Bringing Skills to BLS

[Guest alsfirefighter]

I carry/use the king airway in the tactical environment being its is easier and faster to use then the combitube. I do not feel it is the answer to replace ETI and nor will anything ever justify that to me. If your providers suck at intubation..that means your QA/QI sucks, your training program sucks and your managers suck. Identify the problem, identify those having the problem and correct it...and not by hoping they'll figure it out on the street. 1 screw up, ruins 99 atta boys and 1 shitty medic ruins it for the other 99 of us.

[chovesh 1]

Now, if an RN can do that, I don't think we can even expect an EMT with a 120 hour course not to make the same mistake. It doesn't speak to the EMT's abilitiy; it speaks to the level of training.

By that logic why should a paramedic be able to push drugs? Just because someone is "trained" that doesn't mean they know the material or are proficient. We've all met plenty of incompetent EMTs, Medics, RNs, and MDs. That doesn't mean because some people don't know what they are doing we should never allow anyone to do anything. If the protocols say make sure the patient has no cardiac history before giving albuterol it is fair to assume EMTs are doing so.

This goes not just for Albuterol but for all skills: when we talk about writing protocols we have to assume the providers follow the protocol. Just because there is a minority of people who can't remember a simple protocol that doesn't mean we should make the public suffer. If a provider gives an improper treatment because they didn't do a proper assessment that is not a flaw in the protocol that is a problem with the provider and in that case the provider needs to be disciplined.

[vtach39680 23]

I'm with those who advocate less is more. Even the AEMT written... and practical..... is half BLS. EMT-B and AEMT ought to focus on assessment and history. Many 'emergencies' can be adequately addressed in the field with oxygen and patient positioning.

I had the pleasure of working with a Yorktown BLS crew recently. By the time I got on scene from out of district, the patient was packaged, in the ambulance, a full history had been taken and the 'not well' patient had been evaluated for stroke, ruled out, and the EMT was anxious for me to test blood glucose as he had narrowed his impression to low blood sugar, which it was. Solid, professional basic skills can add as much to level and timeliness of care as ALS.

BLS and ALS alike need to respect the importance of solid basic skills. Good basic care is a craft which we all know when we see and work with it. I'd like EMT-B's to focus on /add pride, thoroughness and confidence.

I am glad that you had a good experience with a BLS crew but the true question is why was he still medic dependent, his clinical evaluation may have been correct but why did he not follow through with a small amount of oral glucose to see if patient status improves. he had the knowledge he had the tools but he only went half way in the treatment of his patient. what if no ALS was avail? do you think then he would have given glucose?

I am not knocking the BLS crew. the person had gone through a class and and had done ride along with strong people. why add more stuff when EMT are afraid to treat pt with the things they already carry

[Guest alsfirefighter]

This goes not just for Albuterol but for all skills: when we talk about writing protocols we have to assume the providers follow the protocol. Just because there is a minority of people who can't remember a simple protocol that doesn't mean we should make the public suffer. If a provider gives an improper treatment because they didn't do a proper assessment that is not a flaw in the protocol that is a problem with the provider and in that case the provider needs to be disciplined.

I also don't believe in management by restriction which is why I agree with your comment about not causing anyone to "suffer" because of a few that don't get it. I'm not so sure the public in my area would suffer if BLS didn't have Albuterol, but it is a good option to have if needed, just like the epi pen, etc.

The only thing I disagree with is that we shouldn't be "assuming" that providers are following protocols for use, etc. We qualify that information through the QA/QI process so there is no assumption of whether they are following it.

[ny10570 745]

Here we are in an era where hospitals are going paperless and networking, computers are making their way into the field, and patients are even carrying their entire medical profile on their key chain but here we are still writing out carbon copy PCR's. We need to get into scannable documentation or even better laptop based documentation. Want to know how many of your pt's diagnosed w/chest pain get aspirin, push a few buttons and you can find out down to the provider. The technology is out there. Its been proven to be effective in all fields and is even heading to the battlefield in the next couple of years.

[OoO 24]

Here we are in an era where hospitals are going paperless and networking, computers are making their way into the field, and patients are even carrying their entire medical profile on their key chain but here we are still writing out carbon copy PCR's. We need to get into scannable documentation or even better laptop based documentation. Want to know how many of your pt's diagnosed w/chest pain get aspirin, push a few buttons and you can find out down to the provider. The technology is out there. Its been proven to be effective in all fields and is even heading to the battlefield in the next couple of years.

I believe that agencies can implement their own electronic PCRs. I don't know exactly how that works out but Empress does it in Yonkers. I have also seen that Transcare has their own custom paper PRC.

[Skooter92 7]

First off, I agree that we need to increase the abilities of BLS providers in this area before handing out any more skills or toys. The anecdote concerning the basic who put a pulse ox on someone instead of actually assessing them rings a bell, and as a matter of fact I am also opposed to BLS units carrying pulse oximeters, glucometers, or AEDs with waveform displays. Too much info without enough decision-making training. Firefighters/cops typically ride as probies for quite some time before being let loose, and during that ride time they are with FTOs. Some area agencies say they have FTOs, but when you need the meat on the street, services push people out the door. Scary scary.

As to the myth that albuterol is BAD in CHF, 1) It ain't true; 2) it REALLY ain't true, and 3) read this link: Putting The Myth To Bed. It will shed a little light on an ems legend I've been debunking for years.. And if you don't like the scientific research, and prefer anecdotal evidence, I have yet to put a CHF'er in flash or any other kind of pulmonary edema by co-administering albuterol with nitrates, lasix, morphine or even oxygen. In 17 years or so, that ain't bad.

Edited November 10, 2008 by Skooter92

[ny10570 745]

Agencies absolutely can do it on their own since the state won't move on this till they're forced to. All you have to do is use either an established form or get your own form approved by I believe your local region.

Skooter, thank you so much for posting that link. I've been trying to fight that one off but didn't have the research.

[Guest]

As an EMT-B, I would have liked to have scene more attention paid to pharmacology. There are to many times you are given names or come in possession of a pt's prescription, and they cant tell you what you are taking it for. ( We have the medics and they are informed, but times when they cant respond) I undersdtand there are a million names but possibly something to identify important ones. Because in class I remember being taught about asthma meds, and diabetic names but that was pretty much it.

I agree that you can quickly gain alot of information form knowing about a patients meds. My suggestion for everyone at all levels is to get a pocket guide that has Generic names, Brand names, and what it is often prescribed for. I am a paramedic and I used mine all the time.

[STAT213 332]

I would like to see the EMT class be longer, but with more focus on assessment skills and A and P. It is the knowledge of the disease processess and the ability to apply the information to each patient that makes the difference in the provider. More classroom time cannot hurt.

As far as skills go, I'd love to see CPAP, 12 Lead ECGs with fax capability. These are things off the top of my head, but they are things that make a difference. They also require a greater understanding of pathology, so you have to expand the class. But, I think that's a good thing!!

EMTs up here are way too medic dependent. It is refreshing to come across the ones who know how to do an assessment, and what to do with the information once they have it.

[Turborich 12]

Just some things to keep in mind..

In NYS curriculum and NREMT the EMT-B, I, CC, and EMT-P assessments vary only slightly. The EMT-P may intervene with advanced skills however interview, transport determination, ABCs, SAMPLE, OPQRST, etc.. are all the same.

IMHO, the individual provider at any level must master the art of a proper interview and assessment above all else. This is the framework that defines the best practitioner(s) in the field today when practiced alongside outstanding patient rapport. These are the skills that will definitavely provide the patient with the best care possible aside from all of the fancy auto injectors and B.S. electronic PCR pads.

It is the almost unanimous thought that the EMT-Basic Curriculum is lacking in many aspects and should be more "holistic". I believe that the EMT-B curriculum in NYS provides just enough for the individual to develop a framework to become an informed prehospital provider. It takes years in the field to become a true "practicioner" of prehospital medicine and this is a thing that all 57,398 providers in NYS at least strive for I would hope. Unfortunately time constraints, second and third jobs to make ends meet, and demanding recertification processes almost make a longer class for those interested parties unrealistic. Think of those Vacs up in St. Lawrence County for example... how many new certs.would you get if the class was say 450 hours.. how many new Paramedics would Alamo get if the class was a 4 year program and paid the same as today.. would we still be satisfied being called a McJob after 4 years of schooling?

As far as advanced skills are concerned I believe it is an asset to our patients that basics may administer select medications such as Albuterol, assist with NTG, ASA, etc.. however it is the duty of the provider's agency and medical director to affirm the competancy in every advanced skill outside of the normal scope of practice. It is the duty of providers to live by that certain thing that we live by day to day in the field and we learn the first day of EMT-B class.. the phrase that is erroneously thought to be contained in the Hippocratic Oath; "Primum non nocere" or "First, do no harm". It is the duty of our regional EMS councils and SEMAC to determine which expanded practices may be implemented which are in laymen's terms "foolproof" keeping in mind that same premise. This is why, while also looking at national and statewide statistics, EMT-Bs do not intubate. Combine with the overwhelming statistics the overall costs of outfitting squads with the additional nessicary equipment to do so and you have successfully ran most volunteer and even some paid services out the door. With the recent (unfunded) regional mandate for continuous capnography you are seeing agencies in spin mode. Believe it or not there are agencies out there wondering how they are going to equip their personnel with ANSI compliant vests due to the economic status of our municipalities locally... let alone the 10 other unfunded mandates by National/ State/ Regional entities this year alone.

It is without a doubt that 12 lead EKG and transmission, endotracheal intubation and advanced airway devices, adult I/O, and prehospital delivery of select medications are a great benefit to those in need of immediate intervention and are proven to work, however the opportunity and economy costs of such investments do not facilitate changing regional or statewide protocols to allow basics to provide such services secondary to those costs, and quality assurance/ improvement issues.

Not to start a flame war with the previous statements, but to put it into perspective with a true example- why do you think most services rely on Albuterol as their primary bronchodialator and not Levalbuterol (Xoponex)? It's not because Albuterol is the better or more efficient drug... it's because it's cheaper! Levalbuterol is a bronchodialator just like Albuterol with the exception of that it effects only the receptors in the lungs (beta 2) as opposed to both the heart and the lungs like its cheaper counterpart. The issue is that most agencies can't stomach the $60.00 per box of 24 and the local EMS regulatory agencies realize that. Thus we deal with a drug that basic level providers can administer, however they now have to worry about a list of contraindications which you must contact medical control about even before administration instead of one that produces far less untoward effect. Is that worth the $52.71 you are saving buying a box of 25 Albuterol? You do the math... is a transmit capable LP12, recieving staion at the hospital, end tidal CO2, continuous waveform capnography, intubation kit, secondary "blind device" (ie. King, EOA, EGTA, Combitube, LMA), CPAP, and nessicary communitcation devices feasible for your "expanded practice" BLS VAC or grassroots BLS commercial service? If so I envy you and do not envy your taxpayers.

For the record I am a HUGE proponent to expanded service however I know that dollars and cents will dishearten me as it has over the past 10 years I have been involved in Emergency Services. I think that CPAP foremost, should be a BLS skill. However knowing the overhead with such equipment I know that this would be a shot in the dark at best if made apparent at a REMAC meeting secondary to compliance and QA/QI.

The sad truth is that ALS providers are far more likely to face the eradication of field intubation before BLS providers will see it as an alternative in their protocols of taught in their curriculum. As much as we have seen it work in the field nationally the decision makers see it as a shortfall. The best thing that present day practitioners can do is keep up on your CME, stay informed, and above all practice good medicine in the form of thorough assessment and early informed determination of treatment modality. Remember that just because it sounds like a "cool" idea and you might be capable of it the other 36,943 EMT-Bs in NYS might not be able to.. and the same goes to Is, CCs, and Medics as well. If you think that something could be better or work more efficiently tell your agency head/ medical director/ region and maybe you can make a difference.

Be safe out there,

Rich

[chovesh 1]

Masterfully said. Sounds like you're writing from experience. It is unfortunate that we have to walk a tight rope between patient care and financial care. It is for this reason I don't like to know the prices of anything we carry, I don't want to have a price tag in the back of my mind every time I open a kling bandage, O2 Tank, or start a line. To my mind if the patient needs it they should get it; let someone else worry about the billing.

There are certain techniques that are currently available with equipment almost all of us carry in our BLS bags today. For example: I read this month's FDNY EMS CME article about asthma. They recommend that their medics give Epinephrine 0.3mg (0.3mL 1:1000) IM (for adults) when albuterol is not working as effectively as one would hope. After looking at 300 patients who did not improve with albuterol they found 76% improved with Epi (3 patients deteriorated because they where using cocaine). So I thought: why can't an EMT (with permission of OLMC) use the EpiPen in their BLS bag to help this patient who is not responding to albuterol? [Aside from the readers of this forum who believe that EMTs are stupid. :lol: ]

[ny10570 745]

You should know the cost of what you're using. When you're talking about a $100 IO needle or $60 medication those costs matter. If the pt needs it they get it, but too often people will use something just to use it and these costs add up.

The vast majority of Asthma pts don't need EPI. While the ones that do usually improve dramatically most are able to maintain long enough to either get to the hospital or await ALS. For me this goes back to BLS needs more emphasis on assessment rather than new skills. Epi when given to the right patient is safe enough where you shouldn't have to go through telemetry to administer it. However with the current training EMT's receive I wouldn't have confidence it wouldn't become a problem.

[Turborich 12]

[Aside from the readers of this forum who believe that EMTs are stupid. :lol: ]

Those whom think EMTs are stupid should look at their cards and see that before the "- Paramedic" or "Intermediate" there are the letters "EMT". Never forget your roots.

You bring up a good point about the Epinephrine and these are the ideas that individuals should take to their peers, officers, REMAC/REMSCO/SEMAC , Etc.. to discuss and furthur review. However...

.. Keep in mind Training, Cost efficiency, liability, and practicioner compliance are all things that are weighed into such decisions. Does it make sense for that or other progressive ideas/ treatments to be rolled out if it is good for the patient? OF COURSE! Do we as dedicated practicioners or John Doe as the patient give a damn about the cost? HELL NO! However to the individuals that ultimately make the determination that we should roll such things out in the field these are substantial topics that cannot be dismissed. As I have learned over the years.. what's good for one is not nessicarilly good for the other. As we strive to take a holistic approach to the patient we must now keep in mind that same holistic approach to the EMS system in general regarding such decisions.

[Masterfully said. Sounds like you're writing from experience. ]

What the hell do I know.. I'm just an EMT like everyone else on this forum...

Rich

[ckroll 101]

Masterfully said. Sounds like you're writing from experience. It is unfortunate that we have to walk a tight rope between patient care and financial care. It is for this reason I don't like to know the prices of anything we carry, I don't want to have a price tag in the back of my mind every time I open a kling bandage, O2 Tank, or start a line. To my mind if the patient needs it they should get it; let someone else worry about the billing.

There are certain techniques that are currently available with equipment almost all of us carry in our BLS bags today. For example: I read this month's FDNY EMS CME article about asthma. They recommend that their medics give Epinephrine 0.3mg (0.3mL 1:1000) IM (for adults) when albuterol is not working as effectively as one would hope. After looking at 300 patients who did not improve with albuterol they found 76% improved with Epi (3 patients deteriorated because they where using cocaine). So I thought: why can't an EMT (with permission of OLMC) use the EpiPen in their BLS bag to help this patient who is not responding to albuterol? [Aside from the readers of this forum who believe that EMTs are stupid. :lol: ]

There is a huge difference between stupidity and experience and education. A brilliant EMTB may still not have the experience or education to make a wise decision. That said, you said with permission of OLMC and that is key. If an EMTB is faced with a life threatening situation and other intervention will not be timely, [that full blown asthma attack in the middle of a blizzard], then call OLMC, get permission. The EMTB should expect they will get called to defend their decision and may take some grief for it, but a life saved is a life saved.... or you decide it wasn't asthma after all but an allergic reaction..... a smart EMTB should be able to work the sytem.

[firecoins 2]

the emt class should have a full semester class on the human body, a second full semester class on doing an assessment, a third class that deals with documentation, legal issues, crime scenes and protocols. There should be alot more clinical time oin the emergency room and on both 911 and transport ambulances.

[crcocr1 8]

I do agree that the EMT curriculum should revert to its prior focus on physiology, assessment, and treatment. When I started off (which wasn't very long ago), I brought a copy of the protocols with me in a bag on every call. I also relied on my father for advice. (He was a volunteer from 1978 until 1993 and 2002 until 2005). Before and after each call, I reviewed the appropriate protocol and asked: Why? Soon, I began to understand each protocol, the purpose of ALS, and the indications and contraindications for certain treatment. I do not know each protocol by heart but strive to do so. I now wish to advance my skills but seem to have reached a glass ceiling as my service area is either BLS or ALS. There is no ILS.

Regretfully, the problem with bringing more skills to BLS rests on a diverse population in this state, where many EMTs do not view themselves as professionals and hide behind statutory immunity. Until all EMTs, from Buffalo to Albany and Plattsburgh to NYC, view themselves as professionals, master the existing curriculum, and, due to the State's inadequacy, teach ourselves the physiology, assessment, and treatment, we are unlikely to convince Albany to add IV therapy and Combitubes to the curriculum.

We must remember that SEMAC is filled with physicians who have mixed feelings about EMTS from certain agencies while trust others. We need physicians to trust us all to convince them to add skills and equipment to our kit bags.

Firecoins, I think we need to teach paramedics AND EMTs more about legal issues and documentation. Reviewing PCRs in my regular employment as a legal professional (taking the oath of admission as an attorney in January or February), I don't think paramedics or EMTs even have adequate education on legal issues facing EMS. I see many PCRs poorly documented, leaving them open to litigation, especially in hard economic times when many citizens will be looking to make a quick buck. I further see paramedics and EMTs mentioning HIPAA when they mean confidentiality in the general sense and failing to mention EMTALA when they are being turned away from hospitals on diversion with critical patients. The lack of education in legal issues and documentation, therefore, is across the board. (I agree with you in part about the physiology and assessment skills and think that clinical time needs to be reorganized to be more effective.)