Calling all PA EMTs!

[djmedic913]

IMHO, albuterol has been a nightmare more often than not in many instances, and that problem extends beyond my services. More BLS providers have been cited and/or faced remedial training for improper application and actions concerning albuterol.

Remedial training after the fact is too common (obviously necessary). It's VERY difficult to train an EMT in the specific MOA, indications, contra, side effects (etc) when they have no true formal education in A&P; it's not fair to either party, mostly concerning the pt. It's like beating a puppy for pissing in your bed when you haven't taken the time to properly train it to go outdoors...

Some of the more common problems encountered range from:

Canceling medics in a non-judicious manner for SOB events, because "albuterol will fix it".

Pts being given albuterol simply because it was an option.

Pts receiving albuterol (sometimes multiple..) who were immediately recognized by receiving facilities as having cardiac wheezes with other gross presentations of CHF symptoms. Those calls from facility staff are always fun. :sad:


If the choice to give it to BLS ever came up again, it'd most likely be shot down. However, there are many BLS providers that know better... and perhaps the added scope will be another inch in the push towards expanding the curriculum?

I agree. I believe that BLS/ALS should remain non-invasive/invasive. I am not trying to be mean, rude or condescending. As I recall from Basic class in PA, I was not taught as to what medications do, how they work, etc. Anyone capable of giving a medication in a therapeutic capacity (EMS, ER, etc) an "antidote" (I know some ppl hate this term) and able to reverse any adverse effects to that medication. Every med we carry on the ambulance, we carry a reverse for it. I understand Patients can administer albuterol themselves and EMT's are allowed to assist the Pt with their inhaler. The reason for this is generally the Pt is more knowledgeable than we are in these matters. They know what "their" asthma attacks feel like better than anyone else...coz, well it is their body and they know their body better than we do.

Blood Glucometry.

Combi-Tube.

That's about it, really. Can't do much more without increasing the overall educational standards. Possibly nitro, but only with online medical command.

Edit: When I say "possibly nitro" I meant to be carried on the trucks. PA EMTs are already allowed to administer one dose of nitroglycerin to a patient with chest pain without online medical direction if it is the patient's own prescribed nitroglycerin and the patient hasn't already used it, the patient's blood pressure isn't too low, and the patient hasn't used ED drugs in the past 7 days. Additional doses require online medical direction.

Nitro shouldn't be given without an IV and 12 lead on board. I'm suprised people are allowed to self medicate with it's potential to bottom out pressure.

I agree Sasha. Nitro should never be administered without an IV. the pre-Nitro 12 lead is nice to have if possible. but 1 Nitro can dump a patients pressure and no IV in place 1st, then you have to scramble. As for the rule of SBP of at least 100...it is still open to interpretation. Example: I had a Pt (lil old lady) with chest pain and a SBP of 180. I had a line and 12-lead, gave ASA and 1 Nitro. The nitro dumped her pressure to SBP of 110 and still having chest pain. needless to say I withheld another Nitro, coz I know it would dump her waaaay too far. she was put on a drip instead.

A glucometer darn well better change your treatment.
As for NTG, each place differs in systolic BP contraindiciations. Some say nothing below 90, others say nothing below 100.

Yes, glucometers can be calibrated wrong, but you can't discount every reading as "wrong" when making a determination, otherwise there'd be no point in having one. Same as with a pulse-ox. It ALONE shouldn't change how you do things, but to say it doesn't change how you treat something is ludicrous.


Someone falls. Do you give them glucose right away, or do you do a d-stick to possibly rule out hypoglycemia? My money is on the latter, and as such, it just changed your treatment, by making you look at other possible causes if the BGL is "normal"



AMS can be caused by a heckuva lot more than just low blood suger, and the sooner you rule it out, the quicker you can move on to other causes.



And guess what. That glucometer just changed your treatment.

the question is BLS having a glucometer and how will that change the BLS treatment. Other than recognizing the most likely main cause of the problem...what will knowing the BGL do to change the treatment?

If BLS encounters a conscious Pt with the ability to swallow safely with a little altered mental status, or "not feeling quite right", etc, giving a diabetic 1 tube of oral glucose will not cause any harm if they were really hyperglycemic.

So Linuss, how does knowing the BGL, change the BLS treatment other than calling for ALS back-up?


PS -->I got my 1st responder and original Basic in the Allentown, PA at LCCC. and I will be applying to reciprocity for PA Paramedic.

 

[Sasha]

I agree Sasha. Nitro should never be administered without an IV. the pre-Nitro 12 lead is nice to have if possible.

Don't right sided MIs have a greater potential for nitro to bottom out a patient? Not that it should be withheld but it would be a nice thing to be aware of beforehand.

 

[ResTech]

If I understand correctly, patients with (R) sided MI are preload dependent and the vasodilation from the NTG decreases that preload causing hemodynamic instability that your gonna have to treat with a fluid bolus or Dopa/Dobutamne.

 

[djmedic913]

Don't right sided MIs have a greater potential for nitro to bottom out a patient? Not that it should be withheld but it would be a nice thing to be aware of beforehand.

If I understand correctly, patients with (R) sided MI are preload dependent and the vasodilation from the NTG decreases that preload causing hemodynamic instability that your gonna have to treat with a fluid bolus or Dopa/Dobutamne.

Actually a right sided MI is a contra indication for Nitro because Nitro decreases preload. and Nitro in right sided MI can put the Pt into arrest. hence the 12-lead. the 12-lead will show reciprocal changes on the standard 12-lead. so then you can do a right sided 12-lead.

sorry for hijacking the thread.

 

[reaper]

You have a study to back that up? NTG is not contraindicated in a Right sided MI. You use caution, with fluid administration. A Right sided MI will need fluids. Depending on how unstable they are, will depend on the fluid need. I have given upwards of 4L on a right sided MI, that was unstable.

You still give NTG, you just have to balance it with more fluids.

 

[CAOX3]

Don't right sided MIs have a greater potential for nitro to bottom out a patient? Not that it should be withheld but it would be a nice thing to be aware of beforehand.

<Moderator's snip>

Sure it can, its also a clinical sign?

JVD, hypotention and clear lung sounds. Ringing any bells?

Sometimes there will be no EKG changes in early stages RVI.

As far as the question, I don't believe EMTs should be giving albuterol treatments unless the patient is diagnosed with asthma.

Half the medics cant figure out when to give it, there just a little more brazen because they have the ability to give lasix if they guess wrong. They will even use it to diagnose it, which is a little F'Ked up in its own rite.

Glucometers and pulse ox's, whatever I don't care about diagnostic tools. You should however be able to do your job without them.

EMTs don't need expanded scope, they need anatomy and physiology. Then again why would you require it for EMT when most of the medics don't have to take it.

 

[djmedic913]

You have a study to back that up? NTG is not contraindicated in a Right sided MI. You use caution, with fluid administration. A Right sided MI will need fluids. Depending on how unstable they are, will depend on the fluid need. I have given upwards of 4L on a right sided MI, that was unstable.

You still give NTG, you just have to balance it with more fluids.

you are correct. Not really contraindicated...a LOT of caution needs to be taken with Nitro in a right sided MI

 

[VentMedic]

I didn't even think of albuterol, but thay is a good one. Fortunately, where I live ALS isn't too far behind, but it would still be nice.

As for CPAP, I like the fact that it is in our scope of practice but we have to be trained on it, and I haven't ever seen a class for it available.

Why are you trying to extend the EMT? More skills and little education is not the way to improve EMS.

Also, as mentioned in many of the other threads, to adequately provide even who you consider just another "skill" usually needs other advanced "skills" to perform that one skill.

To give albuterol, one should have some pharmacology knowledge, cardiac monitoring capability to sometimes determine if that higher HR could actually be the cause of the wheezes and the capability to do a decent cardiac assessment which the EMT curriculum does not provide and would be difficult to obtain in a 2 hour skill "training" session. Even patients diagnosis with asthma and especially COPD will also have cardiac issues either existing or new onset which can be particularly dangerous.

For CPAP, one should have the ability to invasively clear a patient's airway before application and once the CPAP is started if their stomach is sensitive to any air that might cause them to vomit and aspirate. It is a little more involved than just sticking a rigid suction stick to their tonsils causing more vomiting by stimulating the gag.

As well, you should be able to correct the hypotension you may cause with even a little CPAP.

reaper has already described what should be done with NTG.

Thus, you can not or should not just add "a skill" without the possibility of adding others.

For every action there can be a reaction which you must be able to handle.

It seems some want to be like a Paramedic but without the education and responsibility.

 

[VentMedic]

Nothing personal, but an uneducated paramedic is going to do far more damage over the length of a career then an EMT will ever do. Just something to think about.

Possibly...but where does that justify not providing any care other than a speedy trip to the hospital at the BLS level? Providing very little care is not always the best care but, yes, you can say at least you didn't give the wrong med. However, how can watching a patient deteriorate in the back of your truck without being able to do much more than speed and O2 not be causing damage? I can also refer to my statement where EMT-Bs want some of the cool "skills" of the Paramedic but believe as long as they don't have the Paramedic patch they are not "as" responsible and can not do any harm. Afterall, the states says they can.

 

[ffemt8978]

Unless this thread takes a dramatic turn for the better before I get home from work, I'm going to be very busy tonight.

 

[trevor1189]

Can we just get back on topic please. I was looking for input on things you would like added to the BLS scope in PA. Not a thread for everyone trash each other.

I don't understand why treatments can't be added to a BLS scope with further education. Just like CPAP, it is in there but because I have not been taught on it, I can't use it.

All I was trying to do with this thread is see if there are skills other states allow EMTs to do that we can't do in PA, not create a thread to bash each other. Keep that in mind please.

 

[Sasha]

Narcan IN?

Glucometers?

I was originally on this train of thought about narcan, due to potential benefits, until I read up on it. EMTs are not equipped to deal with the possible adverse reactions of Narcan admin.

 

[VentMedic]

<Moderator's snip>

I don't understand why treatments can't be added to a BLS scope with further education. Just like CPAP, it is in there but because I have not been taught on it, I can't use it.

The point some are missing is that you can not add just "one skill" without taking into consideration that that skill may present with the need to have additional advanced skills.

Since you again mentioned CPAP, let's go with that.

To apply CPAP you should be able to clear the airway of mucus, food and vomit. This may require what some call "deep suctioning". I do not know of any EMTs that are taught that. As well, if you do cause further airway compromise, you may need to intubate. CPAP can also cause a reduction in venous return which will drop the BP so you should be able to pharmacologically support the BP.

So it is difficult to look at one individual "skill" without realizing the complications and the need for additional skills. And let us not for get the education which that can go with what I previously stated with albuterol and the argument I just had with ResTech about Atrovent. If you truly do not understand the meds, you can do harm. If you ignor the warnings placed on the insert about the manufacturer's stance for indication and interactions, you can do harm. If you are not able to recognize the various medicines and medical conditins that can cause a reaction with the medication, such as albuterol, you can do harm. So it is a little more than just putting some liquid into the nebulizer and turning on a flowmeter. Again, that is where the education comes in and the knowledge to know that this patient receiving the medication may need a cardiac monitor. If you have a cardiac monitor, you will then need to know how to identify the rhythms and so on and so forth. None of these "skills" should be looked at as one "individual skill".

As well, one can look at the long list of "certs" that Washington State and a few others have to see what a mess just adding one skill can do for the 50+ different EMS "certs" in this country.

Advance your education to the next level and stop promoting this piece mill crap that has gotten EMS into the mess it is today.

 

[Chimpie]

Unless this thread takes a dramatic turn for the better before I get home from work, I'm going to be very busy tonight.

Actually, there are several CLs watching this thread now.

I have just removed 40 off topic posts from this thread. Let's keep it on topic from now on.

 

[Jon]

Wow... I missed this whole party!

Anyway - as the PA EMT certified CL... a few thoughts.

First - EVERYONE functioning at the BLS level in PA DARN BETTER know the PA State Protocols: http://www.dsf.health.state.pa.us/health/lib/health/ems/pa_bls_protocols_effective_11-01-08.pdf

Second - There are SEVERAL optional protocols in the PA Protocols, including:
Pulse Oximetry, Primary Epi-Pens, and CPAP

BLS "assisting" with Nitro is no worse than the patient taking it themselves... and we've said that's OK for years.

As for MY answer - I'd love to see Glucometry - because that is actually a useful diagnostic tool for altered LOC patients... and I think that it can't be used any worse than SpO2 readings are.

Additionally - did anyone realize that SpCO isn't in our protocols in PA? At ANY level? Maybe Masimo needs to petition the state to allow it before they convince more FD/EMS agencies to spend money on them

 

[VentMedic]

BLS "assisting" with Nitro is no worse than the patient taking it themselves... and we've said that's OK for years.

I don't think anyone has a problem with an EMT assisting a patient to take their own meds. It is when they want to carry it and give it to anyone with chest pain that there is an issue.

As for MY answer - I'd love to see Glucometry - because that is actually a useful diagnostic tool for altered LOC patients... and I think that it can't be used any worse than SpO2 readings are.

Additionally - did anyone realize that SpCO isn't in our protocols in PA? At ANY level? Maybe Masimo needs to petition the state to allow it before they convince more FD/EMS agencies to spend money on them

If one is having trouble with SpO2 readings then maybe it is time to stop and do some education before taking on another skill.

Masimo would probably love the extra sales but may not want to stick their neck out if the SpO2 monitor is still a big mystery to some.

 

[Jon]

I don't think anyone has a problem with an EMT assisting a patient to take their own meds. It is when they want to carry it and give it to anyone with chest pain that there is an issue.




If one is having trouble with SpO2 readings then maybe it is time to stop and do some education before taking on another skill.

Masimo would probably love the extra sales but may not want to stick their neck out if the SpO2 monitor is still a big mystery to some.

Vent...

I guess my comment on SpO2 was that I see some BLS providers that don't seem to know how to take a pulse if the SpO2 machine won't give them a number.

Additionally, we both know that to some extent, some amount of the current BLS providers don't understand what the numbers actually mean... and will withhold O2

As for Masimo - they have already sold many of them within the state... but who can use them?

 

[timmy84]

I guess my comment on SpO2 was that I see some BLS providers that don't seem to know how to take a pulse if the SpO2 machine won't give them a number.

I agree with this one big time. Not just BLS providers in EMS, but nurses, paramedics in the ED, and other health care 'workers'/professionals. We have a big problem when our providers loose the ability to count while looking at a second hand (you see the key is to count the pulsation, not the seconds).... if you count for an entire minute you don't even have to bother with the laborious task of multiplication! LOL... but seriously it seem's like basics always want to add skills to their scope on these forums, yet do not want to master the skill of taking a pulse. (or even if they master taking a pulse, do not want to bothered with all the time consuming counting). Just my casual observation.

 

[boingo]

I was originally on this train of thought about narcan, due to potential benefits, until I read up on it. EMTs are not equipped to deal with the possible adverse reactions of Narcan admin.

They hand it out to addicts and outreach workers, in addition to BLS crews here, not a single documented bad outcome in the past 3 or 4 years.

 

[djmedic913]

Does anyone actually need a SPO2 to tell if the Pt is truly having difficulty breathing? And if the Pt is having SOB, does it matter what the percentage is, they are going to get O2 to anyway. a room air sat makes the ER happy. Ever notice you can a Pt in distress and they want to get a room air sat on the Pt?

I agree that the pulse ox ends up causing lazy Basics...I am very against pulse oxes for Basics for that reason.

In a tiered system, I understand that many Basics get to tech a lot of the BS, the psychs, the "stubbed toes", etc, or they can only do general transport work, like return to the nursing home, dialysis runs. Every time a new Basic comes to my company I talk with them. Basics can only do the IFT work only (I think that stinks for them). I explain to them, if they seem serious about EMS, that they now have a great opportunity to practice their new skills. listen to lung sounds (the normal they hear, the better they recognize abnormal), take BP's while in transport (use your scope, and get a systolic and diastolic BP instead of by palp), etc.