BLS pushing ALS drugs in a "pinch"

[Thunderchild145]

Firstly, three relatively unrelated questions.

What kind of medic is too busy to spike a bag on a Long-Distance Transport?

If you were on a transport, and (I'm assuming) transporting, why were you in the back, spiking a bag?

Isn't spiking IV bags a basic skill anyway? (It is here. EMT-Bs spike bags all the time. Usually while the medic is getting the IV started)

Kay. Now that that's out of the way.

I had some time to think about this, and I reread the original post. I totally don't get a basic pushing MS, because there is nothing immediate that would even seem to go along with my last post. (Does MS come in 5mg vials? I've only seen 4mg and 10mg. I -know- MS doesn't come in prefills. Unless you count the fact that that little narcotic vial can be placed in a carpu-ject and pushed directly.)

After rethinking, I can't really think of any good reason to have a basic push meds. I know that when I was a basic, I'd be scared as hell. I know for a fact that I would probably mess something up. Also: This would only go against the basic a little. It would go against the medic a whole lot. Being a medic now, I'm a little iffy about losing that license cause I decided my time was a little short. I'm still okay with defib though. If I interp the rhythm, I'm cool with them pushing the button.

[akroeze]

Vs:

Just wanted to point out that pushing IV meds IS within the scope of some PCPs. Dextrose for example.

[vs-eh?]

Vs:

Just wanted to point out that pushing IV meds IS within the scope of some PCPs. Dextrose for example.

Yes true. But dextrose is the only IV medication PCP's are allowed to administer in Ontario (and it is a standing order). D50W administration is generally uncommon/rare for PCP practice as a rule.

[Dustdevil]

If the Paramedic is busy, and if it is a pre-dose syringe, all has been cleared with the 5 R's.. so what ? I am watching them... so they stuck the needle in the the tubing & plunged the syringe.. it is a mechanical maneuver, just like an IV or med pump.. nothing more!

This is pretty much my position on the matter in theory. Although, I do not agree with it in this particular scenario for several reasons:

2. It was not a medication that could be given without regard to administration rate. Given too slow, you're not providing any benefit because the patient is suffering and the medic could have finished what he was doing and done it himself in that time. Given too rapidly, the patient hurls on you.

3. There was no emergent need for the medication that overrides standards of professional practise. The guy was not crashing, and this was not pre-filled Epi in an arrest.

4. I cannot think of a single thing this paramedic could have or should have been doing that kept him from providing his own ALS care. What was he so busy doing, tying an ankle hitch? If he can't trust his driver to be taking care of all that BLS crap, then I damn sure can't imagine that he would trust him to push drugs!

• Yes, I agree that there are situations of great urgency, where you have an exceptionally sharp, competent, and trustworthy driver (usually a medic student himself) who can be entrusted to push a very select few drugs for you while you are busy managing the airway or something. I have done it and can envision situations in the future where I might continue to do so. But this definitely was not one of those cases. Not even close. Paramedics and RNs with many, many years of hardcore experience make med mistakes every single day. I've done that too. So any naive contention that this cannot be screwed up by an EMT is just plain stupid. This isn't Canadia we're talking about. This is America, where your driver is lucky to have 120 hours of night school, where he learned that there are 206 bones in the body, but can name only about 20 of them. And you're trusting this person with your licence? Ha!

One other issue of concern here is the trustworthiness of your partner. Forget about it. Damn few EMTs have the self-control to get to perform an ALS manoeuvre without running their mouths about it to their loser friends later. This will NOT remain between you two alone. Know that before you make this fateful decision and decide if your career is worth it.

[NREMT-Basic]

I would like to make it clear that I started this post to gain information about this difficult topic. I would also like to state, for the record, since there seems to be some confusion, this isnt one of those "i uh have a friend...you wouldnt know him" deals. I am talking about some who I know, and with whom I went through my Basic course. This person contacted me very distraught. Not so much I think because of being told (by the medic) to go ahead and push the MS into the IV line. From what I have been told, there was an implicit moment of trust here, and all was expected to be well. The Basic I am talking about is now worried because, of his own accord, the medic lied on/falsified the PCR. In what I am trying to re-create as my own HUMBLE opinion, here is where the breakdown of trust occurred. Should a BLS provider be pushing ALS drugs under any cirumstances. Legally, obviously the answer is no. I never meant to indicate that there was a break down in the rig and that the basic had to push the meds because the medic couldnt pull it together as I have been paraphrased as saying. The medic was doing what he was doing (whatever that was). The patient was screaming in pain. The basic made eye contact with the medic and mouthed the word "Morphine?" assuming that she was asking if the medic was planning to give morphine or if they needed to get orders for it, etc. The medic gave the basic the keys to the med box and from what I can tell, my friend the basic pulled out a pre-filled syringe of MS. I could be wrong here because I have not yet had dealings with ALS interventions in which morphine was given. She handed the syringe to the medic who checked it for the 5 rights, asked her if she knew how to push it IV and then instructed her to do so, which she did, assuming that though this was in strict violation of protocol and law, that she had a trust situation with the medic. What got her to contact me, was the fact that when she saw the run report and it listed drugs given as MS given IV by Medic, she started to get worried about what the ramifications would be if this came back to her. Thats all I have been trying to say. As I think Dust stated, the PCR could have been written as "MS administered IV" at such and such a dose and such and such a time. BUt he chose to lie about it, and so she is worried and I think rightly so. Perhaps if I had offered this much information in my initial posting, we wouldnt have had as much confustion and argument as we have had. For that I apologize and as far as I can see, the topic of this thread has burned itself out. Thanks to all that commented and gaave their opinions.

[nsmedic393]

Here is the link to our policys, it is the last one on the list #6174. EHS Policies

[PRPGfirerescuetech]

Interestingly enough, when I made my original post, I wasnt referencing the call specifically, but more in general.

Good point Dust. For an open femur fracture, the only ALS skills to provide are Iv and pain management. Seems the EMT should have been too busy with traction splint, covering the open wound, oxygen at a high flow rate, and considerations for spinal immobilization (variant on mechanism) to be "helping the medic" on this skill.

Just a thought.

[flight-lp]

Legally, in the USA, no the Basic should not have pushed the drug. That being said, we have all been or at some point will be in situations where due to absolute necessity, things will need to be done by who can do them, regardless of rightness or wrongness.

I have never been in a situation that I had to have an unlicensed and undereducated EMT partner perform an ALS intervention. A proficent medic knows how to prioritize and delegate. As previously stated the Medic should have been addressing the pain management aspect while the EMT was bandaging, splinting, etc (although based on the arterial issue, pain control shouldn't have even been a priority at the time, more about that down below).........

Second, you werent on the scene and I should think as a paramedic, a flight paramedic no less, that you have come across situations where its all hands on deck, doing what needs to be done.

Yes, and that is why I have another Paramedic or a nurse as a partner..........

And as I have already said, I never said that the Medic or his Basic assistant were "wigging" or "freaking out." The freak out came after the call when my friend got off duty and contacted me. So no patient saw anyone "wigging."

You are absolutely correct, I did misquote you and I humbly apologize for doing so.............

And if you are a patient who has a broken midshaft femur with a compromised artery, do you think you give two flips who gives you that MS where it was within protocol or not. I have since learned from talking to my pal via IM that the medic was trying to control bleeding, monitor his patient and do about 100 other ALS interventions at the same time. I am sure that we would all like to think that the Medic can do all of these things at the same time but sometimes it just isnt possible.

ABC - C standing for circulation, i.e. bleeding control. Why was this medic already into secondary interventions when the bleeding wasn't even under control? That is a basic day 1 EMT course assessment pearl, yet the issue here is about who pushed the Morphine????????

I find it hard to understand how someone, a flight medic no less, can say tsk tsk and wag their lttle cyber finger when you were no where near that scene, dont know the situation and are thinking sheerly out of protocol and not reality.

Actually the exact opposite. The reality is that the medic did not appropriately manage the patients care as previously mentioned................

Our BLS protocols here in IL allow us to do nothing during an ET intubation but hand things to the medic, but if the medic has a hard tube on his hands and asks me to do this or that, you can better believe I would do it, rather than sitting there watching the patients sats fall.

This is why failed airway adjuncts were invented, 3 attempts then Combitube or LMA. Placed properly, they will provide a more patent and less damged airway than allowing a gung-ho EMT lacerate someones vocal cords!

If you can honestly say, "No. Under no circumstances would I do that" then I have to wonder about someone who would rather let a patient suffer than make sure their BLS partner has the right med at the right dose and watches him introduce that into the IV line. As I have seen written so many times in these forums...dont say oh no thats wrong, they should have their licenses pulled, unless you were there.

You cannot allow a patients suffering to emotionally alter your care. It causes people to rush, miss pertinant items, and cause errors in care. This being a perfect example. You are right, I wasn't there, had I been, this would not have occured. Plain and simple! I hope your friend learns something from this experience.................

[whit72]

How many times do you need to hear that a EMT shouldn't be pushing a controlled substance. What would you like them to say, since you are obviously more competent then most EMTs as you have stated numerous times, you should be allowed to practice outside your scope? BullSH#T, if you or your pal was attending to his responsibilities competently then the medic would have had plenty of time to attend to his. Got it? This be should be easy for someone of your extreme intelligence to understand.

What is so hard to understand. No there is never any circumstances, instances or examples that could possibly arise that would justify it. Most medics I work with are fully self sufficient. They understand the aspects of their job, and can fulfill all the necessary obligations.

I am one to normally side with any EMT that has a valid argument. This however isn't one.

Move on.

[akroeze]

How many times do you need to hear that a EMT shouldn't be pushing a controlled substance. What would you like them to say, since you are obviously more competent then most EMTs as you have stated numerous times, you should be allowed to practice outside your scope? BullSH#T, if you or your pal was attending to his responsibilities competently then the medic would have had plenty of time to attend to his. Got it? This be should be easy for someone of your extreme intelligence to understand.

What is so hard to understand. No there is never any circumstances, instances or examples that could possibly arise that would justify it. Most medics I work with are fully self sufficient. They understand the aspects of their job, and can fulfill all the necessary obligations.

I am one to normally side with any EMT that has a valid argument. This however isn't one.

Move on.

Wow! If whit is siding AGAINST the basic then you KNOW taht it has to be a big deal to the extreme! :shock: