BLS Skills -- What Should We Add?

[Veneficus]

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.

Just an FYI on this topic.

Apparently some guys use their prescription nitro paste as a topical erectile enhancer.

The reproductive system is a body system and should always be reviewed in both men and women during assessment.

If it is too embarassing or taboo, then it is time for the provider to grow up or move on.

 

[NYMedic828]

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

I get called to backup a BLS unit that thinks they have a diabetic who is really a CVA all too often. You can tell its a stroke almost immediately upon assessment most times unless of course they are unconscious.

It baffles me that our BLS can't all carry a device as simple and inexpensive as a glucometer that would ultimately save money and reduce the time a CVA takes to reach the ER.

Just an FYI on this topic.

Apparently some guys use their prescription nitro paste as a topical erectile enhancer.

The reproductive system is a body system and should always be reviewed in both men and women during assessment.

If it is too embarassing or taboo, then it is time for the provider to grow up or move on.

Doc, your mind would be blown by the EMS providers in my home town and surrounding. But hey "we're just volunteers" after all...

It's great people want to volunteer and "save lives" but if you aren't comfortable with so much as having a conversation with the patient, you have no business providing any rendering of true care.

 

[shiroun]

Morphine is my way to go and you won't see that at the BLS level any time soon.

100% agree with. I was asking what kind of pain management he wanted for BLS. Morphine at a BLS level would do more harm then good.

Nassau permits BLS assistance with pre-prescribed nitro...

BLS can administer up to 3 nebulizer treatments of albuterol as long as patient has an asthma history...

You're correct, but both DO require a PMH.

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.

People do find it a joke, when its really just one simple question. I doubt your 75 y/o with 9/10 chest pains is going to complain to the doctors about you asking if he's on viagra.

Yet, we also had a medic in NC who accidentally sprayed himself in the face with nitro a few times, and about 2 minutes later was on the ground with a BP of 60. He got the nickname of Nitro. :rofl:

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.

I'm not talking about as a local numbing agent, I'm talking about as a sedative/tranquilizer. Something BLS could put on our patients that potentially pose a threat to us. It wouldn't be used often (because again, that 75 y/o with the chest pain isn't going to go ape:censored::censored::censored::censored: on us, but the guy who's hyped up on PCP and been shot might), but it'd be nice to have in our basic bag of tricks.

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.

That's probably due to inexperience. If I've got a helper I'll run calls, so long as it's not an MI or hypoglycemic... which brings us to:

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.

instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM, and there's less potential to nick a nerve, or have the needle get lost in the persons skin. The only reason I say the 2nd one is because a nurse went to give me my hep A shot, and she jabbed it in...only to hit a nerve in my rotator cuff. The needle bent horribly and I was cursing up a storm for about ten minutes. If I'd moved my arm a bit more, that needle would have snapped. And she's trained and done it 1000 times over, imagine a BLS provider who's fresh out of school doing that. Atleast with SC there's less risk to the pt.

 

[NYMedic828]

I'm not talking about as a local numbing agent, I'm talking about as a sedative/tranquilizer. Something BLS could put on our patients that potentially pose a threat to us. It wouldn't be used often (because again, that 75 y/o with the chest pain isn't going to go ape:censored::censored::censored::censored: on us, but the guy who's hyped up on PCP and been shot might), but it'd be nice to have in our basic bag of tricks.

Good luck gettin that one approved lol.

For the few departments that have narcotics, my own being one of the first if that helps you deduct my residence, chemical sedation is essentially unheard of and we don't even have a written protocol for it.

We are a LONG time from any form of transdermal sedative for the field and quite honestly it is impractical because the absorption rate is not meant to be fast on things like fentanyl patches for example.

The only effective means for chemical sedation in the field, to my knowledge is IN or IM benzo, assuming you can safely use a needle.

instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM, and there's less potential to nick a nerve, or have the needle get lost in the persons skin. The only reason I say the 2nd one is because a nurse went to give me my hep A shot, and she jabbed it in...only to hit a nerve in my rotator cuff. The needle bent horribly and I was cursing up a storm for about ten minutes. If I'd moved my arm a bit more, that needle would have snapped. And she's trained and done it 1000 times over, imagine a BLS provider who's fresh out of school doing that. Atleast with SC there's less risk to the pt.

Though the safety of administration is in fact more "idiot proof" with SQ, you actually have your facts slightly mismatched.

The subcutaneous tissue is not very vascular and as such the absorption rate is actually slower, not faster. This is therapeutically beneficial in some cases like 1:1000 epi on an elderly patient who may not tolerate such a quick jolt so well, but glucagon we would want to be faster acting since slowing the absorption rate of a small dose as 1mg won't really benefit us when it could take 5-15 minutes to show any effects.

The skeletal muscularture is very vascular and allows for a speedier absorption.

I would have to say the nurse you had made an error somewhere in her administration. It is not that easy to hit the axillary nerve if you are center mass on the deltoid. Too low if anything could cause trouble where it wraps around the humorous. Realistically, IVs have far more risk of nerve impingement.

 

[Veneficus]

instead of IM glucagon, I'd say SC would be better. Its absorbtion rate is quicker then IM

Never heard that before.

Have heard that IM is both faster and more reliable.

 

[NYMedic828]

Never heard that before.

Have heard that IM is both faster and more reliable.

What do you know -_-

 

[shiroun]

Never heard that before.

Have heard that IM is both faster and more reliable.

I heard it from a medic at my school. Go figure.

Good luck gettin that one approved lol.

For the few departments that have narcotics, my own being one of the first if that helps you deduct my residence, chemical sedation is essentially unheard of and we don't even have a written protocol for it.

It actually does help me to figure out what county you're in. If I'm right, you guys had two cars on two consecutive days wrap around the same telephone pole. Your chief wasnt happy.

That or youre the one where I was at school. :\

** CL Edit - quoted post removed **

 

[NYMedic828]

I heard it from a medic at my school. Go figure.



It actually does help me to figure out what county you're in. If I'm right, you guys had two cars on two consecutive days wrap around the same telephone pole. Your chief wasnt happy.

That or youre the one where I was at school. :\

In regards to IN v SQ, I rest my case on incompetence in the area.



And no... Neither. No cars wrapped around poles thankfully. Unless you took your EMT 5 years ago. I took medic with FDNY so that's not it.

I PMd u by the way.

 

[Christopher]

- 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)
- 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.

These have been part of the BLS scope for about 4 years now in North Carolina. Rectal diazepam is the only one from your list EMT's could not do.

 

[leoemt]

(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.

Like I said I'm too new to really know much about the different drugs used for pain management. My point was that if we were to add something to the BLS skills I would like to see some form of pain management. I am well aware that traction can and does reduce pain in fracture injuries.

However, in my career as a cop I have responded to literally hundreds of aid calls and have seen my fair share of patients going BLS to a hospital in severe pain.

What about patients complaining of a headache? Abdominal pain? Pregnancy?

I know there is a lot more I need to learn about this, even if just for my own knowledge, and I am sure that there are contraindications that I am unaware of as to why pain drugs would be inappropriate in situations like these.

Realistically speaking I understand why this would probably never happen. However, in a perfect world I would like to see a Basic be able to offer some form of pain management.

 

[HMartinho]

In Portugal, we can check bgl, and glucometer is a very useful tool.

Anyway, why not entonox? EMT-b's can administer entonox in some countries, with good results.

 

[NYMedic828]

Like I said I'm too new to really know much about the different drugs used for pain management. My point was that if we were to add something to the BLS skills I would like to see some form of pain management. I am well aware that traction can and does reduce pain in fracture injuries.

However, in my career as a cop I have responded to literally hundreds of aid calls and have seen my fair share of patients going BLS to a hospital in severe pain.

What about patients complaining of a headache? Abdominal pain? Pregnancy?

I know there is a lot more I need to learn about this, even if just for my own knowledge, and I am sure that there are contraindications that I am unaware of as to why pain drugs would be inappropriate in situations like these.

Realistically speaking I understand why this would probably never happen. However, in a perfect world I would like to see a Basic be able to offer some form of pain management.

Many have suggested carrying Nitrous Oxide (laughing gas) but it has some FDA restrictions I believe was what came out of the topic.

 

[ironco]

Where I am at it is within our scope to do BGL and they recently put it in Missouri state scope to place and transmit 12 leads.

Someone (I already forgot who) said why let basics do 3 lead if there is no medic around. The reason for this is because you can give a print out to the ER so they know how things have progressed over time, which is nice for the Dr to give a quick appropriate diagnosis wich we also can do here in Missouri.

 

[Bullets]

I get called to backup a BLS unit that thinks they have a diabetic who is really a CVA all too often. You can tell its a stroke almost immediately upon assessment most times unless of course they are unconscious.

It baffles me that our BLS can't all carry a device as simple and inexpensive as a glucometer that would ultimately save money and reduce the time a CVA takes to reach the ER.



Doc, your mind would be blown by the EMS providers in my home town and surrounding. But hey "we're just volunteers" after all...

It's great people want to volunteer and "save lives" but if you aren't comfortable with so much as having a conversation with the patient, you have no business providing any rendering of true care.

And I share this sentiment as a volunteer EMT. During Bamboozle I had a newish EMT as a partner who told me he felt uncomfortable treating our patient

The reason? The patient was an underage girl who was dropped 6 ft onto a barricade while crowd surfing and seized and had thoracic lacerations .He didn't feel comfortable treating after I exposed her chest to treat the chest injuries.

I told him to grow up and find another field then promptly got another partner for the day

 

[18G]

What the OP is suggesting is exactly what the new AEMT level provider can do. Why add additional skills to EMT-Basic when the AEMT is there??

In WV, a Basic can give NTG, ASA, glucagon and albuterol - all carried on the ambulance. And just recently protocol was developed to permit 12-lead acquisition and transmission.

I am in favor of Basics giving albuterol and hopefully all EMT Basics are allowed to use CPAP.

 

[Christopher]

...and hopefully all EMT Basics are allowed to use CPAP.

Amen! I hate when I hear stuff like, "but what if they POP A LUNG?!?!"

Yep, keep them away from 10 cmH2O, so when they tire out and require assistance with a BVM they can provide 40 cmH2O+ of pressure; that'll protect their lungs.

 

[DesertMedic66]

What the OP is suggesting is exactly what the new AEMT level provider can do. Why add additional skills to EMT-Basic when the AEMT is there??

In WV, a Basic can give NTG, ASA, glucagon and albuterol - all carried on the ambulance. And just recently protocol was developed to permit 12-lead acquisition and transmission.

I am in favor of Basics giving albuterol and hopefully all EMT Basics are allowed to use CPAP.

Because not everywhere uses AEMTs. Here is SoCal (my area at least) we only have EMTs and Medics. Nothing in between.

Why are you in favor of EMTs giving albuterol and having CPAP when AEMTs can do it?

 

[NYMedic828]

Wouldn't it be nice to live in a world where the entire country was standardized and an EMT could progress to AEMT with a set amount of field experience and classroom time, and then further progress to paramedic on the same basis.

Ah, a man can dream...

 

[18G]

Because not everywhere uses AEMTs. Here is SoCal (my area at least) we only have EMTs and Medics. Nothing in between.

Why are you in favor of EMTs giving albuterol and having CPAP when AEMTs can do it?

I guess it's kinda like saying why allow an EMT to stop bleeding when an AEMT can do it. I think albuterol's benefit, safety and ease of administration make it a worthwhile drug to have on every ambulance. Honestly, and don't mean to offend anyone, but think Paramedics should be the minimum staffing level for an ambulance in the US.

RN's and doctors are the standard level of care providers in ED's in this country - no one ever says we cant afford them let's go to CNA's and hire an RN to be the physician in the ED. I don't see why we find excuses to compromise with not paying a Paramedic a decent wage to staff every ambulance.

If we went this route then the OP's question wouldn't even matter.

 

[NYMedic828]

I guess it's kinda like saying why allow an EMT to stop bleeding when an AEMT can do it. I think albuterol's benefit, safety and ease of administration make it a worthwhile drug to have on every ambulance. Honestly, and don't mean to offend anyone, but think Paramedics should be the minimum staffing level for an ambulance in the US.

RN's and doctors are the standard level of care providers in ED's in this country - no one ever says we cant afford them let's go to CNA's and hire an RN to be the physician in the ED. I don't see why we find excuses to compromise with not paying a Paramedic a decent wage to staff every ambulance.

If we went this route then the OP's question wouldn't even matter.

I think the most optimal move is dual staffed ambulances.

Here in NYC we have ALS and BLS separate. It baffles me that we don't split off every paramedic pair and double our ALS.

This would allow EMTs to be mentored and in the event of a call requiring more hands, you would still end up with the same 2 emts and 2 medics you had before.

The only downside is, paramedics would not end up practicing skills like intubation as much. But we get quite a few arrests in NYC its not that big of a deal. And on a job requiring intubation, only one person gets to do it anyway (hopefully)