BLS Skills -- What Should We Add?

[Tigger]

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?

There is very little correlation between the education someone already has and their ability be educated in something new.

 

[DrankTheKoolaid]

I absolutely agree tigger. But that will not convince your Medical Director or other MAC members to allow a new skill/medication. You will have to present it in a methodical manner with all research available to show a need. Just because you feel your entitled to do something because you feel it is a mundane act is not a valid argument

 

[NYMedic828]

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

Pretty hard to do damage with 1mg of glucagon.

Its better than people drowning an unconscious diabetic with glucose paste, and expecting it to work to begin with let alone in any timely manner.

 

[shiroun]

In my district (nassau county, NY) a very big name in our area is pushing for intranasal administration of narcan for BLS

 

[Tigger]

I absolutely agree tigger. But that will not convince your Medical Director or other MAC members to allow a new skill/medication. You will have to present it in a methodical manner with all research available to show a need. Just because you feel your entitled to do something because you feel it is a mundane act is not a valid argument

My medical director already agrees that basics should be doing glucometry, and we have glucometers per his instructions. He also supported us having combitubes, nasal narcan, and nebs. However these were not implemented due to cost apparently. I don't feel entitled to do any of these things, I feel they are beneficial to BLS patient care for the reasons I have outlined above and my company, medical directors, and area hospitals agree as well. If they had a problem, I don't think they would have implemented them.

 

[DrankTheKoolaid]

Oh trust me where i am we have expended scope for BLS. That is not the point of my posting to the OP. The point of my posting in here, as a member of a MAC commitee myself is to show him what he will be up against and to give him an oppotunity to try to address these concerns that are sure to come up by some commitee member. Now before he approaches his LEMSA with additions to their scope, he will have answers to these questions.

When attempting to get something added you simply can not look at it from a "It's good patient care stand point" unfortunately.

Are studies in place showing it is absolutely safe in minimally trained BLS hands, because remember a protocol is across the board to include volunteers with little to no experience and lets face it depending on the area and culture little to no true EMS continuing education, not just on an ambulance.

How much training is it going to take.

Is this going to be absolutely mandatory or optional? Who is going to pay for it? IE Epi-Pens are dam expensive and have a very short expiration. Or are you going to allow BLS to play with needles and draw up their own?

You can take it from there as im pretty sure you get my point...

Just caught your comment about my feelings for EMT's

Nothing could be farther from the truth. I was a EMT forever and have the utmost repect for my basic partners. It the other EMT's that scare me sometimes

 

[NYMedic828]

In my district (nassau county, NY) a very big name in our area is pushing for intranasal administration of narcan for BLS

Our Nassau County protocols need more change than narcan for BLS.

 

[Veneficus]

Could I just inquire?

How many patients are you seeing that actually need narcan?

 

[shiroun]

Could I just inquire?

How many patients are you seeing that actually need narcan?

119 Non-Heroin Deaths by Opiates in 2011, 149 inc. Heroin (Heroin and Oxycodone were the top 2 killers in the opiate category, with 30/34 respectively). 310 PTs with Opiates in their system during a Tox-Screen in 2011.

So to answer that, almost every day we have a PT who we would potentially administer Narcan to.

 

[Veneficus]

119 Non-Heroin Deaths by Opiates in 2011, 149 inc. Heroin (Heroin and Oxycodone were the top 2 killers in the opiate category, with 30/34 respectively). 310 PTs with Opiates in their system during a Tox-Screen in 2011.

So to answer that, almost every day we have a PT who we would potentially administer Narcan to.

How many of the dead people were dead before or without EMS intervention?

 

[DrankTheKoolaid]

How many died with EMS intervention that would have been saved with Narcan and not BVM ventilations?

 

[NYMedic828]

How many of the dead people were dead before or without EMS intervention?

As a fellow resident of Nassau County NY if I may add some input;

In Nassau County we have volunteer and paid EMS. A select few towns are covered by a private hospital, the other 60+ towns have coverage by the NCPD ambulance bureau. The NCPD EAB responds primarily to any 911 call in MOST places. Volunteer FDs and ambulance cores in most towns only respond primary if PD is not available, or if called directly instead of via 911.

PD also responds to all calls for EDP, intox or drug relation.

Keep in mind all NCPD ambulances are ALS.

So in reality, the amount of calls that volunteer FDs get involving drugs are few and even fewer are overdoses.

We get so few that even our ALS (the inexperienced) treat wrongly. Example being a gentleman on PCP, a medic in my department gave Narcan.

So, in a system where our protocols are already complete trash, the last PRIMARY focus we need, is giving a mass of mostly inexperienced EMTs, a real medication.

Narcan may not have side effects, but most people don't realize just how much 0.2mg can do on many patients, they get excited and slam the whole amp in.

And quite honestly, we are usually 5 minutes from a hospital. Just freaking bag them.

I'd rather see glucagon before Narcan for EMTs, and our actual protocols need fixing before our scope.

 

[EpiEMS]

Oh trust me where i am we have expended scope for BLS. That is not the point of my posting to the OP. The point of my posting in here, as a member of a MAC commitee myself is to show him what he will be up against and to give him an oppotunity to try to address these concerns that are sure to come up by some commitee member. Now before he approaches his LEMSA with additions to their scope, he will have answers to these questions.

Makes good sense. My protocols are far too restrictive, both considering what I do on a regular basis. Fortunately, I'm in a system where I usually have a medic on calls with me (or one can be there in less than 10 minutes -- either that, or I can get to the ED in 15 minutes, max).

My notion is to expand the national scope. Granted, I am pulling bits and pieces from various expanded scopes and from the AEMT national standards. This being said, as a BLS crew, I want to be able to arrive on scene and begin assessment and treatment. Assessment tools like a glucometer and monitor (with transmission) allow me to assess and triage appropriately. Skills like the use of a blind insertion airway device (easy to use, rarely improperly placed, and pretty darn effective at ventilating), and meds (namely, beta agonists) are easy to use and make a difference.
These are not complicated skills, here (and most of the skills I mentioned are performed by BLS personnel in some areas of the country). I'm just not permitted to perform them because of where I am. Shouldn't my patients receive care equal to that which they'd get anywhere else?

You can take it from there as im pretty sure you get my point...

Everything that you've said is very sensible, and I certainly don't think you have a problem with EMTs, surely not. We just happen to disagree on what the scope of practice should be.

 

[shiroun]

We get so few that even our ALS (the inexperienced) treat wrongly. Example being a gentleman on PCP, a medic in my department gave Narcan.

How did that work out for him?

And I have to agree with you. We do need to re-define it, however our system, as my instructor put it, has been in place for awhile, and overhauling it may be worthless. We switch over to NR in a few months anyway.

 

[NYMedic828]

How did that work out for him?

And I have to agree with you. We do need to re-define it, however our system, as my instructor put it, has been in place for awhile, and overhauling it may be worthless. We switch over to NR in a few months anyway.

It didnt...

 

[shiroun]

It didnt...

That's the joke. I guess sarcasm doesn't transmit well over the internet.

Mind if I shoot you a PM with my number, if you're able to text, or something along those lines? I'm looking to find a place to ride-along, and I don't want to de-rail this thread even more.

 

[leoemt]

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.

Every Rescue vehicle whether BLS or ALS in WA State must have 1 adult and 1 junior Epi-pen on board per law. Every BLS and ALS provider must be trained in how to use it as well. This law is the result of a little boy who died at his elementary school in Spokane because he had a peanut allergy and the responding fire engine, which was BLS, had no epi.

I personally would like to see BLS have some sort of pain management to give our patients. Not being to familiar with the pharmacology I don't know if that would be possible or prudent though at the BLS level.

 

[shiroun]

Every Rescue vehicle whether BLS or ALS in WA State must have 1 adult and 1 junior Epi-pen on board per law. Every BLS and ALS provider must be trained in how to use it as well. This law is the result of a little boy who died at his elementary school in Spokane because he had a peanut allergy and the responding fire engine, which was BLS, had no epi.

I personally would like to see BLS have some sort of pain management to give our patients. Not being to familiar with the pharmacology I don't know if that would be possible or prudent though at the BLS level.

(I've been up for the last 28+ hours, so if i mess anything up forgive me),

What kind of pain management? When you traction splint someone, the pain goes away significantly.
Chest pain? We can assist with nitro, or give aspirin with medcom orders.
Respiratory has oxygen, and I think broncodilators are assistable/medcom (advair, or whatever other asthma meds you have).

Do you mean like general pain management, like morphine?

I think our limited knowledge of pharmacology is what MAKES that a bad idea. Especially without PMH in some cases, such as trauma, where the guy is in splitting pain with a concussion and two broken arms, and can't remember what happened, let alone what medications/allergies he has, that could be a problem. Hell, if you slip up and forget to ask someone if they're on performance enhancing drugs, and you help them take their nitro, they'll be CTD in under 5 minutes. I wouldn't want to add more problems then we fix.

I would actually like to see a rub-on anesthetic, for mildly combative patients. Granted, it would need strict guidelines, but it'd be beneficial for us.

Thats my 2 cents anyway.

 

[NYMedic828]

What kind of pain management? When you traction splint someone, the pain goes away significantly.

I think in 6 years I've had one isolated closed mid-shaft femur fracture. Traction splint certainly results in excellent management for the patient I used it on. Back to our Nassau discussion, we have toradol and morphine. My issue with toradol is that many people at the ALS level here think its just IV Motrin what harm can it do. Things like femur fractures are potential for major blood loss. Toradol being a platelet inhibitor, I'm not so certain is the best move. Morphine is my way to go and you won't see that at the BLS level any time soon. Toradol also doesn't take effect too quickly by comparison, it's more to help by ER arrival than when in our care due to our transport times.

Chest pain? We can assist with nitro, or give aspirin with medcom orders.
Respiratory has oxygen, and I think broncodilators are assistable/medcom (advair, or whatever other asthma meds you have).

Nassau permits BLS assistance with pre-prescribed nitro. If the patient does not theirs on hand, you can call Medcom assuming your ambulance stocks it. Being nitro administration is not technically out of EMT scope, with a competent report the doc will probably permit it.

BLS can administer up to 3 nebulizer treatments of albuterol as long as patient has an asthma history. Again, no history, call Medcom... You can also assist with Rx inhalers but the nebulizer is a better treatment option.

You are always permitted to allow a patient to self administer their own prescribed medicines as indicated by their pcp if they choose to. Whether or not you are comfortable with it is up to you. I usually let people take them if they were supposed to and didn't due to calling EMS. I'd rather my 86 year old patient not miss her morning dose of 4 HTN meds.

Do you mean like general pain management, like morphine?

I think our limited knowledge of pharmacology is what MAKES that a bad idea. Especially without PMH in some cases, such as trauma, where the guy is in splitting pain with a concussion and two broken arms, and can't remember what happened, let alone what medications/allergies he has, that could be a problem. Hell, if you slip up and forget to ask someone if they're on performance enhancing drugs, and you help them take their nitro, they'll be CTD in under 5 minutes. I wouldn't want to add more problems then we fix.

Hate to say it but the majority of ALS in Nassau is CC based, not paramedic. Most of the CCs who don't work for NCPD or having explored further self education have very limited pharmacologic knowledge either. Same goes for some medics as well. The CC class is more "here's a cookbook, here's how
you perform the skill, you see this, do that." This is why a CC needs to call Medcom for meds as simple as Benadryl.

If a patient meets the criteria for nitro assistance, odds are they don't take Viagra and their doctor has made it clear that it is NOT a wise choice. But, most people find the contraindication as a joke and embarrassing to ask someone, which I agree is a potential problem especially when you don't have emergent fluid replacement at your disposal. But, I don't know anyone who this has happened to. My vote goes for the greatest good for the greatest number of people. APE patients and patients with presumed cardiac chest pain benefit greatly from NTG. It is probably one of the best things we carry. I honestly think it should be a med control order in general not just an assistance criteria. This way if people know enough to realize it is indicated, they can get it but at the same time you cover your back by having a doctor check your assessment.

I would actually like to see a rub-on anesthetic, for mildly combative patients. Granted, it would need strict guidelines, but it'd be beneficial for us.

Topical lidocaine doesn't work that well in my experience. . (they use it on non-critical peds alot for starting IVs and it doesn't do much)
Topical agents just really serve no purpose in the field. They are more for muscle aches and pains in the household
The numbing effects of an ice pack go a long way in an acute setting if the patient tolerates it.




As far as the topic in general, I think the days of EMT meaning bandaid brigade does need to come to an end. EMTs have been getting more toys as ALS has but it has to be a slow process due to general lack of experience and education. The majority around here just can't handle it. Many I know, are not even comfortable
running a nonsense call on their own.

But what I think ultimately is practical for BLS now, if implemented properly,

IM glucagon (that paste is so dumb, and EMTs already have glucometry, finally.)
Telemetry nitro administration
IN Narcan
Combitube or other alternative airway.

 

[Bullets]

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

And i have had 3 this week, they do occur

The first one was classic stroke symptoms, left sided weakness, facial droop, warm and dry. I begin to package for a stroke and notify hospital and i see the patients glucometer sitting bedside. I ask the son to check BGL.....of 26! Hold off on packaging, ALS arrives, does the ALS dance, BGL up to 210 patients up and walking, eating, a little upset, RMAs

Now i happened to have a glucometer on hand, but if i didnt i probably would have transported, cancelled medics and looked like a fool at the hospital for calling a stroke on a hypoglycemic