ALS for the BLS Provider -- Assisting ALS

[EpiEMS]

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

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

 

[VFlutter]

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

 

[DesertMedic66]

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

 

[Clare]

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

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

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

 

[EpiEMS]

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

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

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

 

[JDub]

Around here ALS assist skills are:

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

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

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

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

 

[EpiEMS]

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

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

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

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

 

[Tigger]

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

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

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

 

[Tigger]

Regulations for Massachusetts, as referenced above.

 

[Aidey]

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

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

 

[systemet]

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

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

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

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

 

[Brandon O]

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

Well, it is a state requirement.

 

[NomadicMedic]

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

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

 

[EpiEMS]

Regulations for Massachusetts, as referenced above.

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

 

[Tigger]

Well, it is a state requirement.

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

 

[medicdan]

Well, it is a state requirement.

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

 

[RustyShackleford]

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

 

[Tigger]

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

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

 

[medicdan]

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

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

 

[Bullets]

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

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

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