Where I Stand (Today)

I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student’s own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service’s medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again.

17 Comments

  • Jon LeRoy says:

    Great discussion starter, and agreeably an emotional topic. As a BLS provider of 16 years and training director for a BLS agency, I’ve been “warning” our EMTs that change is coming, and many of them are uncomfortable.

    NYS, like CT, requires Epi-Pens and aspirin on all ambulances, regardless of level of service. CPAP at the BLS level is in a pilot study right now and from what I’m hearing, will most likely be introduced state-wide soon. Locally, we’re also hearing that IN Narcan may be coming our way soon. Who knows what’s next?

    Thanks for a great posting; I hope to hear more on this subject in the near future!

  • Andy says:

    It’s funny. While this discussion has been going on here, my 3 year old has become obsessed with “Emergency!”, which is on Hulu now. We watch it repeatedly now, like she used to watch Dora, so I’m starting to memorize the episodes. The theme song plays in my head whenever I respond lights & sirens to a call.

    In the pilot, the lead doctor is dead-set against allowing paramedics to exist. He even says he didn’t go to school for 12 years just to let some guy with few classes practice medicine in the field. He says only doctors should be allowed to do medicine.

    I hear this same argument all the time, and the corollary that if we allow EMTs to do more advanced skills, then services won’t go paramedic. Same thing with people being against volunteer firefighters… if we allow volunteers, then towns will choose not to hire paid departments.

    But in many places, especially rural, it isn’t a choice. There isn’t ever going to be a possibility for a paid fire department in East Podunk. And that town that gets 1 EMS call a week isn’t going to have 24/7 paramedics. Even the private, urban companies can’t staff enough paramedics to cover some nights.

    In the end, the doctor comes around grudgingly. He makes a speech, saying that yes, ideally he’d like to see a doctor be dispatched to every person who calls for medical assistance. But that isn’t feasible. It’s the same here. Yes, ideally every ambulance would be ALS, and every fire department would have paid staff 24/7. But it isn’t going to happen any time soon. So in the interim, lives can be saved if EMTs can offer interventions that can have great benefit with minimal risk.

  • Dominick Walenczak says:

    I have an issue with some of the suggestions. I’ll address those systematically. I’m not opposed to a somewhat expanded basic scope of practice. However, I feel that the current EMT-B education is insufficient to support such practice. Other issues are from a quality of care and risk-benefit aspect.

    Epi-Pen:
    Absolutely! It’s a life saver and easy enough to do. Few risks and contraindications when used appropriately. Would probably do an inservice to point out the giant arrow indicating which way to stick it. An Epi-Pen to the finger is no fun.

    ASA:
    Absolutely! Our of the entire paramedic’s drug box, the most effective medication in the presence of MI/ACS is good ol’ time-tested Aspirin.

    IN Narcan:
    Nope. The prevailing school of thought now is not necessarily to “wake them up” with Narcan, but fix respiratory insufficiency. Give them a BIAD and let them transport to an ED. Especially with the recent correlation between Narcan and ARDS, I don’t think the risk benefit supports it for use by basics at this time. The problem in overdose in hypoventilation, not inadequate naloxonization. Plus, there’s also the risk for polypharmacy with other drugs… and then what? Carry IN Flumazenil too?

    IM Glucagon:
    Generally support. Lilly makes a neat emergency kit, if I recall. It’s a great adjunct for areas where paramedics are unavailable. In fact, lots of endo docs prefer the glucagon because it doesn’t spike their glucose and screw up the A1C’s for long term management. My only concern is that this will be given and the patient will sign off… and then go low again. At which point, you’re SOL with another Glucagon. Perhaps taylor the protocol to allow for administraion DURING transport (or immediately prior) so the patient doesn’t have the opportunity to refuse transport. I believe that Glucagon sign offs are extremely risky and should be reinforced to the providers that the patient really MUST be transported.

    Combivent:
    Generally support. There’s a ton of benefit to providing these as early in patient care. However, the use of these medications in pulmonary edema is generally frowned upon. I’m not against it, but I think that usage of albuterol in particular in CHF related pulmonary edema WITHOUT nitrates and CPAP is inappropriate. Some regions have allowed basics to give albuterol (and ipratropium is a logical adjunct) for diagnosed COPD/Asthma patients, which I think this might be the way to go.

    Zofran ODT:
    Generally support. IM might be another consideration as well (though it burns!). My concern is that it does have an effect on QT prolongation, which you wouldn’t know without a monitor. Then again, I don’t think most paramedics know that little factoid either (not that it’s an excuse). Still Zofran is generally bengign. I would, to be safe, probably word the protocol to indicate that this is for backboarded/supine patients or severely obtunded patients only. In those groups, it is of unquestionable benefit, as vomiting could easily become an airway compromise. Everyone else can wait with their upset tummy until they arrive at the ED.

    Tylenol PO:
    Oppose. One agency near me just got rid of their PR tylenol. There’s really little benefit to prehospital fever management with tylenol. Infection is the real issue. And if you’re suggesting it as a pain medication, allow me to LOL.

    Benadryl PO:
    I’ll see your Benadryl and raise you one. In addition to diphenhydramine, I think PO Zantac should be added to further block histamine. Both are, generally, fairly safe medications.

    IM Versed injector:
    I’m very hesitant to give someone a drug that causes hypotension and respiratory depression without them having a way to make it better. Still, the benefits in certain cases outweigh the risks. I think it should be an option for the agency’s medical director to exercise if he feels confident in the personnel there (perhaps require an inservice on the adverse effects and dosaging to be authorized as a provider to give it). Also think it should require a quick call to the doc-in-a-box to confirm use and dosage as a safeguard.

    Morphine injector (for distant rural services):
    I’m typically against morphine for Basic EMTs. But in a rural setting, it is also inappropriate to leave them in pain for a 2+ hour transport. It should be an option on an agency-by-agency basis and only with medical control order and credentialling of the providers (following a DETAILED inservice). I think that’s the same approach taken with distant paramedics and thrombolytics prehospitally.

    CPAP:
    While it’s beneficial, the advverse effects (specifically pneumothorax) are not uncommon in this. That’s why I think it could be potentially dangerous if given to someone without the appropriate training to recognize one and without the proper tools to fix it. With the additional training and skills required, I think the best approach would be to advocate that the providers go to AEMT level. It’s not just a non-rebreather mask. I would be hesitant to have EMT-Bs running around doing this.

    Selective Spinal Immobilization:
    YES.

    12-Lead Transmission:
    I’m leery of letting them see/print an interpretation. Too many PARAMEDICS have said to the patient “your EKG looks good, you must not be having a heart attack”, so I’m a little concerned having someone who’s not trained in EKG interpretation doing the same (though either case would be just as wrong). Provided that training was given that chest pain should still be treated like suspected MI despite what the EKG looks like, and provided that it was transmitted to a receiving facility and medical direction there contacted for interpretation, and there is no print functionality on the machine, I think this would be a great way to increase STEMI identification in the field and reduce E2B/D2B times. When used appropriately, it’s all benefit and almost no risk.

    Supraglottic Airway:
    Depends. LMA? Never in a million years on any prehospital unit regardless of level of care, even if it’s the last piece of airway equipment onboard or ever invented. Ever. EOA’s? Okay. King Tubes? Heck yes. I think BIADs are great and life-saving. No question. However, providers need to know then indications and contraindications as well. Providers should be required to attend an inservice on this as well.

    While many of these things are good ideas, at some point there comes a time with all the inservicing required, perhaps the emphasis to move up to the next level. The problem is that EMT-Basic education does not prepare them for the skills you mentioned. Even IM administration would have to be taught from scratch. On the flip side, one must consider that sometimes we have to do the best with what we’re given. Every time I start on how Basics, AEMTs, Paramedics, etc aren’t qualified to do something, I always hear Kelly Bracket in the back of my head:

    “Now, I’ve given you the impression I’m in favor of fire department personnel, with a crash course in emergency medicine, taking human lives into their own hands. I am not. I’d like to see a specialist handling every bloody nose, so we’d know whether it’s the result of a good right-cross or a tumor. I’d like to see a cardiologist on the scene every time someone drops in the street with a killing pain in his chest. But, you can’t ask someone not to die while you’re trying to find out what’s wrong with him. And they *do* die, gentlemen; on the way from where it happens to my hospital. They die by the hundreds every year; not from mortal wounds, but from neglected wounds. Not from incompetence or indifference but from time, from lack of time. I’m in favor of more doctors, more hospitals and better equipment. And, I’m also in favor of this bill until those other things come along, because it *will* save lives. Maybe a dozen lives, maybe a thousand, maybe just one. And, who knows which one?”

    • medicscribe says:

      Thanks for the well argued list. We carry Tylenol PO for pediatric fever, but rarely use it. There is a 12-lead BLS initiative getting started around here. BLS doesnot interpret, merely transmits to the base hospital.

      Thanks for the Emergency quote. It is a classic.

  • hilinda says:

    I agree with Jon, this is an excellent conversation starter. Thoughtful and well written.

    I also have more questions than answers right now.

    If you had asked me a year ago, I’d have said that I think there are a variety of very useful things that could be moved down into BLS. CPAP. Capnography for more than “tube placement.” A few select medications. Possibly combitube.

    In the past year or so, I’ve unfortunately seen some very poorly trained BLS providers. Shockingly so. This has changed my perspective.

    I think the real problem isn’t what skills and tools BLS providers are allowed to use, and which are only for ALS. I think it’s that the quality of training required and provided isn’t high enough at this point to be sure that every provider is capable of performing all interventions appropriately. This puts EMS, as a whole, in the position of needing to be very conservative about what providers are allowed to do in the field.

    Although this isn’t a BLS skill, it’s a skill that illustrates my point very well: intubation. If everyone who is trained to intubate really knows what they are doing, it’s a fairly simple skill. I see no problem with allowing it to be done in the field. However, apparently, there have been enough cases of someone bringing in a patient who has a tube in his esophagus, rather than trachea, to cast doubt on the safety of continuing to allow intubation. Training, overall, isn’t at a level to allow a true and fair evaluation of whether or not intubation in the field is a good thing, because enough people simply can’t do it. The training to support it isn’t always there.

    The flipside of the problem with training not being enough is that adding more, or more demanding, training triggers a lot of “people won’t be able to do that much more training” types of comments.

    There’s a line in there somewhere.
    I want excellent training, so that I am confident in my skills and knowledge, and I want everyone else to also have excellent training, so I can trust that any provider I come across in the field has a high level of ability. THEN we can talk about what additional tools we might want to add to which levels.

    IF the BLS provider is a well trained, conscientious provider, there is a lot we can add. But there are some out there I wouldn’t trust to flea comb my dog, let alone be sticking needles into anyone or providing care based on understanding advanced tools. That’s the part that needs to change.

    I sincerely wish it were otherwise, that all EMTs were out there working hard to improve their skills every day, that every provider was actively continuing their education. Alas, it appears not to be so. I am very concerned about putting new tools into the hands of those who are in the “one year experience, repeated 20 times” category, or those who squeak through the Basic class, and never do any additional training that is not strictly required, certainly not anything expanding their understanding of what ALS providers are doing, to better support the continued care of the patient.

    I also HATE that the entire field ends up limited by the existence of some very poor providers out there.

    I don’t have the answer.
    I can look at it in two nearly opposite ways.

    One, to have a very very basic level, for the people who want to help, but aren’t going to do any further training. Limit them to things that are unlikely to kill the patient, teach them to call ALS early and often. Make what they are expected and allowed to do as “idiot proof” as possible. Keep the tools and skills in the hands of people who have demonstrated a commitment by furthering their training beyond what is required for BLS. Have a much wider gap between BLS and ALS.

    The other, to provide better training at the introductory level, make it a longer, more difficult class to become an EMT at all. Focus on getting better tools into the field at all levels, and better ability to treat patients early, without the need to call for ALS. Require more frequent demonstration of practical skills, and a better guideline for continuing education than only a certain number of hours. Create highly skilled, professional providers, in all three learning domains: cognitive, psychomotor, and affective.

    I know which I would prefer- but I don’t know that it is practical.
    At this point, I am only in a position to do what I can do to improve my own abilities.

  • Brandon says:

    In Canada, a national occupational competency profile in 2011 which creates a profile to follow for each province in order to create the same level of care for the whole country. this also allows paramedics to move from province to province without additional training.

    In Saskatchewan we have 4 levels of training.
    Emergency Medical Responder
    epi pen
    patients own asa and nitro
    oral glucose
    blood glucose monitor
    soon to have IV monitoring

    Primary Care Paramedic (replacing EMT)
    nitro (orders need if no rx)
    asa
    instant glucose
    activated charcoal
    amyl nitrate
    nitous oxide
    epi 1:1000 IM
    OPA/NPA/King airway
    12 lead transmission
    CPAP

    soon to have IV administration
    and the medication anticipated to be added are:
    narcan
    ventolin
    atrovent
    d50
    glucagon
    Benadryl

    Intermediate Care Paramedic
    nitro
    asa
    ventolin
    atrovent
    d50
    glucagon IM
    versed IM,IV,IN
    Ativan IV
    gravol
    Tylenol
    nitrous oxide
    epi 1:1000 IM
    IV initiation
    12 interp and transmission
    manual defib
    king airway/combi/lma
    CPAP
    and the possible addition of narcan, Benadryl, as per NOCP

    Advanced care paramedic is the highest level in SK.

    I didn’t want to list all skills in the scope but it appears that our BLS providers at the PCP/EMT level does have some of the mention skills and meds and will be getting more in the near future.

    Here is a link to the provinces treatment protocols:
    http://www.health.gov.sk.ca/ems-protocol-manual

    Here is a link to the NOCP:
    http://paramedic.ca/nocp/

  • Andy says:

    Dominick, I assume we were writing our posts at the same time. It’s hard to overstate how influential that show was.

  • Christopher says:

    Dominick,

    I’ll disagree on CPAP complications, because you can’t actually find case reports about them outside of single lung ventilation and neonatal PPV problems. I have a feeling these “cases” are the same sort of Sasquatch sightings like with spinal immobilization.

    NIPPV is embarrassingly safe, just we’ve told so many old wive’s tales about popping a lung with it, that we run scared. So we leave the EMT with an NRB (not going to help a CHF’er) or worse, a BVM. BVM’s generate pressures upwards of 40 cmH2O. If you believe that CPAP can “pop” a lung, then you certainly would not want EMT’s to use a BVM…

    Otherwise the list given is pretty much what our basics in NC already have with many logical additions.

  • Dominick Walenczak says:

    Chris,

    You raise an excellent point that I had failed to consider, specifically the pressures generated by a BVM. Considering that the BVM will be the “go to” treatment without CPAP (the the high pressures caused therein), I think I would have to revise my opinion and agree. Even as medics, we don’t have all the counteragents to everything we carry. Looking at it now, perhaps CPAP would be a beneficial at the BLS level safer and more effective than a BVM. I am, however, wondering what the actual incidence of barotrauma is in CPAP and BVM use and if there’s any studies on it.

    Off to serach PubMed!

  • R says:

    Has anybody investigated the US military’s experience with Fentanyl lozenges/lollipops for pain control? I would think it would be preferable to IM morphine injection.

    There are multiple programs distributing IN Narcan kits to the public now, I have a hard time believing that trained providers can’t safely use them.

    • medicscribe says:

      Thanks for bringing this up. I had forgotten about this method. I wonder if any EMS systems are using it in the US outside of the military.

  • Christopher says:

    Dominick,

    I’m coming into the idea that the Oxylator is probably an ideal device as a BVM replacement for most patients EMS see’s. Tough to say for certain.

    As for cases w/ a BVM that I already know of:

    “Two cases are presented of pulmonary barotrauma developing during cardiopulmonary resuscitation. This was attributed to high airway pressures developed during ventilation. One patient was ventilated with a self-inflating bag and the second with the Robertshaw demand valve…” Shulman, Beilin, Olshwang. Pulmonary barotrauma during cardiopulmonary resuscitation. Resus (1987).

    “Self-inflating bag-valve devices are commonly used for the ventilation of intubated patients, especially during resuscitation and transport. These devices are generally safe, but minor deviations in their recommended use can expose patients to airway pressures greater than 135 cm H2O. We present a patient in whom a sudden tension pneumothorax developed during ventilation with a bag-valve device…” Silbergleit et al. Sudden severe barotrauma from self-inflating bag-valve devices. J Trauma (1996).

  • Ben Hoffman says:

    In New Zealand a BLS Ambulance Officer is called an “Emergency Medical Technician” and completes the National Diploma in Ambulance Practice over a one year period comprising 300 hours of online and face-to-face learning as well as a Portfolio of Evidence for assessment which is both qualitative and quantitative.

    The scope of practice is as follows

    – OPA
    – NPA
    – LMA
    – PEEP
    – Tourniquet
    – 12 lead ECG acquisition and basic rhythm interpretation
    – Automated defibrillation
    – Automated cardioversion
    – Entonox
    – Methoxyflurane (where used)
    – Paracetamol
    – Aspirin
    – GTN spray
    – Carerro oral glucose
    – IM glucagon
    – Nebulised salbutamol
    – Nebulised ipratropium
    – Nebulised adrenaline
    – Oral ondansetron
    – Oral loratadine

    Methoxyflurane is used in space, or weight, limited areas of the Ambulance Service for example in Ambulance Rescue, the Rapid Response Unit, Motorcycle Response Unit or very rural areas where resupply of entonox is a problem.

    All levels of Ambulance Officer can refer people elsewhere, leave people at home (“treat and release”) etc and there is a big push on to increase this and refer people to places other than an ED.

    I see absolutely no reason why the USA cannot adopt something similar and perhaps move “EMT” in US away from something that looked like what existed in this part of the world 20 or 30 years ago.

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