More BLS Medications

I have been writing about medications or interventions I believe BLS could be doing safely with approval of their medical oversight. To date, in the approve category, I have Epi-pen, ASA, Zofran ODT, and IN Narcan.

Today, I am adding Benadryl and Tylenol PO. These are over the counter meds that unfortunately many people don’t have access to either because of money or circumstance and having an EMT there to start making a kid with a fever or someone with a rash start to feel better on their way to a likely hospital waiting room, I think it is a good thing. These are low risk medications with the reward of making people feel better. It doesn’t take a lot of training to be able to understand when to give these meds. Many of us give them to our kids at home.

I am also adding to the list Glucagon IM in the form of a preloaded syringe. I would make the indication for confirmed hypoglycemia with inability to protect the airway. There has been talk recently of IN glucagon, but I do not favor this favor. IN absorption is not as reliable as IM, and it requires double the dose. At $80-$100 a pop, I don’t see the utility of IN glucagon. If someone is in insulin shock, they need as reliable a method of administration as there is. Absent an IV for Dextrose administration, that would be IM Glucagon.

Now some say EMTs should not be doing invasive procedures, and an IM med is invasive. I think the invasive procedure distinction is artificial. The sole distinction should be risk versus benefit. If the risk is minimal and benefit is large, then I am for it. I think that is true in this case. The fact of the matter is whether in a big city or a rural township, unless there is a paramedic in every ambulance, BLS is going to walk into calls where patients are in insulin shock, and without glucagon, they have little choice but to bag and drag and call for a medic who may not be available.

BLS in many areas can give Epi-pens. Epi-pens are invasive, but they are also life-saving. Preloaded Glucagon syringes may not be as dramatic as Epi-pens when it comes to saving less, but they are also considerably less harmful if given to the wrong patient.

Writing this series is helping me shape my thinking on this issue of “What BLS Should Be Doing Now.” In one of my next posts I will address an interesting conversation I had about the unintended consequences of enhancing BLS. Other posts will address the remaining medication options – pain and anti-seizure meds, breathing treatments, and NTG SL for BLS, and I will also later be addressing interventions for BLS. I will wrap it up with an EMS vision for the future.

Stay tuned.

11 Comments

  • BH says:

    No need for a pre-loaded Glucagon syringe- our state’s EMTs have had regular Glucagon (that requires mixing) for longer than I’ve been in EMS with no issues.

  • Christopher says:

    I believe it is safe and prudent for EMS systems to enable all levels of providers to administer OTC meds if indicated and part of a protocol. If the patient can self medicate without an Rx, why should an EMT have to call for orders?

  • Benjamin Harris says:

    I think that a person suffering from acute asthma, vomiting, or an MI can present remarkably the same, and if you can’t tell the difference between them, you shouldn’t be giving Albuterol, Zofran, or ASA. What, the $12.00 an hour you’re paying ALS providers is just too much? You won’t be happy until you can provide the illusion of EMS coverage with an 18 year old at minimum wage? Have some sense of decency, will you?

    • medicscribe says:

      Hi Benjamin-

      I disagree with you the safety of giving Zofran and ASA. Very little risk with these two drugs. The question is also availability of medics. The fact is BLS often has to treat patients all the way to the hospital because there are no medics available to respond. Read the posts. You do have a point with albuterol and I will be addressing that in a future post. This drug is often missuded even by medics. You also raise an interesting issue about the illusion of coverage. I will be writing a post about the potential drawback of giving BLS a number of these meds. While the meds will provide better care to the patients BLS is seeing, it could have the drawback of preventing communities from updgrading to paramedic. That would be unintended harm. As far as the wages, I know you are being facetious, but the pay for medics and BLS is considerably more where I’m from.

  • Benjamin Harris says:

    Medic, there is very little risk in giving Zofran or ASA. There is a huge risk in taking someone who is cool, pale, and diaphoretic and trying to get them the right treatment with someone with 120 hours of first aid training and some CME. You can be cool, pale, and diaphoretic from vomiting and need Zofran. You can be cool, pale, and diaphoretic, and vomiting, from an MI and need a 12 lead, ASA, and rapid transport to a PCI center. You can be cool, pale and diaphoretic from a lot of things, and simply giving someone some mnemonics and sending them out to treat the critically ill, no matter how you justify it, is the wrong thing to do. I wish I was being facetious about medics making $12.00 an hour, but check the ads sometime, I’m not, and as long as people continue trying to dumb it down and water it down, those wages aren’t going to change.

    • medicscribe says:

      Yes, cool, clammy and vomiting can be a sign of an MI. The patient needs a paramedic. But if no paramedic is available, getting ASA and Zofran ODT from an EMT is beneficial to the patient. It is better for the patient to get these simple meds than it is for them not to get them. There is also little risk to the patient getting these meds and there is demonstrated benefit that far exceeds the risk. A 120 hour class ought to be able to have space for teaching these meds, and if it is not taught in the class, they can be taught in a simple CME session. I will point out I only advocate letting BLS give these with sponsor hospital direction. In Connecticut, that does not mean on-line contact is needed. It only means that the service’s medical director (in Connecticut the medical director is from the sponsor hospital, not the EMS service) approves.

      As far as salaries, I am sorry the pay is so low where you are from. Here, EMTs make $17-$18 to start, medics $21-$22 to start.

  • Sean Brooks says:

    How about some BLS 12-lead preloaded vest telemetery to a physician cardiologist (rather than a vo-tech or even community college paramedic so you can r/o MI prior to albuterol?

    There is no future for field clinicians. There’s just not a market for that level of training in the prehospital setting, at least not enough of one to make such care widely, quickly, and reliably available. There may be a market for a few field clinicians, but that market can be readily covered by PAs and NPs. On the coasts, fire-medics are making almost as much as entry-level PAs.

    A tiered system would work, “hi-low” patterns exist everywhere. However, in EMS, the distinction is blurry until we get there. We *might* be able to designate half of the calls as probably BLS over the phone, but that still causes an ALS dispatch for the other half, which means we need a lot of ALS.

    We need to move the traditional ALS/BLS split well to the advanced side. It should be an EMT/PA split or EMT/NP split, and it shouldn’t be anywhere near 50:50 on the dispatch – it should be at least 80:20, if not 90:10 on dispatch. This means that we need to make EMTs able to handle, in a field-definitive manner, the vast majority of the dispatches, and that means making “basic” EMTs able to handle and administer a wide variety of low-risk, high-payout treatments. I suggest this would include those treatments that can be made low-risk with repetitive training, which, imo, would include IV, IO, and blind airway devices, and possibly PTJV. This means that all 911 EMT look like watered down Ps, or the largely defunct Intermediates.

    In short, 911 EMTs need to be technicians, but high-level technicians.

    • medicscribe says:

      Great post, Sean. I agree with much of what you write here. I particuarly like the concept of higher level technician. I will be addressing my vision for the EMS future as far as distribution of ALS/BLS in a future post at the end of this series. Thanks again.

  • Benjamin Harris says:

    There are two major forces behind this push to put invasive procedures and more medications in to the hands of people with 120 hours of training and a driver’s license. The first force is fire departments, who, after finding their jobs being replaced by smoke detectors and automatic sprinklers, are looking to snatch up prehospital care. The problem is that paramedics are more expensive to maintain and replace, and so they are doing everything they can to give the illusion of proper prehospital care at minimum expense, so they can get some of that Medicaid pie.
    The second force is private, for-profit medical organizations who figured out they can still bill ALS1 rates while paying EMT salaries if they convince those EMTs to pick up the shiny tools and not ask too many questions when they do.
    Now, they can pretend that this is to further benefit public health, but it isn’t. If they were at all interested in making sure the people covered got proper medical care, they would hire fully trained paramedics and pay them a livable salary.
    In the mean time, they will continue to play this game, find some young shiny EMT who wants to the fun things, give him or her a few syringes, and send them out into the field hoping for the best. If it goes right, they get paid the ALS1 rates, and if it goes wrong, they can just let them go, and throw the next one in. If you really feel like putting yourself and patients at risk so someone can have a few more percentage points on the profit margin or reimbursement rate, that’s your decision. Just know that even with all of the equipment, training and capabilities available to the most advanced prehospital or even in-hospital provider, seemingly simple vomiting presentations, or wheezing, or just general malaise, can and often do go sideways into a critical patient, and when that happens, it is not fair to the patient or the provider to only have someone with 120 hours and a few seminars there to treat it.

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Peter Canning

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