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    Default How far should a basic be allowed?

    I have a question. We run BLS respond from the engines, and ladders when the engine is out. We carry basic kit, O2, AED, and are testing the AutoPulse. Our MD has OK use to use Kings tubes, CBG, IV (locks) and the administration is moving that way.
    I was wondering if any BLS engines are using;
    Autopulse
    IV (bag or lock)
    CBG
    King, CombiTube, EOA, PTL, ET,...
    portable ventilator

    I was a P instructor back in the mid 90s and really do not see a problem, but I would like to hear from those that are living it and could give some feedback on the good, bad, and the ugly of these skills in the hands of basics.
    I am not directly involved with the implementing of these skills onto the engines, but I have been ask and have discussed the possibility of these skills being put in service.
    Any real world experiences are welcome.

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    A vent and IV are most def ALS skills.
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    We're doing Autopulse & King's (replacing CombiTubes) as BLS skills. There are some medical directors in Virginia that are allowing thier BLS providers to do IV's. I agree with BLSBoy that vent is an ALS skill.
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    Could you elaborate on why you feel a ventilator should be a P only skill, and not a King\Combi?
    BLSboy, do you feel the gloucometer should also be ALS?

    Let me be clear, I AM NOT TRY TO START A FIGHT. Just to state my position, I am fine with all these skills as long as the training (on going training) is provided. I am looking for basics or Ps that have experience with these skills being used in a BLS setting. When posting please explain why you have taken your position.

    Again thanks.

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    I believe according to the NREMT-B standards, the only real basic skills above are the King and the Autopulse (with training). The King LT is replacing the Combitube in many areas as a non-visualized airway. IMO, it is much easier to use and the success rate on first attempts is extremely high.

    In some areas, IVs and locks can be initiated with additional training and certifications. Visualized airways, such as an ETT, are an ALS skill. From what I know about the PTL and EOA, which I'll admit is minimal, they are non-visualized airways and would thus fall under a BLS skill.

    However, any skill must be approved in your medical protocols by the medical director that is authorizing you to operate under their license. So, I guess that they could technically allow a Basic to do any of the skills.

    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.

    Edit to add in reasoning: Check the EMT-B text book and you won't usually find instruction on the ETT, ventilator or IV. Usually only medic assist for these skills is mentioned. And I agree, if the basic is trained and comfortable doing the skills and medical direction has authorized them, rock on. But it's likely that if you're using some of these skills we're discussing, there's a good possibility you might need some of the other paramedic level skills (such as pushing meds).
    Last edited by zzyyzx; 07-04-2010 at 11:07 AM.

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    Thanks zzyyzx for the feedback. With a little more info. Our Parish runs an ALS service that is staffed with 2 to 3 paramedics and most days several have a doctor riding 8 hour day shifts. We are heavy on the transport side with ALS. By the time we start AED, AutoPulse, and BVM the Ps are rolling in. Our line of reasoning for going CBG, King, and IV (lock) would the Ps would be set to start ALS as they walked in the door.
    I agree with the you on the ET. I threw it in just in case there was a department that allows basics to use them. Also I have not seen a EOA or PTL in over 10 years, but they are still available an some may still be using them.
    I guess I should have limited the discussion to King and Combi.

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    I think a vent is an ALS skill. Down here we have no basic EMT. You are either EMT-IV or Paramedic. The argument of a vent can be used by EMT basic is not a good one. If someone is heavily trained on any ALS skill they should be able to perform it. I think in the near future EMS training will have two levels. Bare bones do nothing First Responder or Paramedic. People want only the level of care and EMS training continues to add skills to the basic list.
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    All of the apparatus, other than the paramedic squads of course, carry BLS equipment. Advance skills here include the King air-way, epinephrine, baby aspirin, and albuterol.

    It does get a little convoluted on days when we have more meds than squads. A piece of fireapparatus then may become a PFR (Paramedic first responder), and they carry a medic bag with ALS level meds and equipment.
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    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...
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    Note. The vent would only be used for CPR, not ALS patients in need of a vent. That instance would be left to the Ps.
    Great discussion so far. Keep the opinions and info coming.

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    Quote Originally Posted by TNFF319 View Post
    I think a vent is an ALS skill. Down here we have no basic EMT. You are either EMT-IV or Paramedic. The argument of a vent can be used by EMT basic is not a good one. If someone is heavily trained on any ALS skill they should be able to perform it. I think in the near future EMS training will have two levels. Bare bones do nothing First Responder or Paramedic. People want only the level of care and EMS training continues to add skills to the basic list.
    I agree on the only having two levels before long, Ga keeps on adding things that the EMT-I can do. ALS skills that a EMT-I can do include advanced airways combi, king ect, epi pens, IVs and fluid administration this includes transporting pts that have iv meds running as long as its not an ACLS drug , D-50, Nitro, asprin, cpap, cronic vent pt tranport.

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    I can see why you might have basics do some of those tasks in your area. In my department, every station has a paramedic if no one is on vacation or sick. Only about half the stations have ambulances. Everyone on the dept hired since about 1990 must maintain at least an EMT-B. I think we only have 1 or 2 of the older guys that don't have that cert. So usually the paramedic is arriving within a minute of the BLS ambulance, if not before. If a BLS crew beats the medic, they're establishing an airway (dropping a King, Res-Q-Pod, BVM, O2, capnography), starting compressions and attaching the defib pads.

    The Lifepaks we use on the ambulance don't have all the features of the ALS ones on the engines (such as manual defib, capnography, resp wave form, etc.) so the paramedic will usually bring their monitor to the ambulance. The BLS ones operate as an AED.

    We also have the EZ-IO available to the medics. This comes in extremely useful during cardiac arrests for a couple reasons: We don't use AutoPulse (yet...) so there's a lot going on at the torso and head already. The lead medic will usually drill into the tibia and manage the arrest from there. They can watch the monitor and push their drugs. If there's a second medic, they'll manage the airway and assure compressions are going well.

    Most FDs in my area don't have any ventilators. Only private transport ambulances mainly used for facility to facility transport might have them. But we're usually within a five minute transport of a facility with lights and siren. Also, on an arrest, we'll usually have about 6-8 FF/EMT-B and 2 FF/EMT-P, so we can shove the manpower needed to maintain compressions, BVM, medic and an alternate in the back of the ambulance if needed.

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    We follow the new BLS EMT protocols which include King or Combi-tube, giving Nitro or Epi that is not the patients, pre-mixed Albuterol and ASA. Under the protocols EPI can be done without permission from med control, and the others can be done without contacting med control initially in emergent situations following specific standing orders. In non-emergent situations, or where manpower is available they prefer you contact med control before administering.

    Basics have been using autopulse and doing thier own dextrose sticks here for several years.

    There are rumors that LA will be moving towards IVs being a basic skill within a couple of years, but we are not there yet.

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    Quote Originally Posted by Acklan View Post
    I have a question. We run BLS respond from the engines, and ladders when the engine is out. We carry basic kit, O2, AED, and are testing the AutoPulse. Our MD has OK use to use Kings tubes, CBG, IV (locks) and the administration is moving that way.
    I was wondering if any BLS engines are using;
    Autopulse
    IV (bag or lock)
    CBG
    King, CombiTube, EOA, PTL, ET,...
    portable ventilator
    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?

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    Hey Acklan, just a heads-up for you in regards to AutoPulse/Vent combo. We've got the AutoPulse at our department, and tried a couple different vents with it, but the vents wouldn't cooperate due to the constant change in pressure in the chest from the AutoPulse compressions. We were trying to get it set up at our Department so that we could transport a full arrest with only 1 person in the back, as we get little-to-no first response from 4 of the 5 small towns in our county.

    And, well, about the EMT-B scope of practice... in all honesty, if you guys want to go through with that, become an ALS service. EMT is an easy class compared to Paramedic, and the scopes should reflect that. I don't have a problem with EMT-Bs utilizing equipment to do something they were taught, like the AutoPulse and advanced airways. But I don't like adding completely new items, such as IVs. That's what your Paramedics are for. If you want to do these additional procedures, take on the extra responsibility and become a Paramedic. Many of us already have.

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    In case you have not noticed, in some parts of the country paramedics are getting hard to find.
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    Quote Originally Posted by FFMedic31 View Post
    Hey Acklan, just a heads-up for you in regards to AutoPulse/Vent combo. We've got the AutoPulse at our department, and tried a couple different vents with it, but the vents wouldn't cooperate due to the constant change in pressure in the chest from the AutoPulse compressions.
    This is what I was looking for. Good stuff. We are not going ALS we just want to have as much out the way to make the Ps job a little easier. Thanks for the input.

    Quote Originally Posted by FireMedic049 View Post
    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?
    You may have missed an earlier post, but we are only considing using the vent on codes. Not for transfers or other medical calls. Take a look about 4 posts back.
    If we could have everything except the drugs out of the way, for the arrival of the paramedics, we just feel the patient would have a better chance. It may not be practical, that is way I am throwing it out here to get some real life feedback. After all it was not that long ago that any airway, except the oral airway, was out of bounds for the basic.

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    Quote Originally Posted by Itshotinhere View Post
    In case you have not noticed, in some parts of the country paramedics are getting hard to find.
    True, but they may also be looking for more than they really need in some parts. Some fire departments that provide ALS first response have been moving to an all FF/Paramedic deployment. I have nothing against ALS first response from the FD in general, but realistically everybody on a 4 person engine doesn't need to be a paramedic.

    Another reason why paramedics are getting hard to find is, at least in my area, a matter of compensation. Many EMS agencies provide poor compensation packages for their workers in general and only 2-3 dollars more per hour from EMT rates for paramedics despite educational requirements that are about 10 times that of EMTs. As such, many have left EMS either completely or only work part-time in favor of "real jobs" that provide much better compensation and/or working conditions.


    I have no issue with some "ALS skills" being provided by non-paramedics, however I don't think adding these skills to the basic EMT level is the most appropriate course of action. These expanded scope of practice type skills should be deployed from an EMT-Intermediate type certification level.

    Having seen the quality of BLS skills for a large number of the EMTs in my area, giving blanket access to ALS skills for all EMTs is a HUGE mistake.

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    Quote Originally Posted by Acklan View Post
    You may have missed an earlier post, but we are only considing using the vent on codes. Not for transfers or other medical calls. Take a look about 4 posts back.
    If we could have everything except the drugs out of the way, for the arrival of the paramedics, we just feel the patient would have a better chance. It may not be practical, that is way I am throwing it out here to get some real life feedback. After all it was not that long ago that any airway, except the oral airway, was out of bounds for the basic.
    No, didn't miss the earlier posts. As I said, I really don't see any viable reason for the use of an autovent by BLS personnel in the pre-hospital setting.

    How many people do you send to medical calls? I would assume you have 2-4 people at most. Using the autovent would essentially "free up" a person once hooked up. So what will this person be doing at that point if the only other thing to do "BLS wise" at that point would be chest compressions, which could possibly be being done by the autopulse?

    The vast majority of cardiac arrests that I've been to have been handled by 2 EMS crews (4 people) plus sometimes PD & FD personnel mostly for pt movement. Unless we have a student riding with us, we only ride 2 in the back to the hospital and we don't use either of these devices. So, I'm just not seeing the practical benefit of using an autovent at the BLS level.

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    Another reason why paramedics are getting hard to find is, at least in my area, a matter of compensation. Many EMS agencies provide poor compensation packages for their workers in general and only 2-3 dollars more per hour from EMT rates for paramedics despite educational requirements that are about 10 times that of EMTs. As such, many have left EMS either completely or only work part-time in favor of "real jobs" that provide much better compensation and/or working conditions.




    Exactly. EMS isn't viewed as a career; it's viewed as a stepping stone to something else, typically either Fire Department or RN. A typical 911 Paramedic job seems to make around half that of a Firefighter, Police Officer, or Registered Nurse (comparing to other Public Safety and Healthcare positions). Around here the pay difference between EMT-Basic and Paramedic is about $1/hour on average, on the 24/48 schedule. So an extra $3k/year. Not a big selling point, especially for all of the extra training you go through to become a Paramedic, as well as the additional responsibilities you take on for being the sole ALS provider on a rig. If we want more Paramedics out there, it has to be a worthwhile career. The more we continue to newter medics and improve basics, the worse off non-fire-based EMS will be.

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    Quote Originally Posted by FireMedic049 View Post
    True, but they may also be looking for more than they really need in some parts. Some fire departments that provide ALS first response have been moving to an all FF/Paramedic deployment. I have nothing against ALS first response from the FD in general, but realistically everybody on a 4 person engine doesn't need to be a paramedic.

    Another reason why paramedics are getting hard to find is, at least in my area, a matter of compensation. Many EMS agencies provide poor compensation packages for their workers in general and only 2-3 dollars more per hour from EMT rates for paramedics despite educational requirements that are about 10 times that of EMTs. As such, many have left EMS either completely or only work part-time in favor of "real jobs" that provide much better compensation and/or working conditions.


    I have no issue with some "ALS skills" being provided by non-paramedics, however I don't think adding these skills to the basic EMT level is the most appropriate course of action. These expanded scope of practice type skills should be deployed from an EMT-Intermediate type certification level.

    Having seen the quality of BLS skills for a large number of the EMTs in my area, giving blanket access to ALS skills for all EMTs is a HUGE mistake.
    All good points, I start paramedic school sept. 20th and when done I will be looking at about 1000-3000 a year more. Thats not much compensation, school is going to be 12 months. Some of the EMT programs here are 12 months now, mine was 9 months around 600 hours but that was back in 2005. Most of the EMTs in ga are intermediates.

    I'm sure I will get beat down for this but... I think that one of the problems with poor providers is most people who want to fight fire don't give a rats *** about EMS.

    That is not intended to be a insult, It's the truth. No one should be made to be a EMT or should not have to be a EMT to be a firefighter. IMHO there should be different levels of compensation, Firefighter only 30-35k, FF-EMT 38-42k, FF-Paramedic 45-50k.

    To be dead honest I went to EMT school to get into firefighting and I liked it a helluva lot more that I thought I would. Which is why I am going to the next level.

    I like this thread by the way
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    Quote Originally Posted by FireMedic049 View Post
    No, didn't miss the earlier posts. As I said, I really don't see any viable reason for the use of an autovent by BLS personnel in the pre-hospital setting.
    I only pointed this out because you made mention of using it for transporting the patient for a doctor's visit.

    Quote Originally Posted by FireMedic049 View Post
    How many people do you send to medical calls? I would assume you have 2-4 people at most. Using the autovent would essentially "free up" a person once hooked up. So what will this person be doing at that point if the only other thing to do "BLS wise" at that point would be chest compressions, which could possibly be being done by the autopulse?
    We have 2 paramedics, sometimes a stundent, on the transport and 4 FF\EMT on the engine.
    I would guess he would do what we have done since there have been paramedics on the transports. 2 work the code with the medic and the others get the backboard, stretcher and make ready for transport.


    Quote Originally Posted by FireMedic049 View Post
    The vast majority of cardiac arrests that I've been to have been handled by 2 EMS crews (4 people) plus sometimes PD & FD personnel mostly for pt movement. Unless we have a student riding with us, we only ride 2 in the back to the hospital and we don't use either of these devices. So, I'm just not seeing the practical benefit of using an autovent at the BLS level.
    I was asking for, not stating, an opinion. I used vents back when I was on the transport, but only for inter-hospital transfers, and have no experince using them on emergencies.

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    I fully agree with you, Itshotinhere. Forcing someone into EMT school when they don't want to be there (typically) results in someone that doesn't care about that side of the job.

    Same thing for me, I took EMT class because my Firefighter I instructor told me it was a good idea. I liked it, so I went on and got my Paramedic. Now I'm working for a government-operated EMS Department. I still want a career Firefighter job, but while I'm in EMS like this, I'll fight tooth and nail for EMS to become a viable career without necessarily being a Firefighter.

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    Quote Originally Posted by Itshotinhere View Post
    I'm sure I will get beat down for this but... I think that one of the problems with poor providers is most people who want to fight fire don't give a rats *** about EMS.
    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?

    That is not intended to be a insult, It's the truth. No one should be made to be a EMT or should not have to be a EMT to be a firefighter. IMHO there should be different levels of compensation, Firefighter only 30-35k, FF-EMT 38-42k, FF-Paramedic 45-50k.
    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.

    The simple reason being that as a firefighter you WILL at numerous times in your career be on an incident scene in which someone needs medical care. Sometimes this will happen and there will not be an EMS unit on scene yet and YOU will need to care for this patient until they arrive. Sometimes this will happen and there will be an EMS unit on scene, but the patient condition or number of patients will necessitate YOU assisting with patient care until more EMS units arrive. Sometimes this will happen and YOU will be the one repelling down a hillside to rescue a victim and have to provide or assist with the initial care of this patient.

    We can debate whether or not the minimum level of care should be EMT, but realistically it's not that difficult or time consuming so I see no good reason for it not to be EMT (at least for career personnel).

    I would agree that nobody should be "forced" to be a Paramedic. However, obtaining Paramedic certification to improve your chances to be hired as a career firefighter IS NOT being "forced" to be a Paramedic. There are still many fire departments that don't require a Paramedic certification to apply and be hired. It is a conscious decision to take that route and to do so without intention to perform that part of the job in the best possible manor is unexcusable in my book.

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    Quote Originally Posted by Acklan View Post
    I only pointed this out because you made mention of using it for transporting the patient for a doctor's visit.
    Ok, like I said, that's pretty much the only time I could see a true use at the BLS level.

    We have 2 paramedics, sometimes a student, on the transport and 4 FF\EMT on the engine.
    I would guess he would do what we have done since there have been paramedics on the transports. 2 work the code with the medic and the others get the backboard, stretcher and make ready for transport.
    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?

    I was asking for, not stating, an opinion. I used vents back when I was on the transport, but only for inter-hospital transfers, and have no experince using them on emergencies.
    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.

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