address these concerns that are sure to come up by some commitee member.  Now before he approaches his LEMSA with additions to their scope, he will have answers to these questions.  

When attempting to get something added you simply can not look at it from a "It's good patient care stand point" unfortunately.   

Are studies in place showing it is absolutely safe in minimally trained BLS hands, because remember a protocol is across the board to include volunteers with little to no experience and lets face it depending on the area and culture little to no true EMS continuing education, not just on an ambulance.

How much training is it going to take.

Is this going to be absolutely mandatory or optional?  Who is going to pay for it?  IE Epi-Pens are dam expensive and have a very short expiration.  Or are you going to allow BLS to play with needles and draw up their own? 

You can take it from there as im pretty sure you get my point...

Just caught your comment about my feelings for EMT's

Nothing could be farther from the truth.  I was a EMT forever and have the utmost repect for my basic partners.  It the other EMT's that scare me sometimes


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## NYMedic828

shiroun said:


> In my district (nassau county, NY) a very big name in our area is pushing for intranasal administration of narcan for BLS



Our Nassau County protocols need more change than narcan for BLS.


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## Veneficus

Could I just inquire?

How many patients are you seeing that actually need narcan?


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## shiroun

Veneficus said:


> Could I just inquire?
> 
> How many patients are you seeing that actually need narcan?



119 Non-Heroin Deaths by Opiates in 2011, 149 inc. Heroin (Heroin and Oxycodone were the top 2 killers in the opiate category, with 30/34 respectively). 310 PTs with Opiates in their system during a Tox-Screen in 2011.

So to answer that, almost every day we have a PT who we would potentially administer Narcan to.


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## Veneficus

shiroun said:


> 119 Non-Heroin Deaths by Opiates in 2011, 149 inc. Heroin (Heroin and Oxycodone were the top 2 killers in the opiate category, with 30/34 respectively). 310 PTs with Opiates in their system during a Tox-Screen in 2011.
> 
> So to answer that, almost every day we have a PT who we would potentially administer Narcan to.



How many of the dead people were dead before or without EMS intervention?


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## DrankTheKoolaid

How many died with EMS intervention that would have been saved with Narcan and not BVM ventilations?


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## NYMedic828

Veneficus said:


> How many of the dead people were dead before or without EMS intervention?



As a fellow resident of Nassau County NY if I may add some input;

In Nassau County we have volunteer and paid EMS. A select few towns are covered by a private hospital, the other 60+ towns have coverage by the NCPD ambulance bureau. The NCPD EAB responds primarily to any 911 call in MOST places. Volunteer FDs and ambulance cores in most towns only respond primary if PD is not available, or if called directly instead of via 911.

PD also responds to all calls for EDP, intox or drug relation.

Keep in mind all NCPD ambulances are ALS.

So in reality, the amount of calls that volunteer FDs get involving drugs are few and even fewer are overdoses.

We get so few that even our ALS (the inexperienced) treat wrongly. Example being a gentleman on PCP, a medic in my department gave Narcan.

So, in a system where our protocols are already complete trash, the last PRIMARY focus we need, is giving a mass of mostly inexperienced EMTs, a real medication.

Narcan may not have side effects, but most people don't realize just how much 0.2mg can do on many patients, they get excited and slam the whole amp in.

And quite honestly, we are usually 5 minutes from a hospital. Just freaking bag them.

I'd rather see glucagon before Narcan for EMTs, and our actual protocols need fixing before our scope.


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## EpiEMS

Corky said:


> Oh trust me where i am we have expended scope for BLS.  That is not the point of my posting to the OP.  The point of my posting in here, as a member of a MAC commitee myself is to show him what he will be up against and to give him an oppotunity to try to address these concerns that are sure to come up by some commitee member.  Now before he approaches his LEMSA with additions to their scope, he will have answers to these questions.



Makes good sense. My protocols are far too restrictive, both considering what I do on a regular basis. Fortunately, I'm in a system where I usually have a medic on calls with me (or one can be there in less than 10 minutes -- either that, or I can get to the ED in 15 minutes, max).

My notion is to expand the national scope. Granted, I am pulling bits and pieces from various expanded scopes and from the AEMT national standards. This being said, as a BLS crew, I want to be able to arrive on scene and begin assessment and treatment. Assessment tools like a glucometer and monitor (with transmission) allow me to assess and triage appropriately. Skills like the use of a blind insertion airway device (easy to use, rarely improperly placed, and pretty darn effective at ventilating), and meds (namely, beta agonists) are easy to use and make a difference. 
These are not complicated skills, here (and most of the skills I mentioned are performed by BLS personnel in some areas of the country). I'm just not permitted to perform them because of where I am. Shouldn't my patients receive care equal to that which they'd get anywhere else?



Corky said:


> You can take it from there as im pretty sure you get my point...



Everything that you've said is very sensible, and I certainly don't think you have a problem with EMTs, surely not. We just happen to disagree on what the scope of practice should be.


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## shiroun

NYMedic828 said:


> We get so few that even our ALS (the inexperienced) treat wrongly. Example being a gentleman on PCP, a medic in my department gave Narcan.



How did that work out for him?

And I have to agree with you. We do need to re-define it, however our system, as my instructor put it, has been in place for awhile, and overhauling it may be worthless. We switch over to NR in a few months anyway.


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## NYMedic828

shiroun said:


> How did that work out for him?
> 
> And I have to agree with you. We do need to re-define it, however our system, as my instructor put it, has been in place for awhile, and overhauling it may be worthless. We switch over to NR in a few months anyway.



It didnt...


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## shiroun

NYMedic828 said:


> It didnt...



That's the joke. I guess sarcasm doesn't transmit well over the internet.

Mind if I shoot you a PM with my number, if you're able to text, or something along those lines? I'm looking to find a place to ride-along, and I don't want to de-rail this thread even more.


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## leoemt

EpiEMS said:


> What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?
> 
> As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.
> 
> I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):
> 
> - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.



Every Rescue vehicle whether BLS or ALS in WA State must have 1 adult and 1 junior Epi-pen on board per law. Every BLS and ALS provider must be trained in how to use it as well. This law is the result of a little boy who died at his elementary school in Spokane because he had a peanut allergy and the responding fire engine, which was BLS, had no epi.

I personally would like to see BLS have some sort of pain management to give our patients. Not being to familiar with the pharmacology I don't know if that would be possible or prudent though at the BLS level.


----------



## shiroun

leoemt said:


> Every Rescue vehicle whether BLS or ALS in WA State must have 1 adult and 1 junior Epi-pen on board per law. Every BLS and ALS provider must be trained in how to use it as well. This law is the result of a little boy who died at his elementary school in Spokane because he had a peanut allergy and the responding fire engine, which was BLS, had no epi.
> 
> I personally would like to see BLS have some sort of pain management to give our patients. Not being to familiar with the pharmacology I don't know if that would be possible or prudent though at the BLS level.



(I've been up for the last 28+ hours, so if i mess anything up forgive me),

What kind of pain management? When you traction splint someone, the pain goes away significantly. 
Chest pain? We can assist with nitro, or give aspirin with medcom orders. 
Respiratory has oxygen, and I think broncodilators are assistable/medcom (advair, or whatever other asthma meds you have). 

Do you mean like general pain management, like morphine? 

I think our limited knowledge of pharmacology is what MAKES that a bad idea. Especially without PMH in some cases, such as trauma, where the guy is in splitting pain with a concussion and two broken arms, and can't remember what happened, let alone what medications/allergies he has, that could be a problem. Hell, if you slip up and forget to ask someone if they're on performance enhancing drugs, and you help them take their nitro, they'll be CTD in under 5 minutes. I wouldn't want to add more problems then we fix. 

I would actually like to see a rub-on anesthetic, for mildly combative patients. Granted, it would need strict guidelines, but it'd be beneficial for us. 

Thats my 2 cents anyway.


----------



## NYMedic828

shiroun said:


> What kind of pain management? When you traction splint someone, the pain goes away significantly.



I think in 6 years I've had one isolated closed mid-shaft femur fracture. Traction splint certainly results in excellent management for the patient I used it on. Back to our Nassau discussion, we have toradol and morphine. My issue with toradol is that many people at the ALS level here think its just IV Motrin what harm can it do. Things like femur fractures are potential for major blood loss. Toradol being a platelet inhibitor, I'm not so certain is the best move. Morphine is my way to go and you won't see that at the BLS level any time soon. Toradol also doesn't take effect too quickly by comparison, it's more to help by ER arrival than when in our care due to our transport times.



shiroun said:


> Chest pain? We can assist with nitro, or give aspirin with medcom orders.
> Respiratory has oxygen, and I think broncodilators are assistable/medcom (advair, or whatever other asthma meds you have).



Nassau permits BLS assistance with pre-prescribed nitro. If the patient does not theirs on hand, you can call Medcom assuming your ambulance stocks it. Being nitro administration is not technically out of EMT scope, with a competent report the doc will probably permit it.

BLS can administer up to 3 nebulizer treatments of albuterol as long as patient has an asthma history. Again, no history, call Medcom... You can also assist with Rx inhalers but the nebulizer is a better treatment option.

You are always permitted to allow a patient to self administer their own prescribed medicines as indicated by their pcp if they choose to. Whether or not you are comfortable with it is up to you. I usually let people take them if they were supposed to and didn't due to calling EMS. I'd rather my 86 year old patient not miss her morning dose of 4 HTN meds.



shiroun said:


> Do you mean like general pain management, like morphine?
> 
> I think our limited knowledge of pharmacology is what MAKES that a bad idea. Especially without PMH in some cases, such as trauma, where the guy is in splitting pain with a concussion and two broken arms, and can't remember what happened, let alone what medications/allergies he has, that could be a problem. Hell, if you slip up and forget to ask someone if they're on performance enhancing drugs, and you help them take their nitro, they'll be CTD in under 5 minutes. I wouldn't want to add more problems then we fix.



Hate to say it but the majority of ALS in Nassau is CC based, not paramedic. Most of the CCs who don't work for NCPD or having explored further self education have very limited pharmacologic knowledge either. Same goes for some medics as well. The CC class is more "here's a cookbook, here's how
you perform the skill, you see this, do that." This is why a CC needs to call Medcom for meds as simple as Benadryl.

If a patient meets the criteria for nitro assistance, odds are they don't take Viagra and their doctor has made it clear that it is NOT a wise choice. But, most people find the contraindication as a joke and embarrassing to ask someone, which I agree is a potential problem especially when you don't have emergent fluid replacement at your disposal. But, I don't know anyone who this has happened to. My vote goes for the greatest good for the greatest number of people. APE patients and patients with presumed cardiac chest pain benefit greatly from NTG. It is probably one of the best things we carry. I honestly think it should be a med control order in general not just an assistance criteria. This way if people know enough to realize it is indicated, they can get it but at the same time you cover your back by having a doctor check your assessment.



shiroun said:


> I would actually like to see a rub-on anesthetic, for mildly combative patients. Granted, it would need strict guidelines, but it'd be beneficial for us.



Topical lidocaine doesn't work that well in my experience. . (they use it on non-critical peds alot for starting IVs and it doesn't do much) 
Topical agents just really serve no purpose in the field. They are more for muscle aches and pains in the household
The numbing effects of an ice pack go a long way in an acute setting if the patient tolerates it.




As far as the topic in general, I think the days of EMT meaning bandaid brigade does need to come to an end. EMTs have been getting more toys as ALS has but it has to be a slow process due to general lack of experience and education. The majority around here just can't handle it. Many I know, are not even comfortable
running a nonsense call on their own.

But what I think ultimately is practical for BLS now, if implemented properly, 

IM glucagon (that paste is so dumb, and EMTs already have glucometry, finally.)
Telemetry nitro administration
IN Narcan
Combitube or other alternative airway.


----------



## Bullets

Corky said:


> Forgot to address this in my last post.
> 
> Never and I mean never have I had any diabetic patient present as a stroke.  Ive had BGL's of 10 F(BGL) full on decorticate posturing to 1700 (number from ED Labs) with a complaint of weakness and everywhere in between.   Sure they may have global weakness and slurred speech, but they have also always been pale cool and wet (low obviously).  But I have never seen unilateral weakness caused by hypoglycemia.  Academic theory, sure it is probably possible but that does not equate to real life argument for glucometer use.  Its still an unneeded procedure in BLS hands.  Give em all sugar and let the ALS/ED sort it out
> 
> And sure they both could have been strokes, but its all about a good solid patient history



And i have had 3 this week, they do occur

The first one was classic stroke symptoms, left sided weakness, facial droop, warm and dry.  I begin to package for a stroke and notify hospital and i see the patients glucometer sitting bedside. I ask the son to check BGL.....of 26! Hold off on packaging, ALS arrives, does the ALS dance, BGL up to 210 patients up and walking, eating, a little upset, RMAs

Now i happened to have a glucometer on hand, but if i didnt i probably would have transported, cancelled medics and looked like a fool at the hospital for calling a stroke on a hypoglycemic


----------



## Veneficus

NYMedic828 said:


> If a patient meets the criteria for nitro assistance, odds are they don't take Viagra and their doctor has made it clear that it is NOT a wise choice. But, most people find the contraindication as a joke and embarrassing to ask someone, which I agree is a potential problem especially when you don't have emergent fluid replacement at your disposal. But, I don't know anyone who this has happened to.



Just an FYI on this topic.

Apparently some guys use their prescription nitro paste as a topical erectile enhancer. 

The reproductive system is a body system and should always be reviewed in both men and women during assessment. 

If it is too embarassing or taboo, then it is time for the provider to grow up or move on.


----------



## NYMedic828

Bullets said:


> And i have had 3 this week, they do occur
> 
> The first one was classic stroke symptoms, left sided weakness, facial droop, warm and dry.  I begin to package for a stroke and notify hospital and i see the patients glucometer sitting bedside. I ask the son to check BGL.....of 26! Hold off on packaging, ALS arrives, does the ALS dance, BGL up to 210 patients up and walking, eating, a little upset, RMAs
> 
> Now i happened to have a glucometer on hand, but if i didnt i probably would have transported, cancelled medics and looked like a fool at the hospital for calling a stroke on a hypoglycemic



I get called to backup a BLS unit that thinks they have a diabetic who is really a CVA all too often. You can tell its a stroke almost immediately upon assessment most times unless of course they are unconscious.

It baffles me that our BLS can't all carry a device as simple and inexpensive as a glucometer that would ultimately save money and reduce the time a CVA takes to reach the ER.



Veneficus said:


> Just an FYI on this topic.
> 
> Apparently some guys use their prescription nitro paste as a topical erectile enhancer.
> 
> The reproductive system is a body system and should always be reviewed in both men and women during assessment.
> 
> If it is too embarassing or taboo, then it is time for the provider to grow up or move on.



Doc, your mind would be blown by the EMS providers in my home town and surrounding. But hey "we're just volunteers" after all...

It's great people want to volunteer and "save lives" but if you aren't comfortable with so much as having a conversation with the patient, you have no business providing any rendering of true care.


----------



## shiroun

NYMedic828 said:


> Morphine is my way to go and you won't see that at the BLS level any time soon.



100% agree with. I was asking what kind of pain management he wanted for BLS. Morphine at a BLS level would do more harm then good.



NYMedic828 said:


> Nassau permits BLS assistance with pre-prescribed nitro...
> 
> BLS can administer up to 3 nebulizer treatments of albuterol as long as patient has an asthma history...



You're correct, but both DO require a PMH.



NYMedic828 said:


> If a patient meets the criteria for nitro assistance, odds are they don't take Viagra and their doctor has made it clear that it is NOT a wise choice. But, most people find the contraindication as a joke and embarrassing to ask someone, which I agree is a potential problem especially when you don't have emergent fluid replacement at your disposal.



People do find it a joke, when its really just one simple question. I doubt your 75 y/o with 9/10 chest pains is going to complain to the doctors about you asking if he's on viagra. 

Yet, we also had a medic in NC who accidentally sprayed himself in the face with nitro a few times, and about 2 minutes later was on the ground with a BP of 60. He got the nickname of Nitro. :rofl:



NYMedic828 said:


> Topical lidocaine doesn't work that well in my experience. . (they use it on non-critical peds alot for starting IVs and it doesn't do much)
> Topical agents just really serve no purpose in the field. They are more for muscle aches and pains in the household
> The numbing effects of an ice pack go a long way in an acute setting if the patient tolerates it.



I'm not talking about as a local numbing agent, I'm talking about as a sedative/tranquilizer. Something BLS could put on our patients that potentially pose a threat to us. It wouldn't be used often (because again, that 75 y/o with the chest pain isn't going to go ape:censored::censored::censored::censored: on us, but the guy who's hyped up on PCP and been shot might), but it'd be nice to have in our basic bag of tricks.



NYMedic828 said:


> As far as the topic in general, I think the days of EMT meaning bandaid brigade does need to come to an end. EMTs have been getting more toys as ALS has but it has to be a slow process due to general lack of experience and education. The majority around here just can't handle it. Many I know, are not even comfortable
> running a nonsense call on their own.



That's probably due to inexperience. If I've got a helper I'll run calls, so long as it's not an MI or hypoglycemic... which brings us to:



NYMedic828 said:


> But what I think ultimately is practical for BLS now, if implemented properly,
> 
> IM glucagon (that paste is so dumb, and EMTs already have glucometry, finally.)
> Telemetry nitro administration
> IN Narcan
> Combitube or other alternative airway.



instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM, and there's less potential to nick a nerve, or have the needle get lost in the persons skin. The only reason I say the 2nd one is because a nurse went to give me my hep A shot, and she jabbed it in...only to hit a nerve in my rotator cuff. The needle bent horribly and I was cursing up a storm for about ten minutes. If I'd moved my arm a bit more, that needle would have snapped. And she's trained and done it 1000 times over, imagine a BLS provider who's fresh out of school doing that. Atleast with SC there's less risk to the pt.


----------



## NYMedic828

shiroun said:


> I'm not talking about as a local numbing agent, I'm talking about as a sedative/tranquilizer. Something BLS could put on our patients that potentially pose a threat to us. It wouldn't be used often (because again, that 75 y/o with the chest pain isn't going to go ape:censored::censored::censored::censored: on us, but the guy who's hyped up on PCP and been shot might), but it'd be nice to have in our basic bag of tricks.



Good luck gettin that one approved lol. 

For the few departments that have narcotics, my own being one of the first if that helps you deduct my residence, chemical sedation is essentially unheard of and we don't even have a written protocol for it.

We are a LONG time from any form of transdermal sedative for the field and quite honestly it is impractical because the absorption rate is not meant to be fast on things like fentanyl patches for example. 

The only effective means for chemical sedation in the field, to my knowledge is IN or IM benzo, assuming you can safely use a needle.




shiroun said:


> instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM, and there's less potential to nick a nerve, or have the needle get lost in the persons skin. The only reason I say the 2nd one is because a nurse went to give me my hep A shot, and she jabbed it in...only to hit a nerve in my rotator cuff. The needle bent horribly and I was cursing up a storm for about ten minutes. If I'd moved my arm a bit more, that needle would have snapped. And she's trained and done it 1000 times over, imagine a BLS provider who's fresh out of school doing that. Atleast with SC there's less risk to the pt.



Though the safety of administration is in fact more "idiot proof" with SQ, you actually have your facts slightly mismatched.

The subcutaneous tissue is not very vascular and as such the absorption rate is actually slower, not faster. This is therapeutically beneficial in some cases like 1:1000 epi on an elderly patient who may not tolerate such a quick jolt so well, but glucagon we would want to be faster acting since slowing the absorption rate of a small dose as 1mg won't really benefit us when it could take 5-15 minutes to show any effects.

The skeletal muscularture is very vascular and allows for a speedier absorption. 

I would have to say the nurse you had made an error somewhere in her administration. It is not that easy to hit the axillary nerve if you are center mass on the deltoid. Too low if anything could cause trouble where it wraps around the humorous. Realistically, IVs have far more risk of nerve impingement.


----------



## Veneficus

shiroun said:


> instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM



Never heard that before.

Have heard that IM is both faster and more reliable.


----------



## NYMedic828

Veneficus said:


> Never heard that before.
> 
> Have heard that IM is both faster and more reliable.



What do you know -_-


----------



## shiroun

Veneficus said:


> Never heard that before.
> 
> Have heard that IM is both faster and more reliable.



I heard it from a medic at my school. Go figure.



NYMedic828 said:


> Good luck gettin that one approved lol.
> 
> For the few departments that have narcotics, my own being one of the first if that helps you deduct my residence, chemical sedation is essentially unheard of and we don't even have a written protocol for it.



It actually does help me to figure out what county you're in. If I'm right, you guys had two cars on two consecutive days wrap around the same telephone pole. Your chief wasnt happy. 

That or youre the one where I was at school. :\

_** CL Edit - quoted post removed **_


----------



## NYMedic828

shiroun said:


> I heard it from a medic at my school. Go figure.
> 
> 
> 
> It actually does help me to figure out what county you're in. If I'm right, you guys had two cars on two consecutive days wrap around the same telephone pole. Your chief wasnt happy.
> 
> That or youre the one where I was at school. :\



In regards to IN v SQ, I rest my case on incompetence in the area.



And no... Neither. No cars wrapped around poles thankfully. Unless you took your EMT 5 years ago. I took medic with FDNY so that's not it.

I PMd u by the way.


----------



## Christopher

EpiEMS said:


> - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.



These have been part of the BLS scope for about 4 years now in North Carolina. Rectal diazepam is the only one from your list EMT's could not do.


----------



## leoemt

shiroun said:


> (I've been up for the last 28+ hours, so if i mess anything up forgive me),
> 
> What kind of pain management? When you traction splint someone, the pain goes away significantly.
> Chest pain? We can assist with nitro, or give aspirin with medcom orders.
> Respiratory has oxygen, and I think broncodilators are assistable/medcom (advair, or whatever other asthma meds you have).
> 
> Do you mean like general pain management, like morphine?
> 
> I think our limited knowledge of pharmacology is what MAKES that a bad idea. Especially without PMH in some cases, such as trauma, where the guy is in splitting pain with a concussion and two broken arms, and can't remember what happened, let alone what medications/allergies he has, that could be a problem. Hell, if you slip up and forget to ask someone if they're on performance enhancing drugs, and you help them take their nitro, they'll be CTD in under 5 minutes. I wouldn't want to add more problems then we fix.
> 
> I would actually like to see a rub-on anesthetic, for mildly combative patients. Granted, it would need strict guidelines, but it'd be beneficial for us.
> 
> Thats my 2 cents anyway.



Like I said I'm too new to really know much about the different drugs used for pain management. My point was that if we were to add something to the BLS skills I would like to see some form of pain management. I am well aware that traction can and does reduce pain in fracture injuries. 

However, in my career as a cop I have responded to literally hundreds of aid calls and have seen my fair share of patients going BLS to a hospital in severe pain. 

What about patients complaining of a headache? Abdominal pain? Pregnancy? 

I know there is a lot more I need to learn about this, even if just for my own knowledge, and I am sure that there are contraindications that I am unaware of as to why pain drugs would be inappropriate in situations like these. 

Realistically speaking I understand why this would probably never happen. However, in a perfect world I would like to see a Basic be able to offer some form of pain management.


----------



## HMartinho

In Portugal, we can check bgl, and glucometer is a very useful tool.

Anyway, why not entonox? EMT-b's can administer entonox in some countries,  with good results.


----------



## NYMedic828

leoemt said:


> Like I said I'm too new to really know much about the different drugs used for pain management. My point was that if we were to add something to the BLS skills I would like to see some form of pain management. I am well aware that traction can and does reduce pain in fracture injuries.
> 
> However, in my career as a cop I have responded to literally hundreds of aid calls and have seen my fair share of patients going BLS to a hospital in severe pain.
> 
> What about patients complaining of a headache? Abdominal pain? Pregnancy?
> 
> I know there is a lot more I need to learn about this, even if just for my own knowledge, and I am sure that there are contraindications that I am unaware of as to why pain drugs would be inappropriate in situations like these.
> 
> Realistically speaking I understand why this would probably never happen. However, in a perfect world I would like to see a Basic be able to offer some form of pain management.



Many have suggested carrying Nitrous Oxide (laughing gas) but it has some FDA restrictions I believe was what came out of the topic.


----------



## ironco

Where I am at it is within our scope to do BGL and they recently put it in Missouri state scope to place and transmit 12 leads. 

Someone (I already forgot who) said why let basics do 3 lead if there is no medic around. The reason for this is because you can give a print out to the ER so they know how things have progressed over time, which is nice for the Dr to give a quick appropriate diagnosis wich we also can do here in Missouri.


----------



## Bullets

NYMedic828 said:


> I get called to backup a BLS unit that thinks they have a diabetic who is really a CVA all too often. You can tell its a stroke almost immediately upon assessment most times unless of course they are unconscious.
> 
> It baffles me that our BLS can't all carry a device as simple and inexpensive as a glucometer that would ultimately save money and reduce the time a CVA takes to reach the ER.
> 
> 
> 
> Doc, your mind would be blown by the EMS providers in my home town and surrounding. But hey "we're just volunteers" after all...
> 
> It's great people want to volunteer and "save lives" but if you aren't comfortable with so much as having a conversation with the patient, you have no business providing any rendering of true care.



And I share this sentiment as a volunteer EMT. During Bamboozle I had a newish EMT as a partner who told me he felt uncomfortable treating our patient

The reason? The patient was an underage girl who was dropped 6 ft onto a barricade while crowd surfing and seized and had thoracic lacerations .He didn't feel comfortable treating after I exposed her chest to treat the chest injuries. 

I told him to grow up and find another field then promptly got another partner for the day


----------



## 18G

What the OP is suggesting is exactly what the new AEMT level provider can do. Why add additional skills to EMT-Basic when the AEMT is there??

In WV, a Basic can give NTG, ASA, glucagon and albuterol - all carried on the ambulance. And just recently protocol was developed to permit 12-lead acquisition and transmission. 

I am in favor of Basics giving albuterol and hopefully all EMT Basics are allowed to use CPAP.


----------



## Christopher

18G said:


> ...and hopefully all EMT Basics are allowed to use CPAP.



Amen! I hate when I hear stuff like, "but what if they POP A LUNG?!?!"

Yep, keep them away from 10 cmH2O, so when they tire out and require assistance with a BVM they can provide 40 cmH2O+ of pressure; that'll protect their lungs.


----------



## DesertMedic66

18G said:


> What the OP is suggesting is exactly what the new AEMT level provider can do. Why add additional skills to EMT-Basic when the AEMT is there??
> 
> In WV, a Basic can give NTG, ASA, glucagon and albuterol - all carried on the ambulance. And just recently protocol was developed to permit 12-lead acquisition and transmission.
> 
> I am in favor of Basics giving albuterol and hopefully all EMT Basics are allowed to use CPAP.



Because not everywhere uses AEMTs. Here is SoCal (my area at least) we only have EMTs and Medics. Nothing in between. 

Why are you in favor of EMTs giving albuterol and having CPAP when AEMTs can do it?


----------



## NYMedic828

Wouldn't it be nice to live in a world where the entire country was standardized and an EMT could progress to AEMT with a set amount of field experience and classroom time, and then further progress to paramedic on the same basis. 

Ah, a man can dream...


----------



## 18G

firefite said:


> Because not everywhere uses AEMTs. Here is SoCal (my area at least) we only have EMTs and Medics. Nothing in between.
> 
> Why are you in favor of EMTs giving albuterol and having CPAP when AEMTs can do it?



I guess it's kinda like saying why allow an EMT to stop bleeding when an AEMT can do it. I think albuterol's benefit, safety and ease of administration make it a worthwhile drug to have on every ambulance. Honestly, and don't mean to offend anyone, but think Paramedics should be the minimum staffing level for an ambulance in the US. 

RN's and doctors are the standard level of care providers in ED's in this country - no one ever says we cant afford them let's go to CNA's and hire an RN to be the physician in the ED. I don't see why we find excuses to compromise with not paying a Paramedic a decent wage to staff every ambulance. 

If we went this route then the OP's question wouldn't even matter.


----------



## NYMedic828

18G said:


> I guess it's kinda like saying why allow an EMT to stop bleeding when an AEMT can do it. I think albuterol's benefit, safety and ease of administration make it a worthwhile drug to have on every ambulance. Honestly, and don't mean to offend anyone, but think Paramedics should be the minimum staffing level for an ambulance in the US.
> 
> RN's and doctors are the standard level of care providers in ED's in this country - no one ever says we cant afford them let's go to CNA's and hire an RN to be the physician in the ED. I don't see why we find excuses to compromise with not paying a Paramedic a decent wage to staff every ambulance.
> 
> If we went this route then the OP's question wouldn't even matter.



I think the most optimal move is dual staffed ambulances.

Here in NYC we have ALS and BLS separate. It baffles me that we don't split off every paramedic pair and double our ALS.

This would allow EMTs to be mentored and in the event of a call requiring more hands, you would still end up with the same 2 emts and 2 medics you had before.

The only downside is, paramedics would not end up practicing skills like intubation as much. But we get quite a few arrests in NYC its not that big of a deal. And on a job requiring intubation, only one person gets to do it anyway (hopefully)


----------



## DesertMedic66

18G said:


> I guess it's kinda like saying why allow an EMT to stop bleeding when an AEMT can do it. I think albuterol's benefit, safety and ease of administration make it a worthwhile drug to have on every ambulance. Honestly, and don't mean to offend anyone, but think Paramedics should be the minimum staffing level for an ambulance in the US.
> 
> RN's and doctors are the standard level of care providers in ED's in this country - no one ever says we cant afford them let's go to CNA's and hire an RN to be the physician in the ED. I don't see why we find excuses to compromise with not paying a Paramedic a decent wage to staff every ambulance.
> 
> If we went this route then the OP's question wouldn't even matter.



I wouldn't say that paramedic needs to be the minimum staffing level. It doesn't take a paramedic to take vitals, CPR, gurney, and drive. IMHO there should be at least one medic on an 911 ambulance. We run a couple of dual medic rigs and one of the medics just plays EMT all day. Pointless to pay a paramedic a paramedics pay to due an EMTs job.


----------



## Handsome Robb

firefite said:


> We run a couple of dual medic rigs and one of the medics just plays EMT all day. Pointless to pay a paramedic a paramedics pay to due an EMTs job.



Our dual medic rigs alternate calls. They both act as paramedics. If one is going to play EMT all day then pay him/her an EMT wage.


----------



## 18G

I don't want to hijack the thread but a patient, no matter the priority, deserves to have a highly trained and college educated healthcare provider to arrive at their side. 

I don't think that is too much to ask for. ED's get patient's that only require a CNA or LPN but hospital's demand RN's. Why? Because the RN can go much deeper if need be and screen for stuff that a a lower nurse level can't. And the public demands it. Same applies to EMT's except the public doesn't demand it because most communities are blind and don't know what their missing. 

An EMT get's assigned a call for weakness as BLS. There are many differentials to consider with a vague complaint of weakness. That weakness could be a CVA, MI, hyperkalemia, hypovolemia, etc, etc. This patient requires more than some vitals and being placed on a stretcher. No what I'm saying?

I was an EMT for many, many years in a paid capacity full-time for a FD so I know the limitations very well. I felt often like all I did was take vitals, ask a bunch of questions to get answers I couldn't do anything about, and transport to the hospital. Heck, many answers I get now I can't do anything about. 

Just want to see the bar raised.


----------



## DesertMedic66

NVRob said:


> Our dual medic rigs alternate calls. They both act as paramedics. If one is going to play EMT all day then pay him/her an EMT wage.



Company isn't allowed to due that. If they are hired as a medic they get medic pay for any work they do. 

I get EMT pay no matter what I do. If I play VST, mechanic, paperwork, sit on my butt and do nothing because my partner called off I still get my EMT pay.


----------



## NYMedic828

firefite said:


> Company isn't allowed to due that. If they are hired as a medic they get medic pay for any work they do.
> 
> I get EMT pay no matter what I do. If I play VST, mechanic, paperwork, sit on my butt and do nothing because my partner called off I still get my EMT pay.



I think the point Rob was going for is not literally to pay a medic less money for their title but rather to replace the second medic with an EMT to save money.


----------



## DrParasite

18G said:


> I don't want to hijack the thread but a patient, no matter the priority, deserves to have a highly trained and college educated healthcare provider to arrive at their side.


I am college educated... but I don't think my degree in history is going to help me on a job.....


18G said:


> I don't think that is too much to ask for. ED's get patient's that only require a CNA or LPN but hospital's demand RN's. Why? Because the RN can go much deeper if need be and screen for stuff that a a lower nurse level can't.


and yet, they will usually have a doctor within shouting distance if they get something that is over their head.





18G said:


> An EMT get's assigned a call for weakness as BLS. There are many differentials to consider with a vague complaint of weakness. That weakness could be a CVA, MI, hyperkalemia, hypovolemia, etc, etc. This patient requires more than some vitals and being placed on a stretcher. No what I'm saying?


or the patient might just feel weak, not be having a CVA, MI, be isokalemic (if that's the right word), normal volemic, etc, and need a ride to the ER for a further evaluation.  or more likely just needs a ride to their PMD for a doctors exam.





18G said:


> I was an EMT for many, many years in a paid capacity full-time for a FD so I know the limitations very well. I felt often like all I did was take vitals, ask a bunch of questions to get answers I couldn't do anything about, and transport to the hospital. Heck, many answers I get now I can't do anything about.
> 
> Just want to see the bar raised.


I wouldn't object to the bar being raised, but you said if yourself, even as a paramedic, many of the answer you get now you can't do anything about.  Sucks being all educated and still being unable to do anything to help the person any more than a person with an advanced first aid card right?


----------



## ironco

Out here where I'm at people are just glad to have professionals to get any emergency care at all. And while we are just "basics"I wonder why people think that we can't do anything. Maybe passing on the grief they get from RNs for just being "medics"


----------



## EpiEMS

18G said:


> What the OP is suggesting is exactly what the new AEMT level provider can do. Why add additional skills to EMT-Basic when the AEMT is there??
> 
> In WV, a Basic can give NTG, ASA, glucagon and albuterol - all carried on the ambulance. And just recently protocol was developed to permit 12-lead acquisition and transmission.
> 
> I am in favor of Basics giving albuterol and hopefully all EMT Basics are allowed to use CPAP.



I'm a fan of the AEMT, absolutely. Then again, when the EMT level provider is supposed to be able to provide what the National Standard Scope calls "fundamental" care for "critical" patients, and "simple" care for "emergent" patients. I would say that not only are assessments and treatments like glucometry, 12-lead (placement and transmission only!) NTG, ASA, IM glucagon, nebulized albuterol both fundamental to good basic triage, treatment, and transport, but absolutely vital - yet they're still missing from the BLS providers in many places. If we had these skills, we'd be wasting ALS resources less, for one, and appropriately treating those patients before ALS arrives (as well as being much more useful in an ALS-assist situation).

:EDIT:

And let me add Combi-tubes and King LT airways to this. They can certainly help (and because they don't take the time of an ET tube to place, they might be better in the prehospital setting).

It is also worth mentioning that to prevent our emergent patients from progressing to critical, early interventions couldn't hurt.


----------



## milesh1

*???*

Not sure what the deal is else where but in Colorado, with the addition of IV certification and ECG interpretation to your EMT-B, you can already do pretty much all of the things you mentioned, and as far as carrying drugs goes, it depends on your ambulance service. I know we carry all of those that you listed as a BLS provider. Having said that though all our trucks have a paramedic on them.


----------



## zmedic

Here's my thinking: Anything that civilians can do for themselves, that may save lives, an EMT should be able to do with minimal training. Examples
Aspirin for chest pain
Glucometer 
Epi pen 
And now narcan intra nasal. 

The first three are things that patients learn how to use in a 10 minute visit with the doctor and they get a script. Narcan they've started giving out to heroin users and their families. So I'm down with those. (and for people who say BLS doesn't need Narcan, you don't work somewhere that the nearest medic is 45 minutes away.  sure you can bag a patient for 45 minutes but I'm not sure that the risk of aspiration is better than just giving them a small does of a drug that has almost no risk and get them breathing on their own.)

Now a lot of the other stuff that has been mentioned you need to train people on. Which is fine. But the whole idea of having something like the EMT-I (or A or whatever) is to give people that info all at once. From a system standpoint I think that's a lot easier than having an hour class of selective spinal imobilization, an hour on combitubes, and hour on this, an hour on that. Or if it's so crucial, add it to the EMT class. But that class would have to be longer than it is now.


----------



## stemi

Definetely EKG lead placement and even interpretation. It really isnt that much of a skill to ask for especially with easy books like Dubin's Rapid Interpretation of EKGs. It would really come in handy while monitoring a patient. Also perhaps use of monitors for ETCO2 and pulseox. If we can do BPs, why not those?


----------



## NYMedic828

stemi said:


> Definetely EKG lead placement and even interpretation. It really isnt that much of a skill to ask for especially with easy books like Dubin's Rapid Interpretation of EKGs. It would really come in handy while monitoring a patient. Also perhaps use of monitors for ETCO2 and pulseox. If we can do BPs, why not those?



You are comparing taking a BP to obtaining, monitoring, treating and interpreting an ECG? Most EMTs I know couldn't tell you what Vfib or Vtach even looked like. Heck, a good few can't take an accurate BP. (some medics/AEMTs I know for that matter can't either...)

EMTs already monitor SpO2 in most areas. 

AEMT/EMT-I and paramedic exist because this needs to be taught at a different level. Paramedic is still far behind what needs to be taught to be proficient in any of these things.

This is all I am seeing


----------



## stemi

NYMedic828 said:


> You are comparing taking a BP to obtaining, monitoring, treating and interpreting an ECG? Most EMTs I know couldn't tell you what Vfib or Vtach even looked like. Heck, a good few can't take an accurate BP. (some medics/AEMTs I know for that matter can't either...)
> 
> EMTs already monitor SpO2 in most areas.
> 
> AEMT/EMT-I and paramedic exist because this needs to be taught at a different level. Paramedic is still far behind what needs to be taught to be proficient in any of these things.



I see where you're coming from, perhaps not all, but it could be something that could be taken into consideration. A lot of the EMTs I work with are very sharp and perhaps would make great medics, but I feel that there would be quite a few who could benefit from it being a skill, at least setup and interpretation, not treating perhaps. Maybe taught basic stuff like vfib and vtach?

Perhaps EKGs are pretty easy to me because setup and interpreted them for a living before. I do think your perspective is probably better than mine though.


----------



## EMT1A

Being able to monitor o2 sats especially since you can take it with an automated pulse ox


----------



## Handsome Robb

stemi said:


> I see where you're coming from, perhaps not all, but it could be something that could be taken into consideration. A lot of the EMTs I work with are very sharp and perhaps would make great medics, but I feel that there would be quite a few who could benefit from it being a skill, at least setup and interpretation, not treating perhaps. Maybe taught basic stuff like vfib and vtach?



The biggest problem with that is the "lowest common denominator" factor. There are plenty of sharp, driven EMTs out there but for every one of those you have 10 that aren't. Therein lies the problem. 

Placement of leads us a no brainer and as far as 3/4 leads are concerned an EMT that can't figure out "white on right with clouds over grass and smoke over fire" probably shouldn't be providing patient care. When it comes to 12-leads I'm all for teaching EMTs to place them, provided they do it correctly, seeing as poor placement can lead to problems. 

Not trying to bash on nurses but I've been in ACLS classes that some nurses had trouble interpreting basic rhythms. I can't imagine making it a standard for EMTs. The big problem I see is having them trying to interpret a more complex rhythm and getting themselves in way over their head and causing more problems than benefit.

When it comes to Sp02 there's no reason EMTs can't do it. Our basics can. They just have to understand that it's only one piece of the puzzle, not "see x do y".


----------



## stemi

NVRob said:


> Not trying to bash on nurses but I've been in ACLS classes that some nurses had trouble interpreting basic rhythms. I can't imagine making it a standard for EMTs. The big problem I see is having them trying to interpret a more complex rhythm and getting themselves in way over their head and causing more problems than benefit.




Very good point on that. Come to think of it, I've actually seen a lot of nurses the exact same way, again, not to bash nurses or anything. Many CCRNs are the best at EKGs, but then again, not every nurse. When interpreting rhythms that contain large amounts of common comorbidities, people can get terribly confused, especially if they are new. 

EKGs are easy enough to read in books, but out in the real world, especially on very sick patients, it can get really tough.


----------



## Bullets

Now i dont think EMTs need any form of ECG monitoring,  but for arguments sake

What if we gave them 3 leads, and educated them to "this is sinus rhythm, know it, love it, enjoy it. If you see anything else, call ALS" kind of thing


----------



## Veneficus

Bullets said:


> Now i dont think EMTs need any form of ECG monitoring,  but for arguments sake
> 
> What if we gave them 3 leads, and educated them to "this is sinus rhythm, know it, love it, enjoy it. If you see anything else, call ALS" kind of thing



Why not just get rid of BLS and cut out the middleman?

Would the cost of putting a monitor on every BLS rig increase or decrease how often ALS is called and would it be worth it?

Why not just make the BLS people go to paramedic school so they can actually do something if they see something wrong?

We don't need more "basic skills."


----------



## 8jimi8

Annnnnd entire post summed up by Vene.  

No more basics.  Mandatory degrees for all paramedics. and mandatory tools to do the job.

What a concept.

just for giggles.  

When would you NOT want to administer a rectal suppository?

I'm all for emt's being able to place and obtain ECGs, but all of this education you are talking about is covered... in the next levels of certifications.

No, i do not believe in turning a 120 hour class into ricky rescue.

NTG without a 12 lead is moronic.


----------



## Anthony7994

I was able to do all of those besides the diazepam and naloxone. Crazy how limited BLS scope is in other states.


----------



## NYMedic828

Anthony7994 said:


> I was able to do all of those besides the diazepam and naloxone. Crazy how limited BLS scope is in other states.



No, it's crazy that it isn't as limited in some states and more over isn't controlled on a federal level.

I see no reason in adding all these skills to a BLS level. A couple things sure, but at some point your are just creating an even lesser trained AEMT.


EMT wants to play AEMT/medic become an AEMT.

AEMT/medic wants to play doctor, become a doctor.


----------



## rescue1

PA allows EMT-B's to administer CPAP, carry Epi-pens, monitor SPO2 levels and titrate O2 administration, though inexplicably no glucometer (which I could do in MD).

Ideally, I agree with Vene. If we have ALS as the standard, this conversation would be unnecessary. The skills that ideally require constant practice and education (intubation, for example) and maybe some advanced pharmacology could be administered by "super ALS" or whatever you want to call it, in fly cars that respond to priority calls, and practice community paramedicine on the side.

But until then, I don't think I'm cool with giving basics a lot of extra skills. I know far too many who have barely mastered the blood pressure cuff, and at least one who gave a patient tachycardia by spraying half her albuterol inhaler down her throat. Aspirin, fine. Naxalone has minimal side effects...I could be talked into it. But I'm not OK with non-prescribed nitro...we just don't have the education and heart monitoring skills to make an informed treatment plan for a cardiac case.


----------



## EpiEMS

NYMedic828 said:


> No, it's crazy that it isn't as limited in some states and more over isn't controlled on a federal level.



The system's not federal for good reasons. The states regulate medical practice, for one. And since the EMS system is parochial by nature, it can fit the needs of the community - greater standardization isn't necessarily going to be helpful (whether due to cost, etc.). Even hospitals aren't standardized. Sure, there are requirements and levels of care, but there is a range - say, the rural ED that operates with a PA during off hours (or all the time, even!) all the way to the R Adams Cowley Shock Trauma Center. It wouldn't be cost effective for a Level I trauma facility to be everywhere:censoredand probably wouldn't improve outcomes very much either). The same argument follows for EMS providers. And the fire service. And police departments. And every other public service.



NYMedic828 said:


> I see no reason in adding all these skills to a BLS level. A couple things sure, but at some point your are just creating an even lesser trained AEMT.



What distinguishes an EMT from an AEMT? I'm of the opinion that it is invasive procedures - starting an IV, namely.


----------



## Tigger

EpiEMS said:


> The system's not federal for good reasons. The states regulate medical practice, for one. And since the EMS system is parochial by nature, it can fit the needs of the community - greater standardization isn't necessarily going to be helpful (whether due to cost, etc.). Even hospitals aren't standardized. Sure, there are requirements and levels of care, but there is a range - say, the rural ED that operates with a PA during off hours (or all the time, even!) all the way to the R Adams Cowley Shock Trauma Center. It wouldn't be cost effective for a Level I trauma facility to be everywhere:censoredand probably wouldn't improve outcomes very much either). The same argument follows for EMS providers. And the fire service. And police departments. And every other public service.
> 
> 
> 
> What distinguishes an EMT from an AEMT? I'm of the opinion that it is invasive procedures - starting an IV, namely.




Not sure how not all hospitals being able to provide the best of the best care is related. No one is arguing that every EMS provider should either, levels are inevitable to keep costs reasonable.

Of note, Crowley Shock Trauma is not (unless it has recently changed) even recognized by the ACS as a Trauma Center, perhaps this is not such a good argument for states regulating all facets of healthcare.

The main difference between AEMT and EMT? AEMT is more hours. If we keep adding hours to the EMT class (and we need to if skill additions happen), then the hours start getting awful close to AEMT. At this point why not just eliminate EMT?


----------



## NYMedic828

I don't think people grasp the concept fully that professions such RN and MD are standardized titles.

EMS is really the only field of healthcare that comes to mind that has such a strong variance depending upon region.

As an MD or RN, I can live and work in NY now, and move to florida tomorrow and already start looking for work. As a paramedic, I more than likely need to jump through hoops to have my certification recognized before I can even apply for work.

Even more ridiculous, My certification is not fully valid if I travel 10 minutes east of my home. Within a 20 mile span of my residence, I have 3 separate regions with 3 separate sets of protocols. You can't possibly argue that that is not ridiculous.

EMS needs to be standardized NATION wide. You wanna have the NREMT do it, great. Tell them to get off their asses and start being useful.



What differs an EMT from an AEMT is the same as what differs an AEMT from a paramedic.

Education. Nothing more, nothing less. Thats all their is to it. Has nothing to do with the skills, it has to do with knowledge behind them. I can teach anyone to stab you in the arm with toradol, but that doesn't mean they know why they are doing it.

It just makes no sense to add 10 skills to the EMT level, when a level capable of all these things and an already too basic understanding of them already exists at the next level.


----------



## Dwindlin

Tigger said:


> Of note, Crowley Shock Trauma is not (unless it has recently changed) even recognized by the ACS as a Trauma Center, perhaps this is not such a good argument for states regulating all facets of healthcare.



ACS has nothing to do with states.  The process is voluntary, you have to apply.  Just because they aren't "recognized" (read paid the ACS a :censored::censored::censored::censored:-ton of money) doesn't mean they aren't one of the premier trauma centers in the world.


----------



## Tigger

Dwindlin said:


> ACS has nothing to do with states.  The process is voluntary, you have to apply.  Just because they aren't "recognized" (read paid the ACS a :censored::censored::censored::censored:-ton of money) doesn't mean they aren't one of the premier trauma centers in the world.



If you say you are the best but refuse to submit to the same standards of the "rest of the best," are you still the best? Many states use the ACS verification process as their own for defining trauma centers, which makes complete since. It is certainly to everyone's advantage to nationally standardize trauma center criteria to allow for accurate comparisons. Why can't we do this in EMS?


----------



## EpiEMS

NYMedic828 said:


> EMS needs to be standardized NATION wide. You wanna have the NREMT do it, great. Tell them to get off their asses and start being useful.



But if EMS is protocol-based and inherently depends on the license of an MD, then we've got a problem -- MDs are licensed by states. MDs have no scope of practice per-se (at least, explicitly, a GP is probably not going to place an ETT in his/her office, say). EMS providers, on the other hand...

To be clear, I don't disagree with you. Physicians, PAs, and nurses have national standard exams - the USMLE (COMLEX for DOs), PANCE, and NCLEX - but their licensure depends on states. I don't see a problem with encouraging  states to take NREMT (at its various levels) passage in the same way they do other national licensure exams. It'd make sense. But, and I think this merits a mention, because EMS providers are inherently limited by being vocationally trained (as technicians), it does make sense for medical directors to be able to give endorsements on a service-by-service or a state-by-state (or region-by-region) basis.


----------



## NYMedic828

Apparently the county that neighbors mine has began an EMT narcan IN pilot program and already used it effectively on one patient in respiratory arrest.


----------



## shiroun

NYMedic828 said:


> Apparently the county that neighbors mine has began an EMT narcan IN pilot program and already used it effectively on one patient in respiratory arrest.



x2. I heard about that. They've had the program for a little while, and its apparently only for police.


----------



## Tigger

NYMedic828 said:


> Apparently the county that neighbors mine has began an EMT narcan IN pilot program and already used it effectively on one patient in respiratory arrest.



Boston EMS has been doing this for a bit with their BLS units (which there are lots of compared to ALS), with good results apparently.


----------



## zmedic

We're piloting intranasal narcan for BLS EMS in New York, my agency hasn't use it yet but it's on the trucks


----------



## LOPLII

i think how to do insulin is very useful to know as emt-b


----------



## EpiEMS

NYMedic828 said:


> Apparently the county that neighbors mine has began an EMT narcan IN pilot program and already used it effectively on one patient in respiratory arrest.



Question from somebody who hasn't ever seen Narcan used except in training: have you ever seen adverse effects?


----------



## usalsfyre

LOPLII said:


> i think how to do insulin is very useful to know as emt-b



:rofl:

Negative sir, handing out sliding scales to Basics has disaster written all over it.


----------



## Medic Tim

EpiEMS said:


> Question from somebody who hasn't ever seen Narcan used except in training: have you ever seen adverse effects?


I have seen over zealous medics push way to much and have a combative ptas a result. I have also seen narcan given to a pt who was also on some sort of stimulant.


----------



## Handsome Robb

LOPLII said:


> i think how to do insulin is very useful to know as emt-b



False. See Kyle's answer for my reasoning.



Medic Tim said:


> I have also seen narcan given to a pt who was also on some sort of stimulant.



That'll ruin your day real quickly.


----------



## EpiEMS

Medic Tim said:


> I have seen over zealous medics push way to much and have a combative ptas a result. I have also seen narcan given to a pt who was also on some sort of stimulant.



Aren't they supposed to titrate to effect? :EDIT: The medics, not the patients


----------



## Handsome Robb

EpiEMS said:


> Aren't they supposed to titrate to effect? :EDIT: The medics, not the patients



You're giving some medics way too much credit.


----------



## EpiEMS

NVRob said:


> You're giving some medics way too much credit.



Truth.
Is there a solution, that is, if you were to bring IN narcan to the BLS level?


----------



## Handsome Robb

EpiEMS said:


> Truth.
> Is there a solution, that is, if you were to bring IN narcan to the BLS level?



Only give them prefills with a max of 0.4 mg in them. That's about the only idea I have other than not giving it to them. 

Intermediates here can give narcan. With that said one of the first lines of our OD protocol says "Cardiac Monitor", so sure the intermediate can give the drug but the medic is still taking the call.


----------



## zmedic

there is 0 reason to give insulin in the field

Don't do it. Don't even talk about it.


----------



## firecoins

We should make the EMT-B go through a medic program and than, they could do everything a medic does.  We should just make that the baseline.


----------



## DesertMedic66

firecoins said:


> We should make the EMT-B go through a medic program and than, they could do everything a medic does.  We should just make that the baseline.



What about the systems that use EMTs to mainly drive the ambulance? You would be putting those EMTs through a medic program just so they could get paid more to drive an ambulance (someone has to drive. So if it's not one medic then it's the other medic). Probably not the most cost effective way of running a system.


----------



## firecoins

firefite said:


> What about the systems that use EMTs to mainly drive the ambulance? You would be putting those EMTs through a medic program just so they could get paid more to drive an ambulance (someone has to drive. So if it's not one medic then it's the other medic). Probably not the most cost effective way of running a system.



WHy do you need a driver to have any EMS training?  Cops can drive, firefighters can drive, CFRs can drive.  EMT-Bs want to give ALS drgs without extra training.  Put them in a medic program.


----------



## DesertMedic66

firecoins said:


> WHy do you need a driver to have any EMS training?  Cops can drive, firefighters can drive, CFRs can drive.  EMT-Bs want to give ALS drgs without extra training.  Put them in a medic program.



Not in Cali. State requires the driver of an ambulance to be at least an EMT.


----------



## firecoins

firefite said:


> Not in Cali. State requires the driver of an ambulance to be at least an EMT.



than by god he should be a medic.


----------



## Tigger

EpiEMS said:


> Truth.
> Is there a solution, that is, if you were to bring IN narcan to the BLS level?



The best I can come up with is provide Naracan doses of the .4mg variety instead of 2mg. Obviously it's not going to stop every misuse but it might be a start...


----------



## Veneficus

Just my logic but if...

We are now talking about repackaging medication or ordering 2 seperate packages of the same medication for a different dose, then we need to not be figuring out how to make administration idiot proof, we just need to not let the idiots play with it.


----------



## Tigger

Veneficus said:


> Just my logic but if...
> 
> We are now talking about repackaging medication or ordering 2 seperate packages of the same medication for a different dose, then we need to not be figuring out how to make administration idiot proof, we just need to not let the idiots play with it.



Nothing to say that medics can't use the .4mg prefills of narcan, it is preferred in one area that I work.

Also are double medic trucks that uncommon? They are commonplace here in MA, even after the state started allowing P/B configurations.


----------



## NYMedic828

It has been my experience, be it brief, that most people respond very well to a dose of narcan as low as 0.2-0.4mg. It's rare that I need to go above that to attain the desired effect of maintaining respiration.

It has also been my experience that incompetence as we already know is quite abundant. I know medics who don't see that much due to where they "practice" and they may use narcan once every 3 years. They aren't aware that all you really need is a few drops and they slam the entire amp in anyway. 

I feel that just because you give an EMT and a medic the same skill, it doesn't always mean the medic will be more competent. It should, but it doesn't.

The two pilot programs that have began recently in my region use a 0.2mg Prefilled IN syringe.


----------



## Veneficus

Tigger said:


> Nothing to say that medics can't use the .4mg prefills of narcan, it is preferred in one area that I work.
> 
> Also are double medic trucks that uncommon? They are commonplace here in MA, even after the state started allowing P/B configurations.



My statement applies equally to medics.

Whether medication application or surgical procedure, if a majority of providers can't do it right, they shouldn't be doing it.

We should not be using technology or packaging to make up for poor ability.


----------



## EpiEMS

Veneficus said:


> My statement applies equally to medics.
> 
> Whether medication application or surgical procedure, if a majority of providers can't do it right, they shouldn't be doing it.
> 
> We should not be using technology or packaging to make up for poor ability.



But there's no reason not to try using technology and/or packaging to improve efficacy, though.


----------



## the_negro_puppy

I've never used Narcan...

However our protocols call for 1.6mg IM for adult.

We don't really have a choice in regards to dose :glare:


----------



## MikeCivitello

NYMedic828 said:


> Many have suggested carrying Nitrous Oxide (laughing gas) but it has some FDA restrictions I believe was what came out of the topic.



Do you have more information on what "FDA restrictions" came up?  Nitrous Oxide and Oxygen are not restricted for use in the US by the FDA.  Its used every day in dental offices, hospitals and by first responders.  

You may be confusing the "pre-mixed" 02 and N20 gas that is commonly used in other countries.  This is not approved for use in the US by the FDA.


----------



## Tigger

MikeCivitello said:


> Do you have more information on what "FDA restrictions" came up?  Nitrous Oxide and Oxygen are not restricted for use in the US by the FDA.  Its used every day in dental offices, hospitals and by first responders.
> 
> You may be confusing the "pre-mixed" 02 and N20 gas that is commonly used in other countries.  This is not approved for use in the US by the FDA.



That was the issue, without it being premixed some believe that it is too bulky to carry around. Personally I still think we could carry it, it's not something that you would bring into every call and in some cases it could just be left in the ambulance until the patient is loaded assuming that getting them onto the stretcher without a significant increase in pain is possible.


----------



## medicdan

Tigger said:


> That was the issue, without it being premixed some believe that it is too bulky to carry around. Personally I still think we could carry it, it's not something that you would bring into every call and in some cases it could just be left in the ambulance until the patient is loaded assuming that getting them onto the stretcher without a significant increase in pain is possible.



As I think the past discussions have indicated, accountability seems to be the reason it hasnt been widely utilized.


----------



## Cup of Joe

emt.dan said:


> As I think the past discussions have indicated, accountability seems to be the reason it hasnt been widely utilized.



I'm going to go with this.  We have plenty of room on our type-IIIs for another tank (and whatever installed hardware may be needed).  It could also probably fit in many type-I or type-II vehicles.

How do you stop people from abusing it? Maybe mandating that before and after tank pressures be written on the PCRs and separate forms filled out to provide accountability within the agency (provider who initiated its use, before and after tank pressures, time administration was started, when it was ended, mix ratios, etc)?

I would like to see BLS have some form of pain management (more so in areas with extended transport times) but ultimately, are BLS providers ready for that responsibility?


----------



## EpiEMS

Cup of Joe said:


> I would like to see BLS have some form of pain management (more so in areas with extended transport times) but ultimately, are BLS providers ready for that responsibility?



In some areas, BLS providers can give narcotics for pain management:

For example, Montana has a program of "endorsements" for various levels of providers so that medical directors can increase the scope of practice for differing levels to fit local circumstances. Viz.: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf


----------



## MikeCivitello

Cup of Joe said:


> I'm going to go with this.  We have plenty of room on our type-IIIs for another tank (and whatever installed hardware may be needed).  It could also probably fit in many type-I or type-II vehicles.
> 
> How do you stop people from abusing it? Maybe mandating that before and after tank pressures be written on the PCRs and separate forms filled out to provide accountability within the agency (provider who initiated its use, before and after tank pressures, time administration was started, when it was ended, mix ratios, etc)?
> 
> I would like to see BLS have some form of pain management (more so in areas with extended transport times) but ultimately, are BLS providers ready for that responsibility?



I think concerns of abuse will always be there.  Having a firm policy, standards on security, and who has access to the N20 cylinders - along with  zero tolerance will be critical.  Perhaps some others that are currently using N20 can chime in with what they do - or suggestions?  

Unfortunately with N20 cylinders there is no way to determine what is in the cylinder by means of cylinder pressure.  The gas is in a liquid form - similar to propane - and turns to a gas as it is released.  This means the cylinder regulator will always read full - until it is just about empty - and the pressure will drop.


----------



## Veneficus

MikeCivitello said:


> I think concerns of abuse will always be there.  Having a firm policy, standards on security, and who has access to the N20 cylinders - along with  zero tolerance will be critical.  Perhaps some others that are currently using N20 can chime in with what they do - or suggestions?
> 
> Unfortunately with N20 cylinders there is no way to determine what is in the cylinder by means of cylinder pressure.  The gas is in a liquid form - similar to propane - and turns to a gas as it is released.  This means the cylinder regulator will always read full - until it is just about empty - and the pressure will drop.



With all of the logisitcal issues regarding inhalents, why not just add IV morphine or fent?

It costs less, easier to account, and is so easy, even the drug abusers on the street can do it.

(disclaimer, I do not believe BLS should be doing pain management with anything other than NSAIDs, if people really value pain management, they need to come up with the money for local ALS, but I offer the above in an effort to solve the problems with nitrous)


----------



## Doczilla

There's even cheaper ways than THAT. 

"I called 911 for a sprained ankle, and he handed me a whipped cream can! The bill was $800!"

Profit.


----------



## emtevan

*narcan to basics*

i have an idea if an emt cant handle medications and or treatments then they shouldnt work on an ambulance.why take stuff away because people cant handle it.Same with medics if u cant do medications and the treatments then dont be a medic.Dont take stuff away from the emt's and medics who can do it right.If someone wants to be a cashier and they screw up the scanning process will that company fire the person or would they take out the scanners and put something else in its place?they would fire the person well it should be the same for ems.


----------



## emtevan

*narcan for basics*

i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.


----------



## Tigger

emtevan said:


> i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.



I work for a private company that provides all three of those things to its BLS crews, and we are located in your area. 

That being said, don't you think that we need a little more education before they give us more "stuff?"


----------



## Christopher

emtevan said:


> i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.



Wow, med school for 12-Leads...really?

We run 12-Leads as basics on our industrial fire brigade and at our fire service. In fact, the State of NC expects EMT-Basics to know how to apply and acquire a 12-Lead ECG.

I don't disagree that we need more education, but when I make such claims I usually capitalize "i" and spell out "you"...but that is just me.


----------



## Achilles

emtevan said:


> i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.



I was doing twelve leads during my basic clinicals. I wasn't reading rhythms, just placing leads, putting their PT id number in and age and, Doctor's name. 
They even let me press the print button 

Also, we can use a glucometer as well as a pulse ox.


----------



## Veneficus

emtevan said:


> .no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.



Like what?


----------



## NYMedic828

emtevan said:


> i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.



So if medics want to do more they should go to medical school but if basics want to do more they...should just be handed it?

Last time I checked when an EMT wanted to do more they want to paramedic school...

EMTs here have pulseox, glucometry and just got narcan...

Do you even know what a pulseox actually tells you that it woul be relevant to your assessment and treatment of applying a NRB to the patient to ensure they receive a massive overdose of oxygen?


----------



## TransportJockey

emtevan said:


> i also think basics should have pulse ox and glucometers and nasal narcan.its pretty pathetic when an ambulance shows up and cant give the narcan yet the police show up and they have it.i also think its funny when medics say well if a basic wants to do more then go to medic school.no thats crap i think basics should do more and i dont mean 12 leads or ivs just the other stuff i suggested.i think als can do way more then they should hell if u want als to do more then GO TO MED SCHOOL.



Lol you'll :censored::censored::censored::censored: bricks if you ever read the NM scope of practice for basics. But our basics are rather well trained... but still not enough education for what they are given. Honestly with how little education basics really have, giving them more toys to play with could be the last thing we do.


----------



## EpiEMS

TransportJockey said:


> Lol you'll :censored::censored::censored::censored: bricks if you ever read the NM scope of practice for basics.



Wow! Your basics can do supraglottic airways, CPAP, start a 12-lead without anybody telling them to (not interpret)? That's awesome.


----------



## NomadicMedic

EpiEMS said:


> Wow! Your basics can do supraglottic airways, CPAP, start a 12-lead without anybody telling them to (not interpret)? That's awesome.



That would be great if they were with a medic partner. Otherwise, it's just half assed ALS.


----------



## EpiEMS

n7lxi said:


> That would be great if they were with a medic partner. Otherwise, it's just half assed ALS.



The supraglottic airways are pretty foolproof, and CPAP's easy enough to use (plus, it can really help in many cases, no?). The 12-lead placement makes sense, too – if a basic can accurately place the leads, transmission allows the ED to activate the cath lab, or divert the ambulance to a facility with a cath lab, etc.?

What's the objection?


----------



## NomadicMedic

<5 minute transport time, no objection.

What I do find objectionable is bureaucrats trying to convince their public constituents that EMT basics who can use CPAP and SGA and stick a 12 lead on somebody are just as good as paramedics. And if you think that doesn't happen, think again. 

We continue to dilute the educational process giving basics more skills to do without education to back them up. I notice how nobody complains about giving basics more to do… But if a paramedic started to step into the nursing realm, the fur would fly.

Either let's just realize that EMT B is simply that, a basic entry-level point... Or let's revamp the training and make the entry-level point closer to EMTI 99 and increase the paramedic training to be more community minded and focused on social service and preventative care along with advanced procedures. 

I just don't think cramming more skills into a basic's toolbox is the right thing to do.


----------



## Christopher

n7lxi said:


> <5 minute transport time, no objection.
> 
> What I do find objectionable is bureaucrats trying to convince their public constituents that EMT basics who can use CPAP and SGA and stick a 12 lead on somebody are just as good as paramedics. And if you think that doesn't happen, think again.
> 
> We continue to dilute the educational process giving basics more skills to do without education to back them up. I notice how nobody complains about giving basics more to do… But if a paramedic started to step into the nursing realm, the fur would fly.
> 
> Either let's just realize that EMT B is simply that, a basic entry-level point... Or let's revamp the training and make the entry-level point closer to EMTI 99 and increase the paramedic training to be more community minded and focused on social service and preventative care along with advanced procedures.
> 
> I just don't think cramming more skills into a basic's toolbox is the right thing to do.



I think leaving basics with a BVM as their only choice for patients when NIPPV would suffice is wrong.

I think supraglottic airways...probably aren't necessary in any BLS service with ALS help reasonably close.

I think 12-Lead acquisition (and transmission) is critical for BLS.

...aaand I think we need to make Paramedic education the lowest common denominator and give the rest first aid cards.


----------



## firecoins

We should add paramedic training to their EMT class.


----------



## NomadicMedic

Christopher, I think you usually make good points, but in the case of 12 leads for basics, I think you're off the mark. 

Maybe it works in the most rural of rural areas, like the Dakota's where a paramedic is far away and BLS may be the only thing coming, but in suburban /urban environments, it is just one more thing that slows down the process. 

If I, as a paramedic, are planning to transport a chest pain patient, I want the BLS crew singularly focused on getting the patient moved to the ambulance and then getting me and my patient to the hospital safely. If I feel comfortable with the BLS provider's skills, I may delegate tasks to them under my supervision. I don't need them stopping forward motion to the hospital to perform 12 leads or anything else. 

I know the basics will hate me for this, but if you want to perform ALS skills, then go to paramedic school. 

That's it.


----------



## Christopher

n7lxi said:


> Christopher, I think you usually make good points, but in the case of 12 leads for basics, I think you're off the mark.
> 
> Maybe it works in the most rural of rural areas, like the Dakota's where a paramedic is far away and BLS may be the only thing coming, but in suburban /urban environments, it is just one more thing that slows down the process.
> 
> If I, as a paramedic, are planning to transport a chest pain patient, I want the BLS crew singularly focused on getting the patient moved to the ambulance and then getting me and my patient to the hospital safely. If I feel comfortable with the BLS provider's skills, I may delegate tasks to them under my supervision. I don't need them stopping forward motion to the hospital to perform 12 leads or anything else.
> 
> I know the basics will hate me for this, but if you want to perform ALS skills, then go to paramedic school.
> 
> That's it.



We acquire 12 leads prior to ALS arrival on our BLS industrial fire brigade. Saves ~10 minutes from first medical contact to acquisition. We've had 3 STEMI's caught prior to ALS arrival, with ECG in hand, ASA on board, and patient packaged.

If somebody made an AED + 12-Lead that would be a game changer, something to go on every BLS/ILS truck around.


----------



## ffemt8978

n7lxi said:


> Maybe it works in the most rural of rural areas, like the Dakota's where a paramedic is far away and BLS may be the only thing coming, but in suburban /urban environments, it is just one more thing that slows down the process.



And therein lies the crux of the problem.  There is no "one size fits all" solution for EMS, and what works or is appropriate for one area doesn't for another.  We need to stop trying to make the square peg fit in the round hole.


----------



## NomadicMedic

But we're in EMS. we've been trying to stuff that round peg in the square hole since the 70s.


----------



## Christopher

n7lxi said:


> But we're in EMS. we've been trying to stuff that round peg in the square hole since the 70s.



And then hyperinflate a cuff to hold it there...


----------



## medichopeful

EpiEMS said:


> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)



Just FYI, an EpiPen is IM, not SQ


----------



## EpiEMS

n7lxi said:


> What I do find objectionable is bureaucrats trying to convince their public constituents that EMT basics who can use CPAP and SGA and stick a 12 lead on somebody are just as good as paramedics. And if you think that doesn't happen, think again.



That is a problem. EMTs < Medics, insofar as skills and training (and ability to help patients, in certain situations) we know this. But it bears mention that for many of the important, measurable outcomes (see: OPALS, Bakalos et al. 2011 in Resuscitation, Isenberg and Bissell 2005 in Prehospital Disaster Medicine), BLS produces better or similar outcomes as ALS at lower cost. 




n7lxi said:


> We continue to dilute the educational process giving basics more skills to do without education to back them up. I notice how nobody complains about giving basics more to do… But if a paramedic started to step into the nursing realm, the fur would fly.



You'll get no argument from me! EMTs need more education, medics need more education. It's also important to remember that medics and RNs are totally different – RNs don't typically act as the sole provider of medical care (plus, they're performing nursing, not medicine), nor do they usually work in the field, etc.



n7lxi said:


> Either let's just realize that EMT B is simply that, a basic entry-level point... Or let's revamp the training and make the entry-level point closer to EMTI 99 and increase the paramedic training to be more community minded and focused on social service and preventative care along with advanced procedures.



I don't disagree at all. I will say, though, if we can have patients self-administer things like NTG, EpiPens, albuterol inhalers, diastat, CPAP, etc., then EMTs should certainly be allowed to carry and administer them on the same authority that we administer O2, use an AED, splint, etc.


----------



## rmabrey

truetiger said:


> EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.



I mostly agree, however, on an ALS truck the EMT is just the assistant right? Why not allow your assistant to do more to help.

I discussed this with my partner the other day. As a basic I am not allowed to check a BGL, place the monitor leads or give nitro. So on a typical chest pain call.

EMT: VS, ASA, Oxygen

Medic: Assesment, Monitor, 12-lead, IV, Nitro, BGL

I would be much more helpful if I were allowed to place the leads and give nitro, while my partner does other things. Or I can just be a good EMT and shut up and drive(which is the direction it is slowly moving at my service)


----------



## Jambi

rmabrey said:


> I mostly agree, however, on an ALS truck the EMT is just the assistant right? Why not allow your assistant to do more to help.
> 
> I discussed this with my partner the other day. As a basic I am not allowed to check a BGL, place the monitor leads or give nitro. So on a typical chest pain call.
> 
> EMT: VS, ASA, Oxygen
> 
> Medic: Assesment, Monitor, 12-lead, IV, Nitro, BGL
> 
> I would be much more helpful if I were allowed to place the leads and give nitro, while my partner does other things. Or I can just be a good EMT and shut up and drive(which is the direction it is slowly moving at my service)



This is essentially the argument for doing away with basic all together and make the entry level cert AEMT. This would cover everything you covered minus ECG/12-lead interp.


----------



## NYMedic828

rmabrey said:


> I mostly agree, however, on an ALS truck the EMT is just the assistant right? Why not allow your assistant to do more to help.
> 
> I discussed this with my partner the other day. As a basic I am not allowed to check a BGL, place the monitor leads or give nitro. So on a typical chest pain call.
> 
> EMT: VS, ASA, Oxygen
> 
> Medic: Assesment, Monitor, 12-lead, IV, Nitro, BGL
> 
> I would be much more helpful if I were allowed to place the leads and give nitro, while my partner does other things. Or I can just be a good EMT and shut up and drive(which is the direction it is slowly moving at my service)



Sounds more like a case of a partner who wants to do everything or does not trust you to do it in conjunction with him. (Not implying the latter, just a statement)

No reason you can't help. Technically is it in your scope, no. But if it isn't invasive it's a little ridiculius to exclude you.


----------



## rmabrey

NYMedic828 said:


> Sounds more like a case of a partner who wants to do everything or does not trust you to do it in conjunction with him. (Not implying the latter, just a statement)
> 
> No reason you can't help. Technically is it in your scope, no. But if it isn't invasive it's a little ridiculius to exclude you.



thats not the case at all, just doing my best not to incriminate myself on an open forum.........oh, i mean theoretically of course


----------



## Christopher

rmabrey said:


> I mostly agree, however, on an ALS truck the EMT is just the assistant right? Why not allow your assistant to do more to help.
> 
> I discussed this with my partner the other day. As a basic I am not allowed to check a BGL, place the monitor leads or give nitro. So on a typical chest pain call.
> 
> EMT: VS, ASA, Oxygen
> 
> Medic: Assesment, Monitor, 12-lead, IV, Nitro, BGL
> 
> I would be much more helpful if I were allowed to place the leads and give nitro, while my partner does other things. Or I can just be a good EMT and shut up and drive(which is the direction it is slowly moving at my service)



If you can't check a BGL as a basic...you're not an EMT. (No offense to you)

BGL is a layperson skill and must be available at all levels of EMS in order to have practitioners be taken seriously.


----------



## rmabrey

Jambi said:


> This is essentially the argument for doing away with basic all together and make the entry level cert AEMT. This would cover everything you covered minus ECG/12-lead interp.



I was excited when I became an EMT, 18 months at a busy service and I'm bored. It didn't take more than a week to realize being an EMT actually kind of sucks. However, I have gotten a lot of great experience to somewhat prepare me for when I'm a medic so I cant say it's all bad.


----------



## rmabrey

Christopher said:


> If you can't check a BGL as a basic...you're not an EMT. (No offense to you)
> 
> BGL is a layperson skill and must be available at all levels of EMS in order to have practitioners be taken seriously.



Tell that to the state of Indiana


----------



## Christopher

rmabrey said:


> Tell that to the state of Indiana



Our EMT's have liberal protocols and high expectations at our service. Hell, from what you've said it appears our medical responders have a higher scope of practice.


----------



## Anjel

We carry Epi pens, oral glucose, and oxygen. And a glucometer.


----------



## DrParasite

Christopher said:


> If you can't check a BGL as a basic...you're not an EMT. (No offense to you)
> 
> BGL is a layperson skill and must be available at all levels of EMS in order to have practitioners be taken seriously.


please mention that to the state of NJ... they don't seem to understand that, despite you being correct about the skill involved.  While you are in the area, mention it to New York too.


----------



## NYMedic828

DrParasite said:


> please mention that to the state of NJ... they don't seem to understand that, despite you being correct about the skill involved.  While you are in the area, mention it to New York too.



NY has nasal narcan, albuterol, asa, epi pens and glucometry... Narcan literally started in september and the others have been for a few years.


----------



## EpiEMS

NYMedic828 said:


> NY has nasal narcan, albuterol, asa, epi pens and glucometry... Narcan literally started in september and the others have been for a few years.



Bringing up these skills and how Narcan is a recent addition, I'm curious if anybody has a good reason why these sorts of skills and equipment shouldn't be BLS skills. Is there, say, a reasonable reason why an EMT shouldn't be allowed to administer albuterol from an inhaler or nebulizer?


----------



## NYMedic828

EpiEMS said:


> Bringing up these skills and how Narcan is a recent addition, I'm curious if anybody has a good reason why these sorts of skills and equipment shouldn't be BLS skills. Is there, say, a reasonable reason why an EMT shouldn't be allowed to administer albuterol from an inhaler or nebulizer?



Mind you the criteria for BLS administration, and AEMT-CC administration for that matter, are very strict. 3-5 various factors technically have to be present for standing order.

Each participating agency must train each BLS provider to meet the minimum standard.

Honestly, its a simple skill as can be. In practice inserting an NPA is more invasive. As long as medical control contact is required for administration it should be a BLS skill. Once you start permitting it to be done without authorization you are crossing the line between BLS and ALS. There should be distinct boundaries either you have the necessary training (which is still not enough) or you don't.


----------



## NomadicMedic

I have some anecdotal experience. In Washington state EMT basics are allowed to administer epi for anaphylaxis. Because the cost of epi-pens is exorbitant and due to legislation that requires every ambulance have a EpiPen on board, protocols were developed to allow basics to draw up and administer the proper dose of epi from a vial of 1 ml 1:1000. 

When I arrived on the scene of a mild allergic reaction, some slight urticaria and no airway involvement… I found the EMT nervously trying to break the top off the ampule to administer epi to this guy. He didn't know what he didn't know. 

That's the same reason I think it's dangerous for basics to administer albuterol to somebody that's wheezing. We just had the cardiac wheeze versus COPD in another thread. Apparently, there are paramedics who have trouble differentiating between CHF and COPD/asthma I can imagine how hard it will be for some basics.


----------



## JPINFV

NYMedic828 said:


> Honestly, its a simple skill as can be. In practice inserting an NPA is more invasive. As long as medical control contact is required for administration it should be a BLS skill. Once you start permitting it to be done without authorization you are crossing the line between BLS and ALS. There should be distinct boundaries either you have the necessary training (which is still not enough) or you don't.



While I agree that there should be somewhat distinct limits in regards to what is appropriate given the minimum training, I think there's a significant logistical issue with requiring med control for life saving treatments. If an EMT thinks that he needs to be administering Albuterol, I'd rather have them make the phone call for paramedics and administer it, than waste time with medical control. Calling medical control is not going to activate medics, and I don't think medical control is going to deny all but the most stupid requests for Albuterol.


----------



## NYMedic828

JPINFV said:


> While I agree that there should be somewhat distinct limits in regards to what is appropriate given the minimum training, I think there's a significant logistical issue with requiring med control for life saving treatments. If an EMT thinks that he needs to be administering Albuterol, I'd rather have them make the phone call for paramedics and administer it, than waste time with medical control. Calling medical control is not going to activate medics, and I don't think medical control is going to deny all but the most stupid requests for Albuterol.



You're right, I agree it is probably a time consuming matter in most places. I don't attest to the BLS administration on standing order here because the criteria is in fact so strict but people do like to jump the gun and disregard the fine print too often. In the case of narcan it doesn't really matter though being so benign.

My gripe with our new protocol is that the dosage parameters are to administer half a vial per nare. No titration, just slam the amp in the nose. 

Personally if I am going to give IN narcan, it's going to be in 0.5mg increments in total. Not 2mgs at a time... It's just improper to me.

Fortunately it isn't a protocol that is just permitted each agency as I stated must train their EMTs and as such I am going to make it my responsibility to ensure our membership is held to a higher standard.

If you want to allow LEOs to administer it in such rapid high doses that's fine but we want to consider ourselves medical professionals and we shouldn't be dumbing down an already simple skill to meet the lowest common denominator. The standards of EMS education MUST evolve at some point and if someone can't keep up with it, it's time to go.


----------



## DrParasite

NYMedic828 said:


> NY has nasal narcan, albuterol, asa, epi pens and glucometry... Narcan literally started in september and the others have been for a few years.


BLS units carry glucometers?  I knew epipens and albuterol were in place (or coming into place) when I left in 2004, they didn't have narcan or asa or glucometry on the trucks.  I guess I need to double check my outdated facts :blush:


----------



## NYMedic828

DrParasite said:


> BLS units carry glucometers?  I knew epipens and albuterol were in place (or coming into place) when I left in 2004, they didn't have narcan or asa or glucometry on the trucks.  I guess I need to double check my outdated facts :blush:



On Long Island yes. NYC, no.


----------



## Veneficus

*Make open cardiac bypass a basic skill.*

Before we get too involved in the why tos and whether fors of basics doing whatever they want, let us consider the mot important factor.

The money.

All this invasive equipment costs money.

In addition to the purchase price, there is the cost of the total logistics chain. From QA/QI to serving, accounting, etc.

But a BLS unit is still only going to be paid the BLS rate. Which of course means all of these invasive gadgets and meds are going to cut into the budget.

When that happens, pay is not likely to go up for these  providers and it may put more than a few out of a job and/or close volunteer houses.

Now consider the liability. (and the cost)

Never mind the terror tactic of getting sued for all you will ever own. Let's consider reality.

The more you perform a procedure, the more likely you are to experience an adverse outcome. It is sort of like roulette.

In order to reduce this risk, very effective systems need to be put in place. (lots of money)

Now as adverse events go up from increased performance, especially by EMS protocol based practice mandating these procedures on patients likely not to need them, some damages will have to be paid. 

By an insurance company. 

This will raise the cost of insurance. (for both organizations and individuals) Which may raise the price out of reach.

So, agencies will self eliminate these "advanced skills."

The more skills you have, the more you have to train. It is not a one time class and done. 

The more invasive the skill, the more it costs to train on. Both in curriculum development (people get paid big $ to do that) and in equipment. (some of which is consumable) 

The more providers have the skill the more competency training and QA will cost.

They still only get the BLS rate for transport.

It is often taught in medical schools that any idiot can perform every test known to man on every patient. 

But the results require education to interpret. 

It is the same for EMS. Not only does the paramedic have an increase in skills to use, they have an increase in knowledge when to apply or not apply various skills. 

In the latest changes to EMS, the EMT was removed from EMT-Paramedic. 
That simple change took away the "technician" aspect of the discription. 

EMTs are still vocational laborers. (for that matter so are medics, but they are very slowly moving away and resisting with their best efforts)

But, the bottom line is, when you are the tech, no matter what you think of yourself, you are still just the person who does what they are told with very little room for interpretation or deviation.

(which is why you see so many EMT-Bs here constantly remind us they have protocols which they rightfully must follow) 

Any advanced procedure or skill is going to have to have standing orders. 

If you haven't been in medicine that long, let me just point out that at some level, there are more exceptions to the rules than not. 

Most medical directors don't give a crap about EMS now. You think they are going to spend hours if not weeks researching and writing protocols for every eventuality?

I assure you they will not.

This thread points out the fact that the Basic EMT provider is not relevant to today's diseases or medicine. 

If you think that more than a handful of your patients are actually saved from the many chronic illnesses or actual acute events (which we now know is only trauma, poisoning, and a handful of infection/inflammation pathologies) you see, then you live in a fantasy world.

You can stab every allergic reaction you want with an epi pen, but the cost of the follow-up care for that is going to quickly cause people to stop it.

Especially when those outside of EMS, like hospitals, have to start eating the cost of all the extra care needed to make sure people are not going to have an adverse reaction to the EMS care provided.

When it is cheaper and safer for society not to call EMS because of the "advanced" care they provide, then not only is that bad for job security, but it absolutely crosses the line from medical care to snake oil sales.

The very reason we have medical licenses in every civilized country is to stop "knowledgable" individuals from providing unregulated care which may harm people.

Follow the money my friends.

Medics, forget defending skills. Defend your knowledge. That is where your value is. That is why you need to advance the standards of education. If knowledge is value, more knowledge is more valuable.

Sooner or later a machine will be built to perform your skills or make them so easy anyone can do it. (like an AED)


----------



## VFlutter

One of the few skills I can argue for adding to BLS is capturing 12 leads, not interpreting them. It is nice to have serial EKGs as well as captured arrhythmias before they potentially self-terminate. 

With some extra training I think NIPPV may be a possibility. 

There was a recent thread about using Nebs with Cardiac Asthma. How many basics would you expect to know the difference? How many cardiac patients would be getting albuterol unnecessarily?


----------



## TransportJockey

ChaseZ33 said:


> One of the few skills I can argue for adding to BLS is capturing 12 leads, not interpreting them. It is nice to have serial EKGs as well as captured arrhythmias before they potentially self-terminate.
> 
> With some extra training I think NIPPV may be a possibility.
> 
> There was a recent thread about using Nebs with Cardiac Asthma. How many basics would you expect to know the difference? How many cardiac patients would be getting albuterol unnecessarily?



NIPPV is a BLS skill in some areas.


----------



## hogwiley

Why would BLS units not be able to use glucometers? Anyone know the reasoning behind this?


----------



## usalsfyre

hogwiley said:


> Why would BLS units not be able to use glucometers? Anyone know the reasoning behind this?



The generally quoted reason is that "it's an invasive skill".


----------



## NYMedic828

hogwiley said:


> Why would BLS units not be able to use glucometers? Anyone know the reasoning behind this?



In NYC, the go to for everything is "call for ALS."

An ALS unit will never take more than 5-10 minutes to arrive at your door in NYC. 

The people in charge would rather they just call for ALS or transport then sit onscene and try to form a differential diagnosis of their own. Realistically, once an EMT determines the presence of low blood sugar, unless the patient is capable of eating then they need to call for ALS anyway.

When I was an EMT, I usually just had the patient or family member check it in my presence with their glucometer. Maybe once or twice I did it for them in 3 years but I was not technically supposed to...


----------



## mycrofft

*What to add?*

Three more years.


----------



## jkiesling

The EMS system I am in allows EMT-B's to do a lot more than the systems surrounding ours, but they feel comfortable that we know what we are doing.  I am sure if we started misusing items we would have them taken away as well.

We are allowed to do 12-leads and based off of what the 12-lead prints off we are allowed to call a STEMI if it prints off acute MI suspected.  We still call for paramedics to start the IV's etc.  EMT-B's transmit all 12-leads performed to the receiving facility though.

We also give ASA, nitro sublingual, albuterol, EPI pens adult and peds, narcan IN, glucagon IN, oral glucose, and have use blind insertion airways.  

We put the EMT's through more training at the start on the use of everything.  The Paramedics are pretty happy that we are allowed to do all of that so when they get there we already have a 12 lead printed off for them and have given ASA and nitro to the pt's.  That way they can get on the ambulance start the IV's look at the 12-lead and go from there.


----------



## Tigger

ChaseZ33 said:


> One of the few skills I can argue for adding to BLS is capturing 12 leads, not interpreting them. It is nice to have serial EKGs as well as captured arrhythmias before they potentially self-terminate.
> 
> With some extra training I think NIPPV may be a possibility.
> 
> There was a recent thread about using Nebs with Cardiac Asthma. How many basics would you expect to know the difference? How many cardiac patients would be getting albuterol unnecessarily?



The services here that have nebs for basics generally require that the patient be diagnosed with asthma for the treatment to be administered. Obviously this cannot eliminate all misuse of the drug, but it no doubt cuts down on its unnecessary use.

Do I think it's a bandaid solution? Yes, but if you're going to give basics nebulizers it's probably the way to go.


----------



## systemet

Same old problems.  Basic EMTs don't have enough education to support what they're already doing, yet people want to add skills.  The same can be said of the paramedic.  Everyone is putting the horse before the cart.  Increase the educational time so that the person stepping off the ambulance when I call 911 is more educated than a hairdresser, and then we can start looking at meaningful scope expansion.


----------



## Melclin

I'm a bit undecided on this topic. 

There are skills that dont require much education. I mean, probably still much more than an EMT but not much none the less. 

BSL monitoring is, for example, a lay person skill. People here spend a day or two in 'diabetes school and can safely and usefully measure their blood sugars and monitor their general health.

I think there are also other realms of treatment where you don't necessarily have to be an expert in the treatment provided. Take Tylenol for example. St John's first aiders hand out paracetamol all the time. Firstly, its a ridiculously safe drug in the grand scheme of things. Secondly, a lay person can go to the 7/11 and buy a pack, so why, given you have a pt presenting in pain to a first aid post at an event, can't you give them a couple of tylenol, following the same instructions for use as they would if they bought it themselves. A lay person need not understand pharmacology to self administer it, so why would a first aider? I think there are probably several skills like this kicking about. Albuterol metered dose inhalers fit into the same category. The MDIs are a frequently used therapy by FAs/FRs to good affect and with no real restrictions. 

That said, I think the EMT level is basically useless. I think for the most part patients fit into one of two categories. Either they need a horizontal taxi, in which case the EMT level is overkill, or they need an actual HCP, in which case the EMT level of education is absurdly inadequate.


----------



## Frozennoodle

systemet said:


> Same old problems.  Basic EMTs don't have enough education to support what they're already doing, yet people want to add skills.  The same can be said of the paramedic.  Everyone is putting the horse before the cart.  Increase the educational time so that the person stepping off the ambulance when I call 911 is more educated than a hairdresser, and then we can start looking at meaningful scope expansion.



Ding ding ding


----------



## Frozennoodle

jkiesling said:


> We put the EMT's through more training at the start on the use of everything.  The Paramedics are pretty happy that we are allowed to do all of that so when they get there we already have a 12 lead printed off for them and have given ASA and nitro to the pt's.  That way they can get on the ambulance start the IV's look at the 12-lead and go from there.



I would be very upset if you gave my pt a drug without asking me first.  If you proudly handed me a 12-lead followed by "I also gave nitro and ASA" I'd be pissed.  If you said, "here's the 12 lead the pt's vitals are blah, I have your lock set up, here's the ASA and nitro if you want them, and I have him on O2 " I'd be much more impressed.  I cant fix a drug administration if you give it inappropriately.  How many times do you get to a scene and see fire there with a NRB on a guy who stubbed his toe on a lego?  It's kinda the same thing.


----------



## Frozennoodle

the_negro_puppy said:


> Narcan- maybe. I guess it depends if you have large scale opioid abuse in your area. I've never used Narcan in 2.5 years on an Ambulance. Been to 1 narc overdose that came up swinging after 1 min of vent



Lol, we have days where our medics go.through 6mg and have to restock before ETOD on a 12 hour shift. Just depends on the region.


----------



## JPINFV

Frozennoodle said:


> I would be very upset if you gave my pt a drug without asking me first.  If you proudly handed me a 12-lead followed by "I also gave nitro and ASA" I'd be pissed.  If you said, "here's the 12 lead the pt's vitals are blah, I have your lock set up, here's the ASA and nitro if you want them, and I have him on O2 "



I think they're talking about giving it before the paramedics arrive, which at that time the EMT crew is primary and it's *their* patient, not the paramedic who is still responding to the scene.


----------



## Frozennoodle

JPINFV said:


> I think they're talking about giving it before the paramedics arrive, which at that time the EMT crew is primary and it's *their* patient, not the paramedic who is still responding to the scene.



Ah, well that's... different.


----------



## systemet

There seems to be confusion in some of these posts about the complexity of a psychomotor skill and the risk/benefit of a given intervention.  

Most of the psychomotor skills commonly used in EMS are not that complex.  The biggest exception is probably intubation which requires a fair amount of practice..  Things like placing NG tubes, IOs, EJs, the act of starting the LP12 pacer, obtaining a 12-lead, giving an IM injection, for 90% of patients, IV initiiation, so forth, are not some sort of magic that takes 3 years to learn how to do.

But let's be clear here --- if I teach a 10 year old child how to place the precordial leads and press 12-lead --- this doesn't make them a paramedic, any more than me knowing how to RSI makes me an anesthetist, or doing a cricothyrotomy makes me an EENT surgeon, or doing an ABG makes me an RRT.  The skills are useless without the necessary background to understand when, how and why to use them.  To take the 12-lead ECG example, to do this well probably takes the same or more time as a 100 hr EMT training program.

Both paramedic and EMT education are woefully inadequate, as they stand.  I say this having taken a 6 month EMT course that included 200 hours on the ambulance, and a 2-year paramedic program with over 1000 hours of ambulance practicum and 400 hours in the ER.  In my opinion, we should fix these inadequacies as our first priority, otherwise this field will never become a profession.

I don't see the push for giving narcan to basics, but maybe that's because most of my career has been working in regions with a low level of narcotic wabuse.  Inappropriate / unskilled narcan use has potential pitfalls, which the EMT is poorly prepared to manage, e.g. pulmonary edema, unmasking the symptoms of a coingested agent, seizure activity, etc.  While some systems support narcan cancellations, in many systems most of these patients will be transported anyway, and their airways can be managed with basic maneuvers.  I don't see the reasoning behind giving this skill to basics.  There's a stronger argument for D50W.

ASA makes sense.  While it might not be the best thing to give to someone with a thoracic aneurysm, or active ulcer disease, the risk benefit is pretty good.  I can't get behind NTG.  It makes the most sense for life-threatening acute pulmonary edema, but this is a very small percentage of the population.  Indiscriminately giving it to potential MIs seems to be a problem waiting to happen, as underlined by the large number of posters who don't seem to be able to differentiate a patient giving self-administering their own nitro for previously diagnosed stable angina, and an EMT / Paramedic giving it to someone whose hemodynamics have just been altered by an MI.  The 12-lead seems reasonable, if we're then going to do something with it, e.g. ER prenotification, ER bypass to cathlab, rendezvous with a paramedic crew that can thrombolyse, or do one of the above, etc.  Glucagon seems like largely a waste of time, unless you then have treat and refer criteria in place -- dextrose solutions seem like a better option here.  Epinephrine may be helpful in clear presentations, but carrys the potential to cause other problems the EMT can't manage.  Ventolin has some potential benefit, and limited downside, but the ability to give nebulised ventolin alone doesn't make someone capable of managing the acutely deteriorating asthmatic appropriately.


----------



## systemet

The other thing to add here, is that this isn't an EMT versus paramedic issue.  This is an issue about EMS as a vocation / potential profession.  This is something we all own.

Patient care is rarely, and very rarely optimally, delivered only by a large group of paramedics.  On a decent call there's usually plenty of EMTs kicking around, doing their thing.  And hopefully everyone's doing what they should be doing competently.

Basic EMT education being incredibly short and lacking in academic rigour isn't an issue that solely affects EMTs -- it affects paramedics, it affects the patients and it affects EMS as a whole.  When another healthcare provider hears an EMT state that CPAP is "a hurricane of air that forces the lungs open", it's as problematic as sitting at an ACLS and hearing a paramedic instructor pronounce met-hemoglobinemia as "MeFFhemoglobinemia", like there's an errant -CH3 group kicking around somewhere.

There's no end of people on these forums complaining about being talked down to by RNs, or about how they make $7 / hour, that the FDs have tried to take over EMS, that medical control/consult often makes bewildering decisions, or that working as an EMT or Paramedic is often a stepping stone to another field.  This mentality that we just take a new skill, do a four hour in-service and all of a sudden, bang! your EMTs are giving narcan, your paramedics suddenly have TXA, or are starting central lines, it pushes us backwards.  Our training programs are extremely short, and just trying to cram more stuff into them every year takes down the average quality.


----------



## NYMedic828

So BLS narcan is officially in affect in my volunteer agency.

I taught the first class.

The general mindset of the 15 people in the class was "how hard can this be you just put it in the nose."

I made it into a 45 minute discussion with scenarios and a 30 page powerpoint on opioid and whatnot. 

VERY few hands went up to answer my questions to the room so I just started reading off the slides I made. 

Overall it didn't go so bad though. Some people had trouble screwing on the atomizer to the shooter...


(Should anyone need a powerpoint to use, let me know I'm happy to share)


----------



## Clare

Oh good heavens I must say this has made for most interesting reading.  How on earth do you cope with not being able to do basic things like obtain an ECG, check a blood sugar level or give drugs like glucagon and salbutamol? 

A couple of years ago the base level was renamed from "Ambulance Officer" to "Emergency Medical Technician".  I don't really like that title but I guess it's here to stay. 

The delegated scope of practice is updated every two years in September and since 2007 has been increased each time.  I don't know what will be added next but the list is currently as follows:

Entonox, methoxyflurane, nasopharyngeal airway, nebulised salbutamol, nebulised ipratropium, GTN spray, IM glucagon, laryngeal mask airway, oral ondansetron, oral loratadine, nebulised adrenaline, PEEP valve, tourniquet.

This does not include what are called "ordinary" interventions that are "not formally described within any delegated scope of practice" such as oropharyngeal airway, blood sugar measurement, obtaining a 12 lead  ECG etc which may be performed by all levels including First Responders.


----------



## EpiEMS

Clare said:


> Oh good heavens I must say this has made for most interesting reading.  How on earth do you cope with not being able to do basic things like obtain an ECG, check a blood sugar level or give drugs like glucagon and salbutamol?
> 
> A couple of years ago the base level was renamed from "Ambulance Officer" to "Emergency Medical Technician".  I don't really like that title but I guess it's here to stay.



I remember reading that the medics in NZ, like those in AUS, are undergraduate-level (first degree?) trained. What's the level of training for BLS providers? In the states, it's vocational training, equivalent to, say, one or two standard university-level courses (I've seen places where it's 3 course hours, some with 6).


----------



## rescue1

My EMT-B course was 4 credits at college, same as any other standard course. Which makes it equivalent to 1/32 of what I had to complete for a bachelor's degree.

I'm not sure if that amount of education is enough to achieve the level of scope that Australian EMS has.


----------



## Clare

EpiEMS said:


> I remember reading that the medics in NZ, like those in AUS, are undergraduate-level (first degree?) trained. What's the level of training for BLS providers? In the states, it's vocational training, equivalent to, say, one or two standard university-level courses (I've seen places where it's 3 course hours, some with 6).



Emergency Medical Technician (BLS) is a Diploma (about a year) whereas Paramedic requires a Degree and Intensive Care Paramedic is a Post-Graduate course.

I think in the future paid recruitment will be from Degree graduates only and certainly in Auckland there is a not much hope of being hired with the Diploma only because its a minimum of two or so years to upgrade to Paramedic but a Degree graduate only takes six to nine months. 

I am a graduate and am upgrading to Paramedic level but I have taken longer than most because I wanted to.

Australia does not have a BLS level as all services there need a Degree.  

Here are the different levels 

Emergency Medical Technician (BLS)
Entonox, methoxyflurane, nasopharyngeal airway, nebulised salbutamol,
nebulised ipratropium, GTN spray, IM glucagon, laryngeal mask airway, oral
ondansetron, oral loratadine, nebulised adrenaline, PEEP valve, tourniquet.

Paramedic (ILS)
All of the above, plus manual defibrillation, synchronised cardioversion, IV
cannulation, IV fluid administration, IV glucose, SC lignocaine for IV
cannulation, plus morphine, fentanyl, naloxone, ondansetron,
IM adrenaline, IV adrenaline for cardiac arrest, IV amiodarone for cardiac
arrest, ceftriaxone, naloxone, IM and IN midazolam for seizures.

Intensive Care Paramedic (ALS)
All of the above, plus laryngoscopy, endotracheal intubation, capnography,
cricothyrotomy, chest decompression, IO access, IO lignocaine, adrenaline,
atropine, amiodarone, adenosine, midazolam, ketamine, pacing,
vecuronium, suxamethonium (selected personnel only).


----------



## EpiEMS

Clare said:


> Emergency Medical Technician (BLS) is a Diploma (about a year) whereas Paramedic requires a Degree and Intensive Care Paramedic is a Post-Graduate course.
> 
> I think in the future paid recruitment will be from Degree graduates only and certainly in Auckland there is a not much hope of being hired with the Diploma only because its a minimum of two or so years to upgrade to Paramedic but a Degree graduate only takes six to nine months.



Makes sense to me. I don't see a bachelor's degree requirement for US EMS in the near future, but I'm curious what it'd do as far as scopes go.

Just curious, no EpiPens at the BLS level?


----------



## Clare

EpiEMS said:


> Just curious, no EpiPens at the BLS level?



An Epipen is an "ordinary intervention" that is not formally described in any scope of practice so can be administered by anybody including First Responders.

A scope of practice includes "... medicines and [specific] interventions ..." whereas things like pulse oximetery, BGL, acquiring a 12 lead ECG are not a specific intervention they are more obtaining clinical information rather than providing a specific intervention to the patient so can be performed by all levels including First Responders. 

An epi-pen is not described within a scope of practice because it is something Joe Smith is taught to do in a first aid course and in fact any member of the public can do.


----------



## Amberlamps916

How to weigh the gurney for dialysis.
How to decipher what the foreign nurse at the snf is telling you.
How to read what's in the "Packet" that those nurses love to refer to when asked something they don't know.
How to transfer patient to dialysis chair.
How to occupy your time while waiting for Mrs. Shmeegelstein's Dr's appointment to finish.


----------



## TheLocalMedic

Addrobo87 said:


> How to weigh the gurney for dialysis.
> How to decipher what the foreign nurse at the snf is telling you.
> How to read what's in the "Packet" that those nurses love to refer to when asked something they don't know.
> How to transfer patient to dialysis chair.
> How to occupy your time while waiting for Mrs. Shmeegelstein's Dr's appointment to finish.



Lol, yes.


----------



## Amberlamps916

Somebody had to show some love towards the IFT side of BLS.


----------



## patzyboi

I think it'll be helpful for BLS to be able to have and use a cardiac monitor (BLS units dont have them here in cali)

and those 10 or so drugs in the orange book to actually be administered (BLS not able to administer any medication in cali)


----------



## DesertMedic66

patzyboi said:


> I think it'll be helpful for BLS to be able to have and use a cardiac monitor (BLS units dont have them here in cali)
> 
> and those 10 or so drugs in the orange book to actually be administered (BLS not able to administer any medication in cali)



How do you think it would be useful for a cardiac monitor on BLS?


----------



## patzyboi

firefite said:


> How do you think it would be useful for a cardiac monitor on BLS?



Well for one thing it'll give you a set of vitals on the spot.


----------



## JPINFV

patzyboi said:


> I think it'll be helpful for BLS to be able to have and use a cardiac monitor (BLS units dont have them here in cali)
> 
> and those 10 or so drugs in the orange book to actually be administered (BLS not able to administer any medication in cali)






> § 100063. Scope of Practice of Emergency Medical Technician.
> (a) During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a certified EMT or supervised EMT student is authorized to do any of the following:
> ...
> (D) basic oxygen delivery devices;
> ...
> (8) Administer oral glucose or sugar solutions.
> ...
> (13) Perform automated external defibrillation when authorized by an EMT AED service
> provider.
> ...
> (14) Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and selfadministered emergency medications, including epinephrine devices.





> § 100064. EMT Optional Skills.
> (a) In addition to the activities authorized by Section 100063 of this Chapter, LEMSA may establish policies and procedures for local accreditation of an EMT student or certified EMT to perform any or all of the following optional skills specified in this section.
> ...
> (c) Administration of naloxone for suspected narcotic overdose.
> ...
> (d) Administration of epinephrine by auto -injector for suspected anaphylaxis and/or severe asthma.
> ...
> (e) Administer the medications listed in this subsection.
> (1) Using prepackaged products, the following medications may be administered:
> (A) Atropine
> (B) Pralidoxime Chloride


http://www.emsa.ca.gov/laws/files/ch2emtIupdate.pdf


Shrug. What more are you looking for? Besides oxygen, most of the other EMT level medications aren't used except in extremely rare circumstances. I could argue that ASA should be added for ACS, but I don't like the idea that all chest pain is ACS.


----------



## JPINFV

patzyboi said:


> Well for one thing it'll give you a set of vitals on the spot.



Ambulances already comes with a vital sign machine.


----------



## NYMedic828

patzyboi said:


> I think it'll be helpful for BLS to be able to have and use a cardiac monitor (BLS units dont have them here in cali)
> 
> and those 10 or so drugs in the orange book to actually be administered (BLS not able to administer any medication in cali)



So you want an EMT to be a paramedic...

They have a class for that.


----------



## JPINFV

NYMedic828 said:


> So you want an EMT to be a paramedic...
> 
> They have a class for that.



To be fair, there is bit of a bait and switch where EMT class talks about everything that's supposed to be in the scope and all of a sudden you're on an ambulance with only one of the medications you learned about. On the other hand the vast majority of the other medications aren't ever used by EMTs anyways.


----------



## DesertMedic66

JPINFV said:


> Ambulances already comes with a vital sign machine.



Exactly what I was thinking. 

I'm on a 911 ALS unit and the only vital sign our monitor gives us is the electrical heart rate and EKG reading...


----------



## Veneficus

firefite said:


> Exactly what I was thinking.
> 
> I'm on a 911 ALS unit and the only vital sign our monitor gives us is the electrical heart rate and EKG reading...



Do your units have holes in the floor boards so you can power the ambulance with your feet?

It sounds like your monitor is second hand from the Flintstones


----------



## DesertMedic66

Veneficus said:


> Do your units have holes in the floor boards so you can power the ambulance with your feet?
> 
> It sounds like your monitor is second hand from the Flintstones



LP12, we just got them "upgraded" to be able to transmit 12-leads 6 months ago. We were talking about upgrading to the Zoll X series but that hasn't happened yet.


----------



## mycrofft




----------



## EMT B

Narcan? NO NO NO NO NO NO NO. Did I mention NO?


----------



## Christopher

EMT B said:


> Narcan? NO NO NO NO NO NO NO. Did I mention NO?



Why? Our EMT's have been doing that for two years now.


----------



## STXmedic

EMT B said:


> Narcan? NO NO NO NO NO NO NO. Did I mention NO?



Lol oh yeah? Have you had a bad experience with it? Any experience with it? Just curious to your reasoning behind being so vehemently against it :unsure:


----------



## EMT B

it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once. 

the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.


----------



## Christopher

EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once.
> 
> the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.



Overstressed the heart and coded is a bit far-fetched and in all likelihood wasn't the cause of the cardiac arrest. You can get some pretty bad pulmonary edema and asthma exacerbations from aggressive narcan administration IV. However, none of these have been described in significant numbers for IM or IN administration.

Our first responders (all EMT-B's) will give it prior to arrival IN. Usually they just give 1 mg IN and ventilate via BVM prior to our arrival. A second 1 mg IN dose if the patient's respiratory rate doesn't improve in 2-3 minutes.

You can write a silly protocol that has you give a huge dose all at once...or you could write a smart protocol. That's your medical director's choice.


----------



## NYMedic828

EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a *paramedic* draw up a whole dose of it and push it all at once.
> 
> the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.



So one would have to assume that particular paramedic needs retraining on appropriate administration.

We just added narcan to the EMT scope here and I have been doing the in-service classes with no issues.

The protocol does state to give a 2mg dose, 1 per nostril but I have been training people to give 1mg and wait 2-5 minutes prior the giving more.


----------



## STXmedic

EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once.
> 
> the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.



If that's the case, I would imagine something was missed and the heroine was laced with something else. Excited delirium or extreme states like that aren't really a side-effect of coming off a depressant, but coming off a depressant and onto a stimulant. A good history and exam could help prevent something like that. Along with... Oh I don't know... Not intravenously slamming 2mg of narcan. Also, you can mitigate the more typical post-narcan aggressiveness by ventilating prior to administering the narcan. All easily remedied by education (or like Chris said, a good protocol).


----------



## Christopher

EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once.
> 
> the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.



Actually, the rates of adverse reactions with IV and IM narcan are higher than that for IN narcan...so advocating just for IV or IM administration is actually advocating for higher rates of these "overstressed his heart and coded" anecdotes.

The plural of anecdote is not data, try not to judge a medication by war stories alone.


----------



## NYMedic828

PoeticInjustice said:


> If that's the case, I would imagine something was missed and the heroine was laced with something else. Excited delirium or extreme states like that aren't really a side-effect of coming off a depressant, but coming off a depressant and onto a stimulant. A good history and exam could help prevent something like that. Along with... Oh I don't know... Not intravenously slamming 2mg of narcan. Also, you can mitigate the more typical post-narcan aggressiveness by ventilating prior to administering the narcan. All easily remedied by education (or like Chris said, a good protocol).



Speedballing has taken many lives...


----------



## Bullets

firefite said:


> LP12, we just got them "upgraded" to be able to transmit 12-leads 6 months ago. We were talking about upgrading to the Zoll X series but that hasn't happened yet.



Um, your LP12s dont take BPs or have a pulse oximeter?




EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once.
> 
> the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient.



A.) that medic is a A-hole
B.) IV is more severe route then IN


A few recent calls have really made me yearn for a IM Glucagon or IV Glucose.  Couple of diabetics, "had the family take a BGL", and just kinda hung out and waited like 5 minutes for the medics to show up, IV access, a minute later patient us up and refusing, EMS cleared. The whole time I was think that i could do this

I really want pain management in someones protocols


----------



## VA Transport EMT

How about some chapters on transport and more in depth knowledge of pt's normal and not the medicalorm.


----------



## EMT B

Bullets said:


> I really want pain management in someones protocols



At the very least Tylenol...


----------



## EMT B

VA Transport EMT said:


> How about some chapters on transport and more in depth knowledge of pt's normal and not the medicalorm.



I think AVOC should be included in EMT curriculum


----------



## mycrofft

*Narcan and other drugs*



EMT B said:


> it is not as benign of a drug as people make it out to be. Ive watched a paramedic draw up a whole dose of it and push it all at once.


But, Narcan is Mother's Milk, right? :huh:

This (consequence aside for now, see below) is one prime example of why scope-enhancement to include drugs is looked at as one more lane in the Highway to Hell. Someone in a hospital does this and she/he gets reamed, maybe reprimanded. On the street..."Oh, he was only following protocols" or "She's just a tech, what do you want?". And the beat goes on...

_"...the patient woke up in a rage and became so hyperactive he overstressed his heart and coded. Isn't that how IN narcan would work, giving the whole dose up the nose at once? the drug needs to be given slowly, and not the whole dose, just enough to let the pt protect their own airway. you do NOT want to wake the patient._".

No disrespect, but this is another reason. Since the reply-poster isn't qualified (s)he is not to be expected to know about pharmacodynamics, drugs on the protocols, and maybe "street pharmacy" and its attendant "physiology of abuse".

A tech (well, anyone) can maim someone with an air splint. Why, then, hand out sharps and drugs, then OKAY parenteral  or oral access without the year of school even "just a nurse" is required to take before they can follow a med order with meds set up by a licensed pharmacist or RxTech?

Note: an abuser who buy/steals drugs from anyone besides a pharmacy is not likely to get pure anything; many if not most abusers (especially in late stages) will do anything to get and keep high, so "speedballing" (mixing opiods with methamphetamines, or either/both's "analogues") is a good chance and with the longstanding changes sometimes seen with drug abuse, fatality is an increased likelihood.


----------



## NYMedic828

^ ah new avatar didnt recognize you.


Where did Mickey go?


----------



## ExpatMedic0

What Should We Add? Maybe 1000 hours in additional training


----------



## Achilles

schulz said:


> What Should We Add? Maybe 1000 hours in additional training



In what?


----------



## NomadicMedic

Achilles said:


> In what?



I think the point is,there should be no new skills for basic EMTs. If you want more "skills", go to paramedic school. 

If you just want to "do cool skills" with no real additional education, go be a vet tech.


----------



## Veneficus

n7lxi said:


> I think the point is,there should be no new skills for basic EMTs. If you want more "skills", go to paramedic school.
> 
> If you just want to "do cool skills" with no real additional education, go be a vet tech.



You know...

I was thinking...

Maybe we could just allow completely uneducated people to perform any medical procedure they want and eliminate the need for EMTs entirely.

You know, let's get rid of all healthcare providers.

We could have a youtube channel.

"Cardiac surgery in 6 easy steps, if you see it, you can do it."

We could even sell kits on ebay.


----------



## EpiEMS

I guess when I started this thread I should've expected how popular it would become!
My focus when I proposed several additional BLS skills was on high benefit/low risk skills that are often performed by non-medical personnel. That's basically the scope under the National Registry scope of practice as listed.

I'm a huge proponent of more training for BLS providers, of course -- and I'd like to see the EMT course lengthened to 200-300 hours.


----------



## NYMedic828

EpiEMS said:


> I guess when I started this thread I should've expected how popular it would become!
> My focus when I proposed several additional BLS skills was on high benefit/low risk skills that are often performed by non-medical personnel. That's basically the scope under the National Registry scope of practice as listed.
> 
> I'm a huge proponent of more training for BLS providers, of course -- and I'd like to see the EMT course lengthened to 200-300 hours.



But why not just make everyone a paramedic at that point?


----------



## Veneficus

EpiEMS said:


> I guess when I started this thread I should've expected how popular it would become!
> My focus when I proposed several additional BLS skills was on high benefit/low risk skills that are often performed by non-medical personnel. That's basically the scope under the National Registry scope of practice as listed.
> 
> I'm a huge proponent of more training for BLS providers, of course -- and I'd like to see the EMT course lengthened to 200-300 hours.



I think what a lot of basic providers forget is that when you know basically nothing, everything seems easy or low risk. 

Look at the suggestion for subQ epi. You are better off with an epipen because IM has better absorbtion. In fact sub Q absorbtion reliability of it has been called into question.

There is also the issue of responsibility. If an unknowing nonn-medical provider self medicates, something goes wrong, and they get mad, it was self determination.

When a provider suggests a course of action, there is responsibility involved.

As it stands, an EMT has almost no personal responsibility. 

Without such, there can be no authority, and therefore, no decsion making.

What do these skills really add? How often are they used? What is the cost of maintaning them? How about documentation? 

Really, if you want to do more, you must learn more. 

When I was an EMT I thought we were more than we really were. It is a taxi driver with no responsibility. Whos 2 primary treatments, backboards and oxygen, do more harm than good. Best to just drive to the hospital and let it be sorted out there.


----------



## mycrofft

NYMedic828 said:


> ^ ah new avatar didnt recognize you.
> 
> 
> Where did Mickey go?



Mickey Possum has gone back to the great graphic closet in the sky.


----------



## EpiEMS

NYMedic828 said:


> But why not just make everyone a paramedic at that point?



The cost of upgrading everybody to paramedic would be excessive -- I would tend to think that the marginal cost is rising and marginal benefit is diminishing as we train more and more (and societal marginal benefits fall even more drastically).



Veneficus said:


> I think what a lot of basic providers forget is that when you know basically nothing, everything seems easy or low risk.





Veneficus said:


> Look at the suggestion for subQ epi. You are better off with an epipen because IM has better absorbtion. In fact sub Q absorbtion reliability of it has been called into question.



This one was my mistake -- I had mistyped, and meant that EpiPens should be permitted for EMTs to use on patients who are exhibiting signs and symptoms of anaphylaxis without having to have had a prior prescription (that is, using the patient's own meds).



Veneficus said:


> There is also the issue of responsibility. If an unknowing nonn-medical provider self medicates, something goes wrong, and they get mad, it was self determination.
> 
> When a provider suggests a course of action, there is responsibility involved.
> 
> As it stands, an EMT has almost no personal responsibility.


 No argument on the first two parts. An EMT does have responsibility, insofar as if he or she were to be negligent or engage in misconduct, no?



Veneficus said:


> What do these skills really add? How often are they used? What is the cost of maintaning them? How about documentation?
> Really, if you want to do more, you must learn more.
> 
> When I was an EMT I thought we were more than we really were. It is a taxi driver with no responsibility. Whos 2 primary treatments, backboards and oxygen, do more harm than good. Best to just drive to the hospital and let it be sorted out there.



Answering these fully necessitates more research on my part, I do apologize.

No arguments on needing more education -- and I'll agree that much of EMS revolves around being a taxi driver, but I think, hopefully, there'll be less of taxi driving and more critical thinking as revisions progress.


----------



## jedi88

Hi! These are somethings I would like to see added. 
Blood glucose monitoring- Definite. 
Maybe some form of IM glucagon or something to treat hypoglycemia if unable to eat or drink? (Maybe put it in an autoinjector if afraid of EMT-B giving injections?)
Supraglottic airways- As long as transport time or paramedic arrival outside of a certain time where intubation can occur instead I would be interested in seeing this. 
CPAP- yes
Cardiac monitoring- I don't know how likely that one is but I pretty much taught myself ACLS before I took the class and EKG technician classes so it is possible. If AEMT becomes more common I would like to see cardiac monitoring, manual defib, cardioversion, pacing, and main ACLS drugs for AEMT.


----------



## jedi88

I would like to see aspirin, albuterol nebulizer, epipen, and nitro administration included without patient's own.


----------



## NomadicMedic

I'd like to see an intensive defensive driving course for EMTs. 
Detailed instructions and clinical practice on moving and carrying bed confined patients. 
Instructions on how to clean and care for patients that are unable to care for themselves during transport. 

All of these are usable skills that would directly relate to the patient care that EMTs provide on a daily basis. Patient care skills that most EMTs are sorely lacking.


----------



## Veneficus

jedi88 said:


> Hi! These are somethings I would like to see added.
> Blood glucose monitoring- Definite.
> Maybe some form of IM glucagon or something to treat hypoglycemia if unable to eat or drink? (Maybe put it in an autoinjector if afraid of EMT-B giving injections?)



I do not think I can agree to this. If a patient is hypoglycemic, that patient is an ALS call and should be transported to the hospital. 

I know a lot of these people do not want to be transported, but that needs to remain against medical advice. 

The EMT curriculum still does not have the depth needed to handle an endocrine emergency. 

As well, there is a point when glucagon will not work. This could delay an ALS response or transport waiting for it to work. 



jedi88 said:


> Supraglottic airways- As long as transport time or paramedic arrival outside of a certain time where intubation can occur instead I would be interested in seeing this..



Unfortunately this illustrates my point that EMTs are not ready for ALS intervention. In a cardiac arrest, airway is  shown to be less and less important. To the point now where NRB and not positive pressure ventilation is likely to become the trend. 

Additionally, these airways are being shown not to be as benign as once thought. 

Without singling you out, it is obvious that not enough is understood about the pathophysiology of arrest or these devices by EMTs, monkey see monkey do is just not an acceptable level. 

Some places already incorperate this into the EMT scope. I suspect as more evidence mounts to potentially harmful effects, the trend will be away from these devices for all levels.



jedi88 said:


> CPAP- yes



Many places already consider this a BLS skill. I am not sure why it is not universal. I agree with this.

Perhaps more education is required on when to use it?




jedi88 said:


> Cardiac monitoring- I don't know how likely that one is but I pretty much taught myself ACLS before I took the class and EKG technician classes so it is possible. If AEMT becomes more common I would like to see cardiac monitoring, manual defib, cardioversion, pacing, and main ACLS drugs for AEMT.



No. Simply no. Learning to identify basic rhythms requires knowledge in physiology and pathophysiology to properly determine. Learning to "interpret" a monitor by visualization is the absolute wrong way to learn this. 

Without this knowledge, manual defib, cardioversion, and pacing decisions cannot be accurately made. More importantly when not to do it. 

While I agree in its current form ACLS can be learned by anyone, it doesn't actually equate to understanding or mastery of cardiac life support. It is simply a class on what to do in an emergency until an expert can take over, it is not comprehensive nor definitive by any stretch of the imagination.

Furthermore, every expert I know is rallying against the use of current routine use of ACLS medications in cardiac arrest. There has already been a reduction in the last guidlines and further reductions expected in 2015. Advocating for the use of these meds, particularly on a larger scale, demonstrates complete nonunderstanding of treating these patients.

We don't need people who do not understand initiating medication treatments that further complicate management of survivors doing it. We need them to do effective CPR and use an AED because that is what gives the patient the best chance of survival.

This demonstrates exactly why EMTs are not permitted to do this.


----------



## systemet

Every time this thread comes up, I feel compelled to reply to it, perpetuating the cycle. I may have a problem.

The issue here isn't that it's a good idea that someone getting out of an ambulance should be able to give someone experiencing an anaphylactic reaction epinephrine or random perceived high yield treatment X (although whats high-yield about SL Nitro in suspected ACS?). It's that perhaps, maybe, just maybe, and I don't want to overstate my case here - a paid healthcare provider semiautonomously administering medication should maybe have to have taken a basic university physiology course? Of course, this is probably around 60 hours or more of classroom time with maybe another 120 of real self study- but this might be reasonable,, mightn't it? Perhaps this could be combined with some basic patho, and, as a second thought some basic... I don't know, um, pharmacology?

This isn't to say that there aren't similar glaringly obvious issues with paramedic training,  like the idea that 2 years of school and 40 OR tubes makes you qualified to go around RSIing people, etc. I'll get a lot more excited when the guys advocating for treat and release are pushing for developing paramedicine towards a Master's or the people wanting IV tranexamic acid for BLS are arguing just as passionately for A&P beyond the contents of Brady PEC.


----------



## EpiEMS

systemet said:


> It's that perhaps, maybe, just maybe, and I don't want to overstate my case here - a paid healthcare provider semiautonomously administering medication should maybe have to have taken a basic university physiology course? Of course, this is probably around 60 hours or more of classroom time with maybe another 120 of real self study- but this might be reasonable,, mightn't it? Perhaps this could be combined with some basic patho, and, as a second thought some basic... I don't know, um, pharmacology?
> 
> This isn't to say that there aren't similar glaringly obvious issues with paramedic training,  like the idea that 2 years of school and 40 OR tubes makes you qualified to go around RSIing people, etc. I'll get a lot more excited when the guys advocating for treat and release are pushing for developing paramedicine towards a Master's or the people wanting IV tranexamic acid for BLS are arguing just as passionately for A&P beyond the contents of Brady PEC.



No disagreement on the requiring more education. I'd love to see something like a higher level of education required to become an EMT -- maybe something like "To be eligible for National Registry as an Emergency Medical Technician, you must have:

  1. Received a score greater than or equal to 1500 of 2400 on the SAT (50th percentile) OR greater than or equal to 21 on the ACT (50th percentile)...AND completed high school or a recognized equivalent (i.e. GED).
  2. Completed high school or a recognized equivalent AND completed at least 60 credit-hours of tertiary education, which must include at least 1 course in general biology with lab and 1 course in mathematics at the college level (i.e. calculus or college-level statistics)
  3. Completed high school or a recognized equivalent and achieved a military rank of E-4 or higher."

I guess my idea is to increase the caliber of people coming in -- that increases the quality of people coming out. Heck, even requiring a college level biology course and a college level mathematics course would increase the caliber of BLS providers markedly.

And, of course, try to bring the Paramedic level to an associate's degree level (progressively increasing up to a bachelors degree over 10 years or so).

Interesting study: http://www.coaemsp.org/Documents/ProbabilityofPassing.pdf with an interesting perspective for paramedic education


----------



## Veneficus

Double post


----------



## Veneficus

EpiEMS said:


> No disagreement on the requiring more education. I'd love to see something like a higher level of education required to become an EMT -- maybe something like "To be eligible for National Registry as an Emergency Medical Technician, you must have:
> 
> 1. Received a score greater than or equal to 1500 of 2400 on the SAT (50th percentile) OR greater than or equal to 21 on the ACT (50th percentile)...AND completed high school or a recognized equivalent (i.e. GED).
> 2. Completed high school or a recognized equivalent AND completed at least 60 credit-hours of tertiary education, which must include at least 1 course in general biology with lab and 1 course in mathematics at the college level (i.e. calculus or college-level statistics)
> 3. Completed high school or a recognized equivalent and achieved a military rank of E-4 or higher.").



I do not think compulsory military service should be required. There are many outstanding healthcare providers of all types who were not in the military.

As for the college entrance exams, I am not sold on those either. I never took one. There was no need. I just went to college and signed up. What most places won't tell you is if you can pay, you are in. 

I think the better way would again, not select upfront, but select over time. Requiring mandatory basic and clinical science, particularly from a 4 year university and not a CC, would be of the most benefit. Perhaps not a full degree for an EMT, but certainly for a medic.  



EpiEMS said:


> I guess my idea is to increase the caliber of people coming in -- that increases the quality of people coming out. Heck, even requiring a college level biology course and a college level mathematics course would increase the caliber of BLS providers markedly.
> 
> And, of course, try to bring the Paramedic level to an associate's degree level (progressively increasing up to a bachelors degree over 10 years or so).



Medical schools tried this and what it basically amounts to now is a lottery. I don't think that is really the best way either. 

Like I said, let everyone start and make it a marathon instead of a sprint. That weeds people and gives everyone a fair chance.


----------



## Christopher

jedi88 said:


> Hi! These are somethings I would like to see added.
> Blood glucose monitoring- Definite.
> Maybe some form of IM glucagon or something to treat hypoglycemia if unable to eat or drink? (Maybe put it in an autoinjector if afraid of EMT-B giving injections?)
> Supraglottic airways- As long as transport time or paramedic arrival outside of a certain time where intubation can occur instead I would be interested in seeing this.
> CPAP- yes
> Cardiac monitoring- I don't know how likely that one is but I pretty much taught myself ACLS before I took the class and EKG technician classes so it is possible. If AEMT becomes more common I would like to see cardiac monitoring, manual defib, cardioversion, pacing, and main ACLS drugs for AEMT.



Please understand I'm not using the second person singular "you" and "you're", but if you're not allowed to "monitor" blood glucose _you're not a real medical provider_. The system you practice in could be replaced by Boy Scouts with CPR/First Aid cards.

I'm frankly bewildered that there still exist areas without the ability to check a BGL...or pulse oximetry.

(likely most systems could be replaced by Boy--or Girl--Scouts with CPR/First Aid cards because EMS in the US doesn't do a whole lot to sell itself as a net benefit)

You're not asking for "blood glucose monitoring" to be added to EMT's, because EMT's can already do this. Any six year old can already do this.

You're not asking for anything more to the EMT scope. Your area may be backwards or backwater, but this has nothing to do with the EMT scope.

Sorry...wooo-saaahh wooooo-saaahhh.


----------



## Bullets

jedi88 said:


> Hi! These are somethings I would like to see added.
> Blood glucose monitoring- Definite.
> Maybe some form of IM glucagon or something to treat hypoglycemia if unable to eat or drink? (Maybe put it in an autoinjector if afraid of EMT-B giving injections?)
> Supraglottic airways- As long as transport time or paramedic arrival outside of a certain time where intubation can occur instead I would be interested in seeing this.
> CPAP- yes
> Cardiac monitoring- I don't know how likely that one is but I pretty much taught myself ACLS before I took the class and EKG technician classes so it is possible. If AEMT becomes more common I would like to see cardiac monitoring, manual defib, cardioversion, pacing, and main ACLS drugs for AEMT.


The only thing on this list that should be considered is BGL monitoring

In CPR airway is being emphasized less, medics statistically cant intubate. Adding a SGA is unnecessary for CPR

CPAP should be

Cardiac monitoring-Maybe just to be able to send the EKG to the hospital, but the interpreting algorithms vary and can be inaccurate. ACLS drugs are basically useless and are really serving to kill the patient faster. The mounting evidence is showing that they result in fewer patient making it to discharge with intact neuro


----------



## EpiEMS

Sadly, EMS practices are yet to come close to evidence based...


If they were, EMTs would be doing BGLs, PD would transport severe penetrating trauma patients in the back of squad cars (http://www.ncbi.nlm.nih.gov/pubmed/21166730), looking to get rid of lots of the components of ACLS, etc. etc.


----------



## STXmedic

EpiEMS said:


> Sadly, EMS practices are yet to come close to evidence based...
> 
> 
> If they were, EMTs would be doing BGLs, PD would transport severe penetrating trauma patients in the back of squad cars (http://www.ncbi.nlm.nih.gov/pubmed/21166730), looking to get rid of lots of the components of ACLS, etc. etc.



Luckily, that's regional and service based. Glad to be a part of an area that does both of the above, and more. (Don't take that as our area is without issues, though...).


----------



## EpiEMS

PoeticInjustice said:


> Luckily, that's regional and service based. Glad to be a part of an area that does both of the above, and more. (Don't take that as our area is without issues, though...).



Every area's got it's issues. I still have to board penetrating trauma -- and every medic is absolutely convinced that we need to board them (not for moving them, which is fine by me, that's what a board is good for) because of the potential for spinal involvement  (http://www.ncbi.nlm.nih.gov/pubmed/20065766)


----------



## JPINFV

Christopher said:


> Please understand I'm not using the second person singular "you" and "you're", but if you're not allowed to "monitor" blood glucose _you're not a real medical provider_. The system you practice in could be replaced by Boy Scouts with CPR/First Aid cards.


 

http://irrev-black.com/wp-content/uploads/black/02-No-True-Scotsman.jpg

(That picture was larger than I thought it was)



The same rock can be thrown at paramedics in a lot of systems. After all, no true medical provider are forced to call for permission to treat inside their scope of practice.


----------



## Christopher

JPINFV said:


> The same rock can be thrown at paramedics in a lot of systems. After all, no true medical provider are forced to call for permission to treat inside their scope of practice.



Your deference to kilts is acknowledged, but my hyperbole for effect was intended.

There is a difference between calling for permission for procedures and specious limitations in scope.


----------



## NYMedic828

Christopher said:


> Please understand I'm not using the second person singular "you" and "you're", but if you're not allowed to "monitor" blood glucose _you're not a real medical provider_. The system you practice in could be replaced by Boy Scouts with CPR/First Aid cards.
> 
> I'm frankly bewildered that there still exist areas without the ability to check a BGL...or pulse oximetry.
> 
> (likely most systems could be replaced by Boy--or Girl--Scouts with CPR/First Aid cards because EMS in the US doesn't do a whole lot to sell itself as a net benefit)
> 
> You're not asking for "blood glucose monitoring" to be added to EMT's, because EMT's can already do this. Any six year old can already do this.
> 
> You're not asking for anything more to the EMT scope. Your area may be backwards or backwater, but this has nothing to do with the EMT scope.
> 
> Sorry...wooo-saaahh wooooo-saaahhh.



The great city of New York still does not allow EMT level providers in its borders to perform a blood glucose check. The state of new york allows it, but the largest EMS organization in the country prefers that almost every call be turfed to a medic when it has anything more involved than a taxi ride.


----------



## kaaatielove

NYMedic828 said:


> The great city of New York still does not allow EMT level providers in its borders to perform a blood glucose check. The state of new york allows it, but the largest EMS organization in the country prefers that almost every call be turfed to a medic when it has anything more involved than a taxi ride.



In my county, EMTs are allowed to do BGLs and so are ED techs who have no certification whatsoever, but it's ironic that licensed CNAs can't because it's "invasive" :unsure:


----------



## VA Transport EMT

Wow your cnas must rock. everytime we ask for help it just so happena that its not their job. :/


----------



## kaaatielove

VA Transport EMT said:


> Wow your cnas must rock. everytime we ask for help it just so happena that its not their job. :/



They're lazy & even if they were able to check BGL's I'm sure they'd make the same excuse. lol


----------



## Bullets

EpiEMS said:


> Every area's got it's issues. I still have to board penetrating trauma -- and every medic is absolutely convinced that we need to board them (not for moving them, which is fine by me, that's what a board is good for) because of the potential for spinal involvement  (http://www.ncbi.nlm.nih.gov/pubmed/20065766)



You dont follow PHTLS guidelines?


----------



## EpiEMS

Bullets said:


> You dont follow PHTLS guidelines?



Protocol monkey says: "Follow your state and local protocols." 

PHTLS guidelines aren't in protocols -- now, technically, yes, I have no requirement to board the patient, but the RNs and MDs don't typically know that, they expect patients to be fully immobilized for some reason.

Usually, I'm with a medic, and they are old-school (not always in good ways).


----------



## emt11

Woow, is about all I can say. That and I'm glad I'm not a basic(though no offense to those who are). I suppose my state, while it uses the EMT-I'85 as the minimum to work on an ambulance is a bit more willing in its state scope of practice. This is what my state allows all providers at all the levels that the state recognizes. Keep in mind that the EMT listed on their(the yellow block) is an EMT-B and the CT or Cardiac Tech(light blue) is the I'99.

http://www.ems.ga.gov/programs/ems/... - Updated 7-1-2011 - ALL LEVELS (no EMR).pdf


----------



## Handsome Robb

VA Transport EMT said:


> Wow your cnas must rock. everytime we ask for help it just so happena that its not their job. :/



I have yet to meet a CNA that I liked.


----------



## VFlutter

NVRob said:


> I have yet to meet a CNA that I liked.



Or LVN h34r: I love the "I am a nurse!" Oh your a RN? "Uh no LVN" ohhhh that explains a lot -_-


----------



## STXmedic

Chase said:


> Or LVN h34r: I love the "I am a nurse!" Oh your a RN? "Uh no LVN" ohhhh that explains a lot -_-



Yes!!! Every LVN I know only introduces themselves as a nurse, and you have to pry it out if they're an LVN and not an RN!


----------



## Handsome Robb

PoeticInjustice said:


> Yes!!! Every LVN I know only introduces themselves as a nurse, and you have to pry it out if they're an LVN and not an RN!



Quoted for truth.

Pissed one off the other day when I was dropping a vented patient off at a long term care facility.

"Where's the nurse."
"I'm right here!!"
"I meant the RN....."
" :angry: "


----------



## JPINFV

Christopher said:


> Your deference to kilts is acknowledged, but my hyperbole for effect was intended.
> 
> There is a difference between calling for permission for procedures and specious limitations in scope.




How is specious limitations in scope without special permission any different than any other specious limitation in scope of practice? Seriously, what the heck kind of "real medical provider" relies on a machine interpretation for a STEMI AND online permission to transport to a STEMI center (orthopedic surgeons excluded)?


----------



## ExpatMedic0

PoeticInjustice said:


> Yes!!! Every LVN I know only introduces themselves as a nurse, and you have to pry it out if they're an LVN and not an RN!



I have had "off duty" CNA's try to do this on scenes. First introduce themselves as a nurse, then once its established an off duty RN holds no authority on an EMS call we dig further to find there not an RN but a CNA. This has happened to me 2 or 3 times over the years.


----------



## Veneficus

JPINFV said:


> (orthopedic surgeons excluded)?



That was priceless.

Well played.


----------



## Veneficus

schulz said:


> I have had "off duty" CNA's try to do this on scenes. First introduce themselves as a nurse, then once its established an off duty RN holds no authority on an EMS call we dig further to find there not an RN but a CNA. This has happened to me 2 or 3 times over the years.



Seems to happen a lot at nursing homes.


----------



## EMT B

in my system i can do bgl. 

however we cant do humidified oxygen...:huh: id like to see humidified oxygen added to my scope. i agree as well thought that Basics need more A&P, more pharmacology (I mean come on I had to learn on my own why I was giving the meds..the teacher only told us when to give the med, not why we were giving it or what it was actually doing in the body) and maybe some organic chem. 

To be honest, i think after you get passed all the medicolegal stuff in the beginning of the course you should have 20h of A&P and 20h of organic chem before you start the medical unit.


----------



## NYMedic828

EMT B said:


> in my system i can do bgl.
> 
> however we cant do humidified oxygen...:huh: id like to see humidified oxygen added to my scope. i agree as well thought that Basics need more A&P, more pharmacology (I mean come on I had to learn on my own why I was giving the meds..the teacher only told us when to give the med, not why we were giving it or what it was actually doing in the body) and maybe some organic chem.
> 
> To be honest, i think after you get passed all the medicolegal stuff in the beginning of the course you should have 20h of A&P and 20h of organic chem before you start the medical unit.



What do you actually need humidified oxygen for? Odds are the patient doesn't need as much oxygen as the providers want to give them anyway. It may be beneficial for a trach'd patient but its really not necessary in our setting.

EMT classes don't teach pharmacology, thats why you had to learn it on your own... It is not part of curriculum in 95% of the programs out there. The reason the teacher told you only when to give the med and not why, is because he/she most likely has no idea of their own. This is why the title is EMTechnician (Mycrofft 2012), technician being the key word.

20 hours of A&P is enough to learn basic, macro anatomy. It is not enough to learn any aspect of physiology to a worthwhile degree. Organic chemistry? Forget it. Many of the "career" EMS folks I know can't comprehend the basics of regular chemistry.


----------



## EMT B

respiratory distress exasorbated by dry air.


----------



## Handsome Robb

EMT B said:


> respiratory distress exasorbated by dry air.



I think the word you are looking for is "exacerbated".


----------



## EMT B

yes it is. spelling is not my forte. 

also i think the pathophysiology of the interventions we take would be helpful so that we can obtain some critical thinking skills. thankfully my preceptors helped me with that.


----------



## NomadicMedic

EMT B said:


> yes it is. spelling is not my forte.
> 
> also i think the pathophysiology of the interventions we take would be helpful so that we can obtain some critical thinking skills. thankfully my preceptors helped me with that.



Give us some examples...


----------



## Veneficus

EMT B said:


> yes it is. spelling is not my forte.
> 
> also i think the pathophysiology of the interventions we take would be helpful so that we can obtain some critical thinking skills. thankfully my preceptors helped me with that.



I do not understand this.

Pathophysiology is the the study of disease mechanisms. 

"Pathophysiology of the interventions we take" would mean the mechanisms of the disease we cause.

I don't think your preceptors helped you as much as you think.


----------



## EMT B

pathophysiology was defined to me as the study of changes in the bodys normal functions due to some outside factor. Also someone asked for examples to my previous statement. Teacher stated respiratory distress could be caused by pulmonary edema, pulmonary embolism, chf, asthma, copd, etc. but he never talked about WHY it could have been those things. My preceptors helped because i asked them about it.


----------



## Veneficus

EMT B said:


> pathophysiology was defined to me as the study of changes in the bodys normal functions due to some outside factor..



Not correct.

Most of the factors are intrinsic, easy ones to name are autoimmune diseases and cancer. 

Even asterosclerosis is a defect of human metabolic evolution. Making it instrinsic. 

Multiple causes of CHF are instrinsic, like cardiomyopathy. Actually the only external factors I can think of for heart disease are trauma, poisoning, and infection.


----------



## Veneficus

Not to worry, hang around here and we will sort you out.


----------



## NYMedic828

EMT B said:


> respiratory distress exasorbated by dry air.



Does not warrant the administration of supplemental oxygen.

If someone is "suffering" respiratory distress secondary to "dry air" administering oxygen will only further _exacerbate_ the condition.

The underlying cause is discomfort, not hypoxia or decreased FiO2. The environmental air being inhaled by that patient still contains 20.9% oxygen and as long as their oxygen saturation is sufficient and no factors of your assessment reveal hypoxia oxygen supplementation is not indicated.

The only time supplemental oxygen is indicated is in the presence of presumed hypoxia. Asthma, pulmonary edema, COPD are probably the most common that we see out of hospital. Believe it or not oxygen is actually not indicated and furthermore completely useless in the treatment of ischemic or hemorrhagic conditions such as CVA/MI/Trauma (as long as pulmonary function is not impaired). If the body can maintain adequate SpO2 then giving more oxygen won't have any effect as you cannot raise PaO2 without increasing pressure.


----------



## EMT B

i was thinking more along the lines of the elderly living in a nursing home (since that makes up about 90% of the calls in my area).


----------



## NYMedic828

EMT B said:


> i was thinking more along the lines of the elderly living in a nursing home (since that makes up about 90% of the calls in my area).




But what is wrong with them that they have called for EMS?


----------



## Christopher

JPINFV said:


> How is specious limitations in scope without special permission any different than any other specious limitation in scope of practice? Seriously, what the heck kind of "real medical provider" relies on a machine interpretation for a STEMI AND online permission to transport to a STEMI center (orthopedic surgeons excluded)?



Limiting BGL acquisition to ALS because it is "invasive" is by definition specious.

Relying on online permission to transport to a STEMI center is also specious. Machine interpretation of STEMI...if your providers aren't educated then perhaps this is a reasonable bridge to an appropriate model of care. That being said, if you're a paramedic in 2013 (weee) and can't read a 12-Lead for at least a STEMI, you're actually an EMT-Intermediate.

Thankfully those are not my reality. We use "permission" for above and beyond, not the "bottom line". We're also not geared towards the lowest common denominator...so it isn't like I do not see where you're coming from.


----------



## EMT B

NYMedic828 said:


> But what is wrong with them that they have called for EMS?



respiratory distress <.<


----------



## EMT B

veneficus said:


> nurse was lazy and figured sending them to the ed for a few hours would get her a break.



*cna


----------



## NYMedic828

Veneficus said:


> Nurse was lazy and figured sending them to the ED for a few hours would get her a break.



O stopppp that never happens...



EMT B said:


> respiratory distress <.<



Ok, but why? If "dry air" is the cause, odds are they for one can't live in that environment and what do you think your most effective treatment for this problem is as the immediate care provider?


----------



## EMT B

buy them a humidifier


----------



## STXmedic

emt b said:


> respiratory distress exasorbated by dry air.


----------



## Veneficus

EMT B said:


> *cna



Don't pretend like that never happens.



NYMedic828 said:


> O stopppp that never happens...



There is another reason they send people out? :lol:


----------



## Handsome Robb

EMT B said:


> yes it is. spelling is not my forte.
> 
> also i think the pathophysiology of the interventions we take would be helpful so that we can obtain some critical thinking skills. thankfully my preceptors helped me with that.



Referring to medications you'd be looking for pharmacokinetics and pharmacodynamics, not pathophysiology. 

Like Vene said, pathophysiology is basically the study of disease processes.


----------



## NYMedic828

EMT B said:


> buy them a humidifier



So then the answer is not to transport them to the hospital on humidified oxygen now is it?  :blush:

Administering oxygen over 20.9% has repercussions, especially in elderly populations whose bodies are no longer capable of adequate anti-oxidation.

So in summary you have answered the question. They need a humidifier or they need to be removed from that environment. A bedroom humidifier does not supplement humidified oxygen. It humidifies environmental air and it solves the problem. 

By this means, we have created a solution while not administering a drug to the patient in order to do it. Always a win.



Veneficus said:


> Don't pretend like that never happens.
> 
> 
> 
> There is another reason they send people out? :lol:


----------



## NomadicMedic

Okay gang... This is starting to get a little off topic. Lets get back to the discussion at hand. 

There have been some good sidebars here. If anyone would like to expand on them, please feel free to start a new topic.


----------



## Veneficus

NVRob said:


> How fast do you think granny could suck down a 60 minute bottle? :lol:



I was thinking more alonfg the lines of just wraping her in a blanket and turning on the AC


----------



## mycrofft

1. Ask a panel of MD's what more data could they use from prehospital providers.
2. From that list, ask what simple measures could be protocolled (word trademarked:lol profitably for prehospital use by techs, probably the same as family members can do, but they need to make a difference.
3. Then draw up protocols and test them.

I'm not sure BLS needs pulse-ox. Fingerstick glucometry would be a good thing to record, but oral sugar can be given presumptively; if parenteral sugar is needed, isn't that above basic?


----------



## NYMedic828

mycrofft said:


> I'm not sure BLS needs pulse-ox. Fingerstick glucometry would be a good thing to record, but oral sugar can be given presumptively; if parenteral sugar is needed, isn't that above basic?




I think it is valuable for how simple it is to evaluate but at the same time I think 1/10 EMTs (if even) actually understand what they are measuring. 

Furthermore, in my experience it is irrelevant to most EMTs treatment. Half the time they get an O2 sat of 98-100% and I still walk in to find the patient on oxygen.

Worse still, they check baseline saturation while the patient is on oxygen.


Side note, I know more than a handful of paramedics who are equally bad...


----------



## EpiEMS

NYMedic828 said:


> I think it is valuable for how simple it is to evaluate but at the same time I think 1/10 EMTs (if even) actually understand what they are measuring.
> 
> Furthermore, in my experience it is irrelevant to most EMTs treatment. Half the time they get an O2 sat of 98-100% and I still walk in to find the patient on oxygen.
> 
> Worse still, they check baseline saturation while the patient is on oxygen.
> 
> 
> Side note, I know more than a handful of paramedics who are equally bad...



I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good."


----------



## NYMedic828

EpiEMS said:


> I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) *unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good*."



Exactly.

We walk a fine line in EMS for both paramedic and EMT level care with what we allow under-educated providers to perform. 

As you stated it isn't directly a bad thing in the absence of misunderstanding but it can potentially be. Kind of like giving narcan just because its benign except for the one that time we slam an amp into someone and they start vomiting and throwing punches.

I also constantly see people obtain an O2 sat on a patient who has been out in the winter and immediately puts them on O2 when they get a low reading.


----------



## EMT B

mycrofft said:


> I'm not sure BLS needs pulse-ox.



why?


----------



## EpiEMS

NYMedic828 said:


> Exactly.
> 
> We walk a fine line in EMS for both paramedic and EMT level care with what we allow under-educated providers to perform.
> 
> As you stated it isn't directly a bad thing in the absence of misunderstanding but it can potentially be. Kind of like giving narcan just because its benign except for the one that time we slam an amp into someone and they start vomiting and throwing punches.
> 
> I also constantly see people obtain an O2 sat on a patient who has been out in the winter and immediately puts them on O2 when they get a low reading.



No argument from me on these points. I also tend to think that we get into this problem because of the lack of basic science, math, and reading skills of far too many providers. Not to mention the limited degree of education provided in EMS provider courses on the science rather than the skills.


----------



## NYMedic828

EpiEMS said:


> No argument from me on these points. I also tend to think that we get into this problem because of the lack of basic science, math, and reading skills of far too many providers. Not to mention the limited degree of education provided in EMS provider courses on the science rather than the skills.



To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...

Everyone seems to think you can exceed a saturation of 100% :blink:


----------



## Christopher

NYMedic828 said:


> To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...
> 
> Everyone seems to think you can exceed a saturation of 100% :blink:



You can exceed a partial pressure of 100 mmHg, which is usually where the confusion exists.


----------



## NYMedic828

Christopher said:


> You can exceed a partial pressure of 100 mmHg, which is usually where the confusion exists.



Not with a non rebreather at sea level though...


----------



## Christopher

NYMedic828 said:


> Not with a non rebreather at sea level though...



At sea level we're working with 760 mmHg of "air pressure", 20.95% of which is oxygen. So at sea level we'd have a partial pressure of 159 mmHg O2 on "room air". QED

I was referring to PaO2 when I said you could "exceed a partial pressure of 100 mmHg".


----------



## abckidsmom

NYMedic828 said:


> To once again reference the pulse-ox issue, in regards to your math comment, I don't think many people actually understand percentages either...
> 
> Everyone seems to think you can exceed a saturation of 100% :blink:



Exceeding 100% only works on putting forth effort.    According to some bosses I've had.


----------



## systemet

NYMedic828 said:


> Not with a non rebreather at sea level though...



Actually, you can. Sea level is 760 mmHg. Room air, FiO2 ~ 0.2 gives you about 150mmHg of O2 in ambient air.  This decreases slightly due to humidification in the upper airways. PaO2 tends to be around 100 mmHf due to V/Q mismatching and anatomic shunting (e.g. Thebesian veins, bronchial system return).

Lets say our NRB approaches FiO2 1.0, which it probably doesn't, we get an alveolar concentration of ~ 670 mmHg, allowing for humidification ( PH2O ~ 50 mmHg) and alveolar CO2 (~ 40 mmHg), we've now got a good gradient to markedly exceed a PaO2 of 100 mmHg. A rough guide for predicting PaO2 is that it shoild be something around 500 * FiO2. In fact we look at the PaO2 / FiO2 numbers for assigning patients to ALI / ARDS.

Of course, additional oxygen beyond SpO2 100% does little to improve arterial O2 content, as I'm sure you're aware, and saturated hemoglobin doesn't eliminate hypoxia if there's issues of stagnancy, e.g. regional ischemia, hypotension,  or disorders of hemoglobin, e.g. anemia, CO or cellular poisoning.


----------



## usalsfyre

I agree with NYMedic, you categorically can not exceed an SpO2 of 100%. Won't happen.

PaO2 is a different matter however .


----------



## mycrofft

Pulse oximetry without instruction is like giving someone an oboe without lessons and tablature. Makes noise, maybe a little imitative music, but not properly played.


----------



## Bullets

EpiEMS said:


> I've the same problem where I'm at, but it's usually FD that has the pt on oxygen unnecessarily. Broadly, I can't see pulse ox for BLS being "bad" (or at least, have a deleterious effect on patient care) unless a BLS provider shows up to a CO poisoning and doesn't give O2 just because the "sats look good."



Wait, if a patient has good saturation and no complaints why would I give them oxygen? Just because their CO Alarm went off?

Also find me a meter that accurately measures CO levels...


----------



## mycrofft

Bullets said:


> Wait, if a patient has good saturation and no complaints why would I give them oxygen? Just because their CO Alarm went off?
> 
> Also find me a meter that accurately measures CO levels...



Especially after banging around in an ambulance in in a jump bag. Pulse Ox probes are notorious for being damaged.


----------



## Tigger

NVRob said:


> I have yet to meet a CNA that I liked.



I like my girlfriend's mom, but she's the only CNA I've ever liked.



NYMedic828 said:


> What do you actually need humidified oxygen for? Odds are the patient doesn't need as much oxygen as the providers want to give them anyway. It may be beneficial for a trach'd patient but its really not necessary in our setting.



If the patient is on humidified oxygen, I try to keep them on it for comfort's sake. 

IIRC correctly it was added to the "new" NREMT EMT curriculum.


----------



## systemet

usalsfyre said:


> I agree with NYMedic, you categorically can not exceed an SpO2 of 100%. Won't happen.
> 
> PaO2 is a different matter however .



ha ha ... I'm an :censored:. I jumped in and answered the question that no one was asking. My apologies to NYMedic, I thought that we were talking PaO2.

Reading comprehension for the win!


----------



## EMT B

mycrofft said:


> Pulse oximetry without instruction is like giving someone an oboe without lessons and tablature. Makes noise, maybe a little imitative music, but not properly played.



how is it being used, and how should it be used?


----------



## NYMedic828

EMT B said:


> how is it being used, and how should it be used?



Its being used a number to document on a report and as a means of having definitive measure of whether the patient is perfusing adequately or not (which it is far from), and furthermore if they require oxygen/ventilation.

Instead, it takes a deeper understanding of

FiO2
PaO2
SpO2
Bohr Effect
Oxygen disassociation curve
Hypoxic conditions
Histotoxic conditions
Carbon Monoxide poisoning (and general hazmat realistically)
Factors affecting the probe itself and its accuracy.
How the device actually acquires a measurement
plethysmography


Theres just a lot more to it then 90% of the EMS providers out there grasp...


We also tend to use it more as a qualitative measurement than a quantitative one. It can and should be used as both. A pulse-oximeter is the only tool we carry to actually measure (statistically) whether or not our oxygen therapy has done anything and if we need to give more, less or none.


----------



## VFlutter

EMT B said:


> how is it being used, and how should it be used?



Many Basics are told something like "Spo2 must be above 93" and that is it. They are not taught anything beyond chasing a number. They do not understand what a pleth wave is, what is normal and what is just noise, latency in pulse ox readings, common causes for erroneous readings, etc. Also, the "NRB @ 15Lpm on everyone" mentality.  

Some examples of lack of understanding (Not just EMTs, this happens in the hospital as well)

*Recording an spo2 of 82% on a patient with Raynauds with no signs of distress
* Hooking a patient up to a NC and switching to a NRB because sats don't come up in the first minute. 
*Bumping up the flow on a COPD patient who is always 90% on 2L NC just to get to 93%


----------



## EMT B

NYMedic828 said:


> FiO2
> PaO2
> SpO2
> Bohr Effect
> Oxygen disassociation curve
> Hypoxic conditions
> Histotoxic conditions
> Carbon Monoxide poisoning (and general hazmat realistically)
> Factors affecting the probe itself and its accuracy.
> plethysmography
> 
> Theres just a lot more to it then 90% of the EMS providers out there grasp...




where might one go looking for more info on this stuff? (other than google..)


----------



## NYMedic828

EMT B said:


> where might one go looking for more info on this stuff? (other than google..)



Google is actually a pretty solid place to start if you know what to put in the search field.

Pathophysiology text may be of value.

Manufacturers manual for the device has good info as well believe it or not. (Masimo does anyway)


----------



## mycrofft

AND the software can't accomodate irregular pulses too well. Turn off the volume and yo will never know your pt's pulse is irregular, it will just give you either a single pulse rate, or a changing one.


----------



## NYMedic828

mycrofft said:


> AND the software can't accomodate irregular pulses too well. Turn off the volume and yo will never know your pt's pulse is irregular, it will just give you either a single pulse rate, or a changing one.



You know that one from personal experience I bet :lol:


----------



## VFlutter

EMT B said:


> where might one go looking for more info on this stuff? (other than google..)



college...h34r:

Sorry I couldn't resist


----------



## mycrofft

NYMedic828 said:


> You know that one from personal experience I bet :lol:



Yes, I do.


----------



## Bullets

mycrofft said:


> AND the software can't accomodate irregular pulses too well. Turn off the volume and yo will never know your pt's pulse is irregular, it will just give you either a single pulse rate, or a changing one.



We use the Masimo RAD-57, a new "tool" which i absolutely despise. It does Heart Rate, Pulse Oximetry and CO levels (Cant think of the word). Now our EMTs and especially the FD think it is a catch all for detecting CO poisoning on CO Alarms. 

EMTs also dont get why it the heart rate would jump from 50 to 100 then back to 50 then to 98 ect. 

And the RAD-57 isnt even that accurate in measuring CO levels...48% accuracy compared to ABG tests


----------



## NomadicMedic

It is a good tool if you come across an apartment full of sick people though.


----------



## NYMedic828

Bullets said:


> We use the Masimo RAD-57, a new "tool" which i absolutely despise. It does Heart Rate, Pulse Oximetry and CO levels (Cant think of the word). Now our EMTs and especially the FD think it is a catch all for detecting CO poisoning on CO Alarms.
> 
> EMTs also dont get why it the heart rate would jump from 50 to 100 then back to 50 then to 98 ect.
> 
> And the RAD-57 isnt even that accurate in measuring CO levels...48% accuracy compared to ABG tests



FDNY ambulances carry them for use at fires/inhalation emergencies.

For pulse-oximetry we use the monitor.

Is it that accurate? Not necessarily. Is it better than nothing? Certainly.


----------



## emt11

To further from my last post, I forgot to mention that here(GA) an EMT-I or an AEMT is considered BLS, to include the I-99's that are still around. Your only ALS if your a medic.


----------



## ThirtyAndTwo

I think advanced training should be available in smaller segments, so that an EMT for instance could be trained to start an IV or read a cardiac monitor without going through an entire paramedic program. 

As a college student with a desire to become a paramedic, I can tell you it was hard enough fitting the EMT-B class into my schedule and I can't even dream of taking a Paramedic course during semesters.


----------



## MidwestEMT

ThirtyAndTwo said:


> I think advanced training should be available in smaller segments, so that an EMT for instance could be trained to start an IV or read a cardiac monitor without going through an entire paramedic program.



Some areas have the option for an EMT to get an IV cert, but you'll be hard pressed to find an employer that allows it, unless you work primarily rural. Also, when it comes to cardiac rhythms, there is nothing saying you can't learn it as a B. Now while you wont be able to act according to the rhythms, or be able to use drugs to correct anything, knowing what you're seeing is a huge benefit. You can give a heads up for any intercepting medics, as well as (after you are sure) receiving facilities. It will also make 'learning' it in medic class a breeze. These days there are countless websites, videos, and books that you can self teach something as relatively basic as interpreting rhythms.


----------



## Summit

Corky said:


> *  - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> *  - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> *  - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone*



In CO these are standard for EMTs (EKG with an EKG class, IN/IV narcan with an IV class).

Non-Rx nitro is for AEMT and higher. Diazepam is for EMT-I and higher.

As all have said before, what is really needed is higher educational minimums at all levels.


----------



## Eddie2170

- Glucometry
  - 4 lead setup and monitoring
  - Blind insertion airway devices
  - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
  - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
  - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)

I do all of these in NY, but some of them are agency dependent.
A lot of stuff not necessarily covered is generally expected of EMTs in my area, and while we ride with the same medics frequently when you are new you tend to get taught a lot so that way on future calls you can do medic assistance, makes everyone's job easier, and obviously the more the medic teaches, the more I can help with next time so it's in everyone's best interest.

You obviously have to be willing to learn more, and even stuff not necessarily in your scope if you just take an interest in can always help you sometime in the future.

I do feel that some basic pharmacology knowledge should be added at some point because just starting out when you get handed a list of medications for a patient, especially a geriatric patient, you feel like such an idiot.


----------



## Veneficus

ThirtyAndTwo said:


> I think advanced training should be available in smaller segments, so that an EMT for instance could be trained to start an IV or read a cardiac monitor without going through an entire paramedic program.
> 
> As a college student with a desire to become a paramedic, I can tell you it was hard enough fitting the EMT-B class into my schedule and I can't even dream of taking a Paramedic course during semesters.



At one of the hospitals I worked at we taught one of the janitors how to look for STEMIs on a 12 lead to prove we could. He was pretty good at it actually. 

IV drug abusers are really good getting lines.

But, now that I said that, your position is you want to learn more advanced skills in a truncated way because you don't have the time to be properly educated on them because you are busy doing something else more important to you?

That is an interesting perspective...

Let me take a wild guess... You are a pre-med or PA student?

The most important part of medicine is not skills. It is knowing when, why, and when not to. Just because you see somebody perform a skill and think you could too doesn't make you ready to. 

I have had administrators watch me cut patients all day, does it mean they are ready to perform surgery? (It probably wouldn't be too hard to teach them how to harvest a saphenous vein or even a mamilary artery.) 

You think it is not that dramatic?

Just the other day I posted a study, one of several I have read in the last few days of critical patients with >10% fluid overload having a 20-30% increase in mortality. 

When that overload is >20%, mortality goes up 50% in the same population.

I posted another study some months ago showing a decrease in AKI in patients who recieved fluid with lower amounts of Cl- compared to Normal Sailine. The mechanism postulated is the formation of hypochlorite. The really powerful compound your immune cells use to kill just about everything. it is a free radical that does a fair amount of damage to the renal medula and the third zone of the liver. In the nonmedical world we call it "bleach."

Did you learn that watching people start an IV? Perhaps in General Chemistry?

Sorry, but this is exactly why EMS is so messed up in the US. A skills approach with no knowledge. Don't be part of the problem.


----------



## Clare

I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything? 

If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.  

Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!


----------



## Hunter

Clare said:


> I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything?
> 
> If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.
> 
> Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!



It's not a US thing, it's a every state does things their own way. If you have a license to work in florida, you can't work anywhere else. I think if paramedic standards where nationalized things would be better, plus it would help the overall unity of ems in the country as a whole.


----------



## Wheel

Clare said:


> I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything?
> 
> If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.
> 
> Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!



I don't understand it either, just like how we're trying to add lab values, blood chemistry, more in depth physiology to the curriculum but still allowing diploma medics to teach the stuff when they themselves don't understand it. The more I learn about education standards of ems vs. other health professions vs. medics in other countries, the more I don't understand how people feel well prepared for this. I guess it's a classic case of "you don't know what you don't know."

I am aware that this is not the case for all medics and all programs in the US, but it still isn't rare.


----------



## ExpatMedic0

Its mind boggling, specifically EMT-B. The national standard is around 110 clock hours I believe which is accepted in most states. These are the people who can staff an ambulance on there own and respond to emergencies as the highest level of care in some areas until definitive care.
Even if you where to keep this a vocational tech occupation, I would be curious to look at morbidity mortality rates in a system like this vs a system with providers who have more education and training. 110 hours can be completed in less than 3 weeks in some programs



Clare said:


> I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything?
> 
> If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.
> 
> Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!


----------



## EMT B

schulz said:


> Its mind boggling, specifically EMT-B. The national standard is around 110 clock hours I believe which is accepted in most states. These are the people who can staff an ambulance on there own and respond to emergencies as the highest level of care in some areas until definitive care.
> Even if you where to keep this a vocational tech occupation, I would be curious to look at morbidity mortality rates in a system like this vs a system with providers who have more education and training. 110 hours can be completed in less than 3 weeks in some programs



why would you want to do it in such a short ammount of time. One of my fire co-workers is taking it at a community college. its over 2 college semesters, one night a week, for 4 hours. he says hes getting a lot out of it. i was misurable in my one college semester last year that was 8 hours a week. i think that time is necessary in between classes so that students have time to absorb all the information that they are getting thrown at them.


----------



## JPINFV

EMT B said:


> why would you want to do it in such a short ammount of time. One of my fire co-workers is taking it at a community college. its over 2 college semesters, one night a week, for 4 hours. he says hes getting a lot out of it. i was misurable in my one college semester last year that was 8 hours a week. i think that time is necessary in between classes so that students have time to absorb all the information that they are getting thrown at them.




Not all students are the same.


----------



## Outbac1

EMT B said:


> why would you want to do it in such a short ammount of time. One of my fire co-workers is taking it at a community college. its over 2 college semesters, one night a week, for 4 hours. he says hes getting a lot out of it. i was misurable in my one college semester last year that was 8 hours a week. i think that time is necessary in between classes so that students have time to absorb all the information that they are getting thrown at them.



Then you really wouldn't like it here. 7-8 hrs a day 5 days a week for months on end. After school studying for hours each night to absorb the information. 
Here we call it work. That nasty 4 letter word. You get out of it what you put into it. 

Here people go to school to be a paramedic. To work full time at it. To earn a decent wage and benifits. To make a carreer out of it. Not to do it for fun or because it is cool and to be able to do that for minimum effort. 

 Maybe someday the USA will get its act together and be the EMS leader they want to be. I know there are many great, knowledgable medics there who want that to happen. I read their posts here everyday.


----------



## EpiEMS

schulz said:


> Its mind boggling, specifically EMT-B. The national standard is around 110 clock hours I believe which is accepted in most states. These are the people who can staff an ambulance on there own and respond to emergencies as the highest level of care in some areas until definitive care.
> Even if you where to keep this a vocational tech occupation, I would be curious to look at morbidity mortality rates in a system like this vs a system with providers who have more education and training. 110 hours can be completed in less than 3 weeks in some programs



I think the new curriculum has increased it a bit, to something closer to 150 hours. Granted, I don't think that's enough.

From an epidemiological perspective, I'd bet that you won't see that much of a difference. Consider the OPALS study -- pretty much the study that I first reference on any "ALS vs. BLS" thread, much as I don't like those threads. ALS systems don't increase survival to discharge for cardiac arrest (http://www.nejm.org/doi/full/10.1056/NEJMoa040325) or for trauma (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/). There's lots of papers drawing on OPALS.

Now, that being said, when it comes to patient comfort? ALS is definitely preferable. If I get injured to the point where I can't drive myself or be driven to the hospital by a friend, I'd much rather have ALS transport -- pain control is the single biggest thing I can think that ALS brings (along with better assessment).

Yes, 110 hours (even 150 or 200 hours) is not enough. Does it mean the vo-tech model needs to die? Yes, absolutely, if at all feasible. But it's not necessarily because of outcomes. It's, in large part, because the process needs to be better.


----------



## ExpatMedic0

Yes I have read a few studies showing ALS for Trauma and arrest actually lead to negative patient outcomes in parts of the USA due to increased scene times or as a result of poorly written protocols, or simply lack of proper training. 

However I can tell you from first hand experience it appears to makes a big difference in a lot of areas. Some that pop into my head are asthma emergencies, allergic reaction, cardiac complications before a full arrest. 
Of course we would need to analyze the data or construct our own study to really make such a statement, but I have had some pretty satisfying days at work from calls like this.


----------



## Lil Medic

Personally I think EMT's should be required to obtain a more substantial certification of non skill related education. For example, some Community colleges offer a 1 year EMT certificate, which includes Anatomy and Physiology, psychology, medical terminology, sociology, etc. 
I think that should be mandatory for even a regular EMT. Skill wise though I think they are set well (King airways and combitubes are blind airway devices). EMTs are BLS. That is why there are AEMTs and Paramedics, for the optional increase in interventions.


----------



## Bullets

The new curriculum mandates about 130-150 hours, but there are programs in NJ that are offering programs as long 300 hours with increases in AP and pharmacology


----------



## hogwiley

I say just get rid of EMT Basic and make AEMT the minimum. At least that way some schools would actually have AEMT classes. As my granny used to say, either S*** or get off the pot. Either get rid of Intermediate or make it possible for people to actually become one, or get rid of Basic and replace all these EMT basic classes that pump out EMTs like an assembly line with AEMT class. 

I wanted to go to EMT specialist school for like 5 friggin years, because its short and sweet and teaches skills which are valuable and makes one a lot more employable in EMS, but not ONE school in my state has has an EMT specialist class in at least 5 years, and none of them are offering it any time soon, despite the fact the local paid ambulance service requires EMT specialist as the minimum for employment.

Keeping this license level but never providing the training required to achieve it has totally screwed over a lot of EMT basics who dont have the time or money to go to school to be a medic or want to gain some experience first, but cant work in EMS because there are no EMT Basic jobs, or none that pay anything close to a living wage. 

I just got my phlebotomy cert but its pretty much useless for EMS because you cant use it in the field as a Basic. Ill just have to wait til I can go to Paramedic school for any other training, but Ive been forced to work in a hospital while im saving up because it was impossible to do as a Basic.

Sorry for the rant, but this has been a source of ongoing frustration for years.


----------



## wanderingmedic

hogwiley said:


> I say just get rid of EMT Basic and make AEMT the minimum. At least that way some schools would actually have AEMT classes. As my granny used to say, either S*** or get off the pot. Either get rid of Intermediate or make it possible for people to actually become one, or get rid of Basic and replace all these EMT basic classes that pump out EMTs like an assembly line with AEMT class.



I agree. AEMT is a logical entry level into EMS.


----------



## PotatoMedic

azemtb255 said:


> I agree. AEMT is a logical entry level into EMS.



And sadly WA state I have not been able to find a class for intermediates.  Oh well... Putting my medic application together.  Only need one more letter of recommendation.  Hard when you have only had one partner and the supervisor is an ***.


----------



## NomadicMedic

Yakima County ran an I class for a while. We routinely had intermediates working on the truck with a medic.


----------



## GaMedic

azemtb255 said:


> I agree. AEMT is a logical entry level into EMS.



Here in Georgia the state has stopped issuing Intermediate license. AEMT is the new Intermediate. People who are currently Intermediate level training have until 2016 I think to do the CE needed to upgrade their licenses. Several schools in the metro area have started offering bridge classes.


----------



## emsdude89

Here in Indiana we are trying out a device call "The Glove". It's a big glove that slips over the patients hand and arm. It's loaded up with electrodes. When the patient puts it on "correctly". An EMT-B is able to print and transmit a 12-Lead EKG. Pretty neat, when it works.


----------



## STXmedic

It barely fits on the average sized guy in the demonstration video.
http://youtu.be/OIX6qHGfy_Y
V6 looks to be sitting in V4's position. A good portion of the cardiac patients I make are considerably larger than that guy. 

Seems like an expensive and less efficient way of getting basics to be able to transmit a 12-lead. If all they are doing is transmitting, just teach them where to put the electrodes...


----------



## Veneficus

PoeticInjustice said:


> It barely fits on the average sized guy in the demonstration video.
> http://youtu.be/OIX6qHGfy_Y
> V6 looks to be sitting in V4's position. A good portion of the cardiac patients I make are considerably larger than that guy.
> 
> Seems like an expensive and less efficient way of getting basics to be able to transmit a 12-lead. If all they are doing is transmitting, just teach them where to put the electrodes...



Just another gimmic device.


----------



## ExpatMedic0

Veneficus said:


> Just another gimmic device.



Ya I agree, also could cause issues for patients of different sizes and shapes, breast, ect.
Cool idea though but seems like I always end up doing ECG's on a obese elderly woman with breast that often require a lift assist to deal with.


----------



## Clare

I am greatly confused 

We learn in year one at uni how to acquire a 12 lead ECG; so long as you understand the basic electrophysiology of the leads (I forget the name of it, but it is some triangle...) coupled a simple anatomy of the thoracic cage it's pretty hard to stuff up putting on sticky dots and making sure its not full of artifact etc.

It's even taught to the vollies on nat dip 

I also don't get why you transmit the ECG? The only time that that is done here is for cardiologist review for thrombolysis; surely nobody who is not ICP is thrombolysing so I don't get it ... 

Am I just not getting something here that is screamingly obvious?


----------



## ExpatMedic0

I did ECG's  in the hospital as a tech before I was a Paramedic, the only training i received on it was "on the job" I had no education in it. Its not complicated.

 I can see the idea behind this device. I think it could help reduce scene times a little and would also make it possible for your BLS partner (if your an ALS/BLS unit) to set this up easily while freeing the ALS up for other things.
 In theory... however I do not think it would work so easily on a lot of the patients we are doing a 12 lead on, plus the cost of the device maybe more than just normal leads.

Also I am not sure how much time would save...


----------



## Clare

Why not just teach how to acquire a 12 lead ECG? It's not that hard, if the vollies and first year uni students can learn and become proficient with it then surely that must be proof it is more than easy enough to learn?


----------



## ExpatMedic0

Yes I agree with you, and I think its very simple. I also do not support this device. I think it was a novel idea to save 1 or 2 minutes on scene time which I can see, but overall I do not think the device is worth it.


----------



## systemet

Clare said:


> Why not just teach how to acquire a 12 lead ECG? It's not that hard, if the vollies and first year uni students can learn and become proficient with it then surely that must be proof it is more than easy enough to learn?



We teach our EMTs how to do this during orientation.  We've also just always taught them to do it.  It makes no sense not to if they're going to be working with a paramedic.

Frankly, it makes no sense not to teach them to do it first place, and have it as a BLS skill.  But then you start running into problems with the short length of EMT training programs.


----------



## Outbac1

In the words of George Carlin.

“Put two things together which have never been put together before, and some schmuck will buy it.”


----------



## JMorin95

Become a higher license level if you want more skills.


----------



## Clare

JMorin95 said:


> Become a higher license level if you want more skills.



For last several years we've been getting new skills/medicines for each level each time clinical procedures are updated.

EMT (BLS) has gotten 12 lead ECG acquisition (although they have always been able to do this it is now just formally added), PEEP, tourniquets, adrenaline, ipratropium, ondansetron, and loratadine

Paramedic (ILS) has gotten ceftriaxone, fentanyl and midazolam 

Intensive Care Paramedic (ALS) has gotten vecuronium, adenosine, ketamine, and had frusemide withdrawn 

There will always be change in what somebody can do so you don't necessarily need to move up to next level and many things that were once "advanced" e.g. morphine or adrenaline are now not considered so.


----------



## RocketMedic

Clare said:


> I am greatly confused
> 
> We learn in year one at uni how to acquire a 12 lead ECG; so long as you understand the basic electrophysiology of the leads (I forget the name of it, but it is some triangle...) coupled a simple anatomy of the thoracic cage it's pretty hard to stuff up putting on sticky dots and making sure its not full of artifact etc.
> 
> It's even taught to the vollies on nat dip
> 
> I also don't get why you transmit the ECG? The only time that that is done here is for cardiologist review for thrombolysis; surely nobody who is not ICP is thrombolysing so I don't get it ...
> 
> Am I just not getting something here that is screamingly obvious?



We transmit our ecgs to the hospital to activate our cath labs and for consults on "odd" ecgs, and in my system, for most antiarrythmics. I like having the option.


----------



## Clare

Rocketmedic40 said:


> We transmit our ecgs to the hospital to activate our cath labs and for consults on "odd" ecgs, and in my system, for most antiarrythmics. I like having the option.



I have been amazed by how many hospitals in NZ cannot do PCI; there are only nine that can, three of which are in Auckland (ACH, MMH and NSH) as well as Hamilton, Tauranga, Wellington, Nelson, Christchurch and Dunedin.  

This leaves a massive proportion of the population spread across vast geography only able to access thrombolysis and then they must be transferred by road or air several hours away for angioplasty and/or stenting.  

In a way I am actually somewhat ashamed to have found this out.


----------



## nolimits

EpiEMS said:


> What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?
> 
> As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.
> 
> I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):
> 
> - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.



Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?


----------



## Clare

nolimits said:


> Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?



No it wouldn't; that is very mean, and unprofessional thing to say.

I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.

Why transmission of ECG?


----------



## nolimits

Clare said:


> No it wouldn't; that is very mean, and unprofessional thing to say.
> 
> I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.
> 
> Why transmission of ECG?




So letting them destroy themselves would be the alternative?


----------



## nolimits

Clare said:


> No it wouldn't; that is very mean, and unprofessional thing to say.
> 
> I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.
> 
> Why transmission of ECG?





I'm not sure of what neck of the woods your from, but Narcan is pretty popular around here.


----------



## Wheel

nolimits said:


> So letting them destroy themselves would be the alternative?



Are you of the opinion that slamming them with narcan will help their addiction problem? Somehow I doubt rapidly removing their buzz is going to make them never want to do heroine again.

I don't agree with that lifestyle, but causing pain for pains sake isn't good medicine.


----------



## CPRinProgress

EpiEMS said:


> What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?
> 
> As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.
> 
> I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):
> 
> - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.


In NJ EMTs need a separate cert to administer an unprescribed epipen.  This is how some of these skills should be treated.  Valium and narcan I don't see a reason for they need in depth skills to administer and for me at least, medics are usually on scene within 5 minutes of bls so for us those wouldn't change much pt outcome.  As for the rest, there should be classes you must take to be able to do these on a pt. Even setting up an iv for medics could be good


----------



## Tigger

nolimits said:


> Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?



Nalaxone is the basic scope of practice in the two states I work in. In Massachusetts basics can give it IN and in Colorado it's either IV or IN. 

Whether we have the proper baseline education to be doing this is up for debate however...


----------



## EpiEMS

Clare said:


> I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.
> 
> Why transmission of ECG?



One of the many problems with EMS in the US is that we don't have consistent national protocols. Then again, it's an advantage in the "laboratories of EMS" sense. Naloxone has been used by non-trained folks in several areas without adverse consequences, if I remember correctly. I understand that it's got problems, but I'd rather have a spontaneously breathing patient than one that needs to be bagged.

Transmission for EMTs without the training to read and interpret for those services that have EMTs or AEMTs as their highest level of training (or no full-time medic coverage) such that the ED doc or cardiologist can, say, activate the cath lab, or whatnot. If you've got the LifePack in the rig, it's worth using it.


----------



## JPINFV

nolimits said:


> So letting them destroy themselves would be the alternative?




Because it's your place to punish them?


----------



## nolimits

CPRinProgress said:


> In NJ EMTs need a separate cert to administer an unprescribed epipen.  This is how some of these skills should be treated.  Valium and narcan I don't see a reason for they need in depth skills to administer and for me at least, medics are usually on scene within 5 minutes of bls so for us those wouldn't change much pt outcome.  As for the rest, there should be classes you must take to be able to do these on a pt. Even setting up an iv for medics could be good





JPINFV said:


> Because it's your place to punish them?




No, but when they cannot follow commands, or maintain an airway, it becomes a tiny issue. No?


----------



## JPINFV

nolimits said:


> No, but when they cannot follow commands, or maintain an airway, it becomes a tiny issue. No?




Follow commands? As long as they're just laying there I see no problem. 

Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.


----------



## Medic Tim

nolimits said:


> Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?



The EMT scope in AB is not as large some other provinces. I have given diazepam and narcan back when I was a PCP ((EMT)Within scope and protocols) . Narcan is still a BLS skill in some areas.

I hope you were trying to be funny for that last part


----------



## Wheel

JPINFV said:


> Follow commands? As long as they're just laying there I see no problem.
> 
> Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.



This. The last thing I want is a combative patient. If they can't maintain their airway or they aren't sufficiently ventilating, then they get enough narcan to help them out, not wake them up.


----------



## DesertMedic66

JPINFV said:


> Follow commands? As long as they're just laying there I see no problem.
> 
> Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.



I love it when I work with medics who do this. Sadly we have some medics who still "slam" the narcan. Fire will normally ask for the meds and then slam them and hand patient care over to us :glare:


----------



## STXmedic

Meh, we typically treat and release heroine ODs. Still don't slam it though, and ventilate 'em before waking them up.


----------



## VFlutter

nolimits said:


> Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?



Ya since every patient who needs Narcan is a chronic heroin user. Ever see a cancer patient who took too much narcotics, not to get high, but just trying to take away the legitimate pain they are suffering from? Wouldn't it be nice to not have to intubate them...


----------



## usalsfyre

nolimits said:


> Although, wouldn't it be nice to piss off a chronic heroin user?



This is exactly why most EMTs (and a hell of a lot of medics) have no business with naloxene.


----------



## DrParasite

CPRinProgress said:


> In NJ EMTs need a separate cert to administer an unprescribed epipen.  This is how some of these skills should be treated.  Valium and narcan I don't see a reason for they need in depth skills to administer and for me at least, medics are usually on scene within 5 minutes of bls so for us those wouldn't change much pt outcome.  As for the rest, there should be classes you must take to be able to do these on a pt. Even setting up an iv for medics could be good


wait what? in almost 15 years in NJ EMS, I can say you do not ned a seperate cert to administer an unpresribed epipen.  you need to take a short class at your agency (since I wasn't in most people's original class), but the records are all kept internally, and the state doesn't track who does and who doesn't take it.

I would love to live nasal narcan.  not killing a high for fun, but to wake up an OD slowly to assist in maintaining their own airway.  And contray to your statement, ALS isn't only 5 minutes away, sometimes they aren't available at all.

and I can set up an IV for the medic.... I can't start one, but I can have it ready to go once they ask for it... don't need a seperate cert for that either....


----------



## KingCountyMedic

Here in Washington State you can get narcan when you exchange your dirty needles for clean ones at many places.


----------



## ExpatMedic0

KingCountyMedic said:


> Here in Washington State you can get narcan when you exchange your dirty needles for clean ones at many places.



Ya, I know of a case where the users friends (who where also high on heroin) successfully used narcan they obtained to bring back in OD in their apartment.


----------



## Tigger

schulz said:


> Ya, I know of a case where the users friends (who where also high on heroin) successfully used narcan they obtained to bring back in OD in their apartment.



There are many success stories from a similar program run by the Massachusetts Department of Health. The state also provides nasal nalaxone to police officers (first responder trained) in areas of high use.


----------



## Av8or007

What the USA really needs is increased paramedic education at the basic level. In canada, our BASIC primary care paramedics have a two year college diploma, and the advanced care medics have 1-2 years more. Critical care paramedic is a year and a bit on top of ACP.

http://en.wikipedia.org/wiki/Paramedics_in_Canada

In ontario, most services allow PCP's to initiate IV therapy, insert SGA's (the king-lt), use CPAP .etc. Ontario PCP's will soon be able to perform manual defibrillation.

In canada, first responders are a tad under an EMT-B, and do NOT require full medical direction to use airway adjuncts AMFR skills off duty.

The best solution for canada and the US would be to bring up ALL medics to the PCP/ACP level, them make the FIRST RESPONDERS an EMT-B level with some extremely basic drugs such as epi-pen, asa and salbutamol (NO NITRO!).


----------



## Medic Tim

Av8or007 said:


> What the USA really needs is increased paramedic education at the basic level. In canada, our BASIC primary care paramedics have a two year college diploma, and the advanced care medics have 1-2 years more. Critical care paramedic is a year and a bit on top of ACP.
> 
> http://en.wikipedia.org/wiki/Paramedics_in_Canada
> 
> In ontario, most services allow PCP's to initiate IV therapy, insert SGA's (the king-lt), use CPAP .etc. Ontario PCP's will soon be able to perform manual defibrillation.
> 
> In canada, first responders are a tad under an EMT-B, and do NOT require full medical direction to use airway adjuncts AMFR skills off duty.
> 
> The best solution for canada and the US would be to bring up ALL medics to the PCP/ACP level, them make the FIRST RESPONDERS an EMT-B level with some extremely basic drugs such as epi-pen, asa and salbutamol (NO NITRO!).


Why no nitro?


----------



## Av8or007

Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.

Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.

If you are talking paramedics, at any level then they do and should carry nitro. 
Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.


----------



## Trashtruck

Clare said:


> I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything?
> 
> If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.
> 
> Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!



It's truly disgusting in some parts of the US. The EMT-B's where I work cannot even take a blood pressure accurately. They look at the needle and make it up.  Don't even mention lungs sounds to them, or how to place an appropriately size cervical collar on somebody. They do not have pulse oximeters or glucometers, nor do they carry any drugs(other than O2, which they don't know how to use since 15lpm NRBM for EVERYBODY is an undisputed practice. Oh, and oral glucose, which is placed down unconscious people's throats more times than I can count). No IV. No EKG. The doctors in the ED roll their eyes and I quote, 'They're absolutely worthless'
They don't say this because of the lack of skills that they are able to do. They say this because they are so poorly educated that they have awful assessment skills and cannot even tell if somebody is dead or not. Seriously. Codes come in unbeknownst to the crew bringing them in.  'They were breathing when we got there...' 
I have no words for that...

I believe EMT-B's should be trained AND EDUCATED(not just be able to read a number off the screen and report it) to use pulse oximeters and glucometers. They should be able to start IV's and perform 12-lead EKG's(not interpret). Supraglottic airways should be in their scope as well as CPAP.  Drugs should include D50, Narcan, B2 agonists, ASA, and IM Epi for anaphylaxis. 
This is light years upon eons upon light speed and time travel physics away for here...

I envy the systems I read about where the EMT's do all this stuff. Sounds good.

Oh, and on the narcan bit. Clare, I remember you saying(I think) that you guys don't have a huge opiate addiction population down there. In the US, and certainly in certain areas, it's very, very common. We carry boatloads of narcan because we use it so much.
And to nolimits, once you wake up a junky by slamming narcan and he tears you up, you'll never do it again. 
Opiate OD's usually get up and walk away. If you do transport them to the ED, they are sent to the waiting room, where they walk out.


----------



## Medic Tim

Av8or007 said:


> Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.
> 
> Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.
> 
> If you are talking paramedics, at any level then they do and should carry nitro.
> Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.



I have no issue with pt assist or giving it if the pt has a script for it. I misunderstood you and thought you were talking about EMTs (PCP)


----------



## Av8or007

Yeah. Obviously paramedics should have basic drugs like nitro. 

 I do think that things need to change to allow at a minimum asa and epi-pen (or amps of epi via im injection - w appropriate education) administration for all fr's, with glucometry and pulse ox (alberta emr's already do spo2 and blood glucose, pretty basic interventions). This would come with the education required for patient assessment and some pathophysiology and pharmacology education. 

In the uk, there are mfr levels that can give those drugs AND use entronox for pain control.

Nitro can be 'scary' in the wrong pts and if the pt doesn't have a hx of nitro use then you shouldn't give it w/o an iv which mfr's can't do - thus the reason why i don't think mfr's should carry nitro (along with a complete lack of education on pathophysiology and pharmacology). To give nitro also requires a 12 (in reality a 15 lead is much better) lead to rule out rvi.

As for asa, salbutamol and epi, these are high benefit, low to medium risk meds that can make a lot of difference. The only med on this list that could be 'nasty' is epi, and only in situations where the pt was not having a severe allergic rxn. For an allergic rxn, epi can be lifesaving.


----------



## Veneficus

Av8or007 said:


> Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.
> 
> Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.
> 
> If you are talking paramedics, at any level then they do and should carry nitro.
> Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.



Medical device companies must love you guys.

The most common sign of a right sided MI is an abysmally low blood pressure, which contraindicated nitro in EMS anyway.  So you really don't need that 12 lead to determine if if there is a right sided MI or not, because you will not be giving the nitro even if they don't have a right sided MI. 



Av8or007 said:


> Nitro can be 'scary' in the wrong pts and if the pt doesn't have a hx of nitro use then you shouldn't give it w/o an iv which mfr's can't do - thus the reason why i don't think mfr's should carry nitro (along with a complete lack of education on pathophysiology and pharmacology). To give nitro also requires a 12 (in reality a 15 lead is much better) lead to rule out rvi



I think it sounds scary to you because of unfamiliarity with it. It has a very short half life, and even with the most profound effect, an IV is not needed to give a sl dose.


----------



## Av8or007

In the right pts, nitro can do a lot of good, such as ACPE/chf or the right mi pt. The half life is very short, but who wants to create iatrogenic PEA if it can be avoided. Causing a pt to crash from your tx is something we try to avoid at all costs.  By running the ekg, you account for the subset of pts that may have a borderline bp. 

Contras for nitro in ontario als standards include sbp<90 and HR<60 but less than 159 bpm.

Ontario land protocols require a 12 or 15 lead ekg. You are right though, it depends on if the pt is preload dependent. 

An iv is required if no prior hx to allow treatment of hypotension if required.


----------



## Veneficus

Av8or007 said:


> In the right pts, nitro can do a lot of good, such as ACPE/chf or the right mi pt.
> 
> Ontario land protocols require a 12 or 15 lead ekg. You are right though, it depends on if the pt is preload dependent.
> 
> An iv is required if no prior hx to allow treatment of hypotension if required.



That may be the protocol, but I think it is a bit conservative, unless you are using IV nitro.


----------



## Medic Tim

Veneficus said:


> That may be the protocol, but I think it is a bit conservative, unless you are using IV nitro.



this ^^


----------



## NomadicMedic

Agreed. Patients self administer nitro all the time, without the benefit of a line or 12 lead prior.


----------



## Clare

n7lxi said:


> Agreed. Patients self administer nitro all the time, without the benefit of a line or 12 lead prior.



That is basically what we got taught.  GTN is not contraindicated in right ventricular infarcts, but it is grounds to give a lesser dose of 0.4 mg SL instead of the usual 0.8 mg and if the patients BP is a little on the low side, give a fluid challenge first or instead of GTN.

A right sided ECG is also a good idea.

GTN is far more useful in patients who have acute pulmonary edema anyway, I don't really think it has much of a role in myocardial infarction unless the patients pain or ST/T wave changes are significantly relieved.  I mean they have called us because (potentially) their GTN is not working, so where is the point in giving them more? same goes for if their pain is not significantly relieved then its not working so why keep giving it?

We generally give 0.8 mg SL x 2 sprays five minutes apart and if it doesn't work then we don't give any more; by "work" I mean their pain or ST or T wave changes must be either completely or nearly almost go away; if for example their pain or ST or T wave changes go away or almost go away with GTN and the come back then we give some more GTN but if they do not then we do not keep giving it.


----------



## Av8or007

Interesting, never knew that. Ontario's protocols on some things aren't exactly cutting edge...

E.g. BLS standards still say NRB @ 15 for all. _REALLY??!!_

The ontario air ambulance service, ORNGE, has protocols that are a lot more aggressive. For example, in those protocols, just like it should be, rvi as determined by a 12 or 15 lead ekg is a relative contra for nitro depending on if the pt is preload dependent and can tolerate a reduction preload from the nitro.
BTW most ems services in ontario have 12 lead capability, so it's not really an issue to use it to check for rv mi, as you are normally going to do a 12 lead in a pt with suspected
mi anyways.


At the same time, i was saying that medical first responders shouldn't carry nitro. Paramedics obviously carry and administer nitro all the time.


----------



## NomadicMedic

I said it before, but I'll say it again because it seems to have gotten lost in the noise of this thread.

The real skills that BLS people need to learn are moving patients safely and effectively, customer service, and courteous, defensive driving. 

Once they manage those, maybe then we'll let them touch some medical stuff.


----------



## Bullets

n7lxi said:


> I said it before, but I'll say it again because it seems to have gotten lost in the noise of this thread.
> 
> The real skills that BLS people need to learn are moving patients safely and effectively, customer service, and courteous, defensive driving.
> 
> Once they manage those, maybe then we'll let them touch some medical stuff.



Ok, ive accomplished those 3 things, no complaints, no accidents in 4 years of EMS work, all patients who were alive when i made contact were moved and transported without incident, over 4k patient contacts

GIVE MEDS PLEASE!!!!!!


----------



## NomadicMedic

Okay. You can have ASA.


----------



## DesertMedic66

n7lxi said:


> Okay. You can have ASA.



That's administered per rectum right?


----------



## NomadicMedic

Only if you have skinny fingers.


----------



## Veneficus

Clare said:


> GTN is far more useful in patients who have acute pulmonary edema anyway, I don't really think it has much of a role in myocardial infarction unless the patients pain or ST/T wave changes are significantly relieved.  I mean they have called us because (potentially) their GTN is not working, so where is the point in giving them more? same goes for if their pain is not significantly relieved then its not working so why keep giving it?



the GTN in acute coronary syndrome is diagnostic. If you have somebody with chest pain which is relieved by nitro, it is very likely angina related and not an MI. 

It is more useful for people without a 12 lead, like a basic.


----------



## Bullets

firefite said:


> That's administered per rectum right?



We have a proposal in the legislatures to require every 911 ambulance to Carry Diastat.  Apparently some mother had the ear of a senator and was upset her son had a seizure and the only way we could treat it is with iv medications. She felt this caused undue harm having to stick her son.


----------



## NomadicMedic

Sounds familiar to Washington. A relative of a political figure dies from anaphylaxis. A law was passed that BLS truck had to carry epi pens. Now there's the added expense of hundreds of dollars every year or two to replace expired epi pens. 

Many counties in Washington have moved to 1mg ampules of epi with a 1ml syringe and have taught basics how to draw up the correct dose. At least it's cheaper to toss an amp of epi 1:1,000 than two epi pens when it expires. 

And FWIW, I was involved in the follow up assessment of this skill. 60 days after training, at least half of the EMTs could not perform the skill satisfactorily.


----------



## Bullets

n7lxi said:


> Sounds familiar to Washington. A relative of a political figure dies from anaphylaxis. A law was passed that BLS truck had to carry epi pens. Now there's the added expense of hundreds of dollars every year or two to replace expired epi pens.
> 
> Many counties in Washington have moved to 1mg ampules of epi with a 1ml syringe and have taught basics how to draw up the correct dose. At least it's cheaper to toss an amp of epi 1:1,000 than two epi pens when it expires.
> 
> And FWIW, I was involved in the follow up assessment of this skill. 60 days after training, at least half of the EMTs could not perform the skill satisfactorily.



Sounds like your getting robbed by the pharmacy.  NJ allows epi- pens with medical director approval.  We have saved 2 people in the three years since they got approved.  They cost $30 a piece and are good for 18-24 months.  $60 every two years is a pittance compared to saving someone that we can actually help


----------



## Medic Tim

Bullets said:


> Sounds like your getting robbed by the pharmacy.  NJ allows epi- pens with medical director approval.  We have saved 2 people in the three years since they got approved.  They cost $30 a piece and are good for 18-24 months.  $60 every two years is a pittance compared to saving someone that we can actually help



I have never seen an epi pen cost less than 100 bucks


----------



## NomadicMedic

I'm certainly not arguing that epi is effective, and I personally believe the the cost is justifiable for an easy to use item that has a definite life saving use. However, the average cost per unit was $70 and each BLS truck had to carry an EpiPen and in EpiPen Jr. and realize, that was anything that was certified as a BLS "response unit". Have a fire engine with BLS gear? They had to carry an EpiPen and EpiPen Jr. The majority if them would sit in a bag and just expire. 

My real issue was (I say was since I'm no longer in WA) with the BLS providers not knowing when or how to administer epi appropriately or correctly. Once the medical directors decided, under pressure from private ambulance management and fire chiefs, that the expense of replacing epi-pens every year to two years was prohibitive they moved to a milligram of Epi with a syringe. That's a little nerve racking.

I responded to a call for an allergic reaction. I arrived on scene to find a patient with no Erway issue and some slight urticaria. He had taken 50 mg of Benadryl prior to our arrival and was in no distress. There was a BLS provider there, who arrived before I did, and he was struggling to try and snap the top off an amp of epi. When I asked him what he was doing he said, "this guys having an allergic reaction and he needs Epi…" 

Yikes. An afternoon of training and injecting an orange with saline was not enough to get these guys up to speed. That's not to say he wouldn't have jammed an EpiPen into this guy's leg either…


----------



## Clare

Intramuscular adrenaline for anaphylaxis for the Emergency Medical Technician (BLS) level is coming if rumours are correct.

The Clinical Practice Guidelines give explicit guidance on when it is appropriate to administer adrenaline including that "allergy" must be differentiated from anaphylaxis.

Sounds like your people need more training perhaps, but I do not think it's an overly difficult skill, its much easier than reconstituting glucagon and only mildly more difficult than drawing up sterile water for injection in that you need to change from a drawing up needle to a sharp needle before you administer it.


----------



## Medic Tim

Clare said:


> Intramuscular adrenaline for anaphylaxis for the Emergency Medical Technician (BLS) level is coming if rumours are correct.
> 
> The Clinical Practice Guidelines give explicit guidance on when it is appropriate to administer adrenaline including that "allergy" must be differentiated from anaphylaxis.
> 
> Sounds like your people need more training perhaps, but I do not think it's an overly difficult skill, its much easier than reconstituting glucagon and only mildly more difficult than drawing up sterile water for injection in that you need to change from a drawing up needle to a sharp needle before you administer it.



The injection is easy to teach. When and where and why on the other hand.....

keep in mind EMT training in the US is less than 200 hours


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## ExpatMedic0

Medic Tim said:


> The injection is easy to teach. When and where and why on the other hand.....
> 
> keep in mind EMT training in the US is less than 200 hours



I think its even closer to 100. It is 120 hours for our national right?


----------



## Veneficus

schulz said:


> I think its even closer to 100. It is 120 hours for our national right?



It has been increased from 120 to 150, but even that barely permits coverning the new material added.


----------



## ExpatMedic0

Clock hours are a funny thing though. The NW of the USA uses quarter credits instead of semesters. So for us, One quarter credit hour is equal to 25 clock hours of instruction. This means EMT is 6 credits and Paramedic 52 credits. On the quarter credit system about 90ish credits is an AAS.

When you look at EMT being 6 credits comparatively.... I do not think we should be giving these people any extra skills. I think we should be giving them more training.
And yes I even said training! Not education ;-)


----------



## Veneficus

schulz said:


> And yes I even said training! Not education ;-)



Probably a much better idea than the pseudoeducation of random facts on powerpoint they are enduring now.


----------



## ThirtyAndTwo

Also I think EMT's should be taught how to take a blood glucose reading, in PA that is a paramedic skill but its probably easier to do than get an accurate manual BP and is obliviously very useful in potential diabetic emergencies. Its a waste of time having to ask a family member to do it and it makes us look like we don't know what we are doing when they hand us the meter and we say "sorry we aren't trained to do that"


----------



## Engineered

Being that I work in the Denver metro area, I think every system should elevate up to where we are.  As a Emt with an IV cert (additional 24 hours classroom and 12 hours clinical) I can  start iv's, push narcan iv and in, d50 ( and all of its lower concentration equivelents), albuterol, bgl test, give boluses and some other small department dependent things.  This makes us more then just glorified taxi drivers, and the system has worked well here. (Some departments I have been told have the emts place the 3 lead and 12 lead pads.)


----------



## Medic Tim

Engineered said:


> Being that I work in the Denver metro area, I think every system should elevate up to where we are.  As a Emt with an IV cert (additional 24 hours classroom and 12 hours clinical) I can  start iv's, push narcan iv and in, d50 ( and all of its lower concentration equivelents), albuterol, bgl test, give boluses and some other small department dependent things.  This makes us more then just glorified taxi drivers, and the system has worked well here. (Some departments I have been told have the emts place the 3 lead and 12 lead pads.)



This is very similar to our EMT's or BLS medics. The difference being the training is 1-2 years as opposed to maybe 200 hours.


----------



## hogwiley

What should BLS add? As far as EMT training they should add A&P as a prerequisite. It doesn't have to be some advanced A&P class, but a simple one semester essentials of A&P should suffice. This would eliminate a lot of yahoos who go to EMT school because it sounds cool and they get to drive around with lights and sirens in a uniform.

There's no excuse not to do it. The field is flooded with EMTs so its not like there's a shortage, and a lot of these EMTs take multiple times to pass the NREMT, so why not require A&P?


----------



## Tigger

Medic Tim said:


> This is very similar to our EMT's or BLS medics. The difference being the training is 1-2 years as opposed to maybe 200 hours.



200 hours is nowhere sufficient to do what we are expected to do with the little add-on cert here. While I like being more useful to my medic, developing a skill takes more than a 24 hour class and a day at the ED getting 10 sticks.


----------



## chaz90

Tigger said:


> 200 hours is nowhere sufficient to do what we are expected to do with the little add-on cert here. While I like being more useful to my medic, developing a skill takes more than a 24 hour class and a day at the ED getting 10 sticks.



But the 24 hr class +10 live sticks isn't supposed to develop the skill. Like anything else, that should prepare you to go into the world and develop the skill with at least some foundation. Remember, the EMT-IV cert isn't supposed to be stand alone or based on knowledge. That add on is pretty much just supposed to make EMTs more useful on an ALS ambulance, which I think it does pretty effectively. It's a purely technical skill, and I think the class as it stands now is enough to teach the skill acquisition alone.


----------



## Bullets

After further consideration ive narrowed it down to 2 things, or two skills

BGL. There is no reason why an EMT, who is theoretically a medical professional cant take a BGL. IT is useful to confirm or rule out strokes, and well as assess altered mentation and diabetic issues. Perhaps IM dextrose, but im hesitant to add needles to the EMT scope

Nebulizers-Duoneb, albuterol or whatever your service uses. We teach lung sounds, so a EMT should be already able to recognize asthmatic lungs. Something like a nebulizer is a relatively easy skill to understand and supplement the EMT scope. If a patient is worse, then ALS can arrive and administer IV prednisone or the steroid du jour. 

Now both of these would require some education in physiology and pharmacology of the drug administered. These EMTs need to know what is happening inside the body

Im wary of allowing them to do IVs, and even not crazy about people discussing CPAP for EMTs


----------



## xrsm002

Bullets said:


> After further consideration ive narrowed it down to 2 things, or two skills
> 
> BGL. There is no reason why an EMT, who is theoretically a medical professional cant take a BGL. IT is useful to confirm or rule out strokes, and well as assess altered mentation and diabetic issues. Perhaps IM dextrose, but im hesitant to add needles to the EMT scope
> 
> Nebulizers-Duoneb, albuterol or whatever your service uses. We teach lung sounds, so a EMT should be already able to recognize asthmatic lungs. Something like a nebulizer is a relatively easy skill to understand and supplement the EMT scope. If a patient is worse, then ALS can arrive and administer IV prednisone or the steroid du jour.
> 
> Now both of these would require some education in physiology and pharmacology of the drug administered. These EMTs need to know what is happening inside the body
> 
> Im wary of allowing them to do IVs, and even not crazy about people discussing CPAP for EMTs



In Texas all the services I've recently worked at allow basics to perform nebulizer treatments, BGLs, CPAP, IM Epi and IN narcan. Of course Texas doesn't have a set of state protocols, it's up to the individual medical director for they service. They can even do combitubes and king airways at those services.


----------



## chaz90

Bullets said:


> After further consideration ive narrowed it down to 2 things, or two skills
> 
> BGL. There is no reason why an EMT, who is theoretically a medical professional cant take a BGL. IT is useful to confirm or rule out strokes, and well as assess altered mentation and diabetic issues. Perhaps IM dextrose, but im hesitant to add needles to the EMT scope
> 
> Nebulizers-Duoneb, albuterol or whatever your service uses. We teach lung sounds, so a EMT should be already able to recognize asthmatic lungs. Something like a nebulizer is a relatively easy skill to understand and supplement the EMT scope. If a patient is worse, then ALS can arrive and administer IV prednisone or the steroid du jour.
> 
> Now both of these would require some education in physiology and pharmacology of the drug administered. These EMTs need to know what is happening inside the body
> 
> Im wary of allowing them to do IVs, and even not crazy about people discussing CPAP for EMTs



Negative on the IM Dextrose. That's actually a skill even your medical director himself can't do. Dextrose is extremely necrotic to tissue due to its hyperosmolarity, so the only possible parenteral route is IV/IO. Perhaps you were thinking IM Glucagon.


----------



## TheLocalMedic

chaz90 said:


> Negative on the IM Dextrose. That's actually a skill even your medical director himself can't do. Dextrose is extremely necrotic to tissue due to its hyperosmolarity, so the only possible parenteral route is IV/IO. Perhaps you were thinking IM Glucagon.



Lol, I totally had a 'WHAT?!' moment when I read that IM bit too.  Just another nail in the coffin against allowing EMTs to administer meds.  Granted, there are some really good, qualified EMTs out there who I'd be more than happy teaching an expanded scope to, but unfortunately the majority of the ones I know and have to work with are just simply never going to make me comfortable enough to give them those extra tools.  Sometimes there's a reason that a lot of them stay at the EMT level and don't advance to become a medic or continue their education...


----------



## chaz90

Bullets does sound like a good EMT, and I'm sure he just made a typo. I do agree with your point about some people making me uncomfortable with the skills they're given, but the same applies to medics, nurses, and even some docs. At every level, there will be some people that you never, ever want treating you or your family.


----------



## Engineered

TheLocalMedic said:


> Lol, I totally had a 'WHAT?!' moment when I read that IM bit too.  Just another nail in the coffin against allowing EMTs to administer meds.  Granted, there are some really good, qualified EMTs out there who I'd be more than happy teaching an expanded scope to, but unfortunately the majority of the ones I know and have to work with are just simply never going to make me comfortable enough to give them those extra tools.  Sometimes there's a reason that a lot of them stay at the EMT level and don't advance to become a medic or continue their education...



I think what might be more important here the restricting a scope is changing a culture.  Instead of limiting all emts to the lowest common denominator, l think companies and departments need to be more vigalant on dismissing those who are incompetent to do their job. In Denver d50, ivs, king tubes, nebs, ect are part of my job, and is I displayed incompentance in deploying those parts of my job then i should be fired, end of story.  Same with any EMT who can not preform a proper pulse ox or bgl if that is what is expected of them.  This is not little league baseball and you dont get a trophy for showing up.


Excuse the spelling please, typing from a phone.


----------



## Bullets

Crap, i meant glucagon

I was sitting in pathopharm class and we were talking about glucose and i was tabbing between my notes and EMTLife, brain fart

We need to split IFT and 911 into separate training and certifications. EMTs get effectively no education in chronic disease pathways, yet a large portion of EMS deals with patients who have chronic illnesses. Its easy to see whos been doing IFT for to long, as soon as they get on a 911 call they loose it


----------



## usalsfyre

chaz90 said:


> Negative on the IM Dextrose. That's actually a skill even your medical director himself can't do. Dextrose is extremely necrotic to tissue due to its hyperosmolarity, so the only possible parenteral route is IV/IO. Perhaps you were thinking IM Glucagon.



Depends on the concentration. D5 or D10 would probably be safe to give IM all day....it just wouldn't do much at the volume you can give an IM injection.


----------



## usalsfyre

Bullets said:


> We need to split IFT and 911 into separate training and certifications. EMTs get effectively no education in chronic disease pathways, yet a large portion of EMS deals with patients who have chronic illnesses.


I dealt with effectively the same patients in IFT as I did in 911. Its just how they got into the system.


----------



## chaz90

usalsfyre said:


> Depends on the concentration. D5 or D10 would probably be safe to give IM all day....it just wouldn't do much at the volume you can give an IM injection.



I was referring to D50 with the hyperosmolar comment. Yeah, I wonder how absorption would be of IM D5?


----------



## Tigger

chaz90 said:


> But the 24 hr class +10 live sticks isn't supposed to develop the skill. Like anything else, that should prepare you to go into the world and develop the skill with at least some foundation. Remember, the EMT-IV cert isn't supposed to be stand alone or based on knowledge. That add on is pretty much just supposed to make EMTs more useful on an ALS ambulance, which I think it does pretty effectively. It's a purely technical skill, and I think the class as it stands now is enough to teach the skill acquisition alone.



The issue for me is that there is no degree of precepting with it, and I know that is not an uncommon problem around here. The mentality of many seems to be "you took the class, you should be able to do it." Meanwhile we're doing it in a moving ambulance and not the ED, which hampers technique. I also have very little experience with "tough sticks" and being alone in the back of the ambulance isn't going to help me learn to find suitable veins when it appears there are none, nor do I get any feedback on why I was unsuccessful.


----------



## chaz90

Tigger said:


> The issue for me is that there is no degree of precepting with it, and I know that is not an uncommon problem around here. The mentality of many seems to be "you took the class, you should be able to do it." Meanwhile we're doing it in a moving ambulance and not the ED, which hampers technique. I also have very little experience with "tough sticks" and being alone in the back of the ambulance isn't going to help me learn to find suitable veins when it appears there are none, nor do I get any feedback on why I was unsuccessful.



That's probably more of a failure with the people who are evaluating you again. I looked at the IV cert as a "license to practice" the skill out in the field. It's really the same as EMT or Medic students. Do we think they're immediately ready to go and can function alone effectively the moment their certificate is in hand? Keep at it, as it really is a skill that improves with time. 

My top few IV tips:
1. Don't be afraid to go smaller. A 20G IV is better than an 18G hole. Look at what the hospitals place too. 20 and 22s can have meds and fluids pushed through them fairly well. Don't take up the AC with a 22 or 24, but I have no shame wheeling in an old lady with a 22 in her hand and a smile on my face. If they need to put in a more proximal 18 for contrast, they can go for it.

2. Don't psyche yourself out. Confidence is a big part of getting the IV, as they can be wily critters and seem to sense fear. Even on a hard stick, tell yourself you will get the vein.

3. Don't go in at too deep of an angle. Many veins lie shallow, and even that big pipe you're palpating isn't as deep as you think most of the time. If you're too shallow and need to go deeper, you can adjust. There's no recovery after going at too deep of an angle, perforating both vein walls, and causing a half dollar sized hematoma. 

4. When all else fails, go back to the anatomical locations. As Veneficus said a few months ago, embryology isn't a secret. There is a rough road map available that all patients will follow to some degree. It shouldn't be common, but anatomical sticks can work well.


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## Tigger

chaz90 said:


> That's probably more of a failure with the people who are evaluating you again. I looked at the IV cert as a "license to practice" the skill out in the field. It's really the same as EMT or Medic students. Do we think they're immediately ready to go and can function alone effectively the moment their certificate is in hand? Keep at it, as it really is a skill that improves with time.



I appreciate the tips a whole lot!

As you mention, no one is expected to function as an EMT or Medic on day one, so it's always seemed odd to me that a preceptor will go out and say "get a line on him" and walk away. I've talked to a lot of basics who have that this problem and it confuses me.


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## MountainMedic

EpiEMS said:


> What additional skills does every patient deserve?
> - Glucometry
> - 3- and 12-lead placement and transmission
> - Blind insertion airway devices
> - SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
> - Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
> - Rectal diazepam (carried on ambulance -- not just prescribed)
> - MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
> - IN naloxone
> 
> Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.



For the most part, this is why we have medics. That said, I'm all for EMT-Bs doing more for their pts. First off, they need better assessment skills. As a medic now, I can't believe the crap I didn't know as a basic. I thought I did then, but boy, was I wrong. Better pharm, esp., to include knowledge about pain meds, benzos, beta blockers, and blood thinners. That said:

Glucometer: Yes. This cannot possibly hurt. And yes, giving sugar to a hyperglycemic is bad for them, even if we wanna pretend it isn't. 

EKGs: No. If your index of suspicion is high enough to place leads, get a medic intercept. If you can't, you're just gonna delay getting a pt to the hospital, where they're gonna get a 12-lead within 60 secs of them getting in the door. I know the research says otherwise, but I've seen basic services do this, and it's always caused surprisingly long delays. If the EMT is basing transport decision off transmission, then OK. 

Airways: Hell yes. King tube all the way. Things are almost as good as ET tubes and are easy as hell to place.

Epi 1:1,000 vials: no. Epi-Pen: Hell yes. Anaphylaxis is easy to recognize and easily treatable. Still, get a medic. I only vote no for the vials since basics won't be drawing up meds frequently and will thus be out of practice when SHTF. 

Nitro: No. If you can't r/o RV STEMI, you have no business giving NTG. 

Rectal diazepam: Hell no. What's the point? It doesn't work, is a pain to administer, and you'll hardly ever give it. Besides, onset is most likely after you'll see ALS and get the pt IV midazolam. 

Neb: Hell yes. Albuterol is mostly harmless and fixes pts.  

Narcan: Nah. Just bag 'em. Give too much and the call becomes a huge pain in the ***. That said, it's kind of hard to give too much IN Narcan with a 2 mg cap.

PAIN MEDS: 50 mcg Fentanyl in each nostril. Really can't do any harm. Won't even hurt a hypotensive pt. It's kind of absurd for EMT's to not have pain control protocols, IMHO.


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## Bullets

MountainMedic said:


> For the most part, this is why we have medics. That said, I'm all for EMT-Bs doing more for their pts. First off, they need better assessment skills. As a medic now, I can't believe the crap I didn't know as a basic. I thought I did then, but boy, was I wrong. Better pharm, esp., to include knowledge about pain meds, benzos, beta blockers, and blood thinners. That said:
> 
> Glucometer: Yes. This cannot possibly hurt. And yes, giving sugar to a hyperglycemic is bad for them, even if we wanna pretend it isn't.
> 
> EKGs: No. If your index of suspicion is high enough to place leads, get a medic intercept. If you can't, you're just gonna delay getting a pt to the hospital, where they're gonna get a 12-lead within 60 secs of them getting in the door. I know the research says otherwise, but I've seen basic services do this, and it's always caused surprisingly long delays. If the EMT is basing transport decision off transmission, then OK.
> 
> Airways: Hell yes. King tube all the way. Things are almost as good as ET tubes and are easy as hell to place.
> 
> Epi 1:1,000 vials: no. Epi-Pen: Hell yes. Anaphylaxis is easy to recognize and easily treatable. Still, get a medic. I only vote no for the vials since basics won't be drawing up meds frequently and will thus be out of practice when SHTF.
> 
> Nitro: No. If you can't r/o RV STEMI, you have no business giving NTG.
> 
> Rectal diazepam: Hell no. What's the point? It doesn't work, is a pain to administer, and you'll hardly ever give it. Besides, onset is most likely after you'll see ALS and get the pt IV midazolam.
> 
> Neb: Hell yes. Albuterol is mostly harmless and fixes pts.
> 
> Narcan: Nah. Just bag 'em. Give too much and the call becomes a huge pain in the ***. That said, it's kind of hard to give too much IN Narcan with a 2 mg cap.
> 
> PAIN MEDS: 50 mcg Fentanyl in each nostril. Really can't do any harm. Won't even hurt a hypotensive pt. It's kind of absurd for EMT's to not have pain control protocols, IMHO.



I agree with you on everything but Nitro

No reason why EMTs cant carry and administer nitro tablets. If we can instruct patient to take them when they have chest pain, why cant we allow EMTs to do so? Theyve already learned the contraindications


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## CPRinProgress

Bullets said:


> I agree with you on everything but Nitro
> 
> No reason why EMTs cant carry and administer nitro tablets. If we can instruct patient to take them when they have chest pain, why cant we allow EMTs to do so? Theyve already learned the contraindications



I don't know when we would administer nitro because people are instructed to take three and then call 911.  So when would we give nitro.


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## NomadicMedic

I believe this is referring to patients with chest pain who do not have they own Rx NTG. In the case of ischemic chest pain, the EMT would administer the NTG.


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## DesertMedic66

CPRinProgress said:


> I don't know when we would administer nitro because people are instructed to take three and then call 911.  So when would we give nitro.



Even though patients are instructed to take 3 doses of Nitro roughly 5 minutes apart doesn't mean they always do it.

Also I would agree with DE. I think that poster was referring to if the patient is not prescribed Nitro.


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## MountainMedic

Nitro hasn't been shown to significantly decrease morbidity or mortality. Aspirin has, and that's what EMTs should be giving. If there's CP over 4/10, EMTs should be able to give IN fentanyl.


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## CPRinProgress

DesertEMT66 said:


> Even though patients are instructed to take 3 doses of Nitro roughly 5 minutes apart doesn't mean they always do it.
> 
> Also I would agree with DE. I think that poster was referring to if the patient is not prescribed Nitro.



In Jersey I'm not sure if we are allowed to administer nitro that isn't prescribed.   My squad definitely doesn't carry it


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## chaz90

I don't know of many places that allow EMTs to carry and dispense their own Nitro. This is a thread discussing what should or should not be in the BLS scope.


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## Clare

chaz90 said:


> I don't know of many places that allow EMTs to carry and dispense their own Nitro.



New Zealand
Australia
Canada
South Africa (ECT)
United Kingdom
Ireland
Germany


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## chaz90

Clare said:


> New Zealand
> Australia
> Canada
> South Africa (ECT)
> United Kingdom
> Ireland
> Germany



I stand corrected. Forgive me for momentarily forgetting our fine non-USA members.


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## STXmedic

chaz90 said:


> I don't know of many places that allow EMTs to carry and dispense their own Nitro. This is a thread discussing what should or should not be in the BLS scope.



A very good chunk of Texas (I don't know anywhere but small IFTs that don't allow them to carry and administer)


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## JPINFV

Bullets said:


> I agree with you on everything but Nitro
> 
> No reason why EMTs cant carry and administer nitro tablets. If we can instruct patient to take them when they have chest pain, why cant we allow EMTs to do so? Theyve already learned the contraindications




...because those patients have been worked up and diagnosed with angina. That's completely different than the first time a patient suffers from acute coronary syndrome.


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## Handsome Robb

Clare said:


> New Zealand
> Australia
> Canada
> South Africa (ECT)
> United Kingdom
> Ireland
> Germany



The education behind BLS providers in those countries is a little different than here in the states though...


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## DesertMedic66

Robb said:


> The education behind BLS providers in those countries is a little different than here in the states though...



In the same aspect of your car being a little different than a smart car


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## Av8or007

As ive said before on the Nitro issue, the reason these countries bls  paramedics (all ems providers are medics, except for first responder level) can carry and give nitro is due to education. Before nitro is administered, we must have a 12 or 15 lead ekg to rule out rv mi. If the pt does not have a hx of nitro use, then we must get iv access.

This is different from pt self administration of nitro since in that case it is known that the pt did not have rv mi or similar issues when it was prescribed. In an ems setting without knowing the patient the 12  lead is a valid precaution. 

Dropping the blood pressure of a preload dependant pt is not a good idea.  
Yes the nitro will wear off, but if you have to give a fluid bolus to bring the pressure back up you've got another set of problems in certain pts. Once the vascular bed tightens back up after the nitro wears off then the pt has a ton of excess blood volume (assuming the fluid hasn't third spaced). This may not cause a problem in pts who were fluid responsive or tolerant to begin with, but could cause issues if they were volume loaded or overloaded.


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## Handsome Robb

Av8or007 said:


> This is different from pt self administration of nitro since in that case it is known that the pt did not have rv mi or similar issues when it was prescribed.



True but t here no reason there current signs and symptoms couldn't have RVI...

We can give nitro without a line with a SBP >100 and no inferior STEMI but I still make a habit of having a line before the nitro unless they're hypertensive and it's not a line we can nab quickly.


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## Bullets

Av8or007 said:


> Dropping the blood pressure of a preload dependant pt is not a good idea.
> Yes the nitro will wear off, but if you have to give a fluid bolus to bring the pressure back up you've got another set of problems in certain pts. Once the vascular bed tightens back up after the nitro wears off then the pt has a ton of excess blood volume (assuming the fluid hasn't third spaced). This may not cause a problem in pts who were fluid responsive or tolerant to begin with, but could cause issues if they were volume loaded or overloaded.



Science doesnt back you up on this. Studies show that nitro doesnt drop BP that much, and the body regulates it pretty well

Also, if a patient has prescribed nitro, and has chest pain, whats to say he isnt having a RVI then? he doesnt have a EKG, he just takes the nitro


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## MountainMedic

Bullets said:


> Science doesnt back you up on this. Studies show that nitro doesnt drop BP that much, and the body regulates it pretty well
> 
> Also, if a patient has prescribed nitro, and has chest pain, whats to say he isnt having a RVI then? he doesnt have a EKG, he just takes the nitro



Nitro doesn't normally drop BP that much, but if the patient is having a RVI or is in pre-cardiogenic shock, it will tank it. IMHO, it should not be given without a 12-lead (15-lead, really), by a medic, ever. 

Most physicians who prescribe NTG to their patients will only do so after EKG and echocardiogram. Their pt will have a calculated risk for RVI, and coronary artery blood flow will likely be assessed before NTG is prescribed.


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