BLS Skills -- What Should We Add?

[chaz90]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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.

 

[Tigger]

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.

 

[MountainMedic]

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.

 

[Bullets]

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

 

[CPRinProgress]

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.

 

[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.

 

[DesertMedic66]

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.

 

[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.