BLS Skills -- What Should We Add?

[EpiEMS]

What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?

As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.

I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):

- Glucometry
- 3- and 12-lead placement and transmission
- Blind insertion airway devices
- SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
- Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
- Rectal diazepam (carried on ambulance -- not just prescribed)
- MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
- IN naloxone

Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.

 

[bahnrokt]

- Glucometry
- SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
- IN naloxone

We already do these with few issues as a BLS squad in NYS. Just started the pilot program for narcan last month.

I would love to see BLS squads trained to use a monitor. Aside from monitors with a manual shock mode, it is a non invasive tool that is hard to do damage with.

IM morphine would be usefull but it would be abused, so I don't see that catching on. It would be nice to have something to give legit trauma pts for pain. But seekers would ruin in.

 

[truetiger]

EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.

 

[firetender]

You mean for the actual job?

What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.

 

[EpiEMS]

Just started the pilot program for narcan last month.

IM morphine would be usefull but it would be abused, so I don't see that catching on. It would be nice to have something to give legit trauma pts for pain. But seekers would ruin in.

How's the Narcan worked out so far?

I like the idea of additional pain control -- maybe IN Fentanyl, or ActiQ (Fentanyl lollipops), or, heck, nitrous?

What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.

Completely agree. Completely. More geriatric medicine education, more pharmacology, and more psych (inclusive of drug abuse, suicide, and behavioral crises) should be included in the curriculum. Social services should be covered by agencies, surely.

Then again, with some of the drug abuse patients and attempted suicides, I'd really like access to IN Narcan.

I'd like to know more about local social services and local non-ER facilities to help triage patients who want to refuse (or have been assessed and have no medical need to go to the ED, but should be seen within 24-48 hours or so).

EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.

I understand your perspective. EMTs, as it stands today, do give drugs. SQ Epinephrine (I carry it on the ambulance), oral glucose (even though it's OTC), activated charcoal, etc. You know this better than I do, surely. I use the monitor –:censored:I place leads, I use the NIBP, pulse oximetry, and capnography. Of course, I'm not *technically* allowed to -- but the paramedics damn well expect it (so let's put it in the protocols, please).

I've no problem with additional education. However, I think that considering my baseline level of education, I am more than capable of learning these additional skills. I don't want to -- nor would it really be helpful for me to -- start IVs. I don't usually have a need to do so -- I've selected the skills above (and CPAP, too) because those are the evidence-based, non-invasive skills that I see used most often by EMT-Ps (who so often tell me that I ought to be doing them as an EMT).

 

[DrankTheKoolaid]

While I agree with BLS providers having more options, I dont think it should be a blanket for all. That is exactly why there is such thing expanded scope.

If you truely want to expand your scope get involved with your LEMSA MAC meetings and provide input. Be warned that if you do you had better of done your homework and be able to show a documented need for it.

Ill tackle them 1 by one to get you started

CPAP, no for BLS providers and I say this because at some point a patient will be put on CPAP in the field by a non transport EMT FR only to find an extended ETA on the ambulance and run out of O2.... Then what do they do.

Narcan......... Hell its hard enough to train ALS personel when it should and should not be given. BLS can just bag them until ALS arrives. Because im sure you know its not given simply because someone is altered. It is for respiratory depression only..

Supraglottic airways........... Emerging science is showing they may not be all they were cracked up to have been in the wrong hands. Will withold on that one.

Epi pens........ Sure

Glucometer for what. Pale Cool and Clammy needs candy dont need a glucometer for that, and if they are hot and dry give it to them anyways to rule out hypo and it wont hurt them.

Rectal Valium. No. Do you realllllllly have that many pedi seizures and als out of position to justify narcotics in the hands of the unlicensed.

MDI only when they are skilled enough to be able to rule out other reasons for wheezing such as cardiac asthma and pulmonary edema.

3 lead placement - why would you bother with no Paramedic at scene to intepret what is going on.

12 Lead placement and transmission I could get behind though.

 

[DrankTheKoolaid]

Asa and NTG i can get behind once documented training and testing on indications contraindications etc etc. That would included performing a C/P exam to include being able to rule out cardiac and identify non cardiac causes

 

[the_negro_puppy]

EMT's that gives drugs and uses a monitor? Oh wait- thats a paramedic. If you want more responsibility you need to continue your education.

Granted I don't have first hand experience with US EMS but I think that your Basic level can't really do a whole lot without calling for a medic.

What if they increased the education level for x number of hours and added-


Glucometer- Speeds up diagnosis, sure its easy to know if its hypo-hyper by presentation but when you call for ALS intercept the medic will already know what the BSL/BGL is and can start treatment straight away. Diabetics do this to themselves every day lol. Basic goes to call 60 y.o F confused. hx reveals IDDM BSL reveals low BGL. Pt able to have oral glucose, ALS intercept and transport not required.

Cardiac monitor with 3 lead- + interpretation of basic arrhythmias. Again pretty basic and will speed up diagnosis and treatment.

300mcg Epi Pens for Anaphylaxis + asthma

Nebulised albuterol- for sure. You guys already use oxygen, and patients give themselves ventolin every day. Put two and two together and you have effective treatment. Extra training obviously given as part of education.

Narcan- maybe. I guess it depends if you have large scale opioid abuse in your area. I've never used Narcan in 2.5 years on an Ambulance. Been to 1 narc overdose that came up swinging after 1 min of ventilation.

These really are basic interventions that every day civilians perform on themselves with little training or education. Would also free up ALS units with Basics doing and treating more things

 

[Handsome Robb]

I'm not a huge fan of EMTs getting more skills unless we increase education as well. That doesn't mean in-services... "This is your new toy, this is how it works, alright sweet go have fun." That's not going to cut it.

NTG...not a fan, I want to see the 12-lead before any NTG is given, I know it's not always possible especially if the patient has their own, that's just my opinion. My coworker called a STEMI the other day and after NTG x 3 there was no elevation and the ER doc cancelled the STEMI only to have to reactivate the cath lab later. I know, n=1.

Epi pens I can agree with, I don't agree with letting them do the math and draw it themselves. There are plenty of EMTs out there that are more than capable of doing so but there are plenty that can/will mess it up and could end up in a very bad situation because of it.

Monitor, no. You can't interpret it, why do you need it? Transmitting 12-leads I can see if you are in an area without good ALS coverage other than that I don't see the point. There is no reason you can't place the leads for an ALS provider but you can't interpret the rhythm so unless you are in the presence of a paramedic who is attending the patient there is no point.

Supraglottic airways I will agree with but like Corky said, there's evidence that they aren't as great as originally thought.

Rectal Diazepam, nope sorry. Wont agree with that.

Narcan - maybe provided there is proper education about it's use so we don't end up having BLS providers slam 2 mgs and making things more difficult for providers and that patient throughout the rest of their care while the narcan is metabolized.

Pain management - there's a pretty extensive thread around here somewhere about it at the ILS level. Maybe nitronox for isolated extremity injuries but like it was stated in the other thread, there is no current manufacturer of a system that will work in the EMS environment. From what I hear one may be popping up soon but until then it just isn't practical. I'm a huge fan of nitrous, our special events crews have it and our ALS ski patrollers do as well and it has always worked when we were taking a patient from one of them and they were using it.

Glucometry - sure why not. Our BLS special events crews can do it already.

Inhaled beta agonists - I'm on the fence about this one. For the same reasons stated by Corky.

When it comes down to it if you want to have more tools available to you go to medic school and further your education.

 

[Veneficus]

What the EMT REALLY needs is an education on social services, a complete knowledge of his/her area's facilities OTHER THAN ERs, a HUGE education in pharmacology, crisis intervention, self-defense, elder-care issues, drug abuse, suicide and all those other little things that they are -- as a rule -- are not prepared to handle but spend most of their time doing.

this, without caviat or condition.

 

[DrParasite]

Glucometer for what. Pale Cool and Clammy needs candy dont need a glucometer for that, and if they are hot and dry give it to them anyways to rule out hypo and it wont hurt them.

because if they are showing all the signs of a CVA (left sided weakness, altered mental status, etc), they are either having a stroke or a diabetic emergency. Let me check the BGL, if it's low, we can wait for ALS to arrive, shoot them full of sugar, and they can RMA once all the symptoms subside. If the BGL is normal, than I have a high index of suspicion that the patient is having a stroke, than I can (and have) cancelled the ALS due to their ETA, had the patient loaded up in the ambulance and be enroute to the stroke center (not that ALS is going to do much for a CVA in the field anyway). And depending on where I am, I can activate the stroke/brain attack team on my own.

ditto for an unresponsive, esp with a diabetic history. sugar drops, raise it up, and they are good to go (after they become AOx3 and eat a sandwich). normal BGL, something else is going on, load and go to the ER.

I would also like to see intranasal narcan on the BLS truck. minimal contraindications when used on a non-opiade overdose, and can restore the breathing drive of a heroin OD. always good when your 300 lb accidental narcotic OD gets woken up, and can walk down 3 flights of stairs, instead of having to carry him and bag him on the way to the cot.

Maybe nitrous for pain management, or some other pain management drug that isn't invasive. too much or certain paint meds can go wrong if you give too much, and i don't think EMTs are educated enough for give stronger stuff.

The biggest thing EMTs need as BLS skills is the ability to recognize sick/need ALS vs sick/need ER but no ALS vs not sick / needs to go to the ER because the patient needs to go. Some people don't recognize a sick patient because they never see one, and others see a sick patient, panic, and don't know what do to except wait for the ALS to arrive and hold their hand. Also EMTs need to understand the limitations of what they can do, both in their POV and in the ambulance. Sometimes there is nothing you can do to help the patient in the field, and can just take them to the ER for the ER docs to do their thing.

 

[DrankTheKoolaid]

I like your rational DrP, and that is exactly the kind of thing I was trying to get out of the OP so he would understand and bring to his MAC commitee.

Gotta say I would / will fight against narcan in BLS hands tooth and nail though. I said it before and Ill say it again. Its hard enough to teach Medics when to give it appropriately. Ive watched / QA'ed new and old medics alike give it simply because someone was altered as im sure most of you have also. Simply not a reason to give it, so what makes you think as a whole, the BLS personel are more trainable then the ALS personel?

BLS should master one of the hardest and most life saving skills in all of EMS.... BVM ventilations

Pain control, maybe someday something safe to be given that works can be identified.


OP great discussion starter I must say. I think this thread has the opportunity to help alot of others that are also interested in trying to expand their local/optional scopes and the information that will need to be presented / and questions answered upon asking for it. Remember you have to not only pitch it to your Medical Director, but the whole MAC commitee.

 

[bahnrokt]

How's the Narcan worked out so far?

No uses so far, I had one that was borderline but decided Id rather bag than wrestle. Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.

 

[Handsome Robb]

No uses so far, I had one that was borderline but decided Id rather bag than wrestle. Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.

What's your dosing?

The whole point of naloxone is to titrate it to respiratory effect, not to wake them up.

Not trying to use you as an example but the whole wrestling comment is exactly why I don't think BLS providers should have naloxone.

 

[DrankTheKoolaid]

Forgot to address this in my last post.

Never and I mean never have I had any diabetic patient present as a stroke. Ive had BGL's of 10 F(BGL) full on decorticate posturing to 1700 (number from ED Labs) with a complaint of weakness and everywhere in between. Sure they may have global weakness and slurred speech, but they have also always been pale cool and wet (low obviously). But I have never seen unilateral weakness caused by hypoglycemia. Academic theory, sure it is probably possible but that does not equate to real life argument for glucometer use. Its still an unneeded procedure in BLS hands. Give em all sugar and let the ALS/ED sort it out

And sure they both could have been strokes, but its all about a good solid patient history

 

[bahnrokt]

What's your dosing?

The whole point of naloxone is to titrate it to respiratory effect, not to wake them up.

Not trying to use you as an example but the whole wrestling comment is exactly why I don't think BLS providers should have naloxone.

.02

Aside from a 35min CME I had no experience with narcan and the guy was just coming into the range of where my protocols allow me to administer it. So rather than whipping out a new toy just for the sake of playing with it, I waited 4 minutes to intercept with a fly car.

 

[Tigger]

What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?

As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.

I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):

- Glucometry
We do this already. I think giving everyone sugar and letting ALS settle it out is terrible medicine. Everyone talks about administering 02 only when appropriate. We should be doing the same with sugar. Any AMS patient is getting their sugar checked especially if they're a diabetic or have another problem with regulating their sugar. I am not going to give patients anything until I get a glucometery reading. I have no idea why anyone thinks basics should not be doing this, it takes about a minute and does have value.

- 3- and 12-lead placement and transmission
If you have no ALS or hospital in the area, fine. If you're in the sticks of Colorado and your ALS comes from a helicopter, yea this could be a good idea. For most though I don't think it's beneficial.

- Blind insertion airway devices
Also doing this already, if properly trained in their insertion and placement it makes BVM use considerably easier and the airway can be managed by one instead of two providers. The AHA wants two providers doing mask ventilation and I agree, the "anesthetist's grip" is too difficult for many, even those with experience.

- SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
Also doing this already. No reason why not, one of the few ways BLS can actually save a life. Just don't do this.

- Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
I don't agree with this one without a significant increase in education. If a patient is prescribed it that's one thing, but as stated ideally a 12 lead will be completed prior to administration. In Colorado I can give it without med control, but the reasoning is that if dumps the patients pressure I can start an IV to bring it back. Not sure how I feel about that...

- Rectal diazepam (carried on ambulance -- not just prescribed)
Absolutely not. BLS should not be carrying, much less administering benzos. Not to mention the massive increase in regulation needed for every service to start to manage and carry a controlled substance.

- MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
Already done here as well, and should be expanded everywhere. Asthma attacks are a fairly common EMS call and BLS can do very little for them especially if the patient can no longer properly use an MDI.

- IN naloxone
Done here and I'm ok with it provided that it is given slowly and only to correct respiratory depression.

Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.

No uses so far, I had one that was borderline but decided Id rather bag than wrestle. Our protocol is Narcan is only delivered to unresponsive pts in resp distress or failure with reason to suspect opioid use.

Proper administration of Naloxone should not end in wrestling. Even at 0.2mg you do not have to give the entire dose. If you push it slowly and notice a change after half the dose, just stop.

 

[DrankTheKoolaid]

Giving a glucometer to BLS will change nothing. If they are that altered they should not be receiving PO glucose paste to begin with. So you now have a mg/dL reading you can do nothing with since you cant start lines to give IV Dextrose.

And generally i agree that blind blanket treatments have no business in EMS. But in the case of a known or suspected diabetic who is symptomatic I feel this is a good exception to the rule. As it truely is benign with a few exceptions such as with alcoholics or if the BLS provider misses the fact that they do not have an intact gag reflex and the patient aspirates

 

[DrankTheKoolaid]

Now giving BLS Glucagon i can get behind for unconscious known diabetics

 

[Tigger]

Giving a glucometer to BLS will change nothing. If they are that altered they should not be receiving PO glucose paste to begin with. So you now have a mg/dL reading you can do nothing with since you cant start lines to give IV Dextrose.

And generally i agree that blind blanket treatments have no business in EMS. But in the case of a known or suspected diabetic who is symptomatic I feel this is a good exception to the rule. As it truely is benign with a few exceptions such as with alcoholics or if the BLS provider misses the fact that they do not have an intact gag reflex and the patient aspirates

As already mentioned, if I get a low reading I'll call ALS, have them come and give some D50 or glucagon and then if needed, RMA the patient. Otherwise the patient is going to the hospital, which is needed. Oral glucose takes at least 15 minutes to have the same effect, which would you want? Also if someone can protect their airway and clearly needs sugar, and says I need sugar, they are going to get it. Wouldn't it be nice to you know, quantify and measure your treatments?

I know how you feel about basics, but honestly considering that lay people do it all the time, there is no excuse for an incomplete assessment. I can't do anything with a high BP either, maybe I should just not take those either?