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  1. #26
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    Quote Originally Posted by FireMedic049 View Post
    So you have 1 EMT doing compressions, 1 doing the BVM, 1 to gather information and 1 to do whatever else. What else needs done before the medics and transport unit gets there that freeing up the person doing ventilations would be beneficial?

    Did not say it was beneficial at all. From a PM I received I believe a vent is not suitable for use with the AutoPulse. From the real world experience they reported the vent does not work well when the AutoPulse is engaged. He\she did not state whether or not it was being used with an ETT, King or Combi.


    Quote Originally Posted by FireMedic049 View Post
    And that's what I gave you, an opinion that the use of the autovent on the BLS level is not appropriate and not essential with the possible exception of taking a vent patient to a doctor's appt.
    Thank you for you for your opinion.

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    I love when people respond to these threads with "You can't do that if youre a this" or "That's not allowed because of this." Not everywhere is where you live. Practices and protocols change from place to place.

    That being said, we run BLS engines. Most advanced skill we perform while working on a fire engine is combitubes and epi pens. We also carry powered suction units. We require EMT-B, but most are EMT-I. We don't carry IV supplies on the engines, but IVs are within the SOP of an intermediate in GA.
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    Our vent/AutoPulse trial was while utilizing an ETT. We have combi-tubes, but rarely utilize them, I'm not entirely sure you could utilize a vent with a blind-insertion airway (not saying it wouldn't work, just not sure that's what the vent is designed for, depending on model).

    GTRider, I know that not all places are the same. NREMT has set up standardized license levels, complete with protocols. Typically, most places are pretty close to these. That's what I go by. I'm not saying only Paramedics should do IVs, hence why Intermediates can. But what I am saying is a lot of the skills that some have stated here that they'd like to see in a Basic-level protocol are covered in the Intermediate. Intermediate around here in IL has all-but-disappeared, there hasn't been an EMT-I class in 4+ years. I know a lot of places still utilize them, I'm just used to not seeing them. That's why I reference EMT-Basic vs. Paramedic, instead of FR vs. EMT-Basic vs. EMT-I vs. Paramedic.

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    Quote Originally Posted by CaptainGonzo View Post
    Try being in Massachusetts. There are 5 EMS regions, each one run like its own little fiefdom and each with its own set of protocols...
    You think thats bad Gonz?! In Ohio we have a state EMS board that writes the scope of practice, but each department has its own medical director who can make protocols as they see fit. For example, drug dosages can vary from department to department even alot of things carried vary alot. Some departments can do RSI while a neighboring department can't. Luckily almost everyone around me does Induced Cooling by EMS for arrest patients with ROSC and uses Res-Q-Pods which have made an impact on our cardiac arrest survival rates.
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    [QUOTE=FireMedic049;1186991]Ok, maybe there's some truth to this, but what's the excuse for the numerous "poor providers" I've encountered working for EMS only agencies?

    I disagree for the most part. All firefighters should have medical training, even if their fire department doesn't provide actual EMS response - whether QRS or transport.


    There is no excuse for "poor providers". But some of the reasons that they hate their job is low pay, getting run into the ground, bad attitude.. I'm beating a dead horse, you know as well as I do. Maybe we are able to look past the bull and still have a desire to give good care to our pts.

    As for the other, yes maybe everyone should be at least a first responder. Not everybody needs to be a EMT-I or a Paramedic, On the run of the mill med call do you really need 3-4 Paramedics and 3-4 Emts? Of course you can throw the MCI curve at me.

    One thing also is where I work is pretty rural so we don't run like y'all do. One thing about it when you do get a bad call and you can't get a bird because of weather, You had better know your stuff... Hour to hour and a half to a level 1.
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    Quote Originally Posted by RFRDxplorer View Post
    You think thats bad Gonz?! In Ohio we have a state EMS board that writes the scope of practice, but each department has its own medical director who can make protocols as they see fit. For example, drug dosages can vary from department to department even alot of things carried vary alot. Some departments can do RSI while a neighboring department can't. Luckily almost everyone around me does Induced Cooling by EMS for arrest patients with ROSC and uses Res-Q-Pods which have made an impact on our cardiac arrest survival rates.
    Okay.. you guys in "oh high oh" have it worse!
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  7. #32
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    Quote Originally Posted by FireMedic049 View Post
    My thoughts on the subject are this:

    I see no issue with the Autopulse, Glucometer and King LT airway being incorporated into the BLS skill set. The reason being, the autopulse is chest compressions, anybody with diabetes or a diabetic family member can check a blood sugar and it's pretty hard to screw up inserting a King airway.

    As for the other stuff, what's the point in starting IVs as BLS if you can't administer IV medications? Even as a paramedic, the vast majority of the IVs I start provide no real "benefit" to the patient and get started simply because that's what the treatment protocols call for. Kind of similar to the "everybody gets O2" thing at the BLS level.

    I agree that the autovent should be an ALS skill, not BLS. It's not so much that it's too complicated to use for a BLS provider, but more that there can be complications associated with it's use and the ALS provider is probably going to be more able to recognize those problems and be authorized to fix them should they occur. Plus, I'm having trouble picturing any scenerio in which you could truly justify its use at the BLS level other than maybe taking a vent patient to a routine doctor visit. Anything pre-hospital that necessitates the use of an autovent clearly should have an ALS response, so why would BLS need it?
    +1 on all the above. Any trained monkey can be trained to do various skills, but what's important is the education behind the decision to do these skills. There's a huge difference between education and training. You need to know why you're staring an IV. It goes a little deeper than "they might need it at the hospital", or "they might need fluids". You need legitimate education in human A&P and pharm at the college level to be able to make that determination, for starters. It's an invasive procedure, after all, and carries certain risks with the procedure, not to mention pt discomfort. Dropping a King is minimally invasive, and you don't need moer that an EMT-B level of education to recognize when the pt is apneic.

    Regarding vents, in addition to the above, we (paramedics) weren't even educated or trained on vents, just what we could gather during clinicals. There's a reason why medics aren't allowed to determine vent settings in the field on standing orders. Respiratory therapists spend several months at least on vents only, compared to the medic with maybe a four hour vent lecture if you're lucky, and some OJT. Nurses, in general, have a more comprehensive clinical education when compared to the paramedic, let alone an EMT, and they don't determine vent settings, either.

    How does the EMT plan to manage the vented pt if they develop a pneumo, for example? Does the basic have the education to preoperly manage the pt in regards to ETCO2 and SPO2? If brain herniation is suspected, does the basic understand what CPP is, and what the target ETCO2 should be to maintain cerebral perfusion? Does the basic have the necessary meds and the educaton to use them in the event that the pt bucks the vent?
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  8. #33
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    However far your state statutes/regulations and the agency that administers them allows limited further by how far your medical control allows. Not one step further.

    It's not a question you can really answer by consensus on a web forum.
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    The Code is more what you'd call "guidelines" than actual rules.

  9. #34
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    Quote Originally Posted by zzyyzx View Post
    In my dept, the Paramedics generally ride the engine and have a limited amount of their ALS supplies in a good sized Pelican style box. Our ambulances are generally staff by FF/EMT-B and then the medic jumps over to the ambulance (which is fully stocked) when a PT is transported ALS. Although I didn't write the policy, I believe this is for 2 reasons: first, most of our medics are senior guys and don't want to be on the ambulance anymore; and second, having the medic on the engine doesn't remove a paramedic from service for a BLS transport.
    Therein lies the problem. If a FD wants to do EMS, be it first response or txp, it needs to be a 100% effort. If you have engine medics and only basics on the ambulance, then it should be expected that the medic will ride with the pt to the hospital. They need that ongoing ecperience managing the pt to the hospital, not just treating onscene for maybe ten minutes and maybe going to the hospital once in the blue. We continuously have privates looking to take over municipal EMS. Fire based EMS in general has been receiving bad publicitiy from places like Colleton County FL with the medics being restricted after failing to ride the requisite ONE ambulance shift quaterly, fraudulent recert issues from DC fire/EMS, and North Las Vegas taking over more txps from teir contracted 911 private txp provider. There are numerous FD takeovers of EMS from single role agencies, be they municipal or private. The reasoning is cost savings and a more effective EMS delivery. If you're going to use that as the reason for takeover, then make it a convincing argument by doing EMS correctly.

    ALS first response has been shown in several studies to not have any effect on pt outcomes. My medical director confirmed this. He believes that the best fire based EMS delivery would be to have all ALS txp units, with EMT-Enhanced engines. The only benefit to first response regarding pt outcomes are with diff breathers, anaphylaxis, an AMI, and an arrest. The enhanced can start a line, give a neb, NTG, epi pen, maybe drop a tube or at least a King. When you're talking maybe 3-7 minutes before a txp unit arrives onscene, these interventions will make the most difference. You're lacking ECG interpretation, but other than defib, the first few minutes of pt contact involve assessment, anyways.

    Like FireMedic049 said, no one is forced to become a medic to join a FD, as it is a conscious choice by the indivdual. If you want to be a firemedic, riding the box is part of the job description, seniority or not. If you think you're above riding the box, then drop your cert. Many want the cert pay but don't want to do the work.
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    Quote Originally Posted by edpmedic View Post
    Regarding vents, in addition to the above, we (paramedics) weren't even educated or trained on vents, just what we could gather during clinicals. There's a reason why medics aren't allowed to determine vent settings in the field on standing orders. Respiratory therapists spend several months at least on vents only, compared to the medic with maybe a four hour vent lecture if you're lucky, and some OJT. Nurses, in general, have a more comprehensive clinical education when compared to the paramedic, let alone an EMT, and they don't determine vent settings, either.

    How does the EMT plan to manage the vented pt if they develop a pneumo, for example? Does the basic have the education to preoperly manage the pt in regards to ETCO2 and SPO2? If brain herniation is suspected, does the basic understand what CPP is, and what the target ETCO2 should be to maintain cerebral perfusion? Does the basic have the necessary meds and the educaton to use them in the event that the pt bucks the vent?
    These are all valid point, and the reason I asked the questions. Keep the responses coming. Thanks.

  11. #36
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    Quote Originally Posted by edpmedic View Post
    ALS first response has been shown in several studies to not have any effect on pt outcomes. My medical director confirmed this. He believes that the best fire based EMS delivery would be to have all ALS txp units, with EMT-Enhanced engines. The only benefit to first response regarding pt outcomes are with diff breathers, anaphylaxis, an AMI, and an arrest. The enhanced can start a line, give a neb, NTG, epi pen, maybe drop a tube or at least a King. When you're talking maybe 3-7 minutes before a txp unit arrives onscene, these interventions will make the most difference. You're lacking ECG interpretation, but other than defib, the first few minutes of pt contact involve assessment, anyways.
    This is what we are aiming for, except we have a stand alone Parish run EMS system.

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    Based partially on opinion, but primarily on what our state allows for licensure, the most invasive EMT-Basics are allowed to get is a non-invasive airway (combitube, LMA, King's, etc), assist a patient with certain meds that they have prescribed (NTG, ASA, epi-pen), giving oral glucose and oxygen, and take a blood glucose.

    Beyond that, I'm not sure that I would want an EMT doing anything more. Regardless of licensure, I think edpmedic hit on the high points. It's not about intubating, starting an IV, etc, it's know why you're doing it and what to do if something goes wrong.

    In regards to the vents, most ambulance agencies around here are getting rid of them. The only time I've used one was for a code or for an interfacility transfer where the RT or ER doc told me what to set it on. However, I did work for a service that used (and still uses) the oxylator. EMT's were even allowed to use it to assist with respirations. While it has similarities to a vent, it has an automatic pop-off to prevent pneumo's. It could be utilized with a combitube or about any other airway. I never had the opportunity to try it with the AutoPulse, but from my understanding they've had some luck using the two together, at least more luck than with a standard vent.

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    I took this from a post on an EMS forum. It really hits the nail on the head: "Any skill mastered as a basic can be more easily and properly mastered once properly educated. Perfect practice makes perfect, imperfect or uneducated practice makes mistakes."
    "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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    Quote Originally Posted by Acklan View Post
    I was wondering if any BLS engines are using;
    Autopulse
    IV (bag or lock)
    CBG
    King, CombiTube, EOA, PTL, ET,...
    portable ventilator
    On our service we do not run engines to medical calls (volunteer service) but instead send ambulances. Our service which at the moment is strictly BLS, can administer 02, check blood sugar levels, administer asprin. Epi,Nitro,and Albuterol (inhaler only) can be administered under medical direction. We do not have an auto pulse so i cant give any feedback about that, but we are not allowed to use IV's, We can use CBG, and are unable to use any advanced airways, or portable ventilators.

    As far as EMS being a career. atleast in my neck of the woods its very hard. Many of the paramedics or EMTs that i know are a member of 2-5 different services. Many services will only take people part time, they pay very little comparatively, and do not offer any benefits packages. A good friend of mine on top of being a volunteer for our dept, he also works for 2 other services part time, and puts in per Diem shifs with our town. its not uncommon for medics to work for a different service for each day of the week.

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    Default If you would like a job on a unit...

    Thanks for the bump zackman1801. Down here we are thick with ALS (private and public) transports and, with limited exception, all FD run at least BLS sprint from pumpers or/and rescue units.

  16. #41
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    Post And.........

    With 4 (Yeah, Four) Levels of Field Providers, we don't usually have a problem with having someone with a certain skill level O/S in a short time. Our older guys, (Joined prior to 1990) Had to have First Responder, or EMT-A. Anyone joining after 1990 had to become an EMT-A. EMT-A later became EMT-B. Maryland also had a "Cardiac Rescue Technician" which has become EMT-I. Then there is the Top of the pile, EMT-P. There are active members out there who still only have First Responder, There is a Majority who are EMT-B (including me) Some EMT-Is and a good Crew of EMT-Ps. I don't see this mix changing dramatically anytime soon, except that as the older folks who are First Responders fade out the "First Responder Level of Care will disappear.

    Back to the O.P........... We really don't do much more than AED, Pulse OX, Epi Pens, etc. Vent and so forth is for Is and Ps...... This seems to work OK for us.
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    Thanks for the input Chief.

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    So what separates an EMT-A from an EMT-B?

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    Quote Originally Posted by LaFireEducator View Post
    So what separates an EMT-A from an EMT-B?
    It might be different by jurisdiction but, at the DOT level, it was just a change in terminology. When I was originally certified, it was as an EMT-A(mbulance) but a few recerts later the level magically changed to EMT-B(asic).
    "Nemo Plus Voluptatis Quam Nos Habant"

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    And now EMT-D (for defribilation)...

    NY has five levels.
    CFR
    EMT-D
    AEMT-I (Advanced EMT - Intermediate)
    AEMT-CC (Critical Care)
    Paramedic.

    CFR, basic, and paramedic are pretty much the same as everywhere else. Basics are being allowed Epipens, aspirin, and glucose monitoring on a case-by-case basis. Few, if any, have any other invasive procedures available.

    Intermediates can tube, shock, and start IV's but are expected to be hooking up with ALS enroute. I believe they were originally intended to serve as "trauma techs."

    CC's can do just about anything a paramedic can do, but while the medics have standing orders for just about everything, CC's have to have an order from medical control for a number of meds, especially narcotics.

    Intermediates (as defined in NY) are a dying breed.

    CC's provided a much needed bridge between BLS and ALS in NY when paramedic programs were few and far between. Their number is dwindling as well, but many volunteer agencies still rely on them for their ALS capability.

    NY is also run by regional organizations which do everything from determining protocols and med lists to authorizing agencies to operate.
    Opinions my own. Standard disclaimers apply.

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    Quote Originally Posted by LaFireEducator View Post
    So what separates an EMT-A from an EMT-B?
    Originally NREMT classified EMTs as EMT-A and EMT-non A, or Ambulance\non-Ambulance..
    EMTs that worked on an ambulance were EMT-A, and everyone else was EMT-non A, such as fire fighters, ER techs, funeral home workers,...
    In the late '80s they changed the classification to EMT-B, with the Enhanced tag (AED, IV, ET\EOA,..).

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