BLS with Advanced Skills

[MedicDelta]

Hey guys. I'm curious what you all think about having someone at a basic level(EMT-B USA, PCP Canada) and giving them advanced skill sets up to even the EMT-P(ACP Canada) level. This happens primarily and i think only in the military. US 68 Whiskey combat medics are NREMT Basics and Canadian Forces Medical Technicians are licensed PCPs. But both receive advanced skills when they do their military medical training up to an advanced life support level. What do you think of this? I've heard some people say it's bad, and some people say it's great. Personally I think it makes perfect sense. My dad was a CF Search And Rescue Technician for 11 ish years and they all receive the same training as our Med Techs(they actually used to be higher). He explained that they started getting civilian qualifications because when working with civilians it was hard to explain what they could and couldn't do. I assume it still somewhat is. But because the military doesn't have the time or the money to make someone go take a 2 year advanced diploma in Advanced Care Paramedicine(I think EMT-P is about the same length in the US in most states, correct me if I'm wrong) they just give them the necessary advanced skills they will need for traumatic patients, makes sense to me. I'm actually hoping after I take a PCP course to join the CF and become a Med Tech. So what do you guys think about having an EMT-B or PCP with advanced skills? Good or bad?

(Note: I was going to put this in the military section but I was sort of looking at it at the education/training these guys get)

 

[DesertMedic66]

Are you asking about giving military "medics" advanced skills or about giving civilian EMTs advanced skills?

Most military medics I've talked to already have some advanced skills at the EMT level.

For civilian EMS, my view point is if you want more skills then become an Advanced EMT or even a Medic. A provider should not only have the training to do the skills but also the education on why we are doing something or why we aren't doing something.

 

[MedicDelta]

Are you asking about giving military "medics" advanced skills or about giving civilian EMTs advanced skills?

Most military medics I've talked to already have some advanced skills at the EMT level.

For civilian EMS, my view point is if you want more skills then become an Advanced EMT or even a Medic. A provider should not only have the training to do the skills but also the education on why we are doing something or why we aren't doing something.

Sorry for the unclarity, I'm talking about military medics. And I completely agree with the civilian EMS thing you said there.

 

[DesertMedic66]

Sorry for the unclarity, I'm talking about military medics. And I completely agree with the civilian EMS thing you said there.

The military "medics" that I have talked to already have advanced skills such as: IVs, IOs, pain meds, and needle decompression

 

[MedicDelta]

The military "medics" that I have talked to already have advanced skills such as: IVs, IOs, pain meds, and needle decompression

From EMT-Basic?

 

[DesertMedic66]

From EMT-Basic?

From my understanding the majority of our military "medics" are only certified in the civilian world with NREMT (EMT-B). As one of my paramedic instructors said "the military can pretty much do whatever they want" (he does a lot of lectures for the military).

 

[STXmedic]

For the military world, I think it's fine. Military casualties are typically young, healthy individuals who have experienced trauma. Trauma management is relatively straight-forward in the prehospital setting, and the skills are easy to teach. They're also often far removed from advanced care. So if we can teach them some advanced skills to treat these traumatic injuries, and they can help increase survivability, then by all means.

 

[Tigger]

I think training people for their environment is the right idea. I do not support then placing these individuals with their "advanced" skills and minimal education back into the usual EMS environment.

 

[cprted]

Canadian Forces Med Techs are trained as PCP with a few extras specific to trauma care and a lot of nursing skills. They aren't ACPs. But yes, they perform IVs (PCP skill set already) and have IO and needle decompression. Don't know about pain management.

Also to provide some info to clarify the discussion ... an EMT-B in the US is basically an EMR in Canada and our "Primary Care Paramedics" are similar to AEMT.

 

[cprted]

Like others have said, Med Techs have some good skills perfectly suited to the environment they work in, but they aren't at the EMT-P/ACP knowledge level. The ACP program is 2 years long and not because thats how long it take to learn how to do insert an IO or ET tube.

 

[MedicDelta]

Canadian Forces Med Techs are trained as PCP with a few extras specific to trauma care and a lot of nursing skills. They aren't ACPs. But yes, they perform IVs (PCP skill set already) and have IO and needle decompression. Don't know about pain management.

Also to provide some info to clarify the discussion ... an EMT-B in the US is basically an EMR in Canada and our "Primary Care Paramedics" are similar to AEMT.

Yes I know, I was just saying that they have some ACP level skills. They can give morphine as far as I know.

 

[Av8or007]

There are some things that are normally considered advanced care paramedic skills that probably should be Primary Care paramedic skills.

For example needle decompression of a tension pneumothorax is a lifesaving procedure that must be done immediately once a clinically significant tension ptx (that is causing cv compromise) is diagnosed.
Given the tools that we have in the prehospital environment to diagnose a tension pneumothorax, by the time we can diagnose the pneumothorax it is more than likely clinically significant and requiring treatment.

Anyone that does a 12 lead (a pcp skill) can landmark for a needle decomp.

In penetrating trauma, the risk benefit is in favour of benefit - although not w/o risk those pts will usually get a chest tube.
Same w blunt trauma and a tension ptx, the ptx will kill the patient before you can get them to "someone else". In this case, 'remote setting' is greater than about 90-120 seconds from the trauma bay at the hospital.
Trauma termination of resus protocols w/o the ability to do bilateral chest decompression is just a bad idea. If you are going to call it, dart both sides of the chest before you do. Both the original issue and/or overaggressive ventilation can cause a tension ptx - a reversible cause of trauma arrest.


Other things include some meds.
Firstly, EPInephrine for anaphylaxis is a basic life support intervention that is standard of care. Period!
Again if you're 10 minutes from the emergency department when your patient has a life threatening anaphylactic reaction then you are 10 minutes too far from hospital.

Anaphylaxis is an immediately life threatening rxn that must be treated immediately, not 5-10 min (at best) later.
The world allergy association guidelines cite several papers demonstrating that failure to administer epi promptly was the single most common reason for death from anaphylaxis.
Further, the guidelines cite other resources that state the median time to complete cardio-respiratory arrest from food and sting allergies is approx 10-15 min. This is from initial antigen exposure to cardiac arrest.

The Dx is pretty simple (this definition for EMT-B/EMR- you can still have anaphylaxis if you do not meet this definition):

An illness consisting of cardiovascular instability (hypotension ) and/or respiratory compromise PLUS signs of an allergic rxn (e.g. itching, hives) or exposure to a suspected or known allergen is automatically anaphylaxis until proven otherwise.

Look up the world allergy association guidelines.

EPInephrine is a basic life support intervention for anaphylaxis. To get around the issues with people giving it when not needed, you use a checklist. These checklists work and are used by organizations such as Ontario's lottery and gaming corporation who stocks their medical kits in casinos with epi.

But it is unacceptable that in 2014 we are still fighting to get epi recognized as a bls lifesaving intervention...

EPInephrine is the standard of care for anaphylaxis. It is pretty much negligence to withhold this intervention from a pt suffering from anaphylaxis.

Next is meds such as salbutamol. Salbutamol is a very safe drug, is the standard of care for asthma exacerbation and other cases of moderate to severe bronchoconstriction.
Although like any drug there are risks, salbutamol is relatively benign, and the only major risks are tachycardia if given in excess and possibly hypokalemia w massive doses. Dosing is simple: 600-800 mcg q5 min x3 prn. Assess breath sounds in between each dose. Even if it was given in absence of bronchoconstriction, the any side effects are likely to be minimal.

ASA is standard of care for MI pts, this is a BLS skill and is negligence to not give in mi if indicated with no contras (which are few and far between).

Tylenol and advil are safe otc analgesics for minor to moderate pain and can be given together if no contras exist for each drug. When given only in one dose, the contras are few, namely allergies, liver or renal impairment, and for ibuprofen, major bleeding/peptic ulcers, pregnancy.

Glucagon is safe as a pcp drug and probably for EMR as well. Simple to use and gives tx option for severe hypoglycemia w/ unresponsive pt. BGL is a bls skill and should be in all providers scope of practice. If you can't figure out how to do and interpret a BGL, you shouldn't be practicing any form of medicine, even bls.

Benadryl and gravol are also very safe drugs that can play a major role in treatment of allergic rxns and nausea/vomiting, respectively. Again, very few contras to these drugs. Given IM or PO if the provider is not IV certified. Can be used by pcp medics and use by EMR level wouldn't be a bad idea.

Supraglottic airways are bls, when used after bls measures are inadequate or ineffective. Not having any backup for failed bvm ventilation is a bad idea.

 

[medicasaurus]

The key thing to the Military is the population and location that these treatments are being applied to. A Med Tech (PCP-IV) in Canada cannot intubate but for the purpose of the mission in Afghanistan were trained and allowed to do so. Those guys and gals are not allowed to perform intubations now that they have returned to Canada. Same thing goes for Morphine, In Afghanistan the standing orders were more broad.
On the Population side your administering these procedures on a population of previously healthy, medically per-screened for disease, fit, 19-40 year olds. Not the Polypharmacy, multiple co-morbidity, or unknown history patient.
Finally there is a different demand in a wartime or military setting. It isn't routine daily care for a military medic to be performing these interventions, in the civilian world it is.

 

[MedicDelta]

There are some things that are normally considered advanced care paramedic skills that probably should be Primary Care paramedic skills.

For example needle decompression of a tension pneumothorax is a lifesaving procedure that must be done immediately once a clinically significant tension ptx (that is causing cv compromise) is diagnosed.
Given the tools that we have in the prehospital environment to diagnose a tension pneumothorax, by the time we can diagnose the pneumothorax it is more than likely clinically significant and requiring treatment.

Anyone that does a 12 lead (a pcp skill) can landmark for a needle decomp.

In penetrating trauma, the risk benefit is in favour of benefit - although not w/o risk those pts will usually get a chest tube.
Same w blunt trauma and a tension ptx, the ptx will kill the patient before you can get them to "someone else". In this case, 'remote setting' is greater than about 90-120 seconds from the trauma bay at the hospital.
Trauma termination of resus protocols w/o the ability to do bilateral chest decompression is just a bad idea. If you are going to call it, dart both sides of the chest before you do. Both the original issue and/or overaggressive ventilation can cause a tension ptx - a reversible cause of trauma arrest.


Other things include some meds.
Firstly, EPInephrine for anaphylaxis is a basic life support intervention that is standard of care. Period!
Again if you're 10 minutes from the emergency department when your patient has a life threatening anaphylactic reaction then you are 10 minutes too far from hospital.

Anaphylaxis is an immediately life threatening rxn that must be treated immediately, not 5-10 min (at best) later.
The world allergy association guidelines cite several papers demonstrating that failure to administer epi promptly was the single most common reason for death from anaphylaxis.
Further, the guidelines cite other resources that state the median time to complete cardio-respiratory arrest from food and sting allergies is approx 10-15 min. This is from initial antigen exposure to cardiac arrest.

The Dx is pretty simple (this definition for EMT-B/EMR- you can still have anaphylaxis if you do not meet this definition):

An illness consisting of cardiovascular instability (hypotension ) and/or respiratory compromise PLUS signs of an allergic rxn (e.g. itching, hives) or exposure to a suspected or known allergen is automatically anaphylaxis until proven otherwise.

Look up the world allergy association guidelines.

EPInephrine is a basic life support intervention for anaphylaxis. To get around the issues with people giving it when not needed, you use a checklist. These checklists work and are used by organizations such as Ontario's lottery and gaming corporation who stocks their medical kits in casinos with epi.

But it is unacceptable that in 2014 we are still fighting to get epi recognized as a bls lifesaving intervention...

EPInephrine is the standard of care for anaphylaxis. It is pretty much negligence to withhold this intervention from a pt suffering from anaphylaxis.

Next is meds such as salbutamol. Salbutamol is a very safe drug, is the standard of care for asthma exacerbation and other cases of moderate to severe bronchoconstriction.
Although like any drug there are risks, salbutamol is relatively benign, and the only major risks are tachycardia if given in excess and possibly hypokalemia w massive doses. Dosing is simple: 600-800 mcg q5 min x3 prn. Assess breath sounds in between each dose. Even if it was given in absence of bronchoconstriction, the any side effects are likely to be minimal.

ASA is standard of care for MI pts, this is a BLS skill and is negligence to not give in mi if indicated with no contras (which are few and far between).

Tylenol and advil are safe otc analgesics for minor to moderate pain and can be given together if no contras exist for each drug. When given only in one dose, the contras are few, namely allergies, liver or renal impairment, and for ibuprofen, major bleeding/peptic ulcers, pregnancy.

Glucagon is safe as a pcp drug and probably for EMR as well. Simple to use and gives tx option for severe hypoglycemia w/ unresponsive pt. BGL is a bls skill and should be in all providers scope of practice. If you can't figure out how to do and interpret a BGL, you shouldn't be practicing any form of medicine, even bls.

Benadryl and gravol are also very safe drugs that can play a major role in treatment of allergic rxns and nausea/vomiting, respectively. Again, very few contras to these drugs. Given IM or PO if the provider is not IV certified. Can be used by pcp medics and use by EMR level wouldn't be a bad idea.

Supraglottic airways are bls, when used after bls measures are inadequate or ineffective. Not having any backup for failed bvm ventilation is a bad idea.

Wow, thanks a lot for your input I appreciate it. I agree 100% with the epi for BLS. PCP and up should be able to give it for anaphylaxis without a doubt.

 

[MedicDelta]

The key thing to the Military is the population and location that these treatments are being applied to. A Med Tech (PCP-IV) in Canada cannot intubate but for the purpose of the mission in Afghanistan were trained and allowed to do so. Those guys and gals are not allowed to perform intubations now that they have returned to Canada. Same thing goes for Morphine, In Afghanistan the standing orders were more broad.
On the Population side your administering these procedures on a population of previously healthy, medically per-screened for disease, fit, 19-40 year olds. Not the Polypharmacy, multiple co-morbidity, or unknown history patient.
Finally there is a different demand in a wartime or military setting. It isn't routine daily care for a military medic to be performing these interventions, in the civilian world it is.

When my dad was a CF SARTech and he did his clinicals in the ER and OR(they have to have so many hours each year) he performed ALS skills such as endotracheal intubation. I don't know if it's the same for Med Techs but he could do everything he was taught in and outside of Canada. The training is now the same, but the difference with Med Techs and SARTechs is that SARTechs specifically operate inside Canada. But, they are PCPs with advanced skills they learn in the military.

 

[cprted]

Before we start adding drugs to the EMR scope, maybe the course should be longer than 15 days ...

Wow, thanks a lot for your input I appreciate it. I agree 100% with the epi for BLS. PCP and up should be able to give it for anaphylaxis without a doubt.

IM Epi for Anaphylaxis is in the PCP scope of practice.

 

[Av8or007]

I had meant to edit that (but could not get into the edit screen) to say that there are some things in the acp scope of practice that should be in the pcp scope of practice, and some things in the pcp scope that should be EMR.

Epi is very basic, is the standard of care for anaphylaxis and should be administered asap.

Those basic meds will likely make more of a difference that some of the current accepted bls interventions, which are not helpful and may be downright harmful.

 

[Av8or007]

Before we start adding drugs to the EMR scope, maybe the course should be longer than 15 days ...

True, but most of the meds i mentioned are very basic medications that have a very good benefit/risk ratio. Many of the stated contras/adverse effects are rare and if they do occur, manageable.

Besides, using EMR level epi as an example, the alternative is anaphylaxis and quite possibly death. The risks of epi are far outweighed by the need to reverse the distributive shock state.

These interventions ARE BLS, and can be taught safely and effectively. If the course is 15 days, then teaching BLS ABC's management, wound care, pt assessment, EVIDENCE BASED oxygen and SpO2, basic meds and symptom relief w/ BGL and evidence based spine care pretty much encompasses everything that WILL make a difference in the immediate prehospital care of the pt.

 

[cprted]

I think an Epi auto-injector would be the road to go with EMR.

 

[Av8or007]

I think an Epi auto-injector would be the road to go with EMR.

Agreed. Simple and easy. I was referring to the fact that in most places, epi autoinjectors are not even considered BLS and carried.

How you get the epi in isn't that important, it just needs to get in asap. Autoinjectors actually improve pt safety in some cases even with ALS providers.

I would leave it open for each service to choose whether to carry an autoinjector or amps and syringes, as some agencies would be willing to do the training for IM injection (which isn't rocket science).

What I'd like to see is a prefilled syringe similar to the diluent in a glucagon kit that contains 0.3 mg of epi. Giving the IM shot is easy, where people will screw up manual epi is on the math or drawing up a dose.

It would also be much cheaper.