Bringing Skills to BLS

[chovesh 1]

What skills would you like to see added to the EMT curriculum?

EMTs in Israel start IVs, in North Carolina they Intubate, in a number of states they use CPAP, in other places they use combitubes. Nasal Narcan is up and coming for ALS and potentially BLS. What do you think about adding skills for BLS and which skills would you like to see added?

[vtach39680 23]

What skills would you like to see added to the EMT curriculum?

EMTs in Israel start IVs, in North Carolina they Intubate, in a number of states they use CPAP, in other places they use combitubes. Nasal Narcan is up and coming for ALS and potentially BLS. What do you think about adding skills for BLS and which skills would you like to see added?

I would rather see a mastery of the skills they already have. and instead of giving them "tasks" and more skills I would like to see better overall clinical judgement and knowledge

[Danger 160]

I would rather see a mastery of the skills they already have. and instead of giving them "tasks" and more skills I would like to see better overall clinical judgement and knowledge

I agree, a lot of B's are really lacking on things like picking up on symptoms, medication correlations, etc., I myself am definitely not an anatomy expert. The only drug I'd like to see added to BLS is Albuterol neb w/o med control.

Maybe instead of adding a few more responsibilities and another week of class, they should consider making EMT-I less marginalized.

[Goose 188]

It will take years for any of this to happen, if at all (my thought is it will never happen). Why? Well, I don't want to burst anyones bubble but you can blame the volunteer system for that. You cant expect a vac or rescue squad to have members keep up with sticks or tubes or anything else. There just isn't enough dedication or call volume in all these agencies.god knows I wouldn't want them sticking or tubing me if they only do a job a month...

[NWFDMedic 58]

I agree, a lot of B's are really lacking on things like picking up on symptoms, medication correlations, etc., I myself am definitely not an anatomy expert. The only drug I'd like to see added to BLS is Albuterol neb w/o med control.

Maybe instead of adding a few more responsibilities and another week of class, they should consider making EMT-I less marginalized.

Personally, I think the state needs to go back to teaching EMT's, rather than trying to make the EMT class a class that everyone can pass. When I took my original EMT class up in St. Lawrence County, there was very little ALS to speak of, and when you did get ALS it was from another volunteer agency that could be up to 60 minutes away. They taught their EMT's assessment skills so when they requested ALS, it was needed and they also knew how to manage and continually assess patients over a long period.

Today we teach a lot of things in EMT class. Students are taught to ask a ton of questions but get little or no education regarding what the answers to those questions mean. The answer is always oxygen and ALS. While that is often the correct answer, many times if you don't have good assessment skills, you will miss the correct question or disregard the correct answer. I know, I've done it as a paramedic.

I am firmly against the use of Albuterol in the field without medical control, mainly because I've seen too many EMT's, medics, nurses, and even doctors give patients nebulizers and at the very least put them in harm's way. If you pull up on a 45 year old male patient with a significant asthma history, you hear wheezes, but then notice his B/P is 210/100, I don't think you'd be quite so willing to stick a treatment in his mouth without an IV line. I had a 50 year old female patient literally begging me for a treatment when she was in CHF because that's what always fixed her before. There are too many precautions with Albuterol and although they may not throw the patient right into failure, they can certainly make the situation worse.

[Guest MVFD334]

As an EMT-B, I would have liked to have scene more attention paid to pharmacology. There are to many times you are given names or come in possession of a pt's prescription, and they cant tell you what you are taking it for. ( We have the medics and they are informed, but times when they cant respond) I undersdtand there are a million names but possibly something to identify important ones. Because in class I remember being taught about asthma meds, and diabetic names but that was pretty much it.

[NYMedic37 22]

I would agree that EMT's need to develop better clinical judgement and common sense.

[chazEMT 5]

As an instructor, I can identify several areas where the cirriculum is lacking on things that are already touched on in the EMT-B course:

• D O C U M E N T A T I O N ! ! !
• Pharmacology (already mentioned) - touch more on different classes of meds, etc

Just to name two, there're other areas...

And there needs to be more accountability on the CICs...alot of EMT students get through this course who SHOULDN'T!! There needs to be more oversight, so we're weeding out those who try to glide through the class...no more SHOWING UP = PASSING/BECOMING CERTIFIED!!! No more instructors who say "You don't need to know this, there'll be a paramedic there who'll be responsible for the call." Let's get back to where the EMT-B can assess and treat a patient, and run a call competently, without having to look to a medic for approval first! Add THAT back into the EMT-B course, THEN start thinking about adding in more skills & topics!

[Guest feraldan]

Add the following:

- At minimum, double the hours of training required to become a Basic.

- Greatly expand the education of pathophysiology, anatomy/physiology and pharmacology.

- More intensive background check of potential EMT's.

- Require 100 hours of clinical rotations.

- More difficult state testing, both practical and written.

But wait, would that discourage a lot of people from becoming EMT's?

Yes. That's the point. Quality not quantity.

[Guest alsfirefighter]

I'm with my other experienced brothers...if there is one thing I'd like to see is for the curriculum to go back to teaching solid assessments and assessment based treatments. I think the balance they have now is fairly sufficient and many need to understand when its appropriate to utilize the skills they have now and what the proper indicators are for its use. For example albuterol. I've seen more patients who don't need it have it administered to them, like those hyperventilating and also when it was given prior to listening to the lung sounds.

[paratrooper75 41]

I agree, I think the best thing would be having EMTs that aren't medic dependant. It would be a good idea to spend more time on pathophysiology and recognizing symptoms. The most important tool a Medic has is the knowledge to correctly diagnose a patient. EMT's already have everything Medics have to make a diagnosis short of being able to read EKG's i.e. Stethascope, BP cuff, Pulse ox. That would be a good start.

[OoO 24]

The only drug I'd like to see added to BLS is Albuterol neb w/o med control.

You can administer albuterol without medical control as long as the patient does not have history of Angina, Myocardial Infarction, Arrhythmia or Congestive Heart Failure.

http://www.health.state.ny.us/nysdoh/ems/p...lsprotocols.pdf Page 102.

Am I missing something?

Edited October 28, 2008 by OoO

[Jybehofd 85]

I have to agree over the past couple of years the standard of EMTs has dropped. They need to address this and make them less medic dependent. More rotations could help... but i think there should be a min. standard of what EMTs see and treat before they get cleared like a medic.... and also hold the agencys responsible for doing a precepting time for the EMTs similiar to new medics so they don't just go out and do calls with a card that is still very wet. almost a mentoring system. Hey some people just can't do it and shouldn't be in the business and they should be let go or put into another area where there skills can be used.

Edited October 28, 2008 by Jybehofd

[JohnnyOV 2]

Add the following:

- At minimum, double the hours of training required to become a Basic.

- Greatly expand the education of pathophysiology, anatomy/physiology and pharmacology.

- More intensive background check of potential EMT's.

- Require 100 hours of clinical rotations.

- More difficult state testing, both practical and written.

But wait, would that discourage a lot of people from becoming EMT's?

Yes. That's the point. Quality not quantity.

down here in FL EMT-B go through a 250 hour course that includes almost triple the ride along time in either the EMS or Fire system + 3, 7 hour ER rotations and classroom time.

FL is more advanced in EMT-B skills as well, Combi-tube w/o med control, and other "advanced" procedures includeing ASA, albuterol and epi. I feel this gives the EMT-B more free reign and makes them feel more useful on a scene; plus they really know what they're doing after all the clinicals and ER rotations. Their programs are so good here, that right out of EMT school in Volusia County, you're basically garunteed a job with the county ambulance service.

[EMS Solutions 0]

It's hard to expect EMT B level providers to be better clinicians and less medic dependent when they only get 120 hours of training and 48 hours of ride time.

How can you give B level providers the ability to give NTG or albuterol when they don't have the training and knowledge to know what these drugs do, when they should be used and how they can effect a patient. A 1-2 hour "update" class isnt going to give them enough training to use these or any other advanced drugs or skills.

I dont think there is a dedication issue when it comes to the volunteers, but as mentioned above there is a call volume issue. This combined with a low educational standard makes it a poor mix to add anything to their skill toolbox.

Let's focus on what we do now, master that and then maybe we can move on to bigger things. Medics included.

[helicopper 1,050]

Add the following:

- At minimum, double the hours of training required to become a Basic.

- Greatly expand the education of pathophysiology, anatomy/physiology and pharmacology.

- More intensive background check of potential EMT's.

- Require 100 hours of clinical rotations.

- More difficult state testing, both practical and written.

But wait, would that discourage a lot of people from becoming EMT's?

Yes. That's the point. Quality not quantity.

I wholeheartedly agree with your point about quality over quantity! Everyone has proposed some meaningful changes and additions to the curriculum but doubling the hours and adding 100 hours of clinical rotations? That's probably going to make it an EMT-I course and then some, not necessarily a bad thing but it may become problematic.

As for skills such as endotracheal intubation and venipuncture (starting an IV), I could not be more opposed to making these basic skills. There are paramedics who cannot perform these skills often enough to be proficient - to make this a BLS skill without incredible continuing education mandates to insure proficiency will have people struggling with unmanageable airways in the field rather than getting on the road to more definitive treatments. Other airway adjuncts I'm in favor of but ET intubation is tough enough for the limited number of paramedics that we have.

Background checks are properly the responsibility of the employing agency but DOH does check for certain convictions to insure that someone is eligible for certification so I'd argue that that is already in place.

It's hard to expect EMT B level providers to be better clinicians and less medic dependent when they only get 120 hours of training and 48 hours of ride time.

To that I say nonsense! EMT's predate paramedics and before ALS services were so prevalent there were a lot of excellent clinicians and extremely qualified EMT's who took only an 80 hour EMT course and had 10 hours of ER "clinical time". EMT's use ALS services as a crutch (and agencies allow it - some even encourage) rather than developing their own decision making processes and clinical judgment. It's ridiculous.

I'm with my other experienced brothers...if there is one thing I'd like to see is for the curriculum to go back to teaching solid assessments and assessment based treatments. I think the balance they have now is fairly sufficient and many need to understand when its appropriate to utilize the skills they have now and what the proper indicators are for its use. For example albuterol. I've seen more patients who don't need it have it administered to them, like those hyperventilating and also when it was given prior to listening to the lung sounds.

What he said! Thanks, Tom, for putting it so succinctly!

Great ideas everybody! Keep 'em coming!

[chovesh 1]

When I originally posed the question I had CPAP in mind specifically. I agree we shouldn't throw skills at EMTs for no reason but there are times when a skill/therapy will greatly benefit patients. Let's take CPAP as an example: the first day on a vent costs $8000 and puts the patient at risk for a whole host of infections, with classic ET Intubation there is also the possibility of knocking out teeth and discomfort for a while after the tube has been removed. So the advantage for ALS is clear. What about in systems like NYC or Yonkers where ALS is not as readily available as it is in Westchester or Rockland. CPAP is a pretty low risk way for a provider to aggressively manage a serious respiratory patient, (I plan to investigate but will assume for now) CPAP maybe used by an EMT to treat serious respiratory distress when ALS is unavailable. Most of the protocols I've seen from states that have BLS CPAP require the EMT to request ALS.

I wholeheartedly agree with everyone else who has said EMTs need more patient assessment. I also agree quality over quantity, what good is having an EMT every ten feet if s/he doesn't know how to assess a patient and recognize emergencies. That is, after all, how the textbook describes the the job of an EMT--to recognize emergencies.

[50-65 205]

Pharmacology was mentioned several times. When I worked as an EMT for a private provider, we did mostly nursing home transports. Nobody likes these but if you take an interest there is a lot to learn.

One, I would read the med list that the NH would usually provide. After a while of comparing the med list to the medical conditions of the patient, you could gain an understanding of what drugs were used to treat what conditions. If I didn't know, I asked.

Secondly, NH transports were a great way to learn about disease processes. Most of these patients had multiple medical problems.

When I took A&P alot of it started making sense. Actually, A&P should be another area of focus for the EMT-B.

[helicopper 1,050]

When I originally posed the question I had CPAP in mind specifically. I agree we shouldn't throw skills at EMTs for no reason but there are times when a skill/therapy will greatly benefit patients. Let's take CPAP as an example: the first day on a vent costs $8000 and puts the patient at risk for a whole host of infections, with classic ET Intubation there is also the possibility of knocking out teeth and discomfort for a while after the tube has been removed. So the advantage for ALS is clear. What about in systems like NYC or Yonkers where ALS is not as readily available as it is in Westchester or Rockland. CPAP is a pretty low risk way for a provider to aggressively manage a serious respiratory patient, (I plan to investigate but will assume for now) CPAP maybe used by an EMT to treat serious respiratory distress when ALS is unavailable. Most of the protocols I've seen from states that have BLS CPAP require the EMT to request ALS.

I wholeheartedly agree with everyone else who has said EMTs need more patient assessment. I also agree quality over quantity, what good is having an EMT every ten feet if s/he doesn't know how to assess a patient and recognize emergencies. That is, after all, how the textbook describes the the job of an EMT--to recognize emergencies.

Um, Yonkers is in Westchester County and has full-time ALS - more often than not. There are going to be calls in every jurisdiction that don't get ALS sometimes. There are only so many medic units and if they're tied up with a prior call they're not available for the next one.

On the subject of endotracheal intubation, damage to teeth is a potential side effect but I think it is far less prevalent than you're implying. Another way of looking at is without the ET tube they'd be dead - if they get tubed and a tooth get chipped or "knocked out" they can visit the dentist when they get out of the hospital. Death vs. Dentist? I think I know which one I'd pick (maybe, I hate going to the dentist!).

The first day on a vent may be very expensive but the alternative is rather final. CPAP may be a great option but you seem to be pitting it against intubation. Both have their place and their usefulness. Let's hear back after you investigate and have more definitive answers about it. I'd like to know: cost of CPAP equipment, required training, required inspections/tests of equipment, cost of maintenance, cost of required training, limitations and contraindications, etc.

[firemoose827 324]

In my area there are too many EMT's that get pushed through the system, and allowed to "Pass" the exam, and the only reason is that we are so short handed for help...Its pathetic. I asked a new EMT to do an assessment on a PT, they took the Pulse Oximeter and put it on the pt's finger, than stared at me...WTF?!!

It all boils down to the instructors and how well they teach, and get the attention of the students and make it a fun learning environment, getting the students to participate and learn. The ones that just read verbatim from the slides and tell you to read umpteen chapters for the next class don't really get the material into the students heads, it puts them to sleep. I favor more of a hands on approach to training and feel it helps me understand the material better. But today, too many are being rushed through the system in order to fill the ranks with more EMT's to respond to calls that are not getting answered. Now you want to add more skills to the EMT Basic? Its a good concept, but I feel that what was mentioned earlier about getting the current EMT's to master the basics first is what is more important. Get the Basic EMT to be able to perform that patient assessment and recognize the signs and symptoms for what they are and treat them accordingly, AND transport to the "Appropriate" facility. Than...Maybe we can start to Think about adding more skills.

I believe the system is set up fine as it is, EMT-B, EMT-I, EMT-CC and EMT-Paramedic, if you want to start an IV and Intubate than take the Intermediate course, you want to push drugs take the CC or Paramedic. Keep it simple, master the basics, provide the care the patient needs. Just my Humble opinion! LOL

[Goose 188]

Again, this will NEVER HAPPEN. Doesn't anyone understand that? In a perfect world EMT-B should be the equivalent of an EMT-I. But, that will never happen because the volunteers have this state by the family jewels. Listen, i really hate to say it but thats where the problem lies. There are just too many volunteers with too little experience and call volume for the state to EVER consider allowing basics to give any more medication or preforming invasive procedures. There is just no way they could keep up with sticks, tubes, and the additional education needed. Look at Albuterol horror stories people are talking about in this very post....it's not exactly rocket science to know when your patient meets and does not meet the criteria for the medication...do you want these people starting IVs, administering CPAP, and giving additional meds???

[JohnnyOV 2]

I am firmly against the use of Albuterol in the field without medical control, mainly because I've seen too many EMT's, medics, nurses, and even doctors give patients nebulizers and at the very least put them in harm's way. If you pull up on a 45 year old male patient with a significant asthma history, you hear wheezes, but then notice his B/P is 210/100, I don't think you'd be quite so willing to stick a treatment in his mouth without an IV line. I had a 50 year old female patient literally begging me for a treatment when she was in CHF because that's what always fixed her before. There are too many precautions with Albuterol and although they may not throw the patient right into failure, they can certainly make the situation worse.

If you read in the NYS protocols, there are no concrete contradictions to the use of albuterol, except for prior heart problems in which you only need to contact medical control for administration approval. What precautions are you referring to in your post? I currently have my EMT book open and cannot find any.

I'm not a paramedic, so if you can explain why a BP of 210/100 is a deterring factor for the treatment of significant asthma history and the presence of wheezing when you listen for lung sounds, it would be appreciated.

Edit: Answered my question here, wasn't found in any NYS protocol or the EMT book, so I'm wondering how much does it increase the BP by in general?

I have the Volusia county (FL) protocols open and it lists the contradictions and side effects listed here:

Copied directly from the ALS protocols

Classification

1.1. Bronchodilator

2. Indications

2.1. Treatment of bronchospasm in patients with reversible obstructive airway disease and acute attacks of bronchospasm.

3. Precautions

3.1. Albuterol should be used with caution in patients with cardiovascular disorders.

3.2. If paradoxical bronchospasm occurs during delivery of this medication, discontinue treatments immediately.

3.3. Albuterol should be administered extremely cautiously to patients being treated with monoamine oxidase inhibitors or tricyclic antidepresents as this may potentiate the cardiovascular effects

3.4. Beta-receptor blocking agents and Albuterol inhibit the effect of each other.

4. Contraindications

4.1. Known hypersensitivity to Albuterol or any of its components.

5. Adverse reactions/Side effects

5.1. Cardiovascular: tachycardia, hypertension.

5.2. Central nervous system: tremors, vertigo, nervousness, headache.

5.3. Gastrointestinal: nausea.

5.4. Respiratory: bronchospasm, cough

Edited October 29, 2008 by EMSJunkie712

[Goose 188]

I don't want to speak for NWFDMedic, but here is what i think he MAY be talking about:

- there is a danger of inducing flash pulmonary edema if you give it to someone with even mild CHF

- albuterol increases heart rate and can put undo stress on an already stressed and oxygen deprived heart/circulatory system even though its a short term beta 2 agonist

Those are the two big issues i can think of off the top of my head. I think a lot of EMTs hear diff breather or listen to breath sounds and hear something and default on Albuterol. Thats when you have major issues (the two i stated above can be deadly).

Not sure if thats what he's referring to specifically, but those are two major problems i can think of.

[Guest MVFD334]

Again, this will NEVER HAPPEN. Doesn't anyone understand that? In a perfect world EMT-B should be the equivalent of an EMT-I. But, that will never happen because the volunteers have this state by the family jewels. Listen, i really hate to say it but thats where the problem lies. There are just too many volunteers with too little experience and call volume for the state to EVER consider allowing basics to give any more medication or preforming invasive procedures. There is just no way they could keep up with sticks, tubes, and the additional education needed. Look at Albuterol horror stories people are talking about in this very post....it's not exactly rocket science to know when your patient meets and does not meet the criteria for the medication...do you want these people starting IVs, administering CPAP, and giving additional meds???

Goose you really dont hate to say anything.. Especially when it comes to the volunteer ems world.

[DDixie 12]

After reading many of the posts, I too think that the EMT class needs to return to a focus on pathophysiology of disease. Today, EMTs are simply taught what to do for what they see or find. For example, any/all breathing problems or chest pain get oxygen. This is simply a "catch-all" to make sure that patients are receiving some kind of treatment at the BLS level. However, there is no (little) training to educate students on how that patient became sick. This is simply the fault of the current EMT curriculum. One post referred to the need for better education on pharmacology. I couldn't agree more! Many of us know that a patient's list of medications is a window looking in on their medical history and a big clue as to why they may presently be sick. Far too often I watch BLS responders simply write down medications, unsure how to spell them and definately not sure what most of them are for. Even though we are not suppose to "diagnose" our patients, medication lists commonly aid us to correctly treat a patient in the field and make them feel better. The general purpose of EMS is to make patients feel better and bring them to the hospital. It is hard to do both of those things when you don't understand why the patient doesn't feel well to begin with. But anyone can be an ambulance driver and simply bring someone to the hospital. Accomplish both tasks together with compassion and that is the epitome of quality EMS.

[ny10570 745]

Get back to assessment. Start EMT's on the path to being clinicians and get them back to treating illnesses rather than symptoms. The only skill I'd like to see added is combi-tube or other like device for cardiac arrest. Endotracheal Intubation is a skill many 911 medics have a hard enough time staying proficient in. How could you expect EMT's to be able to keep their skills up? Besides Intubation may be on its way out in the pre hospital setting. There was a city that I can't remember the name of now that was looking at switching entirely to the King Airway and eliminating Intubation.

[ckroll 101]

I'm with those who advocate less is more. Even the AEMT written... and practical..... is half BLS. EMT-B and AEMT ought to focus on assessment and history. Many 'emergencies' can be adequately addressed in the field with oxygen and patient positioning.

I had the pleasure of working with a Yorktown BLS crew recently. By the time I got on scene from out of district, the patient was packaged, in the ambulance, a full history had been taken and the 'not well' patient had been evaluated for stroke, ruled out, and the EMT was anxious for me to test blood glucose as he had narrowed his impression to low blood sugar, which it was. Solid, professional basic skills can add as much to level and timeliness of care as ALS.

BLS and ALS alike need to respect the importance of solid basic skills. Good basic care is a craft which we all know when we see and work with it. I'd like EMT-B's to focus on /add pride, thoroughness and confidence.

[firemoose827 324]

Get back to assessment. Start EMT's on the path to being clinicians and get them back to treating illnesses rather than symptoms. The only skill I'd like to see added is combi-tube or other like device for cardiac arrest. Endotracheal Intubation is a skill many 911 medics have a hard enough time staying proficient in. How could you expect EMT's to be able to keep their skills up? Besides Intubation may be on its way out in the pre hospital setting. There was a city that I can't remember the name of now that was looking at switching entirely to the King Airway and eliminating Intubation.

What is the King Airway? I have never heard of this tool and Im curious. Is there a link to a site or information? Thanks!

[NWFDMedic 58]

I don't want to speak for NWFDMedic, but here is what i think he MAY be talking about:

- there is a danger of inducing flash pulmonary edema if you give it to someone with even mild CHF

- albuterol increases heart rate and can put undo stress on an already stressed and oxygen deprived heart/circulatory system even though its a short term beta 2 agonist

Those are the two big issues i can think of off the top of my head. I think a lot of EMTs hear diff breather or listen to breath sounds and hear something and default on Albuterol. Thats when you have major issues (the two i stated above can be deadly).

Not sure if thats what he's referring to specifically, but those are two major problems i can think of.

Well, half a month later... agreed. All that wheezes is not asthma. I have gone into a nursing facility with an RN on duty that gave me a great story about a patient in CHF on the way to the room and then told me she had the patient on a treatment. The first thing I asked the patient when I reached her and pulled the treatment out of her mouth ... "Was the treatment making your breathing better or worse?" She answered "Worse". Now, if an RN can do that, I don't think we can even expect an EMT with a 120 hour course not to make the same mistake. It doesn't speak to the EMT's abilitiy; it speaks to the level of training.

[ny10570 745]

Moose, when in doubt hit up the google. http://www.kingsystems.com/PRODUCTS/Airway...79/Default.aspx

Its a supraglottic airway device, comes in 3 versions. Reusable, disposable and a new disposable one with some added bells and whistles.