LonghornMedic
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Amen!!
States and EMT-B Morphine Administration
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Melclin
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I don't really agree with the EMT-B level, but having said that you can't have every provider as top tier. You've guys over there have your skill levels arse up. Its so all or nothing. Everyone being a 'paramedic' dilutes the skill levels.
"But everyone should be educated to the paramedic level, EMT isn't good enough". No its not. Neither is you "paramedic" level in most cases.
Every provider should have an excellent base of education. Then specialize if that's what floats their boat. Just like nursing or medicine. Everyone has the same good basic education (an EMT-B is not a good basic education). Every div one nurse here has a degree, but if we just randomly allocated nurses to any job, you'd dilute the skills you need for the specialty rolls. If you only had to look after one guy in ICU every 12 months, you'd bugger it up more than if you did it everyday. The same could be said for rehab or cardiac care.
I don't see it being any different for the prehospital world.
"But everyone should be educated to the paramedic level, EMT isn't good enough". No its not. Neither is you "paramedic" level in most cases.
Every provider should have an excellent base of education. Then specialize if that's what floats their boat. Just like nursing or medicine. Everyone has the same good basic education (an EMT-B is not a good basic education). Every div one nurse here has a degree, but if we just randomly allocated nurses to any job, you'd dilute the skills you need for the specialty rolls. If you only had to look after one guy in ICU every 12 months, you'd bugger it up more than if you did it everyday. The same could be said for rehab or cardiac care.
I don't see it being any different for the prehospital world.
Hockey
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Here's my uneducated .02
What if they say they aren't allergic to Morphine but turns out they are? I can't really say what sorts of reaction you may have via IM with only 2, but I'd rather not find out (since everyone is different). I feel comfortable knowing I could counteract the Morphine if needed
What if they say they aren't allergic to Morphine but turns out they are? I can't really say what sorts of reaction you may have via IM with only 2, but I'd rather not find out (since everyone is different). I feel comfortable knowing I could counteract the Morphine if needed
Shishkabob
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OP
OP
Hal9000
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And seeing as how I think the purpose of this is to help with long transports/time to ALS or definitive care, I can see EMTs requesting to use a few auto-injectors of morphine...and then getting to go all the way to the hospital with their one or two Epi-Pens.
Anyway, good point.
jjesusfreak01
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I don't think there should be a problem with EMTs giving a few IM medications using syringes and auto-injectors. Just stuff like Glucagon and Epinephrine that can reverse life threatening conditions.
could I just inquire what you would be planning to counteract it with?
medic417
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Heck lets give them narcan. Then we need fent but then we need to ad it's reversal agent. Then because they might cause them to arrest we need to give them cardiac drugs and ............. So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level. Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused. But I digress 120 hours is plenty to kill I mean help someone. 
Heck lets give them narcan. Then we need fent but then we need to ad it's reversal agent. Then because they might cause them to arrest we need to give them cardiac drugs and ............. So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level. Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused. But I digress 120 hours is plenty to kill I mean help someone.
fentanyl ↔ naloxone
Applies to:fentanyl and Narcan (naloxone)
MONITOR CLOSELY: This warning does not apply to the naloxone component in oral pentazocine/naloxone tablets. Naloxone injection is an antagonist that will reverse the actions of opiates. This reversal can occur when the opiate drug is being used clinically and when it is being abused. Physically dependent patients may experience withdrawal symptoms. Abrupt postoperative opioid reversal has resulted in hypotension, ventricular tachycardia and fibrillation, pulmonary edema, cardiac arrest, encephalopathy, and death.
MANAGEMENT: Patients receiving naloxone injection should be monitored for changes in vital signs, nausea, vomiting, diarrhea, aches, fever, runny nose, sneezing, nervousness, irritability, shivering, abdominal cramps.
I agree. I think this makes sense.
But morphine or dilaudid? No way. I don't want that responsibility. I am proud to be an EMT, but just being in the A&P class for the Paramedic cert I'm learning how superficial the EMT-B really is. Paramedic is a whole different can o' worms. Until I have that level of knowledge and experience I'm content to leave the drugs to the pros. As Clint Eastwood says ...
"A man's gotta know his limitations."
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Heck lets give them narcan. Then we need fent but then we need to ad it's reversal agent. Then because they might cause them to arrest we need to give them cardiac drugs and ............. So you see if you want all the toys boys and girls go get an education to at minimum the Paramedic level. Because every drug you push is one more risk thus more drugs and procedures are needed to take care of the problems caused. But I digress 120 hours is plenty to kill I mean help someone.
We're you beat by an angry mob of EMTs at some point in your life? Your hostility is getting a little ridiculous, you seem to hold the EMT personally responsible for the lack of education that is included in the curriculum.
We're all well aware of your opinions on the education level of the EMT, must you regurgitate at every oppurtunity?
You were once an informative poster but you've grown quite tiresome.
By the way some EMTs have been carrying nasal narcan for years.
reaper
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They should carry one drug, Oxygen!
They are so worried about helping their Pts, then get an education. Plain and simple.
They are so worried about helping their Pts, then get an education. Plain and simple.
JPINFV
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Is it fair to blame them for the lack of education, especially foundational education, required to become an EMT? No.
Is it fair to blame them for not understanding the limits of the limited education required for EMTs? Yes.
Is this a thread where, at this point, people are advocating allowing EMTs to administer opioid based on a limited foundational education? Yes.
The question isn't whether some EMTs are administering naloxone IN. The question is both 'from an education standpoint, should they?' and 'why wasn't the system able to provide enough paramedics so that the situation exists where it was needed.'
As far as I know every EMS system has a medical control MD who has the ability to set treatment protocols as he see's fit, correct?
Those would be questions best answered by them.
And no I dont believe in expanded scope at the EMT level.
the practical perspective:
How could EMT-Bs with morphine or other opioid analgesics play out?
Well on the positive side, it would bring faster reduction/elimination of pain in areas that had prolonged response from ALS.
Let us not forget that until the 1900s laudanum was available OTC. More modern formulation available by perscription is still PO self admnistered. Opiod analgesics have been used for centuries, prior to the development of reversal agents.
( I will intentionally leave out any discussion on uses for other conditions so as not to get into the education of EMT-B debate again, we are all very much aware of that topic even if we don't always agree)
Patients may also have various opioid prescriptions for a variety of ailments. An EMT-B can "assist" a patient in taking their own prescribed medication. Practically speaking what is the difference between an EMT-B assisting somebody with putting on the fent patch and administering an opioid by another route approved by their medical direction?
Let us consider for a second some down sides though. (purposefully leaving out the 1980s theory that it might mask a dx and leaving a pt in pain is somehow beneficial)
What happens if respiratory drive is depressed? an EMT-B can certainly manage an airway with simple adjuncts and ventilate. However, what about a potential drop in BP? reactions to other medications including synergies of which they do not have a strong background in? What if a patients physician purposefully didn't prescribe them opioids?
What if an EMT-B is permitted to start an IV and administer NS in a service?
With the ability to ventilate and increase vascular volume, almost all of the adverse effects can be at least managed during transport. Mental status should come around when the effects start declining.
Here are some of my more opinionated thoughts.
If you are going to use analgesia, then you should use it properly. As was pointed out, giving inadequete doses serves absolutely no purpose. (American medicine is also rather conservative with analgesia. I think they are taught to fear it and never get over that.) If EMS administers an opioid, the receiving facility may be reluctant to add to it despite the patients subjective pain.
An autoinjector is not a great idea. Because of the absolute dose an autoinjector delivers, it cannot be adjusted to the patient need or response. If you start with a low dose, are you planning to stab somebody 5 or 6 times to respolve their pain? How are they going to respond to that? If you start with a high dose, say 10mg, what if you have a frail elderly person? A child? Previous self opioid administration in the patient's normal med list?
Are you planning on writing a protocol excuding all these things? If so who would get the medication administered except perfectly healthy people?
Which brings me to reversal agents. As far as I am concerned reversal agents should be stricken from EMS. If a patient is ODing or hypersensitive to what you gave, then manage the symptoms and take them to the hospital.
Reversal of an OD can have consequences. agitated patient, withdrawl, etc.
Reveral of hypersensitivity can remove the ability to treat pain (think about it, you narcan a person and how does the hospital control the pain until narcan wears off?) and as endorphines can be mitigated as well you could actually increase the pain of the patient.
As for the skill, drug abusers use all forms of opioids all the time. Certainly if they can, an EMT-B can?
Just to touch on the education issue, once more, it is the knowledge a paramedic brings, not a skill, a drug, or a toy, that makes them superior to the EMT-B. The issue here isn't if EMT Bs can administer opioids, the issue are when, how, and how much?
Without proper education, the EMT B cannot make those decisions with any accuracy. A few hours training on a drug is not going to be enough to make up for the background of diverse knowledge the EMT B is undisputadly lacking.
However, it is only fair to point out, in very rural or austere environments, an EMT B administering a medication without any background would be no more harmful than doing nothing at all.
I think it is a bit premature to give this idea the thumbs up or down without having at least some idea of the likely circumstances EMTs in a specific system would be likely to administer the medication.
How could EMT-Bs with morphine or other opioid analgesics play out?
Well on the positive side, it would bring faster reduction/elimination of pain in areas that had prolonged response from ALS.
Let us not forget that until the 1900s laudanum was available OTC. More modern formulation available by perscription is still PO self admnistered. Opiod analgesics have been used for centuries, prior to the development of reversal agents.
( I will intentionally leave out any discussion on uses for other conditions so as not to get into the education of EMT-B debate again, we are all very much aware of that topic even if we don't always agree)
Patients may also have various opioid prescriptions for a variety of ailments. An EMT-B can "assist" a patient in taking their own prescribed medication. Practically speaking what is the difference between an EMT-B assisting somebody with putting on the fent patch and administering an opioid by another route approved by their medical direction?
Let us consider for a second some down sides though. (purposefully leaving out the 1980s theory that it might mask a dx and leaving a pt in pain is somehow beneficial)
What happens if respiratory drive is depressed? an EMT-B can certainly manage an airway with simple adjuncts and ventilate. However, what about a potential drop in BP? reactions to other medications including synergies of which they do not have a strong background in? What if a patients physician purposefully didn't prescribe them opioids?
What if an EMT-B is permitted to start an IV and administer NS in a service?
With the ability to ventilate and increase vascular volume, almost all of the adverse effects can be at least managed during transport. Mental status should come around when the effects start declining.
Here are some of my more opinionated thoughts.
If you are going to use analgesia, then you should use it properly. As was pointed out, giving inadequete doses serves absolutely no purpose. (American medicine is also rather conservative with analgesia. I think they are taught to fear it and never get over that.) If EMS administers an opioid, the receiving facility may be reluctant to add to it despite the patients subjective pain.
An autoinjector is not a great idea. Because of the absolute dose an autoinjector delivers, it cannot be adjusted to the patient need or response. If you start with a low dose, are you planning to stab somebody 5 or 6 times to respolve their pain? How are they going to respond to that? If you start with a high dose, say 10mg, what if you have a frail elderly person? A child? Previous self opioid administration in the patient's normal med list?
Are you planning on writing a protocol excuding all these things? If so who would get the medication administered except perfectly healthy people?
Which brings me to reversal agents. As far as I am concerned reversal agents should be stricken from EMS. If a patient is ODing or hypersensitive to what you gave, then manage the symptoms and take them to the hospital.
Reversal of an OD can have consequences. agitated patient, withdrawl, etc.
Reveral of hypersensitivity can remove the ability to treat pain (think about it, you narcan a person and how does the hospital control the pain until narcan wears off?) and as endorphines can be mitigated as well you could actually increase the pain of the patient.
As for the skill, drug abusers use all forms of opioids all the time. Certainly if they can, an EMT-B can?
Just to touch on the education issue, once more, it is the knowledge a paramedic brings, not a skill, a drug, or a toy, that makes them superior to the EMT-B. The issue here isn't if EMT Bs can administer opioids, the issue are when, how, and how much?
Without proper education, the EMT B cannot make those decisions with any accuracy. A few hours training on a drug is not going to be enough to make up for the background of diverse knowledge the EMT B is undisputadly lacking.
However, it is only fair to point out, in very rural or austere environments, an EMT B administering a medication without any background would be no more harmful than doing nothing at all.
I think it is a bit premature to give this idea the thumbs up or down without having at least some idea of the likely circumstances EMTs in a specific system would be likely to administer the medication.
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LonghornMedic
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Then be a EMT-Intermediate. I know in some systems EMT-B's can't even use a glucometer. But if you want to give meds, IM is the least preferred method. Go to school and be an Intermediate or Paramedic where you can start IV's and give meds.
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Hal9000
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Some great points, and thanks, Veneficus, for giving such a detailed answer—you and JPINFV will be the ones who can make these decisions, anyhow.
In some situations, I can see it being used wisely. Given that medical directors have to authorize the trainings to allow the autoinjectors, and then someone has to be on line to give the OK, it's probably not going to cause sweeping deaths across rural areas.
On the other hand, there are a lot of naive EMT-Bs in the rural areas that believe they know a great deal—I've seen this first hand—which could lead to problems. That's an issue of personnel. I know some places where the EMTs will not ask for orders to use the morphine, and the medical directors exist in name only, but a bad system is a bad system, and that will have to work out in the wash.
Some small BLS groups could easily attract the local methheads (small towns can be big for huge meth operations) or other cretins if they're not vigilant. Many EMTs will develop puffed chests over the ability, and the knowledge will spread quickly that narcs are onboard.
As far as pain management, many of the calls areas where I volunteer (paid service is a large city, and the calls vary quite a good deal, obviously) are miles from ALS, at least 30-60 minutes for HEMS. However, due to the nature of the topography and roads, MVCs have a proclivity for producing some nasty results, with pain management often an hour away. The closest Trauma II is 80 miles, and for some services, it's almost 160, with the closest hospital a 60-80 miles.
Still, some areas have advanced providers acting as EMT-Bs (CRNAs, RNs, etc., though I have witnessed many quit over having to "deal" with the adrenaline-junky, uneducated lot that gravitates toward lights and sirens), mostly due to time and budget constraints preventing services from going past BLS. One CRNA I know has his doctorate and has performed anesthesia for many years, so giving him an autoinjector is fine, as he has the education to back its use.
The issue then is rather complicated, and it's hard to make sweeping generalizations with any accuracy, which is a perturbing characteristic inherent to them.
With that said, this thread has been enlightening to me. Perhaps the morphine is OK, given the nature of MT (still under one million people in the whole state, and it's large), but is it the best of choices? Is fentanyl IN better? How about nitrous? Will stabbing a patient five times be OK? Will patients report better pain outcomes, or will mortality rates stupidly change?
I don't know. I'd like to see systems improve their educational levels, but I doubt that will happen. It would be nice if current providers, such as RNs, volunteered more often, even at the -B level, in the rural areas in which they reside. However, it often seems to me that rural EMTs are like politicians—the best one will be the one that doesn't want to be involved. (That adrenaline fixation I've mentioned.)
Anyway, the state made it a state protocol, so it will be up the the providers and medical directors to utilize it well. We'll see the result.
EMS in America has many concerning areas, at least to me, but it's a low-level job (again, at least to me, and given the current requirements) that I've passed educationally for another career. While I'm involved, I'll still do what I can to advocate for and improve safety (including attempted culls of those with phenomenally poor judgment), so this topic will remain of interest to me.
In some situations, I can see it being used wisely. Given that medical directors have to authorize the trainings to allow the autoinjectors, and then someone has to be on line to give the OK, it's probably not going to cause sweeping deaths across rural areas.
On the other hand, there are a lot of naive EMT-Bs in the rural areas that believe they know a great deal—I've seen this first hand—which could lead to problems. That's an issue of personnel. I know some places where the EMTs will not ask for orders to use the morphine, and the medical directors exist in name only, but a bad system is a bad system, and that will have to work out in the wash.
Some small BLS groups could easily attract the local methheads (small towns can be big for huge meth operations) or other cretins if they're not vigilant. Many EMTs will develop puffed chests over the ability, and the knowledge will spread quickly that narcs are onboard.
As far as pain management, many of the calls areas where I volunteer (paid service is a large city, and the calls vary quite a good deal, obviously) are miles from ALS, at least 30-60 minutes for HEMS. However, due to the nature of the topography and roads, MVCs have a proclivity for producing some nasty results, with pain management often an hour away. The closest Trauma II is 80 miles, and for some services, it's almost 160, with the closest hospital a 60-80 miles.
Still, some areas have advanced providers acting as EMT-Bs (CRNAs, RNs, etc., though I have witnessed many quit over having to "deal" with the adrenaline-junky, uneducated lot that gravitates toward lights and sirens), mostly due to time and budget constraints preventing services from going past BLS. One CRNA I know has his doctorate and has performed anesthesia for many years, so giving him an autoinjector is fine, as he has the education to back its use.
The issue then is rather complicated, and it's hard to make sweeping generalizations with any accuracy, which is a perturbing characteristic inherent to them.
With that said, this thread has been enlightening to me. Perhaps the morphine is OK, given the nature of MT (still under one million people in the whole state, and it's large), but is it the best of choices? Is fentanyl IN better? How about nitrous? Will stabbing a patient five times be OK? Will patients report better pain outcomes, or will mortality rates stupidly change?
I don't know. I'd like to see systems improve their educational levels, but I doubt that will happen. It would be nice if current providers, such as RNs, volunteered more often, even at the -B level, in the rural areas in which they reside. However, it often seems to me that rural EMTs are like politicians—the best one will be the one that doesn't want to be involved. (That adrenaline fixation I've mentioned.)
Anyway, the state made it a state protocol, so it will be up the the providers and medical directors to utilize it well. We'll see the result.
EMS in America has many concerning areas, at least to me, but it's a low-level job (again, at least to me, and given the current requirements) that I've passed educationally for another career. While I'm involved, I'll still do what I can to advocate for and improve safety (including attempted culls of those with phenomenally poor judgment), so this topic will remain of interest to me.
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Hal9000
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This reminds me of my previous post, where I mentioned the CRNA. It's sad, but I've seen such professionals not volunteer because they didn't want the hassle of "wasting" 120 hours of their lives listening to an uneducated EMT-B lecture them as a "lead instructor." I understand that the upcoming changes will alleviate this problem to a degree, at least from the NASEMSO literature and webcasts to which I've read and listened.
LonghornMedic
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I guess I read some of these "EMT-B's should be able to do more" posts and think to myself- GO TO SCHOOL! EMT-Basics are just that...BASICS. I think it's admirable that people explore the whys and whens of BLS. Personally, I think EMT-Basics should be phased out and replaced by Intermediates. EMT-B is nothing more than glorified First Aid. All it teaches you to do is a proper assessment. Intermediate school isn't very hard and only requires another few months of part time classroom. But the end result is that ILS in place of BLS results in far superior treatment skills and patient outcomes. In more rural areas, ILS is going to save more lives than BLS ever could. And for those Intermediates who want to push the boundaries and desire Paramedic skills- GO TO SCHOOL!
When a practitioner starts blurring the lines of their respective skill sets and education, then go get the required education and to move to the next level.