NYC EMTs get EpiPens

[CAOX3]

Just for discussion.

Ten year olds administer epi pens, insulin and glugagon usually without incident.

So would that be a ten-year old performing a ALS skill? Yet we should restrict the EMTs from a beneficial treatment because they operate in a system that was provided to them

Im all for education, until that changes what are the options? Every one has opinions but no reasonable solutions on how to get there. In the present economy laying off a million EMTs isnt a option.

 

[ResTech]

Epi-Pens are very beneficial and in terms of severe allergic reactions/anaphylaxis, time is not on the patients side. A patient should not have to wait for a Paramedic unit to arrive to administer this life saving medication when it can be administered relatively safe by BLS. In some locales, ALS may be at least 30mins away. I know in the upper most portion of the county i used to live you were looking at a good 20-30mins for ALS and if one of my kids had allergy issues and was in anaphylaxis I would rather have the BLS unit 5mins away arrive and administer Epi then have my son or daughter deteriorate and suffer in the 20-30mins it takes for an ALS unit to arrive.

Epi-Pens by BLS are based on a benefit vs risk assessment. When Epi is indicated, something very, very bad is going on with the patient and the benefits of having Epi administered by BLS far outweigh the potential risks of not being fully ALS capable. These patients dont have time to wait. Its a need it and need it now situation. And I think its important that we consider the epidemiology of anaphylaxis and the age populations most greatly affected. These are young to middle aged people who most often can handle the adrenergic effects of the epinephrine without any problem. And lets throw in the short half-life of Epinephrine. Overall, the risks of patients not getting the medication is MUCH GREATER then if patients do get it by BLS. I'm not seeing much of a realistic argument here.

Granted, EPi-Pens may be cost prohibitive for some EMS services as 99% expire and get tossed prior to use. However, in rural areas serviced primarily by BLS with ALS coming from a chase unit from a hospital, Epi-Pens are a very worthwhile expenditure and the few hundred dollars spent every year or so on Epi is worth the security and potential life saving ability of that BLS unit.

In PA, it is required for BLS units that choose to carry Epi-Pens to have two adult dose and two pedi doses. So multiply that by two EMS units its roughly about $400 to have that medication on both units.

Sorry for being long winded but this is a subject that really irks me. Just because a treatment modality has traditionally been reserved for an advanced level practitioner, does not mean it cannot be permitted by a lesser level provider. Through history and research, we can determine that some modalities can be safely administered by basic level providers with great benefit. Not only Epi, but also ASA and albuterol.

For example, traditionally prescription-only medications are now OTC meds available at Wal-Mart. Im not interested in joining in the argument so just read my opinion and take it for what its worth.

 

[medic417]

In the present economy laying off a million EMTs isnt a option.

Why not? Would open more positions for Paramedics that could provide some actual medical care.

 

[whizkid1]

We are a basic service,but we can give Epi.We are trained in it yearly as refreshers. We can also give nitro,albuteral,glutose,glucose,MDI's and start IV's for NS and LR.

 

[rmellish]

We are a basic service,but we can give Epi.We are trained in it yearly as refreshers. We can also give nitro,albuteral,glutose,glucose,MDI's and start IV's for NS and LR.

give epi as a autoinjector? Or actually drawing up the desired dose from a 1:1000 vial or 1mg preload for arrests?

 

[whizkid1]

Auto injectors.

 

[FieldMedic2007]

I dont have an issue with the use of epi pens to emts do to the fact that I am a military medic and carry one even without a provider over me. I am aware that military medicine is totally different than civilian medicine and we get to carry a bit more than regular emt-b'b. I also agree that should they issue out epi pens to emt's that they definately need to make sure there is proper training and knowledge because we all know that there will be one person out there to make somethin so simple and totally mess it up Haha, but yeah, thats my thought on it.

 

[46Young]

In NYC, BLS respond for the allergic reaction, and ALS respond for the anaphylaxis. Medic back is usually not more than 3-5 minutes away in most cases if needed. EMT B's are allowed to admin albuterol, and assist with pt's ntg. When I left NY in 10/07, there were two asthma call types, one for BLS, and one for ALS. The BLS asthma calls would be for younger pts, with asthma Hx only, and a mild severity on pt's self assessment. Oftentimes these pts would have run out of their meds, and needed a free Tx and maybe a ride to the hosp if they refuse after Tx. A cardiac condition will always be an ALS call, with BLS back if medics give a greater than 10 eta. When I was BLS, we would give O2, proper positioning, and stair chair txp to the front door to make things move quicker for the medics. As such, BLS really shouldn't be messing aroung with ntg admin in lieu of packaging/moving the pt. Epi, on the other hand, can potentially kill. In a resource rich area, there's no reason BLS should need to carry epi, as they're ill equipped to treat any untoward reactions. You can study as many medical texts as you want, but having an attending emergency room MD's knowledge base is useless unless you have the tools to properly diagnose, administer the intervention, and be able to treat any side effects. Really, the previous sentence pretty sums up this entire thread.

 

[46Young]

Also, I became a medic out of desire to be able to do more for my pt's. I remember as a basic I would get a sense of fufillment and excitement after being able to give albuterol, oral glucose, or assist with ntg. If this describes you, and/or you want to do more for your pt's, become a medic.

 

[Melbourne MICA]

Epi Pens

A logical addition to an EMT's skillset. Yet there must be cost issues and the EMT's would surely benefit from having to draw up Epi instead - valuable practice in assisting ALS types with IV med adminisatration.

Besides, with Epi's short half life, rebound anaphylaxis is a definite probablity porportional to distance to the nearest ED. The ability to give follow-up doses may be life saving for guys on the periphery or in rural areas in particular.

Having Epi as part of the kit will also provide a visual cue to their bosses to think about expanding their skill set to include Epi beyond just anaphyaxis and perhaps even looking at where education can (must) go beyond just bean counting and litigation issues. Every life saved or med-long term illness problem nullified has cost and health benefits for all stakeholders.

Our BLS guys have had Epi for over four years now. They can apply it in arrests (IV and IM), anaphylaxis (IM), croup (neb) and asthma (IV and IM). So far no major dramas with competencies though some of the guys tend to be a bit timid sticking pts especially if inexperienced (not such a bad thing anyway). Sometimes they will wait till the MICA unit arrives to hold their hand. The good ones don't baulk.

A great drug used for the right purpose.

MM

 

[46Young]

A logical addition to an EMT's skillset. Yet there must be cost issues and the EMT's would surely benefit from having to draw up Epi instead - valuable practice in assisting ALS types with IV med adminisatration.

Besides, with Epi's short half life, rebound anaphylaxis is a definite probablity porportional to distance to the nearest ED. The ability to give follow-up doses may be life saving for guys on the periphery or in rural areas in particular.

Having Epi as part of the kit will also provide a visual cue to their bosses to think about expanding their skill set to include Epi beyond just anaphyaxis and perhaps even looking at where education can (must) go beyond just bean counting and litigation issues. Every life saved or med-long term illness problem nullified has cost and health benefits for all stakeholders.

Our BLS guys have had Epi for over four years now. They can apply it in arrests (IV and IM), anaphylaxis (IM), croup (neb) and asthma (IV and IM). So far no major dramas with competencies though some of the guys tend to be a bit timid sticking pts especially if inexperienced (not such a bad thing anyway). Sometimes they will wait till the MICA unit arrives to hold their hand. The good ones don't baulk.

A great drug used for the right purpose.

MM

You say education can (must) go beyond just bean counting and litigation issues. I agree. That's why there's a paramedic program to properly educate, and provide the tools to administer advanced procedures. When one of your basics eventually kills someone via an epi admin, how will you fend off the inevitable litigation? What tools do your BLS providers have to treat any untoward reactions resulting from epi admin? I don't mean an AED and epi IV for an arrest after epi IV/IM admin for asthma. So, you mean to tell me that your basics administer IV/IM pharmocological intervention without intubation capabilities or cardiac monitoring/12 lead? What training have your basics received past the BLS level to fully understand the effects of their procedures? Epi IM for an arrest? I don't recall seing that on any ACLS algorithms.

 

[Melbourne MICA]

Ah you may well ask!!!

You say education can (must) go beyond just bean counting and litigation issues. I agree. That's why there's a paramedic program to properly educate, and provide the tools to administer advanced procedures. When one of your basics eventually kills someone via an epi admin, how will you fend off the inevitable litigation?

There's are few queries here so I'll start with some background that may cover a few bases up front.

Our "basics" aren't so basic anymore - now roughly EMT-I at closest comparison with equivalents in the US - 3 yrs education at uni. "ALS" skills used to be taught as education updates but are now incorporated into the uni programme. (Now age, experience, on road training etc that's another story which is why the MICA guys have always cringed and squirmed a fair bit about our "ALS" colleagues). Having said that there is plenty of work at and least a good proportion have come a fair way over the last 3 or 4 yrs.

Vicarious liability covers the legal angle pretty well assuming the operator was working within guidelines. The process and laws covering us here are probably a little different to the US.

What tools do your BLS providers have to treat any untoward reactions resulting from epi admin? I don't mean an AED and epi IV for an arrest after epi IV/IM admin for asthma.

The BLS guys have IV/IM/IN/Neb/oral admin routes in training to cover the skills. They can fluid load as well. They also all have 3lead monitoring with 12lead training to be introduced sometime in the near future - (that'll sort the men from the boys). So when an anaphylaxis needs treating the pt will get full assessment, monitoring, IV line + fluid loading, Epi, repeat Epi, MICA backup coming etc. The guys all have medium level airway skill sets as well with OP/NP/LMA/laryngo/BVM but no ETT.

This type of job is coded as a two tier response ie ALS (BLS) car + MICA unit. In the case of anaphylaxis an Epi admin say in the setting of a fast tachy is not likely to go on to SVT/VT. Guys will use good judegment if they have concerns and will consult for further options if need be. Alternately they can use less Epi or withhold till a MICA unit arrives. If things go awry, which is always a possibility, there at least some backup options. Four years now and no court cases so far. (crosses fingers)

So, you mean to tell me that your basics administer IV/IM pharmocological intervention without intubation capabilities or cardiac monitoring/12 lead? What training have your basics received past the BLS level to fully understand the effects of their procedures? Epi IM for an arrest? I don't recall seing that on any ACLS algorithms

The first part here is covered above I think as well as the training side. Our "basics" like I say aren't really basics. No 100hrs training here - 3yrs minimum.

(I didn't say/mean they give IM at arrests - muddled the terms up - just that they can give various drugs IV/IM/IN routes etc sorry for the confusion on that one).

Having said all this the first part above about the MICA guys squirming and cringing - thats what you're getting at from a Paramedics point of view and I am with you 100%. Our guys are better covered educationally and with careful planning, supervision and hands on practice you're guidelines could be upgraded as well. (Melbourne is 3 1/2 million people and about 1700 ambos - not a bad study cohort for efficacy studies on various skillsets).

The guys get a reasonable workload but there are a hundred reasons why we MICA types have reservations about our on-roaders doing so much. However, no major dramas yet, a lot are developing an experience base and they can guarantee we MICA types watch, critique, mentor and jump up and down when a "basic" (on a basic) gets a bit carried away with himself or the bosses loosen up the guidelines too much.

Hope that covers it.

Cheers

MM

 

[High Speed Chaser]

I'm trained to use Epi-Pens and I'm not an EMT. Even before I joined St John Ambulance, I was taught to use them. If some one who isn't an EMT can be trained to use them, why shouldn't EMTs, who are trained more than a First Aider, be able to carry them?

St John Ambulance doesn't carry them for various reasons as I have previously stated in another Thread. However sometimes I wished we did because often at a sports events, people are more likely to find and get help quickly from SJA then Ambulance Victoria who are more spread out.

A nurse I spoke with outside SJA said its better to administer an Epi-Pen then to not. Is this true?

Correct me if I'm wrong but the basic units are refered to as Paramedics and ALS are refered to as MICA.

Found the CPG (Scope of Practice) here http://www.ambulance-vic.com.au/media/docs/index.htm

 

[Melbourne MICA]

Als

I'm trained to use Epi-Pens and I'm not an EMT. Even before I joined St John Ambulance, I was taught to use them. If some one who isn't an EMT can be trained to use them, why shouldn't EMTs, who are trained more than a First Aider, be able to carry them?

St John Ambulance doesn't carry them for various reasons as I have previously stated in another Thread. However sometimes I wished we did because often at a sports events, people are more likely to find and get help quickly from SJA then Ambulance Victoria who are more spread out.

A nurse I spoke with outside SJA said its better to administer an Epi-Pen then to not. Is this true?

Found the CPG (Scope of Practice) here http://www.ambulance-vic.com.au/media/docs/index.htm
[/QUOTE]

Correct me if I'm wrong but the basic units are refered to as Paramedics and ALS are refered to as MICA.

Correct though the training is not equivalent between EMT basics in the US and our "ALS" (BLS) road units.

MM

 

[46Young]

Yes, Melboure, that cover it pretty well. Things make more sense now. What you describe is roughly equivalent to the american EMT-I scope of practice.

 

[SauceyEMT]

Trevor, as an EMT-B student, you are about the least qualified person here to tell me when I am right or wrong. And you have proven that with this last post.

EMT-B is not synonymous with BLS. They are not the same thing. One is a title. The other is an intervention. Whether or not you are an EMT-B or not, if you are performing an ADVANCED intervention, you are performing ADVANCED Life Support. Dr. Bledsoe, who wrote the paramedic textbook, says the very same thing. You have to pull your head out of the semantic games and understand that your certification level does not define the level of an intervention. If your system allows an EMT to intubate, that does not make intubation BLS. It simply makes your EMT's ALS.

While I may also be one of the "least qualified" (read: inexperienced) to interject here, I'm going to do so because I can.

I think you're exactly correct in this above post. With that said, this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS?

Just my $0.02

 

[46Young]

While I may also be one of the "least qualified" (read: inexperienced) to interject here, I'm going to do so because I can.

I think you're exactly correct in this above post. With that said, this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS?

Just my $0.02

When I worked in NY, I relied heavily on BLS back, and counted on them to be competent. They've helped by knowing when to call ALS, report, O2 and package, do a decent assessment/Hx, good L/S, good trauma/immobilization skills, giving cric and tube confirmation L/S, good ongoing assessment including mental status, airway/resps, accurate BP/pulse, and a smooth, safe ride to the hosp. I'm disappointed in systems that use an exclusive "one and one" medic/emt crew. Things differ by agency, but from my personal experience, the medic will dominate pt care, with the emt doing a BP, pulse/resp count, O2, BGL, monitor placement, immobilization, and that's about it. The basic never develops strong assessment skills or pt care decisions. Advanced skills are just that, advanced, and require proper education/training, and the tools to properly implement/manage such skills. It's not meant as a knock towards basics, it's just reality. Every medication has the potential to kill, and should be respected as such. When you go through the training, you'll understand the importance having full ALS capabilities to properly perform your skills.

 

[AJ Hidell]

...this battle seems to be more about animosity over Basics performing ALS interventions, rather than what could be/would be the best treatment. Several of your posts in this thread have the undertone of "but you're not medics." Maybe I'm off base with that, but I don't think so. Basics may not be medics, but if introducing a new intervention (for them) will help patients, why start a pissing contest over ALS vs BLS?

I won't presume to define what this battle is about for everyone here. But, as for what it is about for me, yes, you are off base. It has nothing to do with who is performing what. It's about only what I said it is about, which is correctly categorizing the facets of our profession. But I certainly appreciate your efforts to intelligently analyze and understand the issue. I just wouldn't get too hung up trying to determine the motivations behind anyone's argument. This isn't a criminal case. Culpable mental states are not a relevant factor.

 

[Afflixion]

First off I don't know what EpiPens some of you guys are looking at but the acctual EpiPen brand one is IM says right on it "Delivers one 0.3mg intramuscular dose of epinephrine 1:1000" Second some of you may have been going to some crackpot basic school because the NREMT standard and TESTS the use of assisting Pts with the use of their EpiPens so there should be NO reaon why a basic rig shouldn't carry it. I also aggree with AJ that it is not BLS as any invasive proceedure is catagorized as ALS. Why do you basics have to put yourselves down and insist it is BLS? just because your a EMT-B doesn't mean your limited to BLS... in AZ our basics can initiate peripheral IV therapy is that not considered an ALS skill as well?

 

[AJ Hidell]

Why do you basics have to put yourselves down and insist it is BLS?

So they can play the victim and blame it on me.

But I have to say there is a major difference between "assisting" someone with their prescribed medication and prescribing it for them. Major, major difference. A protocol for the former does not necessarily qualify you for the latter.