BLS Skills -- What Should We Add?

[Christopher]

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]

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

Just FYI, an EpiPen is IM, not SQ

 

[EpiEMS]

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.

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.

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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: