Recently, a good bit of publicity has been devoted to allowing EMTs to administer Narcan intranasally to patients who have overdosed on opiates.  speaking purely from a practical and clinical standpoint, these patients aren’t going to die from a lack of Narcan, but they are going to die from a lack of ventilation.   We should be reinforcing good BVM skills rather than adding ALS interventions piecemeal based on the media’s epidemic du jour.

This is nothing new.  Every few years, many BLS providers petition the powers that be for certain ALS skills.  In my EMS career, I’ve seen a few of these skills added or considered from nebulized albuterol to nitroglycerin to Epi-pens and now Narcan. In most of these cases, we limit the application of these (now formerly) ALS skills to specific patients in specific situations.   This is our attempt at managing and mitigating the risk of allowing an EMT with approximately 120 hours of training to perform a skill that was previously reserved for paramedics with over 1,000 hours of training.  (I’ll save the training versus education debate for another day.).  What we end up with is a cookbook, bastardized, piecemeal approach to the provision of advanced life support, based largely on public and political pressures as opposed to sound medical science.   What we don’t end up with are providers who understand the how, when, where, or why to apply these newly acquired skills.

I’d favor EMTs being allowed to perform these ALS skills in two situations. First, where the skills are being performed under the direction and supervision of an ALS provider in an effort to provide a true “extra set of hands.”  Second, and subject to strict clinical oversight, in rural systems without ALS access.

In my opinion, if you want to be able to perform ALS skills, you need the knowledge of an ALS provider.   That means if you want to do the “cool” paramedic stuff, go to paramedic school.   Otherwise, this trend to add ALS skills to the EMT protocols is yet an another example of the instant gratification model that continues to hamper EMS and EMS education in particular.

Yep, I think I’ve finally turned the corner and become one of those crusty (at least relatively speaking) and cynical older medics.


  1. Steve Pike says:

    If you want to do what I do, do what I did.
    That being said, I think intranasal Narcan can be safely administered by pretty much anyone. What I do see though is basics giving a booger bath to any patient with a hang nail who admits to taking a Tylenol III a month ago, just for the thrill of doing the cool paramedic stuff. Rookie medics do it, so why wouldn’t we expect basics to follow suit?

  2. Brent Sacks says:

    Well said Wes. An EMS system that offers its ALS providers the opportunity to be the In-Charge medic on the truck, and subsequently the opportunity to delegate certain skills/procedures to their BLS partner under supervision, seems to function extraordinarily well. I have an intimate knowledge of such a system, and am proud to see this collaboration positively affect the patient care.

  3. Couple of thoughts:

    -The worst thing American EMS ever did to itself was to create a distinction between ALS and BLS.

    -It never fails to amuse me how much medics think of themselves, despite the fact that 90% of them didn’t go to school for as long as the person who cuts their hair. That isn’t to say EMTs are any better, but it sure shortens the height of the Paragod Pedestal when you really look at it.

    -It isn’t about teh mad awsum paramedic skillz (which, let’s not forget, can be learned in less than 90 days if you’re willing to pay for it). It’s about the opportunity to save a life in a low-risk, high-reward situation in a situation where ALS may be unavailable or delayed, even in non-rural areas.

    -EMTs in my state have a dozen medication options, narcan being one of the more recent (but well prior to this most recent surge of opiod deaths. That resulted in removal of the med control requirement for the first dose.) To my knowledge, 30 years later the sky is still firmly in place. The only ones doing any damage with medications are ALS providers.

    • Jon Farrow says:

      I hate the whole “a well trained, educated Paramedic had the gall to have an opinion that doesn’t pat EMT’s on the back for their life saving racing the reaper awesomeness so he must be a paragod” mentality. The author didn’t insult EMTs he simply stated that they should have adequate education for interventions and medications that they are trying to perform. You are right about education though, the average medic has about 70% of the educational hours of the person cutting your hair, of course that means EMTs have about 10% of the education.

      Don’t be a dick bro, insulting and whatever point you were trying to prove spelling like a jackass isn’t going to change anyones mind it is just going to make you look like a jackass.

      Also the argument “the only one doing any damage with medications are ALS providers” is stupid, so your contention is that only the people authorized to administer drugs are screwing up giving drugs? Only gun owners own guns. Drivers cause 78% of vehicle collisions.

  4. Epi pens? Really?

  5. I’m not opposed to someone who isn’t a blessed paramedic to be allowed to pre hospitally administer medications. But why narcan.

    There seems to be a push in multiple States to give narcan to the lay public which is an argument for a later time.

    That being said if they are good BLS providers, then why not just teach to treat the patient. Me not having a problem standing on the shoulders of giants I’ll repeat rogue medic. “If you have a BVM(Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation”

    Let’s worry less about the flashy stuff and more about the stuff that matters. The patients…enough for now.

  6. Midwest Medic says:

    I think a few more crusty old medics who actually demand things like accountability and proof of benefit for new ideas would actually help. Keep being crusty. Some of us still appreciate it.

  7. Jon Farrow says:

    I actually disagree with the context of this post. My system has allowed BLS to start IVs and administer basic IV medications for a few years and it hasn’t had any greater complication rates than ALS providers giving the same medications.

    I don’t understand why EMTs in rural areas should be allowed to administer Narcan. Is there some magic point that BVM’s are not as effective as Narcan? If a transport time of 45 minutes warrants Narcan, why doesn’t a transport of 4.5 minutes? Yes, ventilation is the end goal in these patients but great bagging will still end up with gastric inflation, increased gastric pressures, which can cause vomiting and with the patients in ability to protect their airway can lead to aspiration. Prolonged positive pressure ventilation can also lead to issues with gastric blood flow from increased pressure. I have only used narcan on a few occasions but I never caused complete reversal of the opioids. I gave enough to gently raise the patients LOC to the point they could protect their airway and continued bagging.

    As far as them being able to perform skills under the supervision of a higher level person, I absolutely love that. We have a delegated scope policy that allows a Paramedic to guide BLS providers to perform any skill or administer any med they can. It provides an extra set of hands but also allows for two years of experience people are always saying EMTs should get to actually count. One of my EMT partners is enrolled in Medic school right now and has more experience with cardiac monitors, setting up pumps and vents than some of the people that taught my medic course.

    Continuing education and a hands on training and over sight program is the key to an expanding scope of practice. Yes, it is far easier in a small system but it is essential no matter the size of the service.

    I will also point out that Medics need to be careful, with EMS advocates like Bledsoe pointing out the lack of effect on patient outcomes from ALS providers in metro areas, systems that are moving to more centralized Medics responding in an SUV to multiple BLS ambulances; the rural setting may become the only home for ALS providers in the future.

  8. Having BLS crews and first responders works well in tiered systems and maybe other models of EMS delivery.

    Of course I’d legalize Heroin and outlaw Narcan, but that’s just me.
    I’d also replace air bags with power driven spikes. That way people who don’t want to wear their seat belts would actually have to pay the price for their stupidity.

    That’s the libertarian view of EMS.

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