Pre-hospital ASA

[leviathan]

Is there any research to show a benefit to giving chewable ASA tablets vs. non-chewable in the case of an MI?

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[emtcsmith]

Not that I've seen. I would imagine that it may vary the rate of absorption but in that case why isn't it given IV? I think a bigger debate would be if the research shows a big advantage to it why not bring it to the basic level? Many basics can assist the patient with there nitro and I think there are bigger risks with that then ASA. Mabye its a risk vs. benifit thing or mabye I'm missing a peice of the pie.

 

[leviathan]

Not that I've seen. I would imagine that it may vary the rate of absorption but in that case why isn't it given IV? I think a bigger debate would be if the research shows a big advantage to it why not bring it to the basic level? Many basics can assist the patient with there nitro and I think there are bigger risks with that then ASA. Mabye its a risk vs. benifit thing or mabye I'm missing a peice of the pie.

I don't know any EMT-Bs that aren't allowed to give ASA...and yes, ASA itself does show up to a 50% reduction in mortality when given in combination with thrombolytics, than when 'lytics are given alone. The question was more specific, comparing the admin of pre-crushed ASA (ie., a chewable aspirin) vs. a regular swallowed pill of ASA.

 

[DropkickMurphy]

There are some states that do not allow basics to give ASA, and some services mandate that you call in and recieve OLMC authorization for it. Personally I think it should definitely be part of any BLS service's protocol- along with albuterol, NTG, glucagon, naloxone, epinephrine and nitrous oxide.

 

[docB]

Not that I've seen. I would imagine that it may vary the rate of absorption but in that case why isn't it given IV?

I've never heard of an IV ASA prep. Does it exist? I would imagine (which I suppose is the opposite of data) that the absorption difference between chewable and PO ASA is clinically negligable.

 

[DropkickMurphy]

I was told by a pharmacist once that there was an IV preparation of ASA at one time in Europe, but it was withdrawn due to excessive rates of adverse reactions (he didn't specify what).

 

[emtcsmith]

There are some states that do not allow basics to give ASA, and some services mandate that you call in and recieve OLMC authorization for it. Personally I think it should definitely be part of any BLS service's protocol- along with albuterol, NTG, glucagon, naloxone, epinephrine and nitrous oxide.

We need to draw the "basic" line somewhere. If you figuring Naloxone via nasal and epi-pens then I'm fine with that. I think assisting nitro is probaby plenty because most medics I know wouldn't give nitro without acess and the knowedge to know more about cardiology. The same thing goes for albuterol, and our ALS system doesn't even use nitrous oxide for whatever reason.

 

[Jambi]

Most counties in Califonia, Basics cannot give ASA.

 

[southerndoc]

Most counties in Califonia, Basics cannot give ASA.

Being a controlled substance, I can see why California doesn't allow it.

Isn't it odd that a person can buy an aspirin over the counter, but an EMT cannot administer it?

 

[DropkickMurphy]

We need to draw the "basic" line somewhere. If you figuring Naloxone via nasal and epi-pens then I'm fine with that. I think assisting nitro is probaby plenty because most medics I know wouldn't give nitro without acess and the knowedge to know more about cardiology. The same thing goes for albuterol, and our ALS system doesn't even use nitrous oxide for whatever reason.

I agree with SouthernDoc in that it's strange that you can buy ASA OTC but some EMT's are limited from giving it.

As for albuterol, in 10 years of practice (the last 5 as a respiratory therapist where albuterol is the most common medication I use) I have yet to see a serious side effect of it, even in critically ill patients with multiple systemic diseases including severe atherosclerotic CAD- it's remarkably safe- as opposed to ASA which was described in a journal article as a drug that if it were presented to the FDA today that it would not pass the approval process due to the rate of complications from it's use (or at very least it would get plastered with a black box warning).

Granted, I hesitate to give NTG without vascular access even as an ALS provider simply to cover my butt ("Why didn't you wait the couple of minutes?"). However in the setting of a long transport time where no ALS is available the question becomes which is more important the lesser risk that you might make a patient hypotensive from the NTG or the risk of extending the ischemic lesion or infarct?

Personally I don't see a problem with giving Narcan IM, and glucagon is no more dangerous in the hands of an EMT than in the hands of an utterly untrained family member. In fact I would be FAR more comfortable with an EMT (or even a first responder for that matter) giving glucagon than I would be with that same person giving oral glucose to a patient with a borderline LOC and a questionable gag reflex.

 

[leviathan]

However in the setting of a long transport time where no ALS is available the question becomes which is more important the lesser risk that you might make a patient hypotensive from the NTG or the risk of extending the ischemic lesion or infarct?

Again, is there any research that shows NTG increases survival to discharge in an ACS?

 

[Jambi]

Isn't it odd that a person can buy an aspirin over the counter, but an EMT cannot administer it?

On the surface, yea. When I reflect upon the the actual training an EMT-Basic gets I can see why they do not administer it (for the most part). A person deciding what is best for them is one thing, having a someone in a professional position telling others what is best for them is whole different animal(obviously). I just don't think the average EMT-Basic possesses the needed knowledge in order to make those types of decisions outside of oxygen, transport, and assisting patients with their own medications (afterall, someone has deciced that that patient all ready needed a particular medication).

 

[greytmedic]

Again, is there any research that shows NTG increases survival to discharge in an ACS?

Yes.

 

[leviathan]

Yes.

Source?

 

[greytmedic]

Source?

Why, you don't believe me? You callin' me a lyah?

 

[emtcsmith]

I think obviously alot of what drugs a basic or medic has goes with the location of the system. Urban and many suburban systems that have short transport times don't really need basics that can do alot, but in rural settings it becomes more important. I think nasal narcan would probaby be great to give to basics and right now I wouldn't disagree with that and a King LT rescue airwy being tooks for at least BLS in PA.

 

[viostorm]

1) With the asprin i suggest you give it as directed by the manufacturer, if you want to make it chewable buy childrens ASA. If not, I'd just have them not chew it. I think it is cruel to make people chew adult ASA.

2) My belief basics should not give meds, period.

3) Unless something has changed recently, no study has ever shown that nitroglycerin improves mortality in patients.

 

[leviathan]

Why, you don't believe me? You callin' me a lyah?

You're durn right.

 

[greytmedic]

Yes, there are studies that show that nitroglycerin does improve mortality rates. These studies tend to be smaller in size (100-500) patients and show that NTG improves ventricular function and preventing infarcts from getting bigger.

On the other hand, larger studies and metastudies combining a lot of the little studies show that there is no improvement of mortality rates but shows that the ventricular funtion and smaller infarct sizes still happen.

So, to answer your question, Yes there are studies the show NTG improves mortality rates, but there are also studies that it has no effect on mortality rates. It is still beneficial in giving though because a patient can survive and have decreased ventricular function or survive and have a little bit smaller piece of dead heart and better function(but they both survive).

And back to the ASA question. Chewable aspirin does get absorbed faster and it is easier to give to someone that may be nauseated and/or doesn't require drinking water and a cup(which most ambulances don't carry).

 

[greytmedic]

Here is a couple of examples just to show that I am not making this up.

Here is one that says NTG helps in the short-term but not really in the long run.
Cardiology link

"Evidence from clinical trials suggests that nitroglycerin in the first few hours reduces infarct size and improves short-term and possibly long-term mortality in higher risk patients. Data do not support routine use of nitroglycerin in low-risk, uncomplicated MI."

 

[viostorm]

Thanks greytmedic! That was an interesting read.

-Vio

 

[EMT2RN2MD]

Back when I took the NREMT-B exam, Basics were only allowed to administer O2. We could "assist" someone in taking there own meds. But, we couldn't give/administer anything po not to mention im/iv. Have things changed?

 

[greytmedic]

I think the NREMT-B standards are that EMT-B's can give O2, Activated Charcoal, and oral glucose without the pt having a prescription(Not 100% sure if they still do the Activated charcoal). They can "assist" the pt taking Nitro, epi-pen, and MDI. Then the EMS systems add or take away some of these

 

[medicbs]

Here is my take on this issue…

There are Three major problems with allowing basics to administer multiple medications such as Narcan, Glucagon, NO, …

1. EMT-B’s have 120 hours of training with 10 hrs of “clinic” experience. This is an extraordinarily minute amount of time to truly appreciate the risk/benefits of using multiple medications in a variety so medical “emergencies.” This amount of time barely has enough time to address the current curriculum.

2. Most of the useful knowledge is acquired post class; which is where the major problem lies. I live in Nebraska where the numbers of volunteer basics far exceeds the number of employed. A rough guess would estimate that the average “active” volunteer basic responds to 50 calls a year. This is a hugely small number if ones goal is to gain experience and/or maintain skills. I have had the displeasure of experiencing first-hand some of the atrocities the volunteers have done to their patients under current protocols. ***disclaimer*** not all volunteers suck, in fact I know many who are much better than I could ever dream to be. However, they are out there, and they ruin it for everyone else.

3. The rate of use for these drugs would be low… ergo it is cost-prohibitive.

Long story short, lack of training lack of experience. This is why the meds basics are able to utilize is limited.

Also…
1. Chewable ASA is better. This is because some ASA is enteric-coated and those responsible for inventory may not understand the difference.

2. Leviathon, are you f’ing serious about the Nitro? Furthermore, your statement “ASA itself does show upto a 50% reduction in mortality when given in combination with thrombolytics” is flawed. “ASA itself” does not equal ASA + Thrombolytic. So, since we are not going to site a source the thrombylics were probable responsible for 49% of the 50% reduction in mortality rate.

3. Southerndoc, it’s not odd that one can buy and take ASA but some basics or not allowed to give it. You see, if I give ASA to you and you have an allergic rxn to it and die both my agency and my-self are liable. However, If I buy and take ASA and have an allergic rxn the probability of myself suing myself is virtually nonexistent.

4. Since I am ranting, ASA isn’t offered IV because it too expensive and is not that effective when compared to other IV drugs. Too expensive???? Yes, you see ASA is taken P.O., because ASA does not readily pass through cell membranes it must first be metabolized by the liver in the “first pass” process. So, simply pumping in unaltered ASA into a patient via IV probably won’t work. It must be modified to the biologically active form in the production process which raises cost significantly.

5. This one is nit-picky… Greytmedic, our goal is to reduce our pt’s mortality rate.

Yeah…. I’m really bored. Sorry.

 

[chimichanga]

There are some states that do not allow basics to give ASA, and some services mandate that you call in and recieve OLMC authorization for it. Personally I think it should definitely be part of any BLS service's protocol- along with albuterol, NTG, glucagon, naloxone, epinephrine and nitrous oxide.

Are you saying that albuterol, NTG, glucagon, narcan, epi, and nitrous are part of BLS protocol???

Are you in the USA?

In AZ, EMT-Bs can give oxygen, do chest compressions, C-spine patients...

ANY drug (aside from oxygen) is strictly ALS protocol...

I was an EMT way back when, and had NO business giving ASA to a patient, let alone any of the drugs you mentioned...If I felt that a patient needed more than I could do, then I would upgrade the call, and ALS would arrive within 3-5 minutes, code 3...

And Narcan IM is common in Phoenix, and allowed if no IV access can be obtained...

I'd be curious to see the EMT-B curriculum that allows a B to give meds...

And BTW, I've spoken to many medics who are now nurses and docs, and there is widespread agreement amongst them that for certain interfacility transports, not even a medic has enough education to adequately take care of ICU patients in the rig...Kind of a they don't know what they don't know...

 

[greytmedic]

5. This one is nit-picky… Greytmedic, our goal is to reduce our pt’s mortality rate.

I am confused where this statement came from . Are you saying we shouldn't give NTG even though it is shown to reduce the effects of an MI even if some studies show it doesn't actually reduce mortality rates? Or are you saying we should give NTG because it might reduce mortality rates but we're not quite sure? Basically, I guess I am asking if you're saying we should only be concerned about reducing mortality rates. And then what about things like pain control? I give morphine to pt's with broken bones all the time. It doesn't reduce their mortality rates, but it sure feels a hell-uv-a-lot better.

And just to nit-pick your nit-pickiness, technically our primary goal is "first, do no harm." This doesn't mean reduce mortality rates, it means don't make them worse.

 

[emtcsmith]

I'm really not for basics doing ALS but I really don't see a problem teaching them and letting them give Narcan and have King LT airways in systems that would have limited ALS means.

 

[BaylorHopeful]

Are you saying that albuterol, NTG, glucagon, narcan, epi, and nitrous are part of BLS protocol???

Are you in the USA?

In AZ, EMT-Bs can give oxygen, do chest compressions, C-spine patients...

ANY drug (aside from oxygen) is strictly ALS protocol...

I was an EMT way back when, and had NO business giving ASA to a patient, let alone any of the drugs you mentioned...If I felt that a patient needed more than I could do, then I would upgrade the call, and ALS would arrive within 3-5 minutes, code 3...

And Narcan IM is common in Phoenix, and allowed if no IV access can be obtained...

I'd be curious to see the EMT-B curriculum that allows a B to give meds...

And BTW, I've spoken to many medics who are now nurses and docs, and there is widespread agreement amongst them that for certain interfacility transports, not even a medic has enough education to adequately take care of ICU patients in the rig...Kind of a they don't know what they don't know...

Here in Boston (and Mass. for that matter) basics can give ASA, NTG, Epi, O2, charcoal, oral glucose, Narcan (Intranasally only) and albuterol (both MDI and Nebs). That being said, only Boston EMS carries the last two on basic trucks (that I know of)

In order to keep a BLS truck up to state standards, it MUST be stocked with sufficient ASA (8+ Baby ASA), Epi (both 0.3 and 0.15), Glucose, Charcoal, and of course O2

I feel it's important to provide Basics with at least the essentials with meds. For some places out in Mass, the only EMS providers are Basics. Getting ASA in can improve antiplatelet times. Granted it takes 30 minutes to hit the bloodstream, there are times, even in Boston's "heralded" hospitals, where it takes more than 30 minutes before lytics are given.

 

[wook]

.....

 

[leviathan]

1. Chewable ASA is better. This is because some ASA is enteric-coated and those responsible for inventory may not understand the difference.

Well for the purposes of this discussion, we are comparing non-enteric-coated ASA with crushed/chewable ASA.

2. Leviathon, are you f'ing serious about the Nitro?

Yes. Find me a study that demonstrates an increase in hospital discharge rates. I'm not saying it doesn't make sense that it would; however, I am saying there is no research at present to support it, AFAIK. I wouldn't be surprised if there is something out there, but I've just never seen it.

Furthermore, your statement "ASA itself does show upto a 50% reduction in mortality when given in combination with thrombolytics" is flawed. "ASA itself" does not equal ASA + Thrombolytic. So, since we are not going to site a source the thrombylics were probable responsible for 49% of the 50% reduction in mortality rate.

No, you are wrong. RCTs have been performed comparing groups with thrombolytics alone versus thrombolytics AND aspirin. The latter group had 50% less mortality. I would like to show you a citable article, but I heard this from an ACLS instructor/emergency physician so I would have to ask him where he found it.

 

[leviathan]

1. Chewable ASA is better. This is because some ASA is enteric-coated and those responsible for inventory may not understand the difference.

Well for the purposes of this discussion, we are comparing non-enteric-coated ASA with crushed/chewable ASA.

2. Leviathon, are you f’ing serious about the Nitro?

Yes. Find me a study that demonstrates an increase in hospital discharge rates. I'm not saying it doesn't make sense that it would; however, I am saying there is no research at present to support it, AFAIK. I wouldn't be surprised if there is something out there, but I've just never seen it.

Furthermore, your statement “ASA itself does show upto a 50% reduction in mortality when given in combination with thrombolytics” is flawed. “ASA itself” does not equal ASA + Thrombolytic. So, since we are not going to site a source the thrombylics were probable responsible for 49% of the 50% reduction in mortality rate.

No, you're wrong. I like how you conveniently left out the proceeding words that said "than when 'lytics were given ALONE". RCTs have been performed comparing groups with thrombolytics alone versus thrombolytics AND aspirin. The latter group had 50% less mortality. I apologize if the logic in that experimental design isn't blatantly obvious to you, but it should be. I would like to show you a citable article, but I heard this from an ACLS instructor/emergency physician so I would have to ask him where he found it.

 

[medicbs]

Leviathan,

What can I say other than “Touché salesman, Touché.”

1. Chewable ASA is better. This is because some ASA is enteric-coated and those responsible for inventory may not understand the difference.

I was merely pointing out common human error that makes chewable better. Whether or not non-enteric coated non-chewable ASA is better than chewable was not considered in my response. If I were a betting man (good thing I’m not…read below) I would say that chewable is absorbed faster and so its better… but not by much.

2. I’m an idiot.

“Myocardial Infarction”, Posted in eMedicine Online Journal. Drew E Fenton, MD, Sarah Stahmer, MD. http://www.emedicine.com/EMERG/topic327.htm

“Nitrates are useful for preload reduction and symptomatic relief but have no apparent impact on mortality rate in MI. Systolic BP <90, HR <60 or >100, and RV infarction are a contraindications to nitrate use. Intravenous nitroglycerin is indicated for relief of ongoing ischemic discomfort, control of hypertension, or management of pulmonary congestion.”

… and I retract point number 2 that you brought up.

3. I’m an idiot.

You’re correct in saying it was convenient that I left out a portion that followed the original statement… That was an honest mistake in my reading/processing of the statement.

This is a Review Article - Thrombolysis for Acute Myocardial Infarction, from Medscape General Medicine [TM]
Unfortunately I don’t have subscription to this journal/online site so I could not obtain authors or when it was published.

The Aspirin Factor

“ISIS-2 randomized 17,187 patients with suspected AMI, comparing aspirin, SK, both, and neither (Table 1).[10] This study reported that aspirin decreased the odds of death in 5 weeks in the aspirin arm by 23% (24 per 1000 patient deaths prevented), SK reduced it by 25% (28 per 1000 patient deaths prevented), and both together by 42% (52 per 1000 patient deaths prevented).[10]”

… and I retract point number 3 that you brought up.

I’m awfully red in the face… oops, and sorry.

 

[DropkickMurphy]

Are you saying that albuterol, NTG, glucagon, narcan, epi, and nitrous are part of BLS protocol???

Are you in the USA?

and ALS would arrive within 3-5 minutes, code 3...

I'd be curious to see the EMT-B curriculum that allows a B to give meds...

And BTW, I've spoken to many medics who are now nurses and docs, and there is widespread agreement amongst them that for certain interfacility transports, not even a medic has enough education to adequately take care of ICU patients in the rig...Kind of a they don't know what they don't know...

Addressing your points from the beginning (and sorry for the delay but I didn't see your reply until today):

No I didn't say it was part of protocol (parts of these were included in the , I said I would like to see it as part of protocol (epi by the way in this case meaning EpiPens for overt anaphylaxis even if the patient does not have a prior script for it, not IV epi for cardiac arrest just so we're clear).

Yes, I'm in Indiana at the moment, but getting ready to move.

Precisely, you're in an urban area with a medic unit on every other corner compared to most areas of the US, many of which are lucky to get a BLS unit (transport or non-transport) on scene within 10-15 minutes, let alone ALS.

There is a growing number of persons (see www.fieldmedics.com ; both Leviathan and I are members of that site's forums ) that are advocating for increased educational standards for EMS providers- a quality over quantity approach, the reverse of the current approach to EMS.
As for the "lack of education" among EMT-P's, it depends upon what treatment modalities are being utilized. As a practicing RT, no one.....not nurses, and not docs (outside of critical care and pulmonology fellowship trained ones) besides us has a proper understanding of vent management to handle a transfer of an unstable vent patient. Yes, if the patient is on IABP, ECMO, or a similar modality (both of which I am quite familiar with), then a medic is in over their head.

But then again, if you take a look at the education of your average BSN you'll quickly realize how little of it actually applies to real patient care. They should spend less time on nursing 'diagnoses' and more time on practical matters so that new graduate nurses are a little more rooted in the practices of modern medicine (EBM, etc), but then again most groups fall short of this when it comes to education. EMS is at the opposite end of the spectrum- just enough knowledge to function, and very little in the way of how to figure out when to use that knowledge.

 

[chimichanga]

murphy,

i hadn't thought about rural areas...i supposed if they patched for an order...but when i was a CCT RN, the company i worked for didn't allow basics to patch in...only medics and nurses...and IABP was an RN only skill in the rig...

not to nitpick, but truly unstable patients, on or off the vent should never be transferred, period...though i transported many chronic vent patients that were very ill (in the nursing home) and needed a higher level of care (ER)...

interesting point you make about vents...i always rely on RTs for vent questions, as they are the ones making decisions in the hospital and nursing homes...

BUT, as you likely know, it's not feasable to transport a hospital vent in the rig or bird...the 2 ground transport companies in phx (CCT RN) use the "monkey vents" (TV, rate, fio2 50/100, and a slap on peep valve)...i grasped that vent just fine...though i understand what you are saying, a 20 minute transport w/ a monkey vent seems appropriate for that setting...

and as far as a BSN (or ADN for that matter) being "ready" after graduation, is right on point...that's why you have to take your nursing education into your own hands, and make your own destiny...become an extern, work as a PCT/tech on the unit where you want to be a nurse, pick a hospital that gives you several months of intense classroom and preceptorship...though i tend to like nsg diagnoses, because if taught right, they can help stimulate thinking about what symptom goes with what disease, and eventually helps w/ critical thinking...

 

[DropkickMurphy]

not to nitpick, but truly unstable patients, on or off the vent should never be transferred, period...though i transported many chronic vent patients that were very ill (in the nursing home) and needed a higher level of care (ER)...

I guess we differ in the definitions then.....if you're going from a Level III or Level II trauma center to a Level I because the patient needs.....oh say, neurosurg intervention, yes they need to be transferred.....just as the patient that needs transferred to take advantage of advanced vent therapies- as much as I bitch, moan and try to convince them otherwise some docs (or hospital administrations) simply will not allow high frequency vents to be used despite better outcomes associated with them, a lot of hospitals don't have the capability to do nitric.....yeah, those are unstable vent patients that you will see transferred; you haven't lived until you've seen a transport configured Servo 300 vent.

BTW, we seldom see nurses in the field (sasquatch sightings in the Pacific Northwest are more frequent) here outside of helicopters and the neonatal transport truck from Riley.

 

[chimichanga]

oh definitely, i've taken my share of train wrecks from a level iii facility to (the world renowned ) BARROWS in phx...i may be overstating the "unstable" thing...i just don't want to ground someone that's actively dying, as i was alone in my ambo...yes, in the air, you have an RT or medic w/ you...not so on the ground in phoenix, az...on an RN car, YOU ARE ALONE...so i was REAL specific on the unstable thing...I only had a monkey vent, and being alone (without RT) could be scary at times...but I loved the ambo...there are at least 10 nurse ambos for 2 companies in phoenix...i have noticed that they aren't that common around the US

 

[DropkickMurphy]

There's a reason they aren't that common- nurses are too expensive to make it common and GOOD nurses who function well independently (not to mention limitations on practice- here according to the state nursing board nurses are subordinate to the EMS personnel by the nature of the state nursing practice act) are few and far between.

 

[chimichanga]

being strictly interfacility (though if all the medic cars were busy, we got the nursing home ALOC call), EMS played no part in our company...911 contracts are just those, and nurses don't belong doing that (unless specifically trained by a flight company to do scene calls, and then a medic is part of the team)

the AZ BON has never been too sure about how to handle prehospital RNs...they have an advisory opinion or two, but punt to DHS and the individual company for the regulations...

I was "trained to intubate, and start a central line...would I do either by myself in the back of a rig, with a 15 minute transport ahead of me? NO!!

this is what I meant by unstable for transfer...being alone in my rig, I never left until the patient was safe for transfer, i.e. intubated and hemodynamically stable...

I felt very comfortable w/ my skills in the rig, and hands down was the best job I've held, next to teaching...

and BTW, our company's med director restricted medics from transporting vent patients w/ any PEEP, which necessitated us...as well as some drugs that medics cannot maintain, by virtue of their cert restrictions (national), i.e insulin, levophed, propofol, and others, so an RN is necessary...

 

[chimichanga]

and we were more expensive than the medics, a necessary evil is what we called ourselves...some medics resented the nurses, but I offered to jump calls (being closer) and did other things, and eventually convinced the company to place us in our own quarters (an apartment) and our rig did 20 hour shifts (no OT for us, $$$)...nonetheless, we became more accepted by the medic cars...

DHS doesn't allow ambo companies to specifically bill for an RN transport, but we billed for lots of IV pump tubing (sometimes transported pts on 6-8 drips), peep valves, vent circuits, etc. that aren't used on a "regular ALS" transport...since there is a need to transport patients to a higher level of care, and flying can be cost-prohibitive, the RNs on the ambo became a huge satisfier for our 34 hospitals in the phx metro area...

 

[DropkickMurphy]

as well as some drugs that medics cannot maintain, by virtue of their cert restrictions (national), i.e insulin, levophed, propofol, and others, so an RN is necessary...

Hmmm.....that's odd, our medics gave Levophed in the field, could give insulin (with OLMC authorization), we transferred with propofol drips, etc. As we said, you don't see the nurses on ambulances here unless there are no medics available (which doesn't happen), and the flight nurses are also paramedics.

I don't think the "national" cert restrictions are binding- since the federal government has no authority to issue licenses (at least last time I checked), nor does the NREMT mandate stringent protocols (they tried with other groups but failed miserably).

 

[chimichanga]

likely then the medics were certified by AZ...my mistake...but I know that, in AZ, the medic is restricted from doing certain things...They could not transport patients w/ arterial lines, they could not initiate drugs/IV fluids into a central line, no levo, no propofol, no bumex gtts, no vasopressin gtts, no insulin...

the peep restriction came from our medical director...

i had the same offline protocols that the medics used...

I could take medical direction from ANY doc, PA, NP, whereas a medic could get direction ONLY from his base hospital...

Now I'm in a rural area, and the only ambo company in town won't let their medics transport tridil or heparin...they claim it's a nurse skill...

so i suppose each company's medical director can modify what DHS mandates for each state, but I recall my previous company being very specific about medics not being allowed to transport certain gtts, based on DHS restrictions...

 

[emsa5804]

Hmmm.....that's odd, our medics gave Levophed in the field, could give insulin (with OLMC authorization), we transferred with propofol drips, etc. As we said, you don't see the nurses on ambulances here unless there are no medics available (which doesn't happen), and the flight nurses are also paramedics.

In Tennessee a Paramedic can transport and maintain virtually any medication they are familiar with and feel comfortable transporting. There are medications that a paramedic may give that a RN is not allowed to push... In a local ER I work in PRN as a paramedic I can push Etomidate but a RN is not allowed to. If the ER does not have a paramedic the physician has to push Etomidate. Other proceedures that can only be done by a paramedic (vs. RN) include Ext. Jugular access, ETI, Surgical airways (Needle, surgical, retrograde.) On the other hand a paramedic is not allowed to start a blood transfusion. A paramedic can assist in hanging the blood. A paramedic can maintain and d/c the blood. In summary I don't believe the paramedic vs. RN argument has any reason to continue. In the ER the two disciplines have the same job discription and work side-by-side to give better pt care.

 

[chimichanga]

In Tennessee a Paramedic can transport and maintain virtually any medication they are familiar with and feel comfortable transporting. There are medications that a paramedic may give that a RN is not allowed to push... In a local ER I work in PRN as a paramedic I can push Etomidate but a RN is not allowed to. If the ER does not have a paramedic the physician has to push Etomidate. Other proceedures that can only be done by a paramedic (vs. RN) include Ext. Jugular access, ETI, Surgical airways (Needle, surgical, retrograde.) On the other hand a paramedic is not allowed to start a blood transfusion. A paramedic can assist in hanging the blood. A paramedic can maintain and d/c the blood. In summary I don't believe the paramedic vs. RN argument has any reason to continue. In the ER the two disciplines have the same job discription and work side-by-side to give better pt care.

no argument here...just pointing out Arizona's regs...

in AZ, some ERs employ medics...they are an equal part of my team...but they are restricted (in the ER) as far as what meds they can administer, to what's in their drug box (in the rig)...that's the law

and the Dept of Health Services says what they can transport...