NYMedic828
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But why not just make everyone a paramedic at that point?
BLS Skills -- What Should We Add?
- Thread starter EpiEMS
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But why not just make everyone a paramedic at that point?
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
Still crazy but elsewhere
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Mickey Possum has gone back to the great graphic closet in the sky.
OP
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EpiEMS
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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).
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).
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?
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.
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.
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.
NomadicMedic
I know a guy who knows a guy.
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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.
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.
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.
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.
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?
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.
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.
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.
OP
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EpiEMS
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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
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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.
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
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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.
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Bullets
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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
OP
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EpiEMS
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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.
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.
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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...).
OP
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EpiEMS
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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
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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.
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Christopher
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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
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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.