Basics Doing Advanced Patient Care - Good Or Bad?

[daedalus]

I don't understand why a medical assistant can give medications anyway. With no pharmacology or a very basic pharmacology knowledge I have seen medical assistants giving many injections yet they usually cannot tell me why they are giving the meds. Physicians do their patients a disservice when they have a person with no training in medications giving me or anyone else a med. That's a recipe for disaster and I'm sure that medication errors and adverse reactions occur with surprising frequency yet are not reported because they happened in the confines of a private physicians office.

There is a reasoning behind this and it actually does work out to be a good arrangement. It is not like you are imagining, rather a physician can instruct a medical assistant to give certain medications (like PPD, just an example) by PO, SC, and IM routes. Medical assistants are not educated or expected to understand the drug or the disease the drug is given for, because the physician is physically present in the office and has already examined the patient. MAs are not licensed, and cannot act in any manner like an RN (who can for example, using standing orders, independently decide to give medications without consulting a physician). MAs must be directly instructed by a physician in order to give a medication, and can only do so while the physician is inside of the office. They cannot give drugs by the intravenous route.

In California, MAs can give a patient an IM slug of morphine while an MD/DO is in the same room and personally verified the dose. However, an MA in California is not allowed to document pupillary responses because it is a form of assessment. Patient assessment is beyond the scope of practice of an MA. Initially weird, but when you think of the very specific role they play (keeping costs down by allowing physicians to hire lower paid assistants to staff their office instead of paying RNs a nurse salary to do menial tasks), it makes sense.

Now, in response to this thread, some of the posts do not even deserve a reply. Nobody with a 120 hour "education" or even a whopping 300 hour EMT-I "education" should be claiming to be an expert in BLS level care. I never understood why EMTs think they are better at the basics then Paramedics are. I spent a lot of paramedic school relearning the proper way to bag a patient, insert nasal airways the proper way, etc. I have said this before in another thread, but I was humbled the first time I went into the OR and found that getting a good mask seal was a lot harder then I had thought. Glad I got expert (by anesthesiologists) training in this critical aspect of emergency medicine. EMTs spend maybe one day learning how to bag, and the instructor teaching them may only be an EMT.... It is like the blind leading the blind.

[Timmy]

I’ve said it once, I’ve said it a thousand times - having BLS in emergency pre hospital care is irrelevant. When the public calls the emergency number (000, 911, 999 and so on) they expect a competent professional to arrive and deal with whatever there presentation happens to be, they do not expect someone who has basic first aid knowledge and can provide minimal care both on scene or whilst in transit to tertiary care. Like my headline thing at the bottom of the pages suggests sure, you may be able to deal with any medical eventually BUT it must fall within certain parameters before your knowledge and skill starts to reach those parameters and you don’t have a great deal more you can do for the patient until you reach further care or further care comes to you.

I can assure you were I come from BLS is covered within the first year (of three years) of a paramedic degree. I can rest assure the paramedics are more than competent of managing my airway, controlling my bleeding and all those BLS skills BUT I also know that once those BLS skills have been preformed then the paramedics can go onto ALS care if it’s indicated.

I live in a small rural community. The demographics are something like a population 6000 based around a farming/industrial industry. We have 2 ambulances, of which one is staffed by 2 ALS paramedics and the other is spare. Our hospital is a 30 bed acute care service with a 3 bed emergency department with limited medical imaging or resuscitation facilities thus most patients are stabilised (as much as they can be) at this facility and transported to a base hospital which is an hour away or by air to Melbourne. Now, let’s make things simple here, say tomorrow I fall over and fracture my leg. I call 000 and have confidence that the attending paramedics have adequate knowledge in anatomy & physiology, patient assessment, pharmacology and all things Basic Life Support AND Advanced Life Support. So once they arrive they can assess me appropriately, provide adequate analgesia (methoxyflurane, morphine, fentanyl and even midazolam if I give them too much cheek) then they can splintmy limb appropriately and get me to hospital. Now, in America in a town with a similar demographic area… I might get a group of Volunteer EMTs who are attached to the local Fire Department who can not offer me analgesia, they can split my limb causing more pain and transport me for over an hour to the base hospital with no analgesia. Which option would you take?

Now to the topic at hand. I do not agree with BLS members doing ALS skills, there not qualified and there would be no insurance. I’m a registered nurse division two (LPN), were registered the same as a registered nurse division one (RN) but we have separate scopes of practices, roles and responsibilities. Were regulated by a governing body called the Nurses Board and our code of ethics and policy come from an organisation called The Australian Nursing and Midwifery Council, dare step out of place and be dragged in front of these people and your up the creek with out a paddle. I’m also a second year RN student but I CAN NOT practise out side of my scope of practise as an LPN even if we’ve been marked competent at university for it, this is what clinical placement if for. The whole point of clinical placement is putting your theoretical knowledge into practise in a controlled environment under the supervision of a higher authority. The same would go for an EMT who is a student paramedic… As much as I’m extremely keen to further my knowledge and practise at a higher level and scope of practise there is a process and this process must be completed over time. I’m also only 20 and want a long and rewarding career in healthcare so I’m not going to put my self at risk by doing silly things. But hey, just my opinion.

[Timmy]

In California, MAs can give a patient an IM slug of morphine while an MD/DO is in the same room and personally verified the dose. However, an MA in California is not allowed to document pupillary responses because it is a form of assessment. Patient assessment is beyond the scope of practice of an MA. Initially weird, but when you think of the very specific role they play (keeping costs down by allowing physicians to hire lower paid assistants to staff their office instead of paying RNs a nurse salary to do menial tasks), it makes sense

I hardly think giving Morphine is a menial task! There's a lot to take into consideration when giving it, as I'm sure your well aware its a very dangerous medication...

[uglyEMT]

It seems like we are all saying the same things here LOL We all understand that BLS is woefully under educated and ALS can do what basics do but also be able to immediatelly begin advanced therapies when necessary without the need to wait. Basically the bottom line we are all striving for is proper and complete medical care for every patient in a timely manner.

I read in a post, " Basics are for the most part, [are] unable to determine if an intercept is necessary due to their lack of education." This I do not feel is true. We all have our algorithims and general knowledge of proper patient vitals and anatomy. If you follow what you were taught and know from experience a BLS should be able to know when ALS is necessary. I cant speak for all systems but the system I am in dispatches ALS to almost every call and it is up to BLS to cancel after our initial assessment. Have we called for ALS without them being dispatched already? Yes we have. Has there been times when ALS is not available when needed? Yes there has. Is this system good? Not in my opinion, but that is the way it is in NJ with ALS being hospital based only.

Like I said in my previous post I do NOT feel BLS should be given more responsiblities, no way, but what i do feel needs to be done is a National Standard for all systems that will make them work to take care of the patients in a timely and proper manner.

One thing I have been noticing also in the threads, be it this one or any BLS/ALS thread is this. So many folks work on just ALS rigs in systems that are droping BLS from them then tell folks that every system should be that way. I am only speaking from personal experience in my local area, not internationally (although I have spoken with a number of you) or even nationally. Some areas can't have fully staffed ALS rigs for everything. Be it from the State's mandates or what-have-yous. I know the argument is that if you can afford the cops or the fire dept you can afford ALS only rigs or that the tax payers will understand the need. Yes I wish it was that easy but living in the highest taxed state in the US I can attest to the fact people are fed up with paying ANY higher taxes. Hell right now they are even cutting teachers and closing hospitals and schools to try and allivate some tax burderns!!! I know this is totally wrong and the dumbest thing around but it is what it is.

We all need to realize that our local systems are what they are and no system is better then the next guys because each one is tailored to their specific area. Some are fire based so are independent. Some are all volunteer some are paid. Some have ALS rigs some dont. But what we all have in common is that we as EMS have the patient to worry about and not titles or initials or anything else. We need folks, be it BLS or ALS, to be as well trained and COMPITANT as possible to give the proper interventions at the proper time in the proper sequence to provide the best possible outcome to our patients.

Its been stated before but I will restate it here... when someone calls their emergency number they dont care who comes through the door or to their aid. They just expect that whoever it is can help them, to the best of their abilities, to resolve their issue. Its about our patients not our egos.

Again I stress I DO NOT believe that basics should do anything more then their SOP. Basics need more education to begin with and WE ALL have a role in prehospitial emergency care and our most important thing is our patients.

[Timmy]

Holly Cow! My volunteer event standby first aid service is more equipped and trained to deal with an emergency than an emergency EMT in America. Were the lowest providers on the food chain and there’s no way we’d be allowed to responded to a 000 call or transport a patient to hospital. Most of the members are health care students (trainee doctors, nurses, paramedics, transport officers, physios and so on) or are retired from the above professions who are looking for some exposure and experience or want to keep there BLS skills up to scratch. We have different levels and scopes of practise but it would be a rare occurrence (in my area anyway) that we didn’t have at least an RN or advanced first responder paired with a first aider at every event. The advanced first responders and healthcare officers carry Methoxyflurance, Salbutamol, GTN, Adrenaline, Glucagon, AED, OPAs (talk of LMAs and 3 leads being implemented, already being carried in some areas). To become an advanced first responder it’s over 200 hours of training spread over a year and a half to practise at that level.

I disagree with people taking comfort in anyone just rocking up to help because frankly, why should I get better care at the state lawn bowels pennant or the local school fete than an emergency call within my community?

What’s wrong with having an all ALS system? For the most part Australia is ALS and intensive care, we only have BLS in areas were it’s not viable to have full time ALS (remote, rural, isolated settings) but the BLS crew does not transport and are always co responded with the nearest ALS crew. The difference here is our service is funded by the Government which sadly isn’t the case in America.

[JakeEMTP]

I read in a post, " Basics are for the most part, [are] unable to determine if an intercept is necessary due to their lack of education." This I do not feel is true. We all have our algorithims and general knowledge of proper patient vitals and anatomy. If you follow what you were taught and know from experience a BLS should be able to know when ALS is necessary. I cant speak for all systems but the system I am in dispatches ALS to almost every call and it is up to BLS to cancel after our initial assessment. Have we called for ALS without them being dispatched already? Yes we have. Has there been times when ALS is not available when needed? Yes there has. Is this system good? Not in my opinion, but that is the way it is in NJ with ALS being hospital based only.

Do you seriously believe that? How is it possible for an EMT-B to have the ability to decide whether or not ALS is required when the current entire EMT-B class was shorter then 1 of my A & P classes? Following an algorithm hardly constitutes an thorough assessment. The key is what you don't see. And seriously bro', NJ is hardly a shining example of how EMS should be done.

If ALS is going to be dispatched anyway, why not just send them? It's only fair to the pt.

[Aeromedic]

I guess part of the "issues" with my post come from my lack of experience with the US system. Our "BLS" level here carries IV, D50, Entonox for Pain control, Nitro, ASA, Gravol, Glucagon, epi, ventolin, atrovent and a couple of others I can't remember.

You guys are right, Assessment is the key, and I did somewhat gloss over it. I don't know how detailed the training for EMT-B's is with assessments but I would hope that they have enough sense to be able to spot ABC problems and know if one of those exists that ALS intervention would be warranted. I think that there are a lot of experienced basics out there that we don't give enough credit to. I don't think any Paramedic can comfortably say that they learned to be good at their job just by going to school. I know I learned most of my best techniques and gained my confidence from Practicum and from experience with other medics. A basic who has been on car for 10 years has seen quite a bit and will often know when things are going south, so I don't think it is fair to discount the knowledge and skill of all basics.

I think anybody else who has worked in environments where you are the only practitioner for 4-5 hours around will agree that having somebody with half a clue doing basic interventions for the X minutes or hours until you get there helps. When I was talking about having a basic set up an initial 12 lead, I wasn't talking about when you are 2 or 3 minutes behind, I'm talking about when you are the next service over and you might be 20-30 minutes away.

I disagree with the whole "Scrap BLS" argument. I've spent my whole career in remote areas. Many "Ambulance" services are a single EMT with a driver because they get a call a month if they are really busy. There are no full time paid staff, it is all volunteer and they serve a population of under 200. It is just not feasible to have ALS providers in those situations because ALS skills need to be used to be kept current, and these places are remote enough that you don't have the option of working a second job with a busier service or working in hospital. I fully agree that ALS care should be universal, but sometimes BLS (or even glorified first aid) is better than nothing.Thinking that there could be ALS everywhere is utopian, it just won't ever happen so we need to find ways to make due with what we have. Personally, from what I know of the US System, dropping the EMT-B and upgrading to just EMT-I would be the best way to keep things cost-effective. Keep in mind, however, that paramedics don't grow on trees. I don't know any service that wouldn't love to be double medic, or even better, ride 3 medics to a car. It just isn't possible all the time with staff and available medics. Most cities in Canada try for 2 medics, but there just aren't enough medics to go around. To reply to Timmy with the BLS crew not transporting, the vast areas of nothingness in parts of Canada make it impossible to do. There are communities that are 1-2 hours from ALS service (some even more remote), and to let them sit with BLS providers for 1-2 hours until arrival, and then have another 1-2 hour transport (because lets face it, Air Ambulance can't run all the time, winter storms are common) when there could have been a .5-1 hour window of BLS only care with an intercept, and then only another .5-1 hours to hospital.

Finally, about the drugs and the ALS/BLS stuff. Every drug in the box is important, every drug in the box can save lives. But using these drugs takes a LOT of education and experience. The drugs I mentioned as "Vital" are those that can be administered by anybody from an MD down to an EMT-B without needing to have the training and experience. Yes, a lot of things I mentioned and called "BLS" skills ALS providers do, actually, all of them do. The foundation of ALS is BLS. You don't start ACLS without CPR, (BLS Skill). ALS providers use BLS skills all the time, heck, a lot of calls that we do are straight BLS calls. The point that I am making is that BLS forms a foundation, and these skills are the base for ALS treatment. I'm not totally forgetting about easing suffering, that is the bread and butter of EMS because we're not all running codes all the time. I'll admit to the rocks in my head part for saying that we only need Epi and o2, it was late at night after being ass-deep in muck for a vehicle ex, so yes, there are other drugs that need to be carried. On Pain control, I agree that pain control is important for ALS practitioners, but that is because ALS assessment skills, experience and knowledge facilitates the proper administration, and most of all, knowing when not to administer them (altered LOC, our protocols are to withhold with ABD pain unless you call for a consult). These are ALS things, and you can't give a BLS provider pain meds without a LOT more training, and that is the point that I am making, that to be able to do ALS skills and use ALS meds, you need the confidence and experience that comes with ALS training.

[uglyEMT]

Do you seriously believe that? How is it possible for an EMT-B to have the ability to decide whether or not ALS is required when the current entire EMT-B class was shorter then 1 of my A & P classes? Following an algorithm hardly constitutes an thorough assessment. The key is what you don't see. And seriously bro', NJ is hardly a shining example of how EMS should be done.

If ALS is going to be dispatched anyway, why not just send them? It's only fair to the pt.

Not saying we are a shinning example by a long shot. As I hear it we are the laughing stock of EMS.

As for why not just send them... 2 ALS units for a 75 mile area. Why have an ALS onboard my difficulty breathing thats being managed effectively with 15L NRB and 20 min from the ED and take them off a possibly necessary call? Not saying we dont utilize ALS for alot but we just got done with our 6 month reviews and out of 95 ALS dispatched calls ALS stood on board 3 times, all others they released Pt to our care ( the three times they stood... Cardiac Arrest, Anaphylactic, Cocaine OD). That was the 95 times we didnt cancel them.

Im not trying to make this about ALS or BLS or anything like that. I was just pointing out in my experience thus far in the EMS field a BLS can make an informed decision through both education and experience as to wether or not ALS is required. Are there times we may miss something? Probably but 9 out of 10 times we get it right. Most times ALS jumps onboard hooks up a 12 lead looks at the strip, checks the BP against our findings thus far, then says "really nothing for us here released to you guys." The delay in ongoing higher care just for them to say that after meeting them enroute to the ED plus the added stress to the Pt of more folks on the rig is not necessarly a good thing. Our SOP where I am is ALS gets dispatched along with BLS, they radio us to see our findings, ask if we feel they are needed, and together we make an informed decision as to yes or no. ALS is letting us decide based on our findings.

Again this is my local area and as stated previously by me I feel the biggest disadvantage is not a comprehensive standard of care across the country. What we have is what we follow and our SOP may be diffrent then yours but it doesnt mean what we do is wrong, it just means we work withing our SOPs and thats where , I feel, we get these kind of threads and arguments industry wide from.

[NRPinNEPA]

If you only have two ALS units for 75 miles, there is a simple solution... MORE PARAMEDICS!!

Usually the EMTs who complain about Paramedics not respecting them are the ones who are either too lazy or scared to go to Paramedic school, or have tried several times and failed. I'm sorry, 120 hours does NOT qualify you to perform invasive procedures. Sure, you can start that IV, but what do you do if you suspect you've caused an air embolism? For a CHFer, would you attach saline or just a lock? What happens if you give too much Narcan to an unconscious overdose patient? Your patient is having a Right Ventricular Infarction... would you give them nitro? Can you give Bicarb and Calcium through the same IV? How does Bicarb work? What does it do? How does Calcium work?

I'm sorry, but 120 hours with a few 16 hour "extra cert" courses should not qualify you to administer ANY medication. You have less education than a hairdresser and you want to inject substances into somebody that will alter their body chemistry? Substances that alter how their body is working at the cellular level? Substances that could kill them?

When I finished my EMT class, I had training. Now that I am finishing my Paramedic schooling, I have an education, and I am going to be continuing on to higher education. Yes, there is a difference between training and education... for example, would you want your daughter to get sex education or sex training? Think about it.

Edited June 25, 2010 by EMTinNEPA

[Mateo_1387]

... Yes, there is a difference between training and education... for example, would you want your daughter to get sex education or sex training? Think about it.

That is one of the best lines I've seen on here in a while !