O2 admin in cases of ETOH and AMS

[VentMedic]

It is the mentality behind the "ALS" and "BLS" that has made EMS here so ridiculous.

If a doctor places a nasal cannula on a patient does that make it "BLS" even if the patient is headed for the ICU? If the patient is brought in by "BLS" does that make them less sick because less or no "ALS" procedures were done on them? If a BLS truck brings in an acute stroke patient does that make the patient less sick? If an ALS truck rushes a patient in cardiac arrest to the ED that they have not established any "ALS" interventions on, is that patient "BLS" and less sick?

In the U.S. we tend to get more hung up on labeling the patient by a skill or procedure rather than the knowledge of the provider or the actual patient care where assessment is concerned or whether that patient might actually be sick. If the Paramedic does not see where they can or want to do a "skill" the patient becomes "BLS". Thus, it is then assumed the patient is "less sick".

We can take a severely injured trauma patient as an example since the BLS vs ALS is argued. The fact that only "BLS" procedures are done does not make that patient less sick. It should be the fact that an ALS assessment determined less is best rather than stay and play. Either way the patient needs Advanced Patient Care regardless of whether it is initiated in the field or in the ED. They may not need "ALS" skills but they are entitled to an assessment by someone capable of determining if immediate intervention is required and one that can do that procedure be it "BLS" or "ALS".

 

[FLEMTP]

Meaning what exactly, a bag of fluid? Yes that is truly advanced prehospital care, perhaps performing rapid sequence intubation or thrombolysing them based upon one's 12 lead findings I might call providing "advanced" care.

Now that is mildly unfair because that's not aimed at you specifically and I know Lee County EMS is a good setup.

That aside this "ALS" vs "BLS" thing just drives me absolutely up the wall and across the roof, down the other wall and back up again.

I suppose the biggest factor is that "BLS" in your system includes oh yes, oxygen and everything else is "advanced" so the education and mental conditioning covers just enough to enable you to do this, take some vitals and strap somebody to a board. Let's not get cute and say you can "assist" with GTN because that's not really something you can do medically, you can call and ask to help give somebody a tablet. Not the same thing.

well something i want to point out.. my agency is different from most, in that our EMT's are expected to perform skills above what most EMT's perform. here our EMT"s start IV lines, perform 12 leads, and are able to place any advanced airway with the exception of an ET tube. They are also expected to be able to draw up any medication we call for, with the exception of narcotics, and depending on the level of comfort of the medic, push the medication in certain circumstances. They also are expected to set up and apply CPAP and set up and apply a simple tranport ventilator. Most of this is much more than most typical EMT's are allowed to do on the BLS level... so with us, BLS is a skewed concept from most.

 

[MrBrown]

It is the mentality behind the "ALS" and "BLS" that has made EMS here so ridiculous.

Aw dude seriously I am picturing an ambulance pulling up and a bunch of people in clown getup with the funny pants and face paint and the hillarious sound effects getting out.

That is so wrong but I'm almost having some sort of hypoxic event laughing so hard. Sorry guys but that was pretty funny.

Problem is with the whole terms of "basic" and "advanced life support" is that they are used internationally but in every country they mean different things.

Ambo does way more than "life support" and I think that terminology stopped being relevant long ago.

New Zealand attempted to move beyond that nomanclature when we developed our new Ambulance Standard however there wasn't a consensus on what to replace it with.

Something that seemed to be the most supported was

Primary Care [Paramedic] - the old "basic life support"
Advanced Care [Paramedic] - the old "intermediate life support"
Intensive Care [Paramedic] - the old "advanced life support"
Extended Care [Paramedic] - Paramedic Practitioner

The problem was around "primary care" because well, it's not true primary care as the GP sees it; "basic care" sounds really bad and we couldn't think up a reasonable alternative to that. There was also some resistance to calling those at the basic level "Paramedic".

Canada uses this set (PCP/ACP) but they also have CCP but that's more critical care flight and IFT, lots of meds and pumps.

Queensland and Victoria in Australia use Advanced and Intensive Care Paramedic.

New Zealand used to used to have "intermedite" and "advanced care officer" in the 80s and mid 90s but the application was quite poorly designed and led to a lot of public confusion because patches and nomanclature did not match the terms.

 

[VentMedic]

well something i want to point out.. my agency is different from most, in that our EMT's are expected to perform skills above what most EMT's perform. here our EMT"s start IV lines, perform 12 leads, and are able to place any advanced airway with the exception of an ET tube. They are also expected to be able to draw up any medication we call for, with the exception of narcotics, and depending on the level of comfort of the medic, push the medication in certain circumstances. They also are expected to set up and apply CPAP and set up and apply a simple tranport ventilator. Most of this is much more than most typical EMT's are allowed to do on the BLS level... so with us, BLS is a skewed concept from most.

Those are still "skills" that can be done, unfortunately, with very little education or knowledge. Thus, we still can associate EMT with "BLS" even in the areas that allow EMTs to do ETI. We have had many threads about "EMT-Bs intubating" or "BLS and intubating". What is missing is the "patient care" as it pertains to assessment, knowledge and the level of care of the provider as it relates to the seriousness of the illness/injury and not just a "skill".

At least in FL, there should always be a Paramedic directly supervising the EMT doing these skills. Without that Paramedic, this would be a "BLS" patient because of the level of the provider regardless of how sick that patient is.

 

[FLEMTP]

They may not need "ALS" skills but they are entitled to an assessment by someone capable of determining if immediate intervention is required and one that can do that procedure be it "BLS" or "ALS".

Exactly... anyone in EMS, be an EMT or a paramedic, should be able to look at a patient and very quickly determine if the patient needs ALS intervetion, BLS intervention, or any intervention at all.

As an EMT on a BLS 911 unit, working in a county with only 2 medic flycars in the entire county, I became very good very quickly at determining who needed a medic and who doesnt. Any EMT should be the best they can at doing the same thing, and should be even better at managing that patient at a BLS level until that higher level of care is available, whether it be a paramedic, or an ER.

 

[FLEMTP]

Those are still "skills" that can be done, unfortunately, with very little education or knowledge. Thus, we still can associate EMT with "BLS" even in the areas that allow EMTs to do ETI. We have had many threads about "EMT-Bs intubating" or "BLS and intubating". What is missing is the "patient care" as it pertains to assessment, knowledge and the level of care of the provider as it relates to the seriousness of the illness/injury and not just a "skill".

At least in FL, there should always be a Paramedic directly supervising the EMT doing these skills. Without that Paramedic, this would be a "BLS" patient because of the level of the provider regardless of how sick that patient is.

True, as far as the simple hands on of the skills goes, they are very simple and any EMT could be trained to do those. THe difference is here we try and educate our EMT's as to the why behind the how. And yes, they must be directly supervised by a county credentialed paramedic. It works out quite well for the paramedic in charge though, because they can focus on overall scene management without being tied to doing one specific task, or it also makes it easier to manage the care of the more critically ill patients.

Also keep in mind, we have quite a few state licensed paramedics that work in an EMT capacity because there are not open paramedic positions, or because they feel overwhelmed working in a system with such liberal protocols as ours, and want to learn the system a step at a time. Certainly no shame in it, and I applaud them for knowing their own limitations and recognize the need to educate themsevles and gain experience. They are able to perform ANY paramedic level skill as long as they are being supervised directly by a county credentialed paramedic.

 

[VentMedic]

Exactly... anyone in EMS, be an EMT or a paramedic, should be able to look at a patient and very quickly determine if the patient needs ALS intervetion, BLS intervention, or any intervention at all.

Yet, we hear comments from EMTs about dialysis patients very often as being BLS or "BS" even though they are the sickest patients they may see on their truck. Dialysis is an "advanced" procedure required for supporting life. Even if the patient can go by a "BLS" truck because they do not require an IV or ETI, they should in no way be considered not sick which is unfortunately what happens with the "BLS" label.

Trauma and the obviously ill are one set of examples which require very little assessing to determine there is a problem. Unfortunately there are many other medical and some trauma situations that should require a more thorough assessment especially when it comes to determining appropriate facility. Example: we have also had Paramedics that assumed "BLS", some even before they see the patient, only to take a STEMI to a hospital with no cath lab. They did a "BLS" assessment. We have also had similar patients where the stroke or whatever neuro event was not immediately obvious or masked by alcohol. Thus, in their eagerness to determine the label "BLS" vs "ALS" they overlooked some very serious signs and symptoms which cost valuable time getting a CCT to move the patient to another facility.

 

[VentMedic]

True, as far as the simple hands on of the skills goes, they are very simple and any EMT could be trained to do those. THe difference is here we try and educate our EMT's as to the why behind the how. And yes, they must be directly supervised by a county credentialed paramedic. It works out quite well for the paramedic in charge though, because they can focus on overall scene management without being tied to doing one specific task, or it also makes it easier to manage the care of the more critically ill patients.

Also keep in mind, we have quite a few state licensed paramedics that work in an EMT capacity because there are not open paramedic positions, or because they feel overwhelmed working in a system with such liberal protocols as ours, and want to learn the system a step at a time. Certainly no shame in it, and I applaud them for knowing their own limitations and recognize the need to educate themsevles and gain experience. They are able to perform ANY paramedic level skill as long as they are being supervised directly by a county credentialed paramedic.

Essentially your service has created an Intermediate level which is the ALS skills but not the same depth of knowledge as the Paramedic level.

 

[FLEMTP]

Essentially your service has created an Intermediate level which is the ALS skills but not the same depth of knowledge as the Paramedic level.

More or less yes. It works well for our system, and every EMT and paramedic that works in our system sits for a rather rigorous oral board exam with our training captain, training chief, a Lieutenant, and our medical director, who ultimately has responsibility for what we do as EMS providers.

 

[VentMedic]

More or less yes. It works well for our system, and every EMT and paramedic that works in our system sits for a rather rigorous oral board exam with our training captain, training chief, a Lieutenant, and our medical director, who ultimately has responsibility for what we do as EMS providers.

The Paramedic and EMT team is also cheaper than two Paramedics. It isn't like Florida has a shortage of Paramedics although many are waiting for the FD which is more stable form of employment for many areas in this state.

Even for CCT, Specialty and Flight that does primarily IFT the Paramedic can be viewed as the "Intermediate" as they are hired for "skills" and lack indepth critical care knowledge. Their use as an RN/Paramedic team is also cheaper than RN/RN. California uses RN/2 EMTs with a few extra skills for its CCTs. But again, EMS providers are viewed for their "skills" rather than actual knowledge just as the determination for "ALS" might be the difference of one skill.

 

[MrBrown]

"Advanced" skills here are considered:

Endotracheal intubation and RSI
Cricothyrotomy
Turkel chest decompression
Atropine
Ketamine
Midaz (may change in the future for seizures)
Frusemide
Pacing
Hydrocortisone
Thrombolysis
IV salbutamol
IV magnesium

Everything else is either a Paramedic or Technician skill

 

[johnrsemt]

To go back to the original poster (OP): I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m. it gives them some relief (it does for me anyway). and I have had multiple patients tell me that it gives them relief too.

As a preceptor told me back 13 years ago, when I was on a BLS FD; putting someone on O2 does multiple things:
1: makes the patient feel better
2: makes the patients family feel better
3: gives you something to do while you are trying to figure out 'what the ____ ' to do for your patient, without making you look like a moron.
4: gives the Fire fighters something to do, to make them look useful.

 

[FLEMTP]

Even for CCT, Specialty and Flight that does primarily IFT the Paramedic can be viewed as the "Intermediate" as they are hired for "skills" and lack indepth critical care knowledge. Their use as an RN/Paramedic team is also cheaper than RN/RN. California uses RN/2 EMTs with a few extra skills for its CCTs. But again, EMS providers are viewed for their "skills" rather than actual knowledge just as the determination for "ALS" might be the difference of one skill.

Im not quite sure where you are getting the assumption that we as EMS providers are viewed for skills and not actual knowledge....if it was just about skills we would go back to the day where we were taught to read protocols out of a book and follow instructions without thinking. I was taught to think for myself and use my KNOWLEDGE to assess my patient, form a differential diagnosis and treat my patient based on that diagnosis.

Also, im glad you can cite what california does, but our helicoptor crews consist of 2 CCEMTP level providers who have attended a formal critical care course, and complete daily rounds in the ICU with the medical staff, and routinely demonstrate actual KNOWLEDGE and use that knowledge to form a treatment plan, and use that knowledge to perform skills well beyond what a ground paramedic (or a RRT with an EMT license ) would perform.

Maybe you have a different view of EMS providers, since you really dont function as one, and you work in the hospital instead of in the same enviroment we (paramedics and emt's) face, but please dont imply that we are just skill driven technicians that dont know what we are doing or why

 

[VentMedic]

Im not quite sure where you are getting the assumption that we as EMS providers are viewed for skills and not actual knowledge....if it was just about skills we would go back to the day where we were taught to read protocols out of a book and follow instructions without thinking. I was taught to think for myself and use my KNOWLEDGE to assess my patient, form a differential diagnosis and treat my patient based on that diagnosis.

Also, im glad you can cite what california does, but our helicoptor crews consist of 2 CCEMTP level providers who have attended a formal critical care course, and complete daily rounds in the ICU with the medical staff, and routinely demonstrate actual KNOWLEDGE and use that knowledge to form a treatment plan, and use that knowledge to perform skills well beyond what a ground paramedic (or a RRT with an EMT license) would perform.

Maybe you have a different view of EMS providers, since you really dont function as one, and you work in the hospital instead of in the same enviroment we (paramedics and emt's) face, but please dont imply that we are just skill driven technicians that dont know what we are doing or why

You are only talking about one service in Florida and not every HEMS, CCT or ALS in the state or every EMS in this country. You seem very reluctant to see that EMS still has a long way to go to achieve the same level that other countries have.

Since you used the CCEMTP letters, which is a trademark of UMBC, that is a very limited overview of a few critical care concepts consisting of about 80 hours. It is also open to just about any health care professional that wants to take it and requires no prior experience. It is vastly different from what is required to do "critical care" as a Paramedic in other countries.

As for as my RRT credential, it is very difficult for a Paramedic or EMT in this country to gain much hands on hospital experience and definitely not in a critical care unit. Doing "rounds" is vastly different than actually doing the patient care in an ICU. Thus, some of us have chosen to obtain other credentials such as RN or RRT to get hands on experience and further our education.

And no, I haven't been on a helicopter since last year. Fortunately, now working in a hospital and doing Specialty transport by many means of transportation, I can expand both my skills, knowledge and experience to a level that is not available for most EMS providers. Thus, I encourage people to not stop at one level of their education and if they are serious about advancing either as a Paramedic, RN or RRT, they should continue their education and seek out an area for growth in their chosen profession.

 

[CAOX3]

To go back to the original poster (OP): I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m. it gives them some relief (it does for me anyway). and I have had multiple patients tell me that it gives them relief too.

As a preceptor told me back 13 years ago, when I was on a BLS FD; putting someone on O2 does multiple things:
1: makes the patient feel better
2: makes the patients family feel better
3: gives you something to do while you are trying to figure out 'what the ____ ' to do for your patient, without making you look like a moron.
4: gives the Fire fighters something to do, to make them look useful.

Ok not trying to be difficult here.....But why is everyone under the impression if your not doing something then your failing your patient? We dont do things to look busy or because we need something to do, if they all need is an ice pack and a ride thats what they get.

Oxygen is a medication and should be treated as one and not handed out to make yourself look "busy", it has specific uses and should be administerd in those situations.

You wouldnt do it with morphine or albuterol.

I feel much better now, Thanks

 

[Melclin]

To go back to the original poster (OP): I always put someone who is nauseated and/or vomiting on a NC at 2-4 l/m. it gives them some relief (it does for me anyway). and I have had multiple patients tell me that it gives them relief too.

As a preceptor told me back 13 years ago, when I was on a BLS FD; putting someone on O2 does multiple things:
1: makes the patient feel better
2: makes the patients family feel better
3: gives you something to do while you are trying to figure out 'what the ____ ' to do for your patient, without making you look like a moron.
4: gives the Fire fighters something to do, to make them look useful.

Oh dear.

1 & 2:First of all it doesn't necessarily do either of the first two things. The presence of a mask on someones face often seems to make them quite uncomfortable, and the appearance is (in my obviously limited experience) often upsetting for family and friends, because they look like a sick person.

3: There is no harm in spending a little time considering your care options. It doesn't make you look like a moron, it makes you look like a calm, collected ambulance provider who is obviously putting thought into their pts treatment and who is not worried enough to be rushing around doing random and unhelpful busy work.

4: Another boon for FD based medical services. <_< You guys over there need to realise that having a bunch of FFs barrel in the door in their bloody turnout gear for some nanna who's been a bit crook for a few days, (or for just about anything really) is simply absurd.

EDIT: This is separate to the obvious and excellent point made by CAOX3. Plus 1 too that, old chap.

 

[MrBrown]

I have put one or two old's ladies on one litre via a nasal cannula when they seem quite worried and we're going to take a long time extricating them, made them feel a bit better; even if it's just psychosamatic.

Small white lie really.

 

[Jon]

I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures

But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?

Here's my point. If I'm dispatched BLS, and I get there and they have a patent airway... even if they are somewhat altered, what is a medic going to do.

One of the pertinent negatives I usually rule out is Hx. of diabetes...unfortunately I don't even have a glucometer.

Vent - I do the same H&P exam of my patient... it doesn't matter if I'm on a BLS or ALS truck... but if I'm on a BLS truck, I don't have a glucometer, cardiac monitor, advanced airway equipment, or IV and drugs. Thats what makes the difference for me.


My thinking on this, with the short transport time... by the time I get a medic to me, I can be almost at the ER... why should I wait for a medic, or meet one around the corner from the ER. What is the medic going to do for my patient.

 

[MrBrown]

... but if I'm on a BLS truck, I don't have a glucometer, cardiac monitor, advanced airway equipment, or IV and drugs. Thats what makes the difference for me.

This really suprises me, well, not really. If you are working on a "basic" truck can you not grab your ALS bag and make it an "ALS" trucK?

By contrast our vehicles are all the same; they may be crewed by two Technicians (BLS) but if you look at the equipment on that vehicle vs one crewed by an Intensive Care Paramedic it's all the same except for one green bag for the Intensive Care Paramedic.

That bag will contain intubation and advanced drug rolls and chest decompression kit. By "advanced" drugs I mean amiodarone, atropine, ketmainze and midaz. Stuff like salbutamol, glucagon, glucomonitor, GTN, Lifepak, general resus kit and extrication gear etc is common to all vehicles regardless of crew level.

So what happens if you are called to intercept with a "basic" unit? Do you change vehicles or do you make the patient change vehicles?

My thinking on this, with the short transport time... by the time I get a medic to me, I can be almost at the ER... why should I wait for a medic, or meet one around the corner from the ER. What is the medic going to do for my patient.

That's a good point; the general consensus here is that if your backup can locate you "significantly faster" than you can deliver the patient to hospital then call for it.

No longer is it acceptable to wait on-scene for backup unless they are only a few minutes away or if you are moving farther away from them to begin transport.

 

[medicdan]

MrBrown, in the US care is very fragmented, and each department or region treats their ambulance service differently. I believe the company Jon is describing working for is ONLY BLS, that is, they do not have authorization from the state to provide ALS-level care, and when they employ paramedics, they do so understanding they have a BLS SOP.