# EMT-Basic IV



## EMT11KDL (Jul 3, 2009)

I know in Colorado you can start an IV as a basic, but is there other states that allows this also?


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## Shishkabob (Jul 3, 2009)

_Technically_, Texas.


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## EMT11KDL (Jul 3, 2009)

In Colorado you have to take the IV class, but it is only a 3 day class.  Is that how it is in texas?


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## Shishkabob (Jul 3, 2009)

Nope.


We can do anything and every thing in Texas so long as our MD teaches us and allows us.





You'll be hard pressed to find any docs that actually puts that to the test with Basics though.


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## EMT11KDL (Jul 3, 2009)

It is in the Colorado State Protocols that after the IV Class, Basic are allowed to start IV.


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## Flight-LP (Jul 3, 2009)

http://www.emtlife.com/showthread.php?t=10871&highlight=Basics+starting

http://www.emtlife.com/showthread.php?t=5445&highlight=Basics+starting

This has been covered once or twice (or a hundred times)..........................

Individuals with a 120 hour EMT course +3 day IV class have no business dealing with IV's as it is insufficient time to appropriately learn how easily you can screw things up.


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## pdibsie (Jul 4, 2009)

As an B-IV in Colorado I disagree.  I think it's a huge advantage for our system when we get an IV started while our medic is drawing up drugs or doing other things on their end.  I can understand that for those who are not allowed to start IV's as basics it may seem a little crazy, but from what I've seen first-hand it only further increases our level of service to our customer.  Having the IV cert doesn't enable us to push many drugs, but it does enable us to draw blood as well as give NS, D-50, and narcan.


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## daedalus (Jul 4, 2009)

pdibsie said:


> As an B-IV in Colorado I disagree.  I think it's a huge advantage for our system when we get an IV started while our medic is drawing up drugs or doing other things on their end.  I can understand that for those who are not allowed to start IV's as basics it may seem a little crazy, but from what I've seen first-hand it only further increases our level of service to our customer.  Having the IV cert doesn't enable us to push many drugs, but it does enable us to draw blood as well as give NS, D-50, and narcan.



How can you disagree with him, or even have an opinion on this if you cannot discuss tonicity, homeostasis, fluid compartments, cellular physiology and plasma membranes, cardiac and vascular physiology, concepts in fluid resuscitation, evidence based medicine, shock and MODS, etc???

Do you know the effects of the saline you put into someone's body an hour after you drop them off?


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## Ridryder911 (Jul 4, 2009)

pdibsie said:


> As an B-IV in Colorado I disagree.  I think it's a huge advantage for our system when we get an IV started while our medic is drawing up drugs or doing other things on their end.  I can understand that for those who are not allowed to start IV's as basics it may seem a little crazy, but from what I've seen first-hand it only further increases our level of service to our customer.  Having the IV cert doesn't enable us to push many drugs, but it does enable us to draw blood as well as give NS, D-50, and narcan.



You are just discussing skills and skills only. Using the "what if" as an excuse for allowing personell to perform medical skills without the proper background and education needed. States place skills in the hands of those;without being properly educated upon the dangers and risks. 


R/r 911


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## Scout (Jul 4, 2009)

Is it not different as in his senario he is just :censored::censored::censored::censored::censored:ing and i will assume the medic will do calculations and drug decisions as opposed to him doing to 100%.


Is hat not a benifit?


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## Ridryder911 (Jul 4, 2009)

Scout said:


> Is it not different as in his senario he is just :censored::censored::censored::censored::censored:ing and i will assume the medic will do calculations and drug decisions as opposed to him doing to 100%.
> 
> 
> Is hat not a benifit?



??????

R/r 911


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## Flight-LP (Jul 4, 2009)

pdibsie said:


> As an B-IV in Colorado I disagree.  I think it's a huge advantage for our system when we get an IV started while our medic is drawing up drugs or doing other things on their end.  I can understand that for those who are not allowed to start IV's as basics it may seem a little crazy, but from what I've seen first-hand it only further increases our level of service to our customer.  Having the IV cert doesn't enable us to push many drugs, but it does enable us to draw blood as well as give NS, D-50, and narcan.




Show us tanglible proof that it has been advantagous to your system and improved patient care.

There is NO reason that a medic cannot draw up medications and start the IV. Actually, I prefer the opposite and will have my EMT partner get my drugs out and ready. It serves a multi fold purpose. 

A. It allows them exposure and education to the pharmacology associated with EMS should they decide to pursue additional education in the field.

B. Its something they can do that cannot harm the pt. as I will always double check the medication.

C. It allows another set of eyes to verify the "R's" of medication administration.

VS.

the list of things that could go wrong with IV initiation and the potential for cellular physiology changes. Its a no brainer. The EMT-B need to focus on sound assessment abilities, equipment familiarization, and safe ambulance operation. Outside of that, they can assist the medic as requested or needed. If they have a burning desire to do more, then they can pursue additional education for higher certification.


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## VentMedic (Jul 4, 2009)

Flight-LP said:


> Actually, I prefer the opposite and will have my EMT partner get my drugs out and ready.


 
You have EMT-Bs working on flight?


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## medic417 (Jul 4, 2009)

VentMedic said:


> You have EMT-Bs working on flight?



Flight no longer means you are the best of the best.  I am aware of a number of basic/paramedic crews working flight.  Used to be if flight showed up you knew patient was getting an upgrade in care, now maybe not.


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## Scout (Jul 4, 2009)

Scout said:


> Is it not different as in his scenario, he is just Stabbing and I will assume the medic will do calculations and drug decisions as opposed to the Basic doing the 100%.
> 
> 
> Is that not a benefit?




Sorry the build in censor grabbed one of the words, Its meant as a question.


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## VentMedic (Jul 4, 2009)

medic417 said:


> Flight no longer means you are the best of the best. I am aware of a number of basic/paramedic crews working flight. Used to be if flight showed up you knew patient was getting an upgrade in care, now maybe not.


 
I know Maryland just plucks whatever is on the ground which is usually a volunteer EMT to ride with their sole Paramedic. As well there are several HEMS that just rotates their ground medics without any extra protocols...just another mode of transportation. One service has the pilot fly out to meet the ground crew and one of the medics flies with the patient while the truck drives to the hospital to pick up the Paramedic. Fortunately these systems that I am familar with can not do IFT transfers but merely offer a different transportation mode to the hospital from the scene and actually less may be done since there is only one person in the back who may be bagging the patient for the duration of the trip.

I just thought Flight-LP worked for a better system.


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## EMT11KDL (Jul 4, 2009)

OK everyone, lets get back on topic.  We have Colorado and Texas that basics can start IV.  what other states are out there??


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## reaper (Jul 4, 2009)

FL allows it, but it is a county by county thing and it is up to the MD. I don't agree with it. My last sevice had it, but we made the basics go through a 80 hour IV course.


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## Ridryder911 (Jul 4, 2009)

EMT11KDL said:


> OK everyone, lets get back on topic.  We have Colorado and Texas that basics can start IV.  what other states are out there??



This has been discussed and posted to death. Let's just do a search on it. 

R/r 911


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## Afflixion (Jul 4, 2009)

AZ and NM allow IVs for basics as well. At least Tucson and Las Cruces areas... not to sure about the rest of the state.


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## medichopeful (Jul 4, 2009)

medic417 said:


> Flight no longer means you are the best of the best.  I am aware of a number of basic/paramedic crews working flight.  Used to be if flight showed up you knew patient was getting an upgrade in care, now maybe not.



Are you serious?  I hope I never have to ride in one of those helicopters h34r:


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## medic417 (Jul 4, 2009)

medichopeful said:


> Are you serious?  I hope I never have to ride in one of those helicopters h34r:



Yes.  Used to be we requested flight when we needed a skill not available for our patients.  Now we actually do more than many flight crews so only reason to call flight is time/distance to appropriate level of care.


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## VentMedic (Jul 4, 2009)

medic417 said:


> Yes. Used to be we requested flight when we needed a skill not available for our patients. Now we actually do more than many flight crews so only reason to call flight is time/distance to appropriate level of care.


 
I could not imagine a Paramedic/EMT-B crew being allowed to do RSI even if the EMT could start an IV.


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## medic417 (Jul 4, 2009)

VentMedic said:


> I could not imagine a Paramedic/EMT-B crew being allowed to do RSI even if the EMT could start an IV.



We do that on the ground.  Been that way for years.


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## VentMedic (Jul 4, 2009)

medic417 said:


> We do that on the ground. Been that way for years.


 
You, by yourself, push the drugs and intubate?


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## Flight-LP (Jul 4, 2009)

Woooooooaaahhhhh, way too many assumptions.

Vent - I also still work as a lonely 'ol ground Paramedic, lol................I was referencing my example in that environment. We fly Medic / RN, wouldn't have it with anything less.

I have never seen an effective air service offer any level of critical care with a "P" and "B" combination, seems to be rather counter productive to me.

For the record, the State of Texas does not "allow" an EMT-B to initiate IV's, that is delegated to the individual medical director. I have yet to meet one who is willing to concede to that lack of appropriate responsibility and allow his/her entry level EMT's start them.

Linuss, I know you pointed it out already, but it seems that it may have been perceived as acceptable (which it is not, hence why we do not see it happening!).


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## medic417 (Jul 4, 2009)

VentMedic said:


> You, by yourself, push the drugs and intubate?



Yes sadly when I do not have a Paramedic or Intermediate Partner I do it all.


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## daedalus (Jul 4, 2009)

EMT11KDL said:


> OK everyone, lets get back on topic.  We have Colorado and Texas that basics can start IV.  what other states are out there??



This topic has already been discussed to death. Why do we need to list the states again? They already have been listed multiple times.

Close the thread I think.


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## irish_handgrenade (Jul 4, 2009)

as far as i know in texas a basic can only start an iv if there is a medic in the truck and if the basic is currently attending an advanced class. i work part time for 3 different services and i am a month away from finishing my medic classes, so they allow me to do anything up to my school level as long as i am riding with a medic. if i am with an I then i can do anything that the I can do. Also most of the medics or Is that I work with all trust me due to my good track record.


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## medic417 (Jul 4, 2009)

irish_handgrenade said:


> as far as i know in texas a basic can only start an iv if there is a medic in the truck and if the basic is currently attending an advanced class. i work part time for 3 different services and i am a month away from finishing my medic classes, so they allow me to do anything up to my school level as long as i am riding with a medic. if i am with an I then i can do anything that the I can do. Also most of the medics or Is that I work with all trust me due to my good track record.



No in Texas a basic may only do IV's if the local medical director puts it in the protocol.  We do not have state wide protocols.


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## TransportJockey (Jul 4, 2009)

Afflixion said:


> AZ and NM allow IVs for basics as well. At least Tucson and Las Cruces areas... not to sure about the rest of the state.



NM it is a special skill that I was not aware is done anywhere in the state... I'll call up a friend in Cruces and see what he's saying about Basics doing IVs


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## Shishkabob (Jul 5, 2009)

Double post


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## Shishkabob (Jul 5, 2009)

medic417 said:


> No in Texas a basic may only do IV's if the local medical director puts it in the protocol.  We do not have state wide protocols.



Wait... "we"?

You're in Texas?  Darn.


Can I ask all medics and fellow medic students something?

How long did you actually spend learning about IV's in class?  Not talking about 'just the skill', but about acid/base, complications, and stuff of that nature?


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## HotelCo (Jul 5, 2009)

Linuss said:


> Wait... "we"?
> 
> You're in Texas?  Darn.
> 
> ...



Several weeks. Perhaps a month and some change.


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## Shishkabob (Jul 5, 2009)

So, by "month" you mean 4-5 days, correct?


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## HotelCo (Jul 5, 2009)

Linuss said:


> So, by "month" you mean 4-5 days, correct?



In class, yes.


EDIT: sorry didn't see that. Acid/Base was a whole other topic that we learned at a later time.


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## CAOX3 (Jul 5, 2009)

daedalus said:


> This topic has already been discussed to death. Why do we need to list the states again? They already have been listed multiple times.
> 
> Close the thread I think.



Everything has been discussed to death here, should we just shut down the site?

No we are not allowed to start IVs.


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## Afflixion (Jul 5, 2009)

jtpaintball70 said:


> NM it is a special skill that I was not aware is done anywhere in the state... I'll call up a friend in Cruces and see what he's saying about Basics doing IVs



The AMR guys out around that area do at least according to the EMS program director but then again this was a few years ago


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## Summit (Jul 5, 2009)

Hmmm.... my IV class was 36 hours of classroom plus clinicals. Short, but I already understood acid-base balance and buffering from various chemistry classes and A&P.

Some of the naysayers here talk about "skills so easy a monkey can do it." Well, really, that's about all that happens in CO. It's not like EMTs are really allowed to do much other than starting, monitoring, and d/cing peripheral lines. That's really why it exists... so that they can do IFTs on patients with existing IVs and so that they can be used as ER techs to start lines. Also, so that they can do finger BGL sticks. 

What drugs can you actually give? D50 and NS. Yes, those are dangerous if you don't understand what you are doing, thus most agencies are pretty restrictive about how or when you can use them (for B-IVs D50 is usually online and NS often is too for more than TKO).


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## ResTech (Jul 5, 2009)

Im kinda on the fence as to rather EMT-B's should be allowed to start IV's. It is a pretty easy skill once you get the hang of it but certainly there is much more to IV therapy then the venipuncture part of it. 

We learned how to start an IV in class in one night. But the actual didactic and studying part that backs up the skill happened over the entire semester and the skill was honed in the ED and field over the entire semester as well. 

I do see some advantages especially in systems where its common to have a Paramedic and EMT-B paired together. The EMT-B could start the line while the Medic does other treatment... and that may make things a little more efficient. But in that case, the Paramedic is there to oversee and ultimately monitor the amount of fluid infused. I don't think the Basic should be allowed to administer any meds through it though. 

Its often said pre-hospital that an IV never saved anybody... especially in trauma. So other than for efficiency purposes in a PM/EMT crew scenerio, I'm not sure if allowing Basic's to start IV's really offers any better patient care.

Those of you as Basics that can start IV's, what do your protocols allow once IV access is obtained? Are you allowed to treat dehydration, heat related illnesses, trauma, etc? Ot just keep it at KVO?


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## Afflixion (Jul 5, 2009)

ResTech said:


> ...Its often said pre-hospital that an IV never saved anybody... especially in trauma. So other than for efficiency purposes in a PM/EMT crew scenerio, I'm not sure if allowing Basic's to start IV's really offers any better patient care...



I hope you are speaking of no remote area's because I can cite several instances where infusing colloids has saved numerous lives.

It honestly does not take that much time to spike a bag, perform the venipuncture and initiate fluid resuscitation... There is little to no need for basics to perform IVs, the only way I can see it feasible is during an MCI.


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## Ridryder911 (Jul 5, 2009)

Afflixion said:


> It honestly does not take that much time to spike a bag, perform the venipuncture and initiate fluid resuscitation... There is little to no need for basics to perform IVs, the only way I can see it feasible is during an MCI.



And in that case fluid resuscitation would be futile anyway. 

R/r 911


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## Afflixion (Jul 5, 2009)

Indeed it would. But only time I could see the need for basics to start IVs.


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## Level1pedstech (Jul 6, 2009)

We have an EMT-IV tech program here in Washington. It consists of an additional 56 hours of class and 24 hours of ER time, it is offered after one year of certification as a basic and with the approval of your departments EMS director. In Washington you have to be associated with an EMS agency to be certified through the department of health and practice in the state. This insures that most providers will have some level of experience in pre hospital patient care before moving to the next level. The program is set up and run by the county MPD and is overseen by the state DOH. 

 I don't see to many ED MD's or ED charge nurses posting on this site so I will take negative comments on the issue with a grain of salt. The ED staff are most likely going to be the ones to chew you a new one if you screw up. Everyone has an opinion but many don't practice in the areas where having an IV Tech is a benefit so their opinions are not based on first hand knowledge of the subject. Providing NS (following protocols) and having med access are always going to be a plus on trauma calls and even critical med patients can benefit having a line placed by an IV tech while a medic takes history and forms a treatment plan. With proper oversight and ongoing education I think the program is a great option for agencies where long response and transport times are the norm.

  Having the unique position of working on both sides I am  more than willing to share the ER teams thoughts on field providers lines, the most common words I hear are "a 20g are you serious" and "don't bother trying to draw off that PTA line its blown". I'm not putting all pre-hospital providers in this box I just want to point out that most lines started by field providers are either redone or DC'd once in the ER. It has been a real learning experience for me and it has helped to build my field skills hearing what the field providers are doing both right and wrong. With level one and two traumas most PTA lines even when they are viable are never used, trauma teams will always start new large bore lines. Just my two cents.


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## TransportJockey (Jul 6, 2009)

Level1pedstech said:


> Having the unique position of working on both sides I am  more than willing to share the ER teams thoughts on field providers lines, the most common words I hear are "a 20g are you serious" and "don't bother trying to draw off that PTA line its blown". I'm not putting all pre-hospital providers in this box I just want to point out that most lines started by field providers are either redone or DC'd once in the ER. It has been a real learning experience for me and it has helped to build my field skills hearing what the field providers are doing both right and wrong. With level one and two traumas most PTA lines even when they are viable are never used, trauma teams will always start new large bore lines. Just my two cents.



Sounds like your hospitals don't trust the field providers. Here in ABQ, the only thing that happens to PTA lines at the facility is the bags are swapped out to hospital bags (a lot of times from NS to LR), although that is due to an unlabeled Lido bag that was left running open by the hospital because the medic didn't tell them which bag.


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## VentMedic (Jul 6, 2009)

jtpaintball70 said:


> Sounds like your hospitals don't trust the field providers. Here in ABQ, the only thing that happens to PTA lines at the facility is the bags are swapped out to hospital bags (a lot of times from NS to LR), although that is due to an *unlabeled Lido bag that was left running open* by the hospital because the medic didn't tell them which bag.


 
Labeling is definitely an issue which is why blood draws from EMS are also frowned upon.

After years of EMS providers bragging how they have to start IVs in dirty places doing it the "EMS way", hospitals have come to just change out field IV within 24 hours. We have also had Paramedics students trying to do their sticks in our EDs as their instructors have taught them the "way it is done in the field" and have basically almost caused their school's programs to lose privileges at our hospitals. 

Hospitals will now eat the cost of any infection that is acquired in their facility and that has been made very clear by the insurers. So, unless the EMS providers themselves stop bragging about having no time to clean an IV site because it is "different" in the field, hospitals will continue to be cautious. As well, unless EMS providers can start coming up with consistency in education and competencies for IVs and blood draws, hospitals will also be cautious. CLIA will and have come down hard on labs that accept blood samples from providers that can not provide proof of training that they understand the procedure or the need for labeling.

These issues are not isolated to one hospital in one area but this is part of a nationwide awareness for patient safety.


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## NVBowhunter (Jul 6, 2009)

Here in NV, Basics cannot do IV therapy. Technically, we cannot even take glucose readings, although we were taught how. I have to attend 3 more months of school to obtain my I certification before I get in to that fun stuff. 

Starts in Aug B)


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## daedalus (Jul 6, 2009)

Level1pedstech said:


> an IV Tech is a benefit so their opinions are not based on first hand knowledge of the subject. *Providing NS (following protocols) and having med access are always going to be a plus on trauma calls* and even critical med patients can benefit having a line placed by an IV tech while a medic takes history and forms a treatment plan.



Really?

From now on in EMS, things like this are going to have to be backed up by cold hard science. Can you produce research that shows EMTs providing IV infusion is beneficial to patient outcomes? And, if none such exists, why let a less educated provider mess around with fluid balances? As many experienced critical care paramedics have stated in this very thread (that do happen to have RN, CCP and/or RRT degrees and work in EDs and/or flight crews), there is no real circumstances where a paramedic should have to have an EMT assistant set up the IV.


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## Shishkabob (Jul 6, 2009)

Where does "set up" equate to "push fluids / drugs"?










Just asking.


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## daedalus (Jul 6, 2009)

You like to ask a whole lot of questions all the time, don't you? 

In the case of my post, set up and initiate are meant to mean the same thing.


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## Shishkabob (Jul 6, 2009)

Hey, I'm the chop buster of the forum! ^_^


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## CAOX3 (Jul 7, 2009)

daedalus said:


> Really?
> 
> From now on in EMS, things like this are going to have to be backed up by cold hard science. Can you produce research that shows EMTs providing IV infusion is beneficial to patient outcomes? And, if none such exists, why let a less educated provider mess around with fluid balances? As many experienced critical care paramedics have stated in this very thread (that do happen to have RN, CCP and/or RRT degrees and work in EDs and/or flight crews), there is no real circumstances where a paramedic should have to have an EMT assistant set up the IV.



Backed up by cold hard evidence?  Let me know when EMS adopts that practise.


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## usafmedic45 (Jul 7, 2009)

CAOX3 said:


> Backed up by cold hard evidence?  Let me know when EMS adopts that practise.


As soon as people drop exactly the attitude you just expressed.  The practice will be adopted one person at a time until it becomes a standard.  As the saying goes, "Be an example of the change you wish to see in others."


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## CAOX3 (Jul 7, 2009)

usafmedic45 said:


> As soon as people drop exactly the attitude you just expressed.  The practice will be adopted one person at a time until it becomes a standard.  As the saying goes, "Be an example of the change you wish to see in others."



 Thats right together we can change the world.  

Attitude? Actually this is evidence based opinion.

Evidence based medicine depends on who you ask. A smart guy like you, should know that.

Sure some systems are progressive, those systems pale in comparison to the ones that cant get out of there own way.


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## Level1pedstech (Jul 7, 2009)

Since I was pulling a shift on the adult side of our facility tonight I thought I would do a little research and ask a few people from different areas of the emergency medicine world thier opinion of lower level field providers starting lines in the field. I explained the additional class room and clinical time above the EMT-B level and that there are IV Tech specific protocols that must be followed. I included two trauma sugeons,two ED docs,two PA students a few RN's and a few medics. The overwhelming response was a thumbs up providing a few rules were followed, mainly that there is ongoing Md oversight,continuing and ongoing education and quality control including follow up when there are problems. Just a little research backed up by some foot work. Im sure it wont change everyones mind but I think it shows there is room for growth in the field.

 As far as our facility not trusting field providers, I was careful to not lump all field providers into one bunch. We love our medics and most do a very good job. Vent had a pretty good explanation of how the folks upstairs see things when it comes to policy.


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## VentMedic (Jul 7, 2009)

Level1pedstech said:


> I explained the additional class room and clinical time above the EMT-B level and that there are IV Tech specific protocols that must be followed. I included two trauma sugeons,two ED docs,two PA students a few RN's and a few medics. The overwhelming response was a thumbs up providing a few rules were followed, mainly that there is ongoing Md oversight,continuing and ongoing education and quality control including follow up when there are problems. Just a little research backed up by some foot work.


 
Do any of those polled remember when only specially trained RNs were allowed to start IVs in the hospital or why "IV techs" were eliminated? Or what happened to the LVN in the hospital and IVs? Why it was thought an LVN was not appropriate to do IVs because of only have 1 year of education? Those controversies still exist in hospitals throughout this country and are coming back with the infection control issues.

How about the doctors?  Why are some allowed to intubate and some aren't?  Why can some put in central lines and some can't?  Why can some write orders on a tele or ICU floor and some can't?  Why can some write orders for Diprivan and some can't?  For most it takes a little more than a couple hours of training to get certain privileges even though they seem routine and "easy".


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## Level1pedstech (Jul 7, 2009)

You make some interesting points and its worth a chat with the crew here tonight. We are in slow mode after being slammed pretty hard with traumas since 1900. I dont remember LVN's, I have only been on the inside for four years. You have stated before how different things are on the inside when it comes to procedures, that its skills on the outside and procedures on the inside. I know when it comes to intubation it is almost always an ED doc. Central and art lines can be done by PA students but residents get first shot. I am being asked to point out that RN's can intubate but its not really a procedure RN's do at our facility.


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## VentMedic (Jul 7, 2009)

Level1pedstech said:


> I am being asked to point out that RN's can intubate but its not really a procedure RN's do at our facility.


 
There are only a couple of states that do not include intubation for RNs. However, it would be impossible to maintain the skills of RNs if they did intubate in the hospital. Even the smaller ICUs employ over 60 nurses. Larger hospitals can have almost 1000 RNs working just in critical care. As well, who would be fetching all the meds and setting up procedure trays. Believe it or not, doctors and PA students don't always have access to the drug machine and some have not found their way around the storeroom. In an emergency, there should be priorities and job descriptions to avoid confusion.

Our RNs share intubation with the RRTs on all of the transport teams as the RRTs also do some of the procedures that is usually included in their job set. Both must still get 10 intubations in 6 months in addition to the other advanced procedures. Each must also get 25 tubes in their initial training to intubate. Since RRTs are considered primary intubators in Neo, to apply for the transport team they must have no less than 100 intubations and 2 years of NICU experience which it takes 2 years of other RT experience before being accepted into NICU. So you can see how difficult it would be to have the same requirements of a group as large as nursing remain proficient at intubation. 

For Flight, if hospital based, the RNs can get their procedures(intubation, central lines etc) in the ED or ICUs. Many also will still work the ICUs on their off days just to maintain proficiency with their RN knowledge and skills since Flight may not give them many patients and medicine changes quickly. They hate to arrive at a facility and pick up a patient who is on a couple of drips they had no idea was even available. 

It would also not be feasible to have a Nephrologist have intubation privileges since it is doubtful he/she could meet the requirements to maintain competency. The best person for the procedure should be the one providing it. That also includes the education and what to do after the tube is in. Those who intubate at our hospitals also must know what tube the patient requires and must be thinking about tomorrow and not just one skill at the moment. 

I'm sure your hospital has a book or section on their computer intranet that lists all the physicians and what each has been given invasive procedure privileges for. We take the competencies seriously and are allowed to tell a physician to step aside if they are not cleared by the various medical directors and chiefs of medicine or critical care to intubate.


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## Summit (Jul 7, 2009)

VentMedic said:


> There are only a couple of states that do not include intubation for RNs. However, it would be impossible to maintain the skills of RNs if they did intubate in the hospital. Even the smaller ICUs employ over 60 nurses. Larger hospitals can have almost 1000 RNs working just in critical care. As well, who would be fetching all the meds and setting up procedure trays. Believe it or not, doctors and PA students don't always have access to the drug machine and some have not found their way around the storeroom. In an emergency, there should be priorities and job descriptions to avoid confusion.
> 
> Our RNs share intubation with the RRTs on all of the transport teams as the RRTs also do some of the procedures that is usually included in their job set. Both must still get 10 intubations in 6 months in addition to the other advanced procedures. Each must also get 25 tubes in their initial training to intubate. Since RRTs are considered primary intubators in Neo, to apply for the transport team they must have no less than 100 intubations and 2 years of NICU experience which it takes 2 years of other RT experience before being accepted into NICU. So you can see how difficult it would be to have the same requirements of a group as large as nursing remain proficient at intubation.
> 
> ...



That's very informative... but let me get this straight.

The lesson you are trying to imply, your message, is that starting and monitoring peripheral IVs is equivalent in complexity and consequence to ET intubation and there just aren't enough IV starts in this world to let EMT-B's with IV clearance take these experience opportunities away from RNs and Medics? 

I'm not buying it.


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## VentMedic (Jul 7, 2009)

Summit said:


> Your argument is that starting and monitoring peripheral IVs is equivalent in complexity and consequence to ET intubation and there just aren't enough IV starts in this world to let EMT-B's with IV clearance take these experience opportunities away from RNs and Medics?
> 
> I'm not buying it.


 
The discussion has moved on.

Read my post before that.

The argument in the hospital for doing IVs was education. Some believed that an LVN with a mere 1 year of education could not do IVs. Hospitals do value the "whys" and education behind each procedure and don't just allow any warm body to poke holes in people. Also the LVN has been removed in many areas from acute care. I don't believe we have any in our system now and that includes the SNF and NH sections.

The discussion you just mentioned was why a hospital could not keep 1000 or even 60 Critical Care RNs proficent in intubation.


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## daedalus (Jul 7, 2009)

Level1pedstech said:


> Since I was pulling a shift on the adult side of our facility tonight I thought I would do a little research and ask a few people from different areas of the emergency medicine world thier opinion of lower level field providers starting lines in the field. I explained the additional class room and clinical time above the EMT-B level and that there are IV Tech specific protocols that must be followed. I included two trauma sugeons,two ED docs,two PA students a few RN's and a few medics. The overwhelming response was a thumbs up providing a few rules were followed, mainly that there is ongoing Md oversight,continuing and ongoing education and quality control including follow up when there are problems. Just a little research backed up by some foot work. Im sure it wont change everyones mind but I think it shows there is room for growth in the field.
> 
> As far as our facility not trusting field providers, I was careful to not lump all field providers into one bunch. We love our medics and most do a very good job. Vent had a pretty good explanation of how the folks upstairs see things when it comes to policy.


I asked for scientific evidence and this is what you post? It seems like you are evading my question by runnng to a trauma surgeon and asking him I it's ok. Here is a hint, if someone asks for evidence to support your treatment one day and you come back to that person saying so and so said it was ok, you will have lost respect as a provider and you will facv the consequences of whatever you have done. 

CAOX3, my county bases many practices on best available medical research. Your attitude is disapponting.


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## ResTech (Jul 7, 2009)

In the hospital I do clinicals, the ED Techs who are trained to do IV's, 12-lead acquisition, BG readings, and foley catheters are a huge help and resource to the RN's. If it wouldnt be for the ED Techs, the nurses would be overwhelmed and the ED wouldn't flow near as smoothly. ANd it would cost the hospital a lot more $$$$$.  

The skill of starting an IV is simple... practice makes perfect. As long as medical oversight is provided I don't really see why an ED Tech who is a CNA, EMT or LPN can't start an IV safely. Aseptic technique isn't hard to learn and in some care situations, not all care providers need to have 2 or 4 years of education to do certain skills. 

I am all for research based EMS and not EMS based on what appears to work. But take two groups... one group of ED Tech's that are CNA or EMT trained and another group that are all RN. Let them all practice IV venipuncture and at the end of a year compare results from the two groups. Do you really think there would be a higher rate of infection or infiltration in the Tech group? Would an RN have more successful sticks on less attempts? I really do not think you would see any clinical or statistical difference between the two groups. I really don't. 

There are RN's who may have a difficult stick and after two try's that can't get it... know who they often call? An ED Tech... because they are experienced in finding veins and getting the catheter where it needs to go.. in the vein.. and that is the primary goal. 

I think through time and practice, it is possible to determine that certain treatment modalities can be performed safely by lesser trained personnel with great patient benefit. I don't want to start an albuterol by Basic's debate... but that is an example I would like to cite. Some States allow for Basics to administer albuterol because of the benefit and almost immediate relief of SOB combined with the safety profile of the medication.  

If your an asthmatic who lives 20-30 minutes from an ALS unit... are you gonna wanna remain SOB for that time period and possibly worsen or get the medication safely from your local BLS company 5 minutes away? For my family and myself would be from the BLS station. There is a risk versus benefit assessment that must be made. Would albuterol in this scenerio not be good patient care?

Sorry so long


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## VentMedic (Jul 7, 2009)

ResTech said:


> In the hospital I do clinicals, the ED Techs who are trained to do IV's, 12-lead acquisition, BG readings, and foley catheters are a huge help and resource to the RN's. If it wouldnt be for the ED Techs, the nurses would be overwhelmed and the ED wouldn't flow near as smoothly. ANd it would cost the hospital a lot more $$$$$.
> 
> The skill of starting an IV is simple... practice makes perfect. As long as medical oversight is provided I don't really see why an ED Tech who is a CNA, EMT or LPN can't start an IV safely. Aseptic technique isn't hard to learn and in some care situations, not all care providers need to have 2 or 4 years of education to *do certain skills. *
> 
> ...


 
Again, you are only measuring skills.

We sorta have a rule in hospitals. Don't screw with what you can not put back in or reverse. If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it. Or, if Plan A for intubation does not work, they have access to Plans B and C. If the albuterol causes a reaction or there is a good probability of causing an adverse reaction judging by the meds a patient is on, the RRT or RN can put the patient on a monitor or give a med to alleviate the symptoms.

Almost any human or animal can be taught "skills". However, skills should be viewed as procedures that also come with a set of guidelines and protocols that goes along with the education of the providers. Just poking a hole in the patient's skin is again a no brainer. What to do when you muck up is another ballgame. Usually you have to yell for another provider with a higher license.



> *If your an asthmatic who lives 20-30 minutes from an ALS unit*




40 + years after it was thought a Paramedic could provide better care in the U.S., we are still relying on EMTs and then this is what happens to the patient.  No, they do not need an EMT with another "skill".  They need a higher level provider.  Period.


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## Shishkabob (Jul 7, 2009)

VentMedic said:


> We sorta have a rule in hospitals.* Don't screw with what you can not put back in or reverse.* If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it.



And that was the ONLY reasoning I was looking for this whole time... not of that "Not enough A&P" crap, but something that actually makes sense, and is real.


B)


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## Summit (Jul 7, 2009)

VentMedic said:


> Again, you are only measuring skills.
> 
> We sorta have a rule in hospitals. Don't screw with what you can not put back in or reverse. If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it. Or, if Plan A for intubation does not work, they have access to Plans B and C. If the albuterol causes a reaction or there is a good probability of causing an adverse reaction judging by the meds a patient is on, the RRT or RN can put the patient on a monitor or give a med to alleviate the symptoms.
> 
> ...



This should have been your original response in the thread.


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## ResTech (Jul 7, 2009)

So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering? 

What about the pilot studies and programs that are conducted prior to widespread implementation of "additional skills"? These studies assess the safety of the skill by Basics, the accuracy of their respiratory assessment, effective administration, and clinical benefit from assessing how well patients improved from Basic administration. Are these pilot programs not reviewed by physicians at the State level? Are these pilot programs not designed to identify major concerns for safety? 


Don't get me wrong, I agree with the educational standards and that ALS should be the minimum level of care. I believe that wholeheartedly. But this is EMS, not in-hospital. I've said this before, many dynamics and logistical obstacles exist in EMS and communities across our country that don't exist in the hospital. Hospital methodology doesn't always work out in the field. 

Everyone promotes education (as they should) and likes to be critical of EMT's, but I rarely ever hear anyone promoting methods of implementing this higher education model within EMS. It really takes more than graduating from college to make this happen. Many of you from an urban setting have no clue what EMS is like in the rural communities and what obstacles there are.


Now for the questions.....

How do you suppose we staff a 24/7 Paramedic unit within a volunteer station, in a town of 10,000 or less, and without municipal funding? .....when expenses are paid strictly through services provided and bingo and carnivals. Let me tell you, most services don't do much better than break even. It can be done but it isn't easy to get off the ground and keep going.... what about the initial expense of starting such a service? 

What about ALS personnel retention? Are degreed Paramedics gonna work in BFE for $11-12hr and only run 3 or 4 calls a week? Or are they gonna be attracted to the city or busier services who can pay more?

Who in the primarily volunteer organization is gonna coordinate the ALS service? Do we now have to pay extra for an ALS Coordinator? Should we offer free tuition for the volunteers to go to College to become Paramedics?

These questions just scratch the surface of things that need considered to provide a higher level of service. Its not as easy as some like to think. It cost money to provide ALS and unfortunately most local governments don't wanna pay nor do the residents that live in the community.

While education is important.... thats only the first step of many.   

I look forward to hearing practical plans for taking a BLS station and transitioning them to ALS in a small, rural community.


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## medic417 (Jul 7, 2009)

ResTech said:


> I look forward to hearing practical plans for taking a BLS station and transitioning them to ALS in a small, rural community.



That horse has been beaten to death.  I and many others have posted ways that any community can get away from volunteer service and go paid 24/7 Paramedic staffed.  

Now if you plan to stay volunteer service not much more annual expense for advanced supply's.  Only hold up is people refusing to get education.  Now days you can get Paramedic online from reputable colleges distance is no longer an excuse.  

And back to dead horse I work in a poverty stricken community of less than 2000 and we are staffed paid Paramedics 24/7.


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## ResTech (Jul 7, 2009)

> And back to dead horse I work in a poverty stricken community of less than 2000 and we are staffed paid Paramedics 24/7.



That's awesome... share how it is accomplished in your community. Where does the funding come from to keep it going? Where did the money come from for the start-up costs? 

I don't recall reading the threads were this has been a major discussion but I very well could have missed it. Point is... its not always easy.... and maybe more discussion should be shifted to plans of implementation of this higher education model and realizing that EMS isn't the hospital setting.


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## CAOX3 (Jul 7, 2009)

daedalus said:


> . CAOX3, my county bases many practices on best available medical research. Your attitude is disapponting.



You didnt say that, you said "based on cold hard evidence".  Which is different from best available research.  MAST trousers was based on best available research, how did that work out.

My attitude is disappointing, Im sorry if the truth hurts.


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## WolfmanHarris (Jul 7, 2009)

ResTech said:


> That's awesome... share how it is accomplished in your community. Where does the funding come from to keep it going? Where did the money come from for the start-up costs?
> 
> I don't recall reading the threads were this has been a major discussion but I very well could have missed it. Point is... its not always easy.... and maybe more discussion should be shifted to plans of implementation of this higher education model and realizing that EMS isn't the hospital setting.



Since you asked.
In the year 2000 the Province of Ontario, which previously fully funded and controlled Ambulance Service downloaded it to the Upper Tier Municipalities (Counties or Regional Governments) in the South of the province and to the Social Services Administration Boards in the remote northern areas. At around this time, the province also increased requirements for response times (easy to do when no longer footing the bill).

The UTM's and SSAB found themselves in a pickle. They'd received the responsibility for EMS, with a tentative promise from the Province to maintain 50% of previous funding, increased regulatory requirements placed on the system AND they had to determine how they would operate their services while simultaneous having to renegotiate contracts with all of their Paramedics. Oh and I forgot to mention around this time BLS increased to a two year program which created first a temporary staffing shortage followed by demands for increased wages. (Which just about doubled over this transition period).

How you ask did these rural and remote areas of Ontario manage to provide 24/7 paid EMS? Simple they had the responsibility to provide it and were forced to make it a priority. Amazing what can be made to work when you have no option.



> So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering?



The extra training you're arguing for to truly make these skill additions work, including patho and requisite pharmacology would indeed make the addition of albuterol (aka Salbutamol) or IV therapy acceptable. Of course the academic commitment to do it right, even for such small things is a great deal longer then I think you were actually suggesting.


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## VentMedic (Jul 7, 2009)

ResTech said:


> So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering?


 
Read this again and see how ridiculous it sounds to provide such inadequate care. Adding *a *skill without the ability to do much else is just half arsed. And, if the the patient is asthmatic, they probably already have albuterol, atrovent and a whole cabinet full of meds for their breathing. They need a line, possibly CPAP, possibly corticosteroids, possibly Mag Sulfate and maybe even intubation. One albuterol will NOT fix a patient with a severe asthma attack. 



ResTech said:


> What about the pilot studies and programs that are conducted prior to widespread implementation of "additional skills"? These studies assess the safety of the skill by Basics, the accuracy of their respiratory assessment, effective administration, and clinical benefit from assessing how well patients improved from Basic administration. Are these pilot programs not reviewed by physicians at the State level? Are these pilot programs not designed to identify major concerns for safety?


 
Maybe the CNAs should do a study if they can replace the RN. NOT! Do you not understand that what these studies are saying is that the EMT can be taught a skill and probably won't kill anyone by allowing them to perform that skill? They have not done estensive studies as to the benefit. When the studies were done to allow EMT-Bs use CombiTubes and ETI, the patients were essentially dead. Yes, states have written that EMT-Bs can do these skills on a patient that has coded. Yes, an EMT-B can start a pretty IV. Then what?

The EMT was NEVER intended to be the primary provider. Again, in the 1960s the founders of modern EMS wanted to upgrade the ambulance attendants to Paramedics. For some reason those in EMS do not want this upgrade and that is what has left some areas in the dark ages for the last 40 years. 



ResTech said:


> Everyone promotes education (as they should) and likes to be critical of EMT's, but I rarely ever hear anyone promoting methods of implementing this higher education model within EMS. It really takes more than graduating from college to make this happen. Many of you from an urban setting have no clue what EMS is like in the rural communities and what obstacles there are.
> 
> 
> Now for the questions.....
> ...


 
Oh cry me a river! Florida provides 24/7 to every citizen in the state and that includes communities a lot smaller than 10,000.

My comments might sound harsh but I am just disgusted with hearing excuses from people wanting to stay "BLS" as an EMT-B and just want to learn anotehr skill. And, it is usually the providers who are BLS telling their communities that it will be so bad if strangers come to town to provide ALS or that the FD will be crap at it.


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## ResTech (Jul 7, 2009)

> Read this again and see how ridiculous it sounds to provide such inadequate care. Adding a skill without the ability to do much else is just half arsed. And, if the the patient is asthmatic, they probably already have albuterol, atrovent and a whole cabinet full of meds for their breathing. They need a line, possibly CPAP, possibly corticosteroids, possibly Mag Sulfate and maybe even intubation. One albuterol will NOT fix a patient with a severe asthma attack.



The purpose of a Basic in providing albuterol is not to take the place of a primary care provider obviously. It is to fill a void and provide patient relief as early as possible until ALS arrives. Its not that ridiculous of a concept in the context of a system that is not all ALS. And just perhaps, the patient is out and about and forgot their inhaler... so yeah one albuterol may provide significant relief.  



> Maybe the CNAs should do a study if they can replace the RN. NOT! Do you not understand that what these studies are saying is that the EMT can be taught a skill and probably won't kill anyone by allowing them to perform that skill?



No. I think the study findings in my hypothetical study would say that it is very beneficial to have ED Techs in a hospital be trained to start IV's. They would safely achieve the desired result of IV access, be a great asset for resource management in the ED, and if they encountered a problem, a RN, PA, or Physician is right there. The complication risk of starting an IV is minimal and parameters for safety would be easily implemented.  



> I am just disgusted with hearing excuses from people wanting to stay "BLS" as an EMT-B and just want to learn anotehr skill.



I don't want to just learn another skill which is why I am going to school. Nor am I advocating any community staying BLS and adding skills. I am however, being prudent in recognizing the problems and obstacles that must be identified and overcome to have an all ALS system. Your talking like its a simple Monday night meeting decision...."listen up everybody, next month were going ALS... we have no clue where the staffing or money is coming from or who is gonna manage it yet, but were going ALS because I have a college degree and am a Paramedic, RN, RRT, and a G.O.D and my education says we must be ALS".

What I am talking about is Systems Development and the obstacles that exist for providing Advanced Life Support in Smalltown, USA. 

Yes, sometimes (if not largely) it is a matter of priority and convincing the powers-to-be it is in the best interest of the community to transition to ALS. Until they are convinced, no money is gonna be handed your way. 

Vent, you should send your resume to the Pennsylvania Dept of Health and all other States and inform them you have all the answers to their Systems Development problems and you can bring EVERY EMS service up to the Paramedic level and overcome any hurdle that may come your way. Just think of the money they would pay you to solve all their problem... you would be in very high demand!


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## VentMedic (Jul 7, 2009)

ResTech said:


> The purpose of a Basic in providing albuterol is not to take the place of a primary care provider obviously. It is to fill a void and provide patient relief as early as possible until ALS arrives. Its not that ridiculous of a concept in the context of a system that is not all ALS. And just perhaps, the patient is out and about and forgot their inhaler... so yeah one albuterol may provide significant relief.


 
If the patient has been doing albuterol all day prior to calling you...... 



ResTech said:


> No. I think the study findings in my hypothetical study would say that it is very beneficial to have ED Techs in a hospital be trained to start IV's. They would safely achieve the desired result of IV access, be a great asset for resource management in the ED, and if they encountered a problem, a RN, PA, or Physician is right there. The complication risk of starting an IV is minimal and parameters for safety would be easily implemented.


 
Yes, ED Techs are useful. But, in the hospital there are continued competencies, QA and numerous chances to do the IV. As well, there will always be an RN in the area to start the meds or fix whatever goes wrong. But, EMS sometimes fails to maintain records for training, QA and continued evaluation for competency.




ResTech said:


> I don't want to just learn another skill which is why I am going to school. Nor am I advocating any community staying BLS and adding skills. I am however, being prudent in recognizing the problems and obstacles that must be identified and overcome to have an all ALS system. Your talking like its a simple Monday night meeting decision...."listen up everybody, next month were going ALS... we have no clue where the staffing or money is coming from or who is gonna manage it yet, but were going ALS because I have a college degree and am a Paramedic, RN, RRT, and a G.O.D and my education says we must be ALS".


 
What type of service do your hospitals provide? Are they all staffed with LVNs and the doctors are all GPs? Do you have any specialists or trauma centers in the state? Have you even looked at job listings for other professionals to see what is required in addition to the bare minimum education? Hospitals and other facilities did not accomplish quality by making excuses. Their accrediting agencies would also not fall for excuses and EMS is lucky they have few agencies to please. 

. 


ResTech said:


> Vent, you should send your resume to the Pennsylvania Dept of Health and all other States and inform them you have all the answers to their Systems Development problems and you can bring EVERY EMS service up to the Paramedic level and overcome any hurdle that may come your way. Just think of the money they would pay you to solve all their problem... you would be in very high demand!


 
Why should I send my resume? Doesn't your state have people who have an interest in education and making a difference? I have been part of a movement that accomplished providing EMS throughout my state and while Florida has its faults, the foundation has been laid. Now we can focus on improving the quality of education by at least attempting to accredit the medic mills which might take some doing since we don't use the NREMT for the Paramedic exam.


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## reaper (Jul 7, 2009)

Maybe you need to petition at your state level for all ALS services! If the state mandates it, then your community will have no choice but to figure out how to get it done.

FL is a leader in this phase. Every county in the state has ALS service. These are counties that have less then 10,000 people in the whole county. Some how they get it done and have for years. They retain Paramedics and pay them decent wages. This is all because the state of FL is very involved in EMS and mandates the changes.

I have worked systems in towns of 5000 people in the middle of the Midwest. They seem to be able to have a paid ALS crew in those towns.

So, lets stop the argument that it cannot be done, due to money. It can be done anywhere, if the effort is put forth!


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## ResTech (Jul 7, 2009)

You do make some good points in your last posts.. but for any State to just come in and say... this is the deadline... every station must be ALS... isn't going to work. I could be wrong... maybe that would be the wakeup call and is what it would take. But States are gonna be hesitant to do that because they don't have the millions of dollars budgeted to assist with every licensed BLS service going ALS. At least in PA, its a local level endeavor to go ALS.


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## Summit (Jul 7, 2009)

Not in this economy anyways... oh wait... maybe the Federal government can just majikally make some more money appear out of nowwhere. I approve of the ALS Stimulus Bill!


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## EMTinNEPA (Jul 7, 2009)

A government-run EMS system would be great!  Just look at what the government's done for healthcare so far... medicare, medicaid... and let's not forget the stunning job they've done fixing the economy!


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## Ridryder911 (Jul 7, 2009)

I ask if is it because the majority of those in EMS, have no real exposure to medicine or is the teaching (or lack of) causing the lack of understanding of medicine?

Why do those in EMS always to refer to the easy way out or wanting to take drastic short cuts? It has been documented, researched and presented that it never works out, patients suffer, the system suffers, yet.. we still continue? 

A good example is the intubation procedure. A well needed procedure and research has shown that the success of the procedure has gone down, as the education levels and required knowledge and clinical performance requirements have decreased. Now, even the "more" educated Paramedic lacks enough training and expertise lacks the ability of being successful and we want to "continue focusing on lower levels performing these skills?"
It makes no sense! 

Communities exclaim they have no methods of providing emergency medical care. Yes, there are some very remote areas, where the best will always be first responder care. One cannot ever expect much more than that but as states such as Alaska has demonstrated one does not have to compromise care. 

Why do we as a so called profession still allow the entry level only to be less than a hundred clock hour course? Then worse, we project to those that have completed this course that they are actually part of the medical community as health care providers? That they actually are educated enough to offer opinions and offer positions to determine the wave and future of EMS? What other profession, would even consider such idiocy? 

Could one imagine the nursing profession allowing CNA to determine the future and role of the nursing profession? Entry level trained firefighters determining the future of fire protection? Again asinine! 

Do we of those that have obtained a formal education, clinical experience, and further into advanced education and diversity in health care believe we are above others? Maybe. So be it. Each profession base their profession upon experts within that field (except EMS). 

What many fail to realize and recognize is that it is scientifically proven the skills of the EMT is very, very basic and crude. Elementary rated skllls that it is considered almost fail safe enough to say that with repetitious practice, no one should ever fail. Again, it is not the action of the skills but the theory and intellect behind the actions. 

Hernia repair is supposedly one of the easiest surgical procedures. Yet, I doubt that anyone would want someone to just be taught on how to do the procedure alone to perform this on them. Same analogy. 

I find it ironic how compliant those in EMS become. Most would never allow their children to attend a non-accredited public school or University, and I could only imagine the outcries if they were to find that their teacher highest level of education was a GED. Yet, we endorse and even brag ...."how fast, shortcut, cool or instructors have experience not schooling"...  Make sense? Of course it does, look at the "type" we attract. 

Time we change it! 

R/r 911


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## extant (Jul 7, 2009)

Flight-LP said:


> http://www.emtlife.com/showthread.php?t=10871&highlight=Basics+starting
> 
> http://www.emtlife.com/showthread.php?t=5445&highlight=Basics+starting
> 
> ...



I don't see how starting a saline lock is so easy screwed up.  In the Army we were doing IV's every day for months, its easy, we did them in classrooms, in the dirt, in the rain, while the casualty is on a litter.  3 days of training for a saline lock is acceptable, and necessary.  Pushing fluids, a much different story.


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## Ridryder911 (Jul 7, 2009)

extant said:


> I don't see how starting a saline lock is so easy screwed up.  In the Army we were doing IV's every day for months, its easy, we did them in classrooms, in the dirt, in the rain, while the casualty is on a litter.  3 days of training for a saline lock is acceptable, and necessary.  Pushing fluids, a much different story.



Again, please try to understand it is not the skill it is the knowledge of starting the intravenous line. The reason the military does as it does is for entirely different reason. It is a prophylactic and methodical type situation. Military verily rarely expects definitions or allows questions in regards of not knowing but more than is expected. 

From what expertise do you really have to state that the 3 days of training is adequate? Do you really know the risks involved in intravenous therapy? Not all patients are alike what military profile of healthy 20-30 year olds and no past medical history. Not to ridicule by far but unfortunately, assumption is too often made. 

R/r911


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## Foxbat (Jul 7, 2009)

VentMedic said:


> Florida provides 24/7 to every citizen in the state and that includes communities a lot smaller than 10,000


Without funding by county or state?
Are medic fly-cars utilized, or there is a medic on every ambulance?


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## Ridryder911 (Jul 7, 2009)

Foxbat said:


> Without funding by county or state?
> Are medic fly-cars utilized, or there is a medic on every ambulance?



Actually, if properly billed and managed it can be done with very little tax revenue and yes, a Paramedic on each unit. 

R/r 911


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## EMTinNEPA (Jul 7, 2009)

ResTech said:


> I look forward to hearing practical plans for taking a BLS station and transitioning them to ALS in a small, rural community.



Ok, here's an idea.  Enter into a partnership with an ALS private service that does IFTs... i.e., a company with a buttload of money.  Have them staff a paramedic on your ambulance 24/7 while you provide a volunteer driver.  In return, let them have a decent portion of the bill, and maybe a bit of administrative pull.  Sure, they may lose money, but who cares?  They're providing ALS services, and they more than make up for it with the transports, which are their bread and butter.  My service has this arrangement with a local volunteer service and it works excellently.


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## spisco85 (Jul 7, 2009)

My town had the option of having the agency I work for provide 12 hours of guaranteed paramedic coverage or having 12 hours of guaranteed basic coverage. 

Their choice? The basic coverage which cost the town 1/5 of what the paramedic coverage would have cost. 

Their reasoning? They wanted the town's ambulance's to be used and the local hospital fly medics, are sometimes available. These fly medics are outstanding and cover a county and a half with four per shift.

Sucks for my town.


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## Foxbat (Jul 8, 2009)

EMTinNEPA said:


> Sure, they may lose money, but who cares?


I was under impression that private companies really care about profits. Sure, thay can earn money from IFTs, but what makes them do 911 calls in an area which would only make them lose money?


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## EMTinNEPA (Jul 8, 2009)

Foxbat said:


> I was under impression that private companies really care about profits. Sure, thay can earn money from IFTs, but what makes them do 911 calls in an area which would only make them lose money?



But they aren't losing money in the grand scheme.  They make up for it with transports.  My god, private services doing something out of the goodness of their hearts?!? SAY IT ISN'T SO!!


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## Foxbat (Jul 8, 2009)

I guess I misunderstood.
Do you mean that:
a)company does 911 in this area and does IFTs in the same area, and therefore gains money by covering this area, or
b)company loses money from operating in this area but earns money by doing IFTs in other places?


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## EMTinNEPA (Jul 8, 2009)

Foxbat said:


> I guess I misunderstood.
> Do you mean that:
> a)company does 911 in this area and does IFTs in the same area, and therefore gains money by covering this area, or
> b)company loses money from operating in this area but earns money by doing IFTs in other places?



I mean that it doesn't matter if they lose money by staffing a paramedic 24/7 if the call volume doesn't warrant it because they can easily make up for it by doing IFTs in this area (and others).

Keep in mind, though, two transported ALS calls per day will pay for the truck to be there.

There are three services in my area that do it.  One staffs paramedics for a service and makes up for the money spent by doing IFTs other places.  My service lets the paramedic and volunteer handle most of the 911 calls because having the volunteer driver and the volunteer service pay for the truck, they actually save money by just paying for the paramedic.  The third is a hospital-based chase truck that staffs EMTs on the local volunteer units.  If there are no volunteers, the paid guys take it.  If volunteers are there, they take it.  See?  Everybody's happy.


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## CAOX3 (Jul 8, 2009)

Foxbat said:


> I was under impression that private companies really care about profits. Sure, thay can earn money from IFTs, but what makes them do 911 calls in an area which would only make them lose money?



They never do anything for free. They will always have their best interests in mind.  That interest may be your EMS contract as soon as your residents cant afford another tax increase.  Then they slide in on their white horse and its ball game over.


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## EMTinNEPA (Jul 8, 2009)

CAOX3 said:


> They never do anything for free. They will always have their best interests in mind.  That interest may be your EMS contract as soon as your residents cant afford another tax increase.  Then they slide in on their white horse and its ball game over.



And would that really be such a bad thing?  The town would have ALS service 24/7 from EMS professionals.  At least they would be decent enough to help you until volunteer EMS gradually fades away instead of coming in a forcibly taking over.


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## CAOX3 (Jul 8, 2009)

EMTinNEPA said:


> And would that really be such a bad thing?  The town would have ALS service 24/7 from EMS professionals.  At least they would be decent enough to help you until volunteer EMS gradually fades away instead of coming in a forcibly taking over.



Only if your an employee of the town and are the one losing your job.


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## daedalus (Jul 8, 2009)

CAOX3 said:


> You didnt say that, you said "based on cold hard evidence".  Which is different from best available research.  MAST trousers was based on best available research, how did that work out.
> 
> My attitude is disappointing, Im sorry if the truth hurts.



Best available research is cold hard science. Also, the MAST system was certainly part of science. It was tried and it failed. That is what science is, for example, Newtonian physics is wrong (replaced by Relativity), yet we still use it to make basic predictions because it works at the crude level. There will be a day when we come up with something better than Relativity. This is science, always dynamic, and humble. We diligently work to disprove things once accepted and strive for better theories, while using what works best at the time. 

Definition of science:


> a method of learning about the [biology] by applying the principles of the scientific method, which includes making empirical observations, proposing hypotheses to explain those observations, and testing those hypotheses in valid and reliable ways


 Source- nasa.gov

The very definition of science is application of research.


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## Level1pedstech (Jul 9, 2009)

daedalus said:


> I asked for scientific evidence and this is what you post? It seems like you are evading my question by runnng to a trauma surgeon and asking him I it's ok. Here is a hint, if someone asks for evidence to support your treatment one day and you come back to that person saying so and so said it was ok, you will have lost respect as a provider and you will facv the consequences of whatever you have done.
> 
> CAOX3, my county bases many practices on best available medical research. Your attitude is disapponting.



 What can I say Im just a simple guy trying to add my two cents. I dont run to anyone for anything, in my simple way of thinking it made sense to ask providers of different levels where I work. I presented the information and asked for opinion not approval. I then passed on the information for the people who might find it interesting. I dont need approval from anyone I work with, to be honest I dont really care I have my time in and dont fell the need to prove jack. My certification from the state says it all. If you are so much into disproving IV therapy in the pre hospital setting show me what you have and I would be glad to pass the information along. Im sure it would be appreciated. I wont turn in my equipment (yes like many rural volunteer providers I respond POV most of the time) until the state accepts your proof of why we should stop the practice.


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## Ridryder911 (Jul 9, 2009)

Level1pedstech said:


> What can I say Im just a simple guy trying to add my two cents. I dont run to anyone for anything, in my simple way of thinking it made sense to ask providers of different levels where I work. I presented the information and asked for opinion not approval. I then passed on the information for the people who might find it interesting. I dont need approval from anyone I work with, to be honest I dont really care I have my time in and dont fell the need to prove jack. My certification from the state says it all. If you are so much into disproving IV therapy in the pre hospital setting show me what you have and I would be glad to pass the information along. Im sure it would be appreciated. I wont turn in my equipment (yes like many rural volunteer providers I respond POV most of the time) until the state accepts your proof of why we should stop the practice.



Wow! Did you read your statement? Did you really want to present yourself this way? I would assume no one that acclaims to be in the medical field to want to describe themselves competent because they passed a 10'th grade level State test. 

I just read some of you posts. Since you like asking others instead of seeking information and education yourself (there's usually a verb for that) ask them what the liability is of you carrying equipment with you? How much medical malpractice do you have? 

Now, I ask you this. What is benefit does the patient get by your IV treatment? Since there is only really two reasons to establish intravenous therapy in the prehospital setting (from the National Curriculum) 1) Fluid therapy 2) Route for medication administration. Please, I hope you do not respond with an embarrassing statement such as "fluid resuscitation" because I will refer you back to your medical peers to ask them about the "debunk" of that and how that has been disproved nearly a decade and a half ago. So now I ask, what medicines do you administer? If you do administer, of course you should be monitoring them... So now I ask what true therapeutic treatments are you providing other than just doing a skill? 

In medicine, one should be able to justify their actions or lack of actions. That is just part of life. If you can not then possibly what you are doing should not be done or the person should not be providing the action. Yeah, it is a simple as that. 

R/r 911

* There are tons of literature on the reason(s) IV therapy should not even be performed in prehospital setting.


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## VentMedic (Jul 9, 2009)

Level1pedstech said:


> My certification from the state says it all. If you are so much into disproving IV therapy in the pre hospital setting show me what you have and I would be glad to pass the information along. Im sure it would be appreciated. I wont turn in my equipment (yes like many rural volunteer providers I respond POV most of the time) until the state accepts your proof of why we should stop the practice.


 
Many states still have central lines, pericardiocentesis and pedi (or Adult) ETI in the Paramedic scope of practice but that does mean because the state has written it into the statutes that every Paramedic should be allowed to perform these procedures.  The medical directors will have say in what their providers can perform based on the need and confidence.  If their providers were to take the "entitlement" attitude, there would probably be even less skills performed in the field by providers.  We could ETI for both pedi and adults as an example.  Just because it is in your scope, if the provider is not properly educated/trained and maintained, ETI is dangerous to the patient.


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## Level1pedstech (Jul 9, 2009)

I guess I could have replied a bit more professionally, I apologise. I don't like being backed into a corner or called out because there are questions and concerns with the practice of performing IV therapy in the field. I have taken the required training,passed the state test and I follow a strict set of protocols.

 Do you think I am some sort of privateer running around with an ambulance worth of gear in my trunk just waiting to put myself in a situation where I can harm someone and open myself and my department up to liability. I really dislike that impression people get of rural providers that have to practice without the big city tools and toys but get the job done just as well as our big city counterparts.  I am covered under my department just as if I went to the station and responded in a department vehicle. In all my years with my department I cant think of any patient that has been harmed or come after us for malpractice.

 Does my ability to preform the skill mean that all patients get fluid therapy or even a line for med access, it all depends on what the protocols call for. In the ER almost everyone gets a line for anticipation of need. I think far more people get lines in the ER than would get them in the field under the guidelines we follow. We can only put up NS and once again that's following specific protocols.

 I have always been very careful not to overstep my scope of practice both in the field and in the ER. In the ten years I have been a provider the largest chunk of my time has been used trying to be the best educated provider I can be.  I don't claim to have all the education and knowledge of some of the folks that post here but I hope to get there one day.


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## EMTinNEPA (Jul 9, 2009)

CAOX3 said:


> Only if your an employee of the town and are the one losing your job.



My solution was to how a volunteer BLS-only service could provide ALS in a rural setting.


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## Foxbat (Jul 9, 2009)

Ridryder911 said:


> * There are tons of literature on the reason(s) IV therapy should not even be performed in prehospital setting.


IV therapy, as in fluid replacement, or as in administering any medications via IV route?


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## Ridryder911 (Jul 9, 2009)

Foxbat said:


> IV therapy, as in fluid replacement, or as in administering any medications via IV route?



All. Choose a decade, there was a push to remove IV therapy from EMS roles alike the intubation debate  now. Acclaiming it took an average of > 10 minutes to establish an IV. Multiple academic studies acclaiming such. Even discussion that IV's not even be established in the ED due to time delay and be started in the O.R. Thus it is why it is essential to really review on how and why studies are performed. 

We have swung the pendulum from one extreme to another with IV's. Yes, there is a happy middle. The main emphasis all  treatments we do should be able to be justifiable. It being placing a splint, oxygen or even starting an IV. 

R/r 911


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## ResTech (Jul 9, 2009)

Rid has a point... studies can be performed and sometimes results swayed to support one groups position. A study could be performed with results saying we should do away with EMS all together.


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## Ridryder911 (Jul 9, 2009)

ResTech said:


> Rid has a point... studies can be performed and sometimes results swayed to support one groups position. A study could be performed with results saying we should do away with EMS all together.



Actually, there was one not that long ago. If I recall placed in ACEP publication as the description of that possibly just load and go would be in the best interest as no real drastic changes of outcomes has developed with EMS. The benefits of cost reduction and less delaying of detailed care. 

Like described, if one has thought about it; there probably was a study performed. If there was a study performed, then there was probably another study performed to discredit that study or challenge it. 

R/r 911


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## ResTech (Jul 9, 2009)

Along those same lines of the study your referencing... I remember a few years back a study was done in LA County where they evaluated outcomes of trauma patients who arrived by EMS (ALS) and those who arrived by private auto. 

The study found that the patients who arrived by private auto had a statistically much better outcome than the group that arrived by EMS. The study contributed the improved outcomes in the private group due to no scene delay caused by calling 911, EMS response, IV starts, patient packaging, etc. The patient was simply loaded in a car and transported immediately after injury to the hospital bringing the trauma patient to definitive care much sooner.


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## VentMedic (Jul 9, 2009)

ResTech said:


> I remember a few years back a study was done in LA County where they evaluated outcomes of trauma patients who arrived by EMS (ALS) and those who arrived by private auto.


 
If I was in LA County and a trauma patient, POV would also be my preference unless *daedalus* or *JPINFV* was around.


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## daedalus (Jul 9, 2009)

VentMedic said:


> If I was in LA County and a trauma patient, POV would also be my preference unless *daedalus* or *JPINFV* was around.



Why thank you! My preference would be Vent if I was ever in need of any sort of emergency transfer.

There will be better days in Southern California, one future JPINFV medical director at a time.


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## ResTech (Jul 10, 2009)

I have a few preferences on here... but for other reasons than medical expertise!


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## CAOX3 (Jul 10, 2009)

daedalus said:


> Best available research is cold hard science. Also, the MAST system was certainly part of science. It was tried and it failed. That is what science is, for example, Newtonian physics is wrong (replaced by Relativity), yet we still use it to make basic predictions because it works at the crude level. There will be a day when we come up with something better than Relativity. This is science, always dynamic, and humble. We diligently work to disprove things once accepted and strive for better theories, while using what works best at the time.
> 
> Definition of science:
> Source- nasa.gov
> ...



Again when EMS decides to base tratment on evidence based medicine, just because it happens in a few areas.....


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## CAOX3 (Jul 10, 2009)

This is all cute warm and fuzzy but can we get back on topic here, I mean if your done with the lovefest....


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## Level1pedstech (Jul 11, 2009)

Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.


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## daedalus (Jul 11, 2009)

Level1pedstech said:


> Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.


Absolutely not! Your fluid resuscitation might actually kill the patient in your scenario. Lets break down why.

You are going to be decreasing the hematocrit (% of RBCs in blood/volume) by providing saline or ringers to this patient, which will further drop oxygen carrying capacity of the blood, which will make the shock _even worse_. Remember that shock is not defined by BP or blood loss, but by lack of perfusion of oxygenated blood to vital tissue beds. The treatment for blood loss secondary to trauma is *not* fluid replacement, but surgery to stop the blood loss. I reccommend Dr. Jeffery Guy's lectures available through iTunes for free. Guy is a burn and trauma surgeon attending at Vanderbelt University . Leading experts in trauma are strongly recommending against aggressive fluid resuscitation in the field and the ED. The only safe fluid for these patients is of course blood, and in your case in the field, O-, which you are not going to have access to.

Also, as you stated, the patient is hypothermic. You might remember to warm the fluids, but others may not. Water has an excellent capacity to remain cool, which is one of the reasons our body uses it in the first place. 

If I was an ALS provider, I would start an IV on this patient and provide no fluids unless the blood pressure was below 90. Than I would titrate to control it at around 90 mmhg. It would be dangerous for me to do such, and I would be high tailing it to the trauma center (safely of course). It would be even worse for EMTs to initiate this treatment while waiting for ALS.


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## Ridryder911 (Jul 11, 2009)

Level1pedstech said:


> Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.



Something hard to convince those in EMS is it is not always the best interest to go to the nearest but to take them to most appropriate. Have you developed a "trauma plan" where first response can place HEMS on stand by? Hopefully, your HEMS carries O-. 

Alike what daedalus described is permissive hypotension and the wash out theory. This information has been out there for at least 15 years. Does any of your personnel have PHTLS or ITLS as it has been discussed for over at least 10 years. 

One has to be very careful on rewarming, as more and more research has demonstrated. When you start rewarming patient many things occur. More than I have time to discuss but basically increased bleeding and the release of free radical enzymes, acidosis, etc. Do some lit research on Google scholar and you will be surprised on the ton of information on this subject. In fact, many are inducing controlled hypothermia on patients and increasing survivability. 

R/r911


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## Level1pedstech (Jul 11, 2009)

Good points and the advice is well taken. As always I would follow protocol and the guidelines set down by my MPD. I do still question patient stability with the long transport time. What if we move the patients condition to stable with no signs of shock but positive for hypothermia, a very common scenario with all the snowmachine riders we have in the winter months. As far as warm fluids, I will usually toss a bag or two of NS on the dash to warm them up if its a winter scenario. In a cold environment it actually makes a big difference.

 Just for the record I almost always have radio communication and will receive direction from my responding medic, it would be rare for me to be without the advice of an advanced provider. Maybe I should have also mentioned this before hand.


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## Level1pedstech (Jul 11, 2009)

Ridryder911 said:


> Something hard to convince those in EMS is it is not always the best interest to go to the nearest but to take them to most appropriate. Have you developed a "trauma plan" where first response can place HEMS on stand by? Hopefully, your HEMS carries O-.
> 
> Alike what daedalus described is permissive hypotension and the wash out theory. This information has been out there for at least 15 years. Does any of your personnel have PHTLS or ITLS as it has been discussed for over at least 10 years.
> 
> ...



 Our transport agency makes the call on where the patient ends up, they are seperate from my department but are well aware of all thats involved with transports out of our area including which facility best suits the patients needs.

 I took PHTLS a few years ago but its time for a refresher. Its a great class even for basics but moves very quickly, I would like to see a few more hours added to cover the ever expanding material.


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## daedalus (Jul 11, 2009)

One should optimally pre read a lot of the provided text before actually attending the PHTLS/ITLS class. The classroom portion is really an overview.

Things are not always as they seem in emergency medicine. Our efforts should do no harm and hasten to help, read: get these patients to the surgeon with no further damage than already done, all while treating what we can safely treat in the field. Alike what rid has said, HEMS should be called to provide transport to trauma facilities, along with the HEMS having access to advanced education and scope.


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