# IV Endorsement



## MTEMTB (May 12, 2010)

Got a 2 day class coming up next week.
Protocol has been changed (again) and we are going to learn to not only set up the IV, but to do the vein puncture.

Any tips?

I also volunteered to be stuck. I have some good veins on my hands.


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## LucidResq (May 12, 2010)

Get sticks on the hard people in your class.


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## Veneficus (May 12, 2010)

MTEMTB said:


> Got a 2 day class coming up next week.
> Protocol has been changed (again) and we are going to learn to not only set up the IV, but to do the vein puncture.
> 
> Any tips?.




Pointy end goes into the other person


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## Shishkabob (May 12, 2010)

Dont confuse a tendon for a vein. 

Youll regret it.


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## TransportJockey (May 12, 2010)

Linuss said:


> Dont confuse a tendon for a vein.
> 
> Youll regret it.



And so will the person being stuck


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## LucidResq (May 12, 2010)

If you're going for a hand vein and you can't get it, digging the needle in at a 90 degree angle will not help. If you for some reason feel the need to put a needle in to someones hand at 90 degrees, please do not let them see it. 

I was the lucky stickee, and I don't know who looked more terrified once they saw what was going on.... me or the instructor.


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## MonkeySquasher (May 13, 2010)

-   Slow is smooth, smooth is fast.  It's not a race, the person isn't dying yet.

-   Apply the tournequet, lower the arm at a slight angle, maybe have them squeeze their fist a couple times.  Start low at the hand and work your way up.  Look at the back of the hand, but DONT go for the first thing you see, check out all your options.

Look at your own hand.  Look at your thumb.  See that little "dip" at the bottom of your thumb near the wrist?  Now rotate your wrist outward (ulnar deviation, if you care.  lol), you should see a small vein appear.  That tends to be palpable, and a good vein to go for.  It can be positional, however, and CAN be tricky on some people.

Check the top of the forearm, some thinner people have huge veins just proximal to the wrist.  Finally, work your way up to the AC.  If you aren't 100% on the AC, start at the wrist.  If you start at the AC, anything lower is a no-go.

-   For gods sake, don't leave the tournequet on for 20 minutes while you look at veins.  lol

-   Before you poke with your needle hand, use your other hand to slightly pull the skin around the vein taunt.  This can keep it from rolling on you.  Do NOT make that cause your hand to be in the way of the needle, its a good way to stab yourself in the back of the rig.

-   Finally, when you poke into the vein and get a flash, advance the CATHETER forward, not the entire goddamn needle.  It goes completely through the vein into the muscle, causes lots of pain, and makes the other person want to punch you.  Man, was I pissed at my buddy when he did that.  lol


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## MrBrown (May 13, 2010)

MTEMTB said:


> Got a 2 day class coming up next week.
> Any tips?



Yes, don't do a 2 day course, how on earth do you expect to learn fluid dynamics and homeostasis in that length of time?


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## MTEMTB (May 18, 2010)

Did the first class last night. Alot more people showed up then were expected.

We got to stick our partner twice and they stuck us twice. I got mine in first try. My poor partner blew mine. My hand still aches this morning.

Thank you to everyone who replied it was a great help.

yes I was sweating bullets and nervous that I would hit a tendon or blow the vein.


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## Shishkabob (May 18, 2010)

I blew a vein on someone last night.  No big deal, apologize and move on.


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## EMSLaw (May 18, 2010)

I couldn't get a line for love or money the other day.  But none of my preceptors could either, so I felt a bit better.


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## MrBrown (May 18, 2010)

EMSLaw said:


> I couldn't get a line for love or money the other day.  But none of my preceptors could either, so I felt a bit better.



Are you in medic school mate?


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## abuan (May 19, 2010)

EMSLaw said:


> I couldn't get a line for love or money the other day.  But none of my preceptors could either, so I felt a bit better.


that always makes me feel better when that happens. hahahaha. 

i love starting IVs. i have a couple tips:

1.TRACTION TRACTION TRACTION! but be careful with old people, you can really hurt them if you pull too hard.

2. tighten the screwable parts on the stopcock if you decide to use one. mr. murphy rears his head all the time with stopcocks. for me at least.

3. don't toss the needle till you milk it for a dex stick reading. ((thumb up))


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## MTEMTB (May 20, 2010)

Took me 6 tries to get the IV in last night.
my partner stopped after 3 tries.
No one got one in me.

Dumbest thing. I would get the needle into the vein, but would not advance it enough for the cath to go in.
The instructor caught it and got me going correctly again.

Now we were told to slap the vein by one instructor and to not slap it by the other.
Any thoughts on this?

Got to also do the IO. We used chicken legs.

We were told to check the blood sugar when setting an IV line.
The ones we have you can not get the blood out of it it is completely enclosed. We would have to get it from the cath before we hook up the fluid.


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## abuan (May 20, 2010)

MTEMTB said:


> We were told to check the blood sugar when setting an IV line.
> The ones we have you can not get the blood out of it it is completely enclosed. We would have to get it from the cath before we hook up the fluid.


sounds complicated. i guess the equipment we have here in hawaii is a little old school, cuz there's a couple of ways to "milk the needle" to get a blood sample with the equipment we have.

and i've seen a lot of people slap the veins, and i've tried it and it hasn't really worked, so i stopped doing it. maybe my technique sucks. 

but as i think about it more, if you're slapping a vein to get it to engorge, you're probably better off looking for another site. 

i try to let gravity do a lot of the work.


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## Miss EMT (May 20, 2010)

I work as a phlebotomist at the hospital so I get plenty of practice with hard stick patients. I still find starting I.Vs a lot harder. I would always want to hold the needle at an angle and go straight in. Not a good thing with I.Vs.


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## Shishkabob (May 20, 2010)

MTEMTB said:


> Now we were told to slap the vein by one instructor and to not slap it by the other.
> Any thoughts on this?
> 
> We were told to check the blood sugar when setting an IV line.
> The ones we have you can not get the blood out of it it is completely enclosed. We would have to get it from the cath before we hook up the fluid.





Slapping the vein really doesn't do anything at all, but hey, it's your technique.



As far as getting blood out of a safety cath when the needle is fully retracted, just push a pen in to the opposite end and it will slightly pusht he needle out to where you can get blood on to a BGL strip....

As far as it being a good way to get a BGL reading, that's another thing entirely.


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## Miss EMT (May 20, 2010)

I heard that checking the blood sugar with venous blood can give you inacurate readings. I don't know for sure. I have had a chance to research it.


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## Shishkabob (May 20, 2010)

Miss EMT said:


> I heard that checking the blood sugar with venous blood can give you inacurate readings. I don't know for sure. I have had a chance to research it.



It all depends.  Some meters are only calibrated for cap. blood, while some can do capillary and venous.  Some of the newer meters can be within 1% difference between cap and venous samples, you just need to check with your protocols.


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## Miss EMT (May 20, 2010)

See I didn't know that. very interesting.


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## Pneumothorax (May 20, 2010)

MTEMTB said:


> Took me 6 tries to get the IV in last night.
> my partner stopped after 3 tries.
> No one got one in me.
> 
> ...



did u use the EZ-IO or the bone gun?

i find the ez-io to be soooooo cool, there is a video on youtube of all the IO drills,guns etc... they use them on eggs..look it up its pretty coolB)


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## Hal9000 (May 20, 2010)

I find the Montana EMT-B IV endorsement to be more harmful than good.  However, I also have it.  If you don't feel comfortable with it, think of your patient and forgo skewering them, especially if you're in a rural area where you won't have much practice.

Oh, and don't go using D50.


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## MTEMTB (May 20, 2010)

No we didn't use the IO drill. We were told about it though. i will have to go watch it on the youtube.

Now those of you who do a lot of IV sticks.
How do you hold the needle?

We had a guy holding it like he was throwing a dart.


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## CAOX3 (May 20, 2010)

What is the rationale of having an EMT start an IV?


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## adamjh3 (May 21, 2010)

CAOX3 said:


> What is the rationale of having an EMT start an IV?



EMT-b = Every Medic's Trained *****. 



I could see the rationale in some rural areas where ALS is a good ways away, or when the rigs run 1 medic and 1 basic, why not get the practice in?


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## Shishkabob (May 21, 2010)

CAOX3 said:


> What is the rationale of having an EMT start an IV?




When *** hits the fan and you don't have enough hands.


Never hurts to have an EMT start an IV, the medic will/should still be the one pushing the drugs.


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## abuan (May 21, 2010)

CAOX3 said:


> What is the rationale of having an EMT start an IV?



venous access


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## Hal9000 (May 21, 2010)

Linuss said:


> When *** hits the fan and you don't have enough hands.
> Never hurts to have an EMT start an IV, the medic will/should still be the one pushing the drugs.



Linuss,

This is designed for _a medic-less/EMT-B only system. _ These endorsements are implemented because "not all places can have medics," so it is the supposition of the state that giving EMT-Bs these skills provides paramedical services without the need to have the education and licensure. I think it is a terrible and flawed system in many respects, with EMT-Bs teaching other EMT-Bs the endorsements; I know of at least two EMT-Bs that teach the endorsements to other services when they themselves do not have them.  I managed to get my endorsements all within 8 hours, just to see if the system has any controls.  

YMMV with this, but there is a great lot of shoddy "I have this endorsement" mentality that goes on.  Colloidal osmotic pressures?  Who cares about those?  Often there is little to no oversight, and medical directors sign off without looking at the papers.  

For the record, the EMTs in Montana are allowed to have these endorsements:

*Airway:* _The purpose of the Airway Endorsement for EMT-B is to provide the EMT-B with theknowledge and skills to manage difficult airways and initiate corrective action with a DLT and CPAP.  Patient care should always be based on patient presentation and Montana Prehospital Treatment Protocols.

*PSYCHOMOTOR OBJECTIVES*
At the completion of this unit, the EMT-Basic will be able to:
Perform body substance isolation (BSI) procedures during basic airway
management, advanced airway management, and ventilation.
Demonstrate ventilating a patient by the following techniques:
a. One person bag-valve-mask
b. Two person bag-valve-mask
Ventilate a pediatric patient using the one and two person techniques.
Insert a dual lumen airway.
Ventilate a patient with a dual lumen airway or King airway inserted.
Set up and assist a patient with a (CPAP) device (not to exceed 5cm H2O)
_

*IV & IO Initiation and Maintenance:*
_The purpose of the IV / IO Initiation Endorsement for EMT-B is to provide the EMT-B with the knowledge and skills to cannulate peripheral veins and place intraosseous devices, initiate and maintain clear intravenous fluids (D5W, D10W. LR and NS).
Patient care should always be based on patient presentation and Montana Prehospital Treatment Protocols.
*
PSYCHOMOTOR OBJECTIVES:*
Use universal precautions and body substance isolation (BSI)
procedures
Demonstrate cannulation of peripheral veins.
Demonstrate intraosseous needle placement and infusion.
Demonstrate clean technique during medication administration.
Demonstrate disposal of contaminated items and sharps.
_


*Monitoring (ETCO2, Manual Defib, etc.):*

"_The purpose of the Monitoring Endorsement for EMT-B is to provide the EMT-B with the knowledge and skills to collect diagnostic values and initiate corrective actions including operating a pulse oximeter, blood glucose monitor, end-tidal CO2 monitor, and manual defibrillation. Patient care should always be based on patient presentation and Montana Prehospital Treatment Protocols.

*PSYCHOMOTOR OBJECTIVES*

Demonstrate the correct application of a pulse oximetrymonitoring
device.
Demonstrate obtaining a pulse oximetry reading.
Demonstrate ability to correctly troubleshoot and correct simple
problems.
Appropriately obtain a blood specimen for testing purposesG1-1.7
the student shall obtain a blood glucose level reading.
Dispose of all sharps while adhering to Body Substance Isolation
(BSI) procedures.
Correctly troubleshoot and correct simple problems.
Follow manufacturer and later developed service specific
preventive maintenance procedures related to the monitoring
device.
Demonstrate proper safety techniques
List three situations which may result in a shock to the operator of
the defibrillator
The student must demonstrate control of the emergency scene
and direct the resuscitation efforts
Demonstrate appropriate voice documentation of events on the
scene
Demonstrate appropriate written documentation of events on the
scene
Demonstrate appropriate assessment and care of the patient
before, during, and after defibrillation
Demonstrate the completion of a preventive maintenance
checklist on manual and automatic defibrillators
Given a normal ECG tracing, identify the following: P wave, QRS
complex, T wave
On ECG graph paper, label the following time measurements:
0.04, 3 seconds, Identify examples of artifacts
List the sequence of steps necessary for manual monitoring
Demonstrate with a manual defibrillator, how to turn on the power,
attach the device to the resuscitation manikin with the adhesive
defibrillator pads, determine rhythm, and deliver a shock
Demonstrate different treatment sequences with a manual
defibrillator: Multiple shocks for persistent ventricular fibrillation,
shocks with conversion to normal sinus rhythm, shocks with return
of a rhythm and then re-fibrillation
Properly place electrodes in Lead II and MCL1 position for manual
monitoring
Place the paddles in appropriate position on chest for manual
defibrillation
Demonstrate correct adherence to the protocol in a simulated
cardiac arrest while correctly defibrillating a manikin, with a
manual defibrillator, within 90 seconds of arrival at the manikins’
side
Demonstrate SAFE use of a manual defibrillator; answer
questions about the controls, disposable supplies, and
maintenance; and demonstrate troubleshooting techniques
Attach an CO2 detector and determine the presence of CO2_"

*Endotracheal Intubation:*

_The purpose of the Endotracheal Intubation Endorsement for EMT-B is to provide the EMT-B with the knowledge and skills to manage difficult airways and initiate corrective action. Patient care should always be based on patient presentation and Montana Prehospital Treatment Protocols

*PSYCHOMOTOR OBJECTIVES*
Perform body substance isolation (BSI) procedures during basic
airway management, advanced airway management, and
ventilation.
Demonstrate ventilating a patient by the following techniques:
One person bag-valve-mask and Two person bag-valve-mask
Ventilate a pediatric patient using the one and two person
techniques.
Insert a dual lumen or King airway.
Insert an appropriate sized endotracheal tube
Ventilate a patient with a endotracheal tube inserted
Ventilate a patient with a dual lumen airway or King Airway
inserted.
Set up and assist a patient with a (CPAP) device
(not to exceed 5cm H2O)_



*Medications: *
_The purpose of the Medication Endorsement for EMT-B is to provide the EMT-B with the knowledge and skills to carry and administer medications that they are currently only able to assist with.
*PSYCHOMOTOR OBJECTIVES*

Demonstrate universal precautions and body substance isolation
(BSI) procedures during medication administration.
Demonstrate clean technique during medication administration.
Demonstrate preparation and administration of all approved
medications
Demonstrate disposal of contaminated items and sharps._






I'll let you decide if you think the system is safe or not.  I concur with Mr. Brown on this one; I once had the pleasure of two EMT-Bs attempting to start an IV over a 45 minute period on a patient complaining of severe chest pains, and less than 3/4 mile from the hospital. As I said, YMMV.


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## Hal9000 (May 21, 2010)

Oh, and Lead Instructor will also show up on the MT card, which adds another, but it's not involving patient care, so I didn't include it.

EDIT:  Links to PDFs:

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_airway_endorse.pdf

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_iv_endorse.pdf

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_iv_main_endorse.pdf

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_monitor_endorse.pdf

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_et_endorse.pdf

http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf


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## CAOX3 (May 21, 2010)

I can barely justify it in a PB system however in a system with double EMTs there is no benefit but a decoration, they cant push a medication through it so whats the point.

I have never once been on scene and said I wish I could put an IV in this patient.  If they need an IV there is a good chance they will require some other advanced procedure.


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## MrBrown (May 21, 2010)

I see no real benefit in having somebody able to cannulate only and think its rather dangerous to give a 120 hour wonder course graduate the ability to do so, or to perform any of the other skills listed here for that matter.

New Zealand is phasing out the "IV/Cardiac" level which has cannulation, IV fluids/glucose and manual defibrillation.  Staff at this level either have to go up to ILS Paramedic and get the ability to administer medications or can chose to move down to Ambulance Technician level which does not have the ability to cannulate.


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## Sandog (May 21, 2010)

Linuss said:


> It all depends.  Some meters are only calibrated for cap. blood, while some can do capillary and venous.  Some of the newer meters can be within 1% difference between cap and venous samples, you just need to check with your protocols.



Granted, there is a small difference between capillary and venous glucose levels, but I do not see how a meter would be calibrated for a vein or a capillary, the blood should be the same. Most meters work on the same principal, a strip oxidizes the glucose and is measured optically. I think the more important point is it better to test at the V or the C? Since C gives worst case, I would opt for that number in an EMS situation. 

http://ajcc.aacnjournals.org/cgi/reprint/18/3/224

Not trying to be disagreeable, I just had a double take on your statement.


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## MTEMTB (May 21, 2010)

Ok since this went a different direction then answering my question.

Try this scenerio.

Mr.X calls with an accident. From my residents going on gravel roads, a dirt track and if needed cutting through some crops it will take about 30 minutes to get there. That is going 60mph. I know i did once already.
Nearest BLS ambulance is 45+ minutes away.
Nearest ALS ground ambulance is over an hour and a half away.
The helicopter is not available.
This is a farm accident.
Now figure it is an auger accident.
With the way these wonderful chewing machines are, I would start an IV. So when ALS does get there they can push morphine to this pt if there is no allergy to it. Probably meet them on the way and grab them. Have done that before.

Maybe both you naysayers should come out here and cover my area. It is only 200 square miles of rural farms.



Now can someone answer my question. Figured it is better to ask and learn then ask nothing and learn nothing.


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## Shishkabob (May 21, 2010)

Hal9000 said:


> Linuss,
> *Airway:*
> *PSYCHOMOTOR OBJECTIVES*
> At the completion of this unit, the EMT-Basic will be able to:
> ...



I have no problem with the dual-lumen devices being used by EMT-Bs, so long as they are adequately trained (IE don't use a tube on someone with esophageal varices).  

I don't get the CPAP one though... it says assist a patient, is that assist like with Nitro and Albuterol where they can only use the patients equipment?





> *Medications: *
> _The purpose of the Medication Endorsement for EMT-B is to provide the EMT-B with the knowledge and skills to carry and administer medications that they are currently only able to assist with.
> *PSYCHOMOTOR OBJECTIVES*
> 
> ...


_

What drugs are we talking about here?  Nitro, Epi-pen and Albuterol?






			I see no real benefit in having somebody able to cannulate only and think its rather dangerous to give a 120 hour wonder course graduate the ability to do so, or to perform any of the other skills listed here for that matter.
		
Click to expand...


I gave you a benefit.  EMT with a medic partner... medic is doing something else like drawing up meds, so he has the EMT cannulate.  Not push drugs, not give fluids, just do the cannulation.

Plus... Medics allowing their EMTs to start lines is WAY more prevalent than you would think... only difference is this would keep the Medic and EMT from losing their license if found out._


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## Hal9000 (May 21, 2010)

MTEMTB said:


> Ok since this went a different direction then answering my question.
> 
> Try this scenerio.
> 
> ...




I covered 600 square miles in rural Montana with no ALS availability.   I've seen no verifiable proof that it provides statistical benefit to any patients, but I have seen it be of great harm.

As I said, YMMV.   I also believe I said that, if you're going to have it, practice a lot.  Don't be one of the many EMTs out in Montana that repeatedly stabs the patient without getting a patent cannulation, just because you have the endorsement.


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## Hal9000 (May 21, 2010)

Linuss said:


> I don't get the CPAP one though... it says assist a patient, is that assist like with Nitro and Albuterol where they can only use the patients equipment?



No, it means to both setup and assist, using a CPAP purchased by the EMT's service. 



Linuss said:


> What drugs are we talking about here?  Nitro, Epi-pen and Albuterol?



Epinephrine (auto injector or prefilled syringe)
Nitroglycerin (tablet or spray)
Albuterol, Isoetharine, Metaproteranol, etc. (inhaler & nebulizer)
Glucagon
Oral Glucose
Aspirin
Benadryl

Not D50, like some EMT-Bs were buying and using. 



Linuss said:


> I gave you a benefit.  EMT with a medic partner... medic is doing something else like drawing up meds, so he has the EMT cannulate.  Not push drugs, not give fluids, just do the cannulation.
> 
> Plus... Medics allowing their EMTs to start lines is WAY more prevalent than you would think... only difference is this would keep the Medic and EMT from losing their license if found out.



Perhaps of benefit in a PB system.  Of statistical benefit?  Doubt that one will be proved in the near future.  In one of Montana's "large" PB systems, I wasn't even allowed to tie on the King; I could, however, put the drop tubing together—are you referring to venous access or assembling the supplies?


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## Veneficus (May 21, 2010)

*IVs and fluids and meds, oh my.*

I was just wondering if anyone considered an EMT starting IVs as simply a tech skill to help out with. The same as setting up an IV set or connecting a monitor, etc. 

Most med techs I have seen in the hospital have no idea about IV solutions, osmolarity, medications, etc. The just go patient to patient putting in saline locks and drawing blood.

If they can do it without initiating treatments, why not an EMT in a similar way?

Just food for thought on this whole debate.


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## Hal9000 (May 21, 2010)

Veneficus said:


> I was just wondering if anyone considered an EMT starting IVs as simply a tech skill to help out with. The same as setting up an IV set or connecting a monitor, etc.
> 
> Most med techs I have seen in the hospital have no idea about IV solutions, osmolarity, medications, etc. The just go patient to patient putting in saline locks and drawing blood.
> 
> ...



Yes, I do believe it is a YMMV situation, as I mentioned, but I've also seen EMTs squeezing two 1000Ls through an 18G and using pressure infusers.  

I think this behavior occurs because EMTs are allowed to teach other EMTs the courses without truly knowing what they're doing themselves.  Also, as  mentioned, it has led to lengthy delays in patient handoff at the hospital.

But all this is why I said that your mileage may vary, and why I don't like it personally, having dealt with it for years, personally.   Many of the EMTs using the IV skill have very few patient contacts every year (by very few, I mean less than 60), and even fewer chances to start an IV.  

I'm not saying this to be critical of MTEMTB—which is why I mentioned that I'm also MT licensed with the various endorsements—and I know that an RN can be an EMT and make good use of the endorsement.

Despite that, I've seen it cause harm many times, provide noticeable benefit (one medical director commented that at least it would help our chronically-dehydrated society) rarely, and be lambasted by the state on multiple occasions.  It's still around, so that's proof that people like it.  Overall, I don't believe it is worthwhile in much of NW Montana.


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## MrBrown (May 21, 2010)

I don't even like the idea of somebody being able to start an IV but not give fluids or medications .... acquiring an ECG for example is a different as its some sticky dots.  That said however if you do not know what you are looking at are you going to recognise a poor quality ECG?

To anybody who wants a bunch of endorsments or fancy skill certificates I say get with the program and go obtain a proper education.


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## MTEMTB (May 22, 2010)

Brown I don't care about your self righteous opinion. Your a world away from me and its best you stay that way since you are just spouting off your ideas and NOT answering a question.

Now I ask that this thread be locked because it turned into a big debate and NOBODY will answer my last question!


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## Hal9000 (May 22, 2010)

> How do you hold the needle?



Is this the missed question?  And for IVs?  I mostly use my thumb and middle finger, with the bugger right in between doing the manual work.  I also use a nice, shallow angle most of the time.  

I'm too lazy to find a good picture, but this is the first one that came up:







Apologies for missing that question; while I don't fully agree with the state of Montana, I didn't mean to skip what you said. Also, I still stand behind the "practice" suggestion, especially since you won't have many patient contacts.


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## SeeNoMore (May 22, 2010)

We tried this out the first time the other night. I would reccomend making sure you understand how the equipment works before you begin. I know it sounds basic, but it helps. 

Other than that practice. I was able to get most of the lines I started, missed one. Learned how to set up fluids, take blood samples (which I assume no hospitals will ever want from me) 

I also got stuck 6 or so times and had a few get pretty messed up. Lots of blood and some big bruises. Made me more careful on other people! 

Overall practice practice practice. And more importantly understand why you are starting an IV when you do. h34r:


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