NYMedic828
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On Long Island yes. NYC, no.
BLS Skills -- What Should We Add?
- Thread starter EpiEMS
- Start date
On Long Island yes. NYC, no.
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)
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
Flight Nurse
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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?
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
Forum Chief
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NIPPV is a BLS skill in some areas.
The generally quoted reason is that "it's an invasive skill".
NYMedic828
Forum Deputy Chief
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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
Still crazy but elsewhere
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What to add?
Three more years.
Three more years.
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.
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.
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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.
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
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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.
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
Sir Drinks-a-lot
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Ding ding ding
Frozennoodle
Sir Drinks-a-lot
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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
Sir Drinks-a-lot
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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
Gadfly
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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
Sir Drinks-a-lot
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Ah, well that's... different.
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.
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.
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.
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
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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)
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)