Why is Pacing an ALS skill?

[MikeEMT]

I was being trained on our Zoll Monitor and the video was talking about the Pacing mode.

I have never seen Pacing yet in real life so I don't know what exactly goes on with it. I do know that only ALS providers can do it.

My EMT class did not cover pacing or even mention it.

So why is it an ALS skill? Is it because you have to interpret the EKG? Or does the d-fib send out electricity or something?

I know this is a stupid question but I am really curious, any help would be appreciated. Thanks.

[island emt]

WOW : where to start.::: first you need to get some cardiology textbooks and learn how the electrical conduction system works.

Then get a pathophysiology text and study it.

then get some A+P texts :: you get the idea.

Or you could just go to collage and get a degree in Paramedicine, then you would understand WHY it's a Paramedic level intervention & how it functions.

Sorry I guess that was a wee bit snarky.

It's good that you Basic class didn't talk about Pacing. It is not a simple skill like bleeding control or splinting a possible FX. Whatever you do don't mess with things you don't understand or are not trained & licensed to perform.

Pacing is applying a controlled amount of electrical energy to the heart at the precise moment it is needed to obtain capture to help a heart that is not functioning normally from a number of different problems or causes.

[chbare]

Mike, I think you answered your own question. Your EMT class simply did not have a robust enough curriculum to provide enough of a foundation for you to even understand what pacing actually is, let alone how and why we use it. This is not an insult against your intelligence, rather I am simply pointing out that certain procedures cannot be performed by people who do not have a certain level of education. For example, I could not go around administering general anaesthesia or performing hip ORIF's because my level of educational preparation has not prepared me to adequately understand those concepts in any detail beyond a rudimentary appreciation

[Arctickat]

Hey there Mike.

That's a great question, and like the others have said, much of requirement for pacing requires a substantial foundation in education related to the topics Island had mentioned. That's the reason it's an ALS skill, if you were to learn everything there is to know about pacing, well, then you'd be able to do that skill, but you'd also be in school for much, much longer. EMT school curricula simply does not have the educational basis for many paramedic level skills.

I believe that the biggest difference between the EMT level skill set and the Paramedic level skill set is that if used wrongly, it could kill your patient. Without the knowledge to understand what we are doing, why we are doing it, when to do it, what should happen if we do it right, and finally, what to do if we did it wrong, we'd be killing people left and right. Pacing is just not a case of slapping on the pads and turning a knob or pushing a button, it's much more involved.

To answer your questions now....

Pacing is the use of an electrical current delivered through the defib pads to the heart when pharmacological therapies do not work or the patient is too unstable to wait for meds to work. Typically, the electrical conduction is in the area of 100 - 140 milliamps (mA). slightly less than half that used in defibrillation.

The indication for pacing is a symptomatic bradycardia, often a 3rd degree block or a 2nd degree type II. If the patient is conscious, alert, and has otherwise normal vital signs...just a low heart rate in the 20s or 30s, transcutaneous pacing is not indicated...but if the patient begins to decompensate, then it would be. Pacing is an extremely painful treatment, so sedation is also required. Usually midazolam. Therefore you'd also need more pharmacological training. When we pace someone we start at a low amperage setting and increase it slowly. We are looking for a change in the ECG rhythm that is known as electrical capture. Once we see this change...and it will be a drastic change, we evaluate the patient to determine if the heart is actually beating at the same rate we see on the monitor...usually it isn't, so we have to increase the amperage until we have mechanical capture, ie a pulse rate equal to that being paced. Finally we increase the power level 10 mA more to ensure mechanical capture is maintained.

Following this we will continually monitor the patient and ensure that mechanical capture is being sustained.

I hope this answers your question appropriately.

[dandanthemedicineman]

Sorry I guess that was a wee bit snarky.

You are correct.

Us dumb EMTs can't even think good. By the way, what's a book?

Don't worry - It's cool man, us ambulance drivers can take the criticism and insult, for that is the meaning of our existence.

All joking aside, this skill is nowhere near the EMT scope for the exact reasons that Island Medic stated. We don't concern ourselves with extensive cardiology. If you take an EKG class, you learn that you put the stickers on the patient, the magicians inside the box tell the paramedic if the person's heart is sick, the paramedic zaps the person's heart after that sometimes. We drive fast so that the hospital people can use further witchery to make the person's heart less sick. That's all you need to know. Glory.

[dandanthemedicineman]

he/she and I are going to have a serious come to Jesus talk....the outcome will not be good.

Once again, part of the existence of an ambulance driver. (I'm totally joking)

Safety and a smooth ride are most important of course. Speeding seldom gains you much time anyways. That being said, I hate to lolligag unless it's in the best interest of the patient. Luckily, the medics I've worked with only lolligag in these circumstances and let the doctors play doctor.

[island emt]

You are correct.

Us dumb EMTs can't even think good. By the way, what's a book?

Don't worry - It's cool man, us ambulance drivers can take the criticism and insult, for that is the meaning of our existence.

All joking aside, this skill is nowhere near the EMT scope for the exact reasons that Island Medic stated. We don't concern ourselves with extensive cardiology. If you take an EKG class, you learn that you put the stickers on the patient, the magicians inside the box tell the paramedic if the person's heart is sick, the paramedic zaps the person's heart after that sometimes. We drive fast so that the hospital people can use further witchery to make the person's heart less sick. That's all you need to know. Glory.

Just so you know: It was not intended to demean the skills or ability of the Basic EMT. Yes the current curriculum for EMTB is lacking in so many ways, it's sad.

I say this as someone who was a Basic for many years and then became an Intermediate. The additional 700 hours of education taught me how little I really knew, even working at a high volume knife & gun club in a major urban environment and 20 years part time at a motorsports venue with crowds in excess of 100 thousand spectators to treat. It was there that I had the opportunity to work with some incredibly smart & talented Paramedics who spent the time to make sure we understood the how & why of many things. They also pushed us to get educated in All of the things that make prehospital care better. instead of sitting around the station watching the tube we would go through college level A+P or pathophysiology , or acid base.

Morning coffee was spent looking at & discussing rhythm strips that showed up as out of the ordinary.

There are those in this profession that glide along meeting the minimums for relicensing:: & there are those of us who choose to be better and go the extra mile to improve our knowledge and our skills everyday.

It is up to all of us to decide whether we want to slide along in mediocrity , or stand out at the forefront of modern day Prehospital emergency care.

You decide where you want to be!

[Quakefire]

In addition to pacing, you have to remember that there are other things to try before pacing, so some of it is knowing when not to pace, plus what you need know for when pacing doesn't work. Arctickat has once again provided an excellent explanation.

[Lone Star]

Island seems to have hit the nail on the head here....

As an EMT-B, your main focus is learning everything that the course can teach you, and learning it inside and out. EMT-B isn't rocket science, and you'll be qualified to put band-aids on boo-boos. (I can say that with authority, since I was an EMT-B for 12 years)

Don't fret over what you can't do, (but the other license levels can). This will only get you into trouble at your level.

If you want to be able to play with all the 'cool toys' like the Intermediates and the Medics do, then by all means enroll your bad self into your local college and get with the educational program!

EMT-B is the very BASIC building blocks that the other license levels are built upon.

Another tidbit of advice (at least as how I see it): Just because that 'cool medic' you work with allows you to do things that are outside of your scope of practice, doesn't mean that you should be doing it! I know what's in the EMT-B course, the Intermediate Course AND all but the last semester of the Medic course; and I can tell you that as an EMT-B, you've got NO qualifications to be working with the defibrillator, reaching into the drug bag, starting IV's or touching a laryngoscope!

[MikeEMT]

Thanks everyone. I wasn't concerned with it because I CAN'T do it, rather it was a curiosity to me.

I have heard pacing mentioned and heard of it being done, but no one took the time to explain it to me. I have no interest in working with something outside my scope. When I master basic I will move on into Paramedic.

We actually went pretty indepth into cardiology in my class. We also covered some EKG rhythms. I seriously doubt a 80 - 100 page chapter on cardiology doesn't even begin to touch on it.

Thanks again for the answers.