# BLS and IV's



## Gbro (Sep 23, 2007)

In previous threads we have heard from some ALS members that BLS services have no business using IV's.
The service i am with doesn't, although we do have the option to become trained and use IV's for shock/Trauma. 
There are 2 BLS services in our county that have IV's on board.


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## KEVD18 (Sep 24, 2007)

here we go again...

intravenous therapry is an invasive, advanced life support skill. when i was trained is this skill, we spent a full week of classes(m-f 9-330) covering the anatomy/physiology of the veinous system. the indications and contraindications of iv therapy. fluid/electrolyte balance. how much fluid to give and how fast. catheter types and thier uses. preperation, insertion, securement. how to examine for patency. what to do when it goes wrong. and the list goes on. its my opinion, given the dumbing down of ems curriculum nationwide, that the bls version of this course material would amount to maybe 10hrs of lecture, a few pokes at the rubber arm and a card to put in your wallet. while i strongly believe that 95% of the basic out there could handle this skill, the other 5% ruin it for you.

case in point: a rural system has just authorized bls iv therapy. bls truck get call for c/p. crew arrives on scene and decides to initiate an iv. they spend 40min onscene, blow every vein they could find and decide to t/p. their transport time to the H, 14min. while this may be the exception to the rule, it still happens. and yes, maybe it happens with -p's too but not as much.

not every pt needs a line just "because i can". there are physiological considerations that need to be factored in. now i under stand that there are plenty of services that use -iv or -i crews that start hundreds of lines every day. but you have to have a need, not just a toy you want to play with.

as we all said in the magill thread, if you want to be a medic, go to medic school. learn how to do this stuff well and you be a better tech for it.


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## bstone (Sep 24, 2007)

While on a camping trip 2 summers ago I came across a very severely injured hiker. Had a seizure, fell, hit his head, bleeding, etc. Held c-spine for over an hour until EMS got there. They had one EMT-B an one FR. I am an NREMT-Intermediate, tho not licensed in that state. They asked me to come along to the hospital in order to assist BLS care in the back (the EMT-B was clearly very new and very uncertain as to the proper things...he messed up basic backboarding and c-collar). 

En route he instructs the driver to stop while he "starts a line". Blows both lateral ACs. I am cringing at his poor skill sets. One of the first things they taught us in Intermediate school was "start distal, go proximal". A certain part of me wanted to take over starting the line or at least offer some instruction to him, but I kept my mouth shut as I didn't want to step on any toes or do anything with dubious legal issues.

In any case, it's clear to me that IV skills should only be taught in Intermediate or higher level class rooms. No offense to the Basics, but when I got out of Basic school I barely knew my BP cuff from my foley catheter.


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## Summit (Sep 24, 2007)

EMT-B with a successful Colorado IV Approval may perform peripheral IV starts/dc/monitoring, administer saline and dextrose, perform blood draws, and check BGL. This is state regulated and may be implemented by individual services as their MDs see fit.

To receive the approval I had to complete the class (24 classroom hours where passing is a grade of 80% minimum (got an A+)) and clinical (15 successful clinical IV starts and preceptor signoff)


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## bstone (Sep 24, 2007)

Summit said:


> EMT-B with Colorado IV Approval class and clinicals may perform peripheral IV starts/dc/monitoring, admister saline and dextrose, perform blood draws, and check BGL. This is state regulated and may be implemented by individual services as their MDs see fit.



Interestingly, in my above posted situation, I was in CO. I am not so impressed with the competency of the EMT-Bs and this skill set.


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## crash_cart (Sep 24, 2007)

In my state, classification is set up-EMT, EMT-I, and EMT-P(aramedic.)  EMTs may _monitor_ intravenous solutions, but that's it in regards to this topic.  EMT-Intermediates are certified to carry out intravenous therapy, though paramedics are only approved to do intravenous drug administration and injections. To me, it sounds like an advanced skill, an interesting one at that.


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## medicdan (Sep 24, 2007)

KEVD18 said:


> here we go again...
> 
> intravenous therapry is an invasive, advanced life support skill. when i was trained is this skill, we spent a full week of classes(m-f 9-330) covering the anatomy/physiology of the veinous system. the indications and contraindications of iv therapy. fluid/electrolyte balance. how much fluid to give and how fast. catheter types and thier uses. preperation, insertion, securement. how to examine for patency. what to do when it goes wrong. and the list goes on. its my opinion, given the dumbing down of ems curriculum nationwide, that the bls version of this course material would amount to maybe 10hrs of lecture, a few pokes at the rubber arm and a card to put in your wallet. while i strongly believe that 95% of the basic out there could handle this skill, the other 5% ruin it for you.
> 
> ...



I completely hear you-- I am not arguing that Bs should be able to put in IVs. I do know Basic services in MA that carry IV supplies and only Basics, but they are ALSO trained either as ER-Techs or Phlebotomists (sp?). Some of the hospitals in the area like to have blood drawn when the patient arrives and TRAINED basics are happy to do this. 
Is your distrust of Basics with needles an issue with the amount of time that IVs are covered in class-- or not knowing A/P? I agree that for some Basics it is another toy and is often misused, but with proper training, would you support it?


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## Ridryder911 (Sep 24, 2007)

Okay.. We need to ask ourselves what reasons IV's are initiated in the first place. 

There are only two reasons:
Fluid replacement
Route to administer medications

That's it.. now, with that in hand, can a basic really diagnose and treat those that need fluid replacement, as well as other have discussed of having the understanding of physiology behind them? If one is going to learn fluids & electrolytes, and IV therapy then one would no longer will be a basic, would they? 

Pharmacology, as represented in other posts Basics have no reason to administer (not assist) medications per IV. Period. 

R/r 911


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## KEVD18 (Sep 24, 2007)

aloow me to clarify. its not that i dont trust basics to start lines. i am a basic. i can start a line, monitor it, push meds through it, dc when necessary. my lack of faith is in the system. i dont believe -iv programs will cover enough of the anciliary information to make it a safe situation. the a/p, fluid/electrolyte balance, med administration, imho, wont be covered. it would(or is in some cases) taught as purely a mechanical skill with none of the medicine behind it.

24hrs in the classroom and 15 starts? we did over 40(maybe more i wasnt counting) and by the time i leave my clinical rotation i will have an average of 300+. thats the diff betweenreal training and just throwing a skill and hoping it sticks.

"I do know Basic services in MA that carry IV supplies and only Basics, but they are ALSO trained either as ER-Techs or Phlebotomists (sp?). Some of the hospitals in the area like to have blood drawn when the patient arrives and TRAINED basics are happy to do this."

it is entirely possible that this type of thing is happening in the western part of the state(illegaly i might add) but there is no way this is going on east of 495. this isnt even a grey area. this is blatantly outside ma bls protocols and is ground for immediate revocation of certification regardless of certification as a phlebotomist or ed tech. these certs do not carry over into mass ems in anyway.


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## BossyCow (Sep 24, 2007)

My state does have a cert for EMT-B- IV.  It is an additional class and requires prior permission of the MPD before you can take it.  We are a BLS agency and our ALS is about 30 miles away.  Once an IV is started, we must call for ALS support.  The advantage is that when we do meet ALS, generally on the side of the road, the IV access has already been acquired and generally done before leaving the scene, in a more well lit, unbouncy environment.  

Bad IV starts, blown veins, and repeated failures are signs of poor skills.  Regardless of the level of certification, the level of skill is below par.  There is no need to turn a Pt into a purple pin cushion.  

Also, once the IV certification has been added to EMT-B, according to our protocols, the EMT then has to recert at the EMT-I level from then on.  So the standard of education and testing is higher.


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## Flight-LP (Sep 24, 2007)

This again falls into the "can vs. should" issue. As Rid stated there is limited TRUE REASONS to start a line and when it is TRULY needed, then it REQUIRES someone who can utilize the forethought and critical thought process to interprete and understand WHY they are doing it. Not a common occurance in the BLS environment......................

It can't be justified, no matter how hard you try.................


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## emtmomof2 (Sep 24, 2007)

As a volunteer EMT-b here in Jersey, we are not allowed to administer IV.  Personally i wouldn't want to anyway...leave that to the medics.


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## Gbro (Sep 24, 2007)

The intent of this thread is to show that there are BLS services that Have IV skills, and that it should be looked at as a good thing.
This site "could" be a place for those using skills like IV, And other base line procedures to find a comfortable place to discuss situations that have been encountered, or are likely to be encountered. A place to find support for their skills, and gain confidence in the use of these items carried on their rigs.
The Medic's (EMT-P's) could be very valuable in instilling confidence in these BLS providers.

Lets look at the positive side for now, Please?


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## Flight-LP (Sep 24, 2007)

There isn't a positive side to it. It is not justified, that is a fact. Emt-B's are incapable of providing pseudo ALS care. Again, a proven fact (hence why after many years of existance, the DOT ciriculum has not included ALS skills for a BLS provider). Keep bringing it to the table, you will see that our beliefs and views will not waiver. Collectively, your beliefs are not recognized by industry experts, ER physicians, or the medical community as a whole. I fail to see any productive reason for you to continue on what WILL be a failed crusade. You just do not have the backing and our patient's care is too valuable to allow someone with under 200 hours of training taught at an 8th grade level to perform invasive procedures. SIMPLE AS THAT. There IS nothing more than can be said about it, period.

/rant...........Have a great evening!


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## reaper (Sep 24, 2007)

In Florida basics can "start" IV's, in the presence of a medic. They cannot run fluids, cannot push meds, and cannot ride with the pt.

They do have to go through extensive IV therapy training and it is still up to the med dir. to allow this.

Our system does allow basics to start IV's, we are one of the few around. Yes, this does help out on scene, that they can do IV's. But, there is no way I would want to let them do this on their own, on a BLS unit. 

As was said before. If you want to preform ALS skills, then go to medic school just like the rest of us had to. There is so much you do not understand about IV therapy to be allowed to preform this skill without supervision.


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## bstone (Sep 24, 2007)

I think that learning the basics of IV therapy should be part of the Basic cirriculum- if only to be able to assist medics and demystify this fundamental part of ALS. Of course this would add additional time to the BLS course so it's probably been considered and dropped.


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## focal06 (Sep 25, 2007)

I just started my ride time on an ALS truck here in florida and we have an EMT-B on the truck who just finished "IV school" (2 day course) and she started two lines in front of me and gave fluids in presence of a medic. I dont think its a bad thing really, she did a good job..thats my .02.


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## ffemt8978 (Sep 25, 2007)

Can anyone name one instance where an IV saved a patient's life?











Didn't think so.  I'm an EMT-ILS, which means that I can start IV's or IO's, and push Narcan or D50 via these routes, or administer Albuterol, NTG, Epi-pen, activated charcoal.  Personally, I don't feel that the physiology or pharmacology was in depth enough for what we administer.  In addition, we breezed over acid-base balance.  I blame the dumbing down of curriculum for this.  Too many people consider IV's to be a routine part of EMS, or a basic skill for an advanced provider.  What they are forgetting is that it is not a basic skill for a basic provider.

That being said, I can see a use for people who can start IV's to assist an ALS provider in certain areas.  I know that in the ideal world, every rig would be an ALS unit, but that isn't going to happen any time soon.  Smaller, lesser funded department have to make due with what they have.


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## Ridryder911 (Sep 25, 2007)

focal06 said:


> I just started my ride time on an ALS truck here in florida and we have an EMT-B on the truck who just finished "IV school" (2 day course) and she started two lines in front of me and gave fluids in presence of a medic. I dont think its a bad thing really, she did a good job..thats my .02.




You should understand the process of an IV is a skill. A monkey could be taught the process (yes, they can use their thumbs) but; to understand and have the knowledge of why, when and the risks of what happens when we do establish one. One needs to understand the pathophysiology that every time we administer fluids, (no matter if they need it or not) we are changing homeostasis.  

As in my state, Basics are required to have a "working knowledge" of IV's. This being on how to spike a bag (set up) as well they are tested on IV drips etc, since they are able to transport them (monitor them). 

R/r 911


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## focal06 (Sep 25, 2007)

Ridryder911 said:


> You should understand the process of an IV is a skill. A monkey could be taught the process (yes, they can use their thumbs) but; to understand and have the knowledge of why, when and the risks of what happens when we do establish one. One needs to understand the pathophysiology that every time we administer fluids, (no matter if they need it or not) we are changing homeostasis.
> 
> As in my state, Basics are required to have a "working knowledge" of IV's. This being on how to spike a bag (set up) as well they are tested on IV drips etc, since they are able to transport them (monitor them).
> 
> R/r 911



I realize this, However all Im saying is, If you know how to do it and the medic "ok's" it I dont see the problem in letting the bls provider do it. The only thing the EMT-B is allowed to do with this "certificate" is administer fluids anyways. They are not pushing drugs, that is out of thier scope of care, but if administering fluids can be "taught to a monkey" then whats the problem letting an EMT-B do it?


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## bstone (Sep 25, 2007)

ffemt8978 said:


> Can anyone name one instance where an IV saved a patient's life?
> 
> 
> 
> ...



Um...Narcan and D5W save the lives of my PTs daily. Had a PT with a blood sugar of 10. Unresponsive, not in good shape. I do believe the IV D5W saved him.

And Narcan...over and over.


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## reaper (Sep 25, 2007)

Did the EMT do this with the medic there? Who rode with the pt to the hospital?

If the EMT just hung the bag, then they did not "run fluids". The medic was there to make sure what and how much was administered. Do not think that administering NS is no big deal and basics should be able to do it. You can kill a pt with NS, if you have no clue when and why you are giving it.

You are there doing ride alongs to learn the correct way to do things. Don't let people that are working out of their SOP, show the wrong way to do things.

Have fun and learn all you can. But, use your judgement with it too!


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## triemal04 (Sep 25, 2007)

bstone said:


> Um...Narcan and D5W save the lives of my PTs daily. Had a PT with a blood sugar of 10. Unresponsive, not in good shape. I do believe the IV D5W saved him.
> 
> And Narcan...over and over.


Uhm...I'm going to repeat the question:  when did an IV save a life?  Narcan is not an IV, neither is D50 regardless of how they are given.  An IV, meaning a catheter inserted into a vein is an IV.  Not the meds that may follow.  

I don't have a problem with Intermedietes here (and that only means in my state) starting IV's or giving meds.  For what they can do and when they can do it, the course isn't bad.  It's cookbook mediecine, but at that level that's pretty much to be expected.  (we won't talk about the new scope)  But I don't consider them BLS either.  (or really ALS...that's also another topic)  For BLS providers, basics and first responders...no.  Absolutely not.  It's to bad for a lot of basic's out there, but there are way more out there that this would be a horrible idea for.  The class they take is simple enough that adding a more advanced skill would be stupid; it'd just be a "feel that and poke it" 5 hour class more than likely.  Without being able to give any meds, the times when it would really make a difference are extremely limited.  The times it could cause problems would be much more common.  So no.  Basic's get minimal training as it is.  Another skill is not needed.

I am sick and disgusted with the amount of people out there who want to look, act, talk like a medic and do medic skills without taking the time to actually become a medic or ALS provider.  If you don't like your skill set, go back to school.  Do not try and add more skills that you will not be properly trained in or qualified to use.  EMT-B's are called BASIC for a reason; they are supposed to be able to provide intial actions until ALS support is reached. 

Has anybody ever stopped to think that EMS isn't advancing and getting the respect and acknowledgement it deserves because of #$%^ like this?  Untrained people performing skills they should never have had in the first place and causing problems?  Low skill levels begging more the "fun" skills even when they don't need them?  I'm sorry, but when was the last time you saw a CNA or LPN whining that they should be able to intubate?  Never.  Won't happen because they have set standards and education levels and the people know that if they want to do more they have to go back to school.  Not pitch a hissy fit until someone gives in.

Wow.  That felt good.


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## bstone (Sep 25, 2007)

I am an NREMT-Intermediate and 100% ALS provider. I may not have as many skills or the same scope as you, but I am an ALS provider.

There was nothing "cookbook" about my Intermediate program, thank you very much. For every skill we had many hours and presentations on the A&P, biochemical mechanism, pathophysiology, etc etc. In fact our course was not unlike the medic course (same people taught it). We just have fewer skills and less scope so we needed less time, but it was just as rigorous in depth as the medic program.


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## focal06 (Sep 25, 2007)

reaper said:


> Did the EMT do this with the medic there? Who rode with the pt to the hospital?
> 
> If the EMT just hung the bag, then they did not "run fluids". The medic was there to make sure what and how much was administered. Do not think that administering NS is no big deal and basics should be able to do it. You can kill a pt with NS, if you have no clue when and why you are giving it.
> 
> ...




medic was in the jump seat when the EMT-B started the line and administerd fluids. then after that the EMT-B jumped up front and drove to the hospital with the medic and me still in the back. IM not saying an EMT-B should be able to do it with no supervision, that would be wrong, but if a medic is present I dont see why the EMT-B cant lend a helping hand and start the IV. None of our medics around here complain when they get help...call me crazy.


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## bstone (Sep 25, 2007)

There is nothing wrong with an EMT-B starting an IV under the direct supervision of a medic (or Intermediate...or doctor, or nurse, etc). At that point they are acting more like an assistant/tech than a licensed EMT-B. 

A medical student assists in surgery, even making the first incision, but does so only under the direct supervision of the attending surgeon. I think it would be a similar guidline for the EMT-B start a line under an EMT-I or P.


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## Flight-LP (Sep 25, 2007)

bstone said:


> There is nothing wrong with an EMT-B starting an IV under the direct supervision of a medic (or Intermediate...or doctor, or nurse, etc). At that point they are acting more like an assistant/tech than a licensed EMT-B.
> 
> A medical student assists in surgery, even making the first incision, but does so only under the direct supervision of the attending surgeon. I think it would be a similar guidline for the EMT-B start a line under an EMT-I or P.



The absolute saddest part of this whole thread is not the belief that EMT's should be able to perform intravenous cannulation, but the lack of comprehension as to why IT IS NOT BENFICIAL. Therefore, EMT-B's, how can you remotely justify reasoning if you fail to identify it in the first place?????

Med student vs. EMT-B. Apples vs. oranges....................

A Med student assisting in surgery has already completed 2 years of medical school preceded by 4 years of undergraduate studies. They are enrolled in a professional medical prgram. They are covered under the program's liability insurance. And I see very few surgeons who will allow a med student to make any incision, let alone the initial. If there are med students, then there are residents and they are the ones who are there to learn the trade. The med students are there to get a taste of whats to come. 

-5 for a horrible analogy, but +20 for taking your education more seriously than most ( another +5 for choosing one of the best educational institutions in the country!)

I leave you with a question though, you mentioned D50 and Narcan save the lives of your pts. daily. Do you routinely give Narcan with D50? and if so why?


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## bstone (Sep 25, 2007)

Flight-LP said:


> The absolute saddest part of this whole thread is not the belief that EMT's should be able to perform intravenous cannulation, but the lack of comprehension as to why IT IS NOT BENFICIAL. Therefore, EMT-B's, how can you remotely justify reasoning if you fail to identify it in the first place?????
> 
> Med student vs. EMT-B. Apples vs. oranges....................
> 
> ...



I'd be willing to rethink the analogy. It isn't the best one. How about an EMT-B who is in Intermediate or Paramedic school doing IVs under the direct supervision of an Intermediate or Paramedic but not necessarily during their actual clinical times? It would be like informal clinical training. I think many Is and Ps would be cool with this- assuming it was legal and OKd by the med director.

Why do I routinely give D50 and Narcan? Well- I am an Intermediate and where I trained (New Hampshire) our protocols allow for Intermediates to start IVs and based on blood sugar check or positive opiate OD administer D50 or Narcan. We have a lot of protocols that we don't need authorization for, including Epi (1:1000 and 1:10,000), Atropine, Alubterol, Narcan, D50, Oxygen, some of the nerve agent antidotes. Not nearly as many meds as the Medics, of course, but many. We also do 3 lead EKG with dynamic interpretation, manual defibrillation, endotrachael intubation with some meds down the ETT. No traches/crichs, chest decompression, opiates or 12-leads. 

Intermediates in New Hampshire most often work with Medics, but many times don't.

I am currently in school so I am taking a break from EMS to concentrate on school, studying for the MCAT and doing well. It is my hope to go to med school, become a great doc and post on these sorts of forums as a resource for information. Communication between EMS providers and physicians is so, so important and not enough of it is done outside the lecture hall or "you're in trouble, take a seat" senario. I hope to change that.


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## BossyCow (Sep 25, 2007)

Here we go again.  First of all, I do not have my IV cert yet and am pursuing my EMT-I as soon as I can get into a class.  

A lot of the issues I see arising from these types of threads are based on an urban system or EMT-B's who want to play with all the cool toys without an understanding of the possible problems that can result.  

In my system, if we are on the western edge of the district, we can have an hour long transport time.  Our closest airlift requires at least a half hour lead time so often that hour by ambulance is going to be the fastest route to the hospital for the patient.  

My state does have a cert for EMT-B - IV.  It is not 'a couple of days' training but an extensive course.  It can only be taken with the prior permission of the MPD and he's refused more applicants than he's accepted.  Once certified as an EMT-B-IV, you are no longer allowed to recert under the EMT-B training or rules but must take the EMT-I test every three years to recert.  as well as send in your list of sucessful sticks.  

Once an IV has been started, we *must* call for ALS support.  Our closest ALS is at least 20 minutes out and generally meets us enroute to the hospital. The value of the start of the IV is that it shortens the time spent on the side of the road after we meet up with ALS.  

As to saving a life, I do have an instance where it did.  We had a traumatic amputation.  Crackhead in a car vs old guy on a motorcycle.  Took the motorcyclist's leg off right below the hip.  We had about 3" of femur and that's was it.  He was bleeding from the femeral artery when his buddy who was travelling behind him found him and tied a tourniquet around the stump. The EMT-I who was first on scene started two large bore IV's and called for ALS support.  We were lucky to have ALS available and to the west side of their district so the time until rendezvous with ALS was only about 35 minutes. This guy's blood resembled strawberry koolaid by the time he got to the ER.  He got 5 units of blood in the ER and everyone was on pins and needles as to whether or not he had enough of his own blood left to make it. He did survive.  According to our MPD it was the combination of events that allowed him to survive this event.  If his buddy hadn't stopped the bleeding, if the initial fluids hadn't been given, if ALS was not able to meet up with us as rapidly as they did, this guy would not have made it. 

Is the best treatment for those kinds of injuries an ALS system?  Absolutely!  Would I rather have had a Paramedic on scene immediately?  You betcha!  But it's not going to happen in my lifetime. As a volunteer with a full time job outside of EMS, I am not going to assume the financial burden of training myself to EMT-P so that I can provide care for free.  EMT-I is all that is available to me and it is rare.  I have to attend the class outside of my county and then prove to my MPD that I can translate that teaching into our protocols by passing his protocol test.  Then I have to re-test every 3 years because there are no ILS Oteps provided in my county. 

I'm willing to do that because I want to be able to do all I can and all I am allowed to do within my system.  I don't want permission to do everything a paramedic can do, but I do want as many certifications as I can earn and as many skills as I can learn.  

Not all of us are just whackers thinking "Hey I could do that" after seeing a medic do a skill.  Not all of us are trying to be mini-medics.  But I want to give every patient I see the best chance of survival.


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## bstone (Sep 25, 2007)

BossyCow, that's very interesting.

Let me just say, however, that Intermediate level is ALS. Just not as many "tools in the toolbox". In New Hampshire I have a lot of tools. States which use I-99 have an even bigger toolbox. States that use I-85 have only a few tools. But they are there.


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## knxemt1983 (Sep 25, 2007)

KEVD18 said:


> aloow me to clarify. its not that i dont trust basics to start lines. i am a basic. i can start a line, monitor it, push meds through it, dc when necessary. my lack of faith is in the system. i dont believe -iv programs will cover enough of the anciliary information to make it a safe situation. the a/p, fluid/electrolyte balance, med administration, imho, wont be covered. it would(or is in some cases) taught as purely a mechanical skill with none of the medicine behind it.
> 
> 24hrs in the classroom and 15 starts? we did over 40(maybe more i wasnt counting) and by the time i leave my clinical rotation i will have an average of 300+. thats the diff betweenreal training and just throwing a skill and hoping it sticks.
> 
> ...



I dont really know how it is done in the rest of the country hut here in Tn we only have emt-iv, which are basics with the a&p od iv's built into the course. Until recently I thought that the course covered it pretty well, and even thought I had a good grasp on the physiology of it, that was until I started paramedic school, and learned about the different types of fluids and the types of fluid shifts, and all the cellular stuff, that they never mentioned in emt school.
With that being said, I think there is a place in some systems for it, but we should really change the requirements for the iv cert. I understand where you are coming from with the skill issue is coming from, we have to start around the same number of iv's before we can get the medic cert, and I haven't done near that many iv's in the past 5 years of ems. 

just my 2 cents


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## triemal04 (Sep 25, 2007)

bstone said:


> I am an NREMT-Intermediate and 100% ALS provider. I may not have as many skills or the same scope as you, but I am an ALS provider.
> 
> There was nothing "cookbook" about my Intermediate program, thank you very much. For every skill we had many hours and presentations on the A&P, biochemical mechanism, pathophysiology, etc etc. In fact our course was not unlike the medic course (same people taught it). We just have fewer skills and less scope so we needed less time, but it was just as rigorous in depth as the medic program.


This is a topic for a whole 'nother thread, so I'll just say a few things and then shut up.  1.  How long did you spend on A&P, pharmocology, etc etc?  2.  Your attitude is quite common it seems and never fails to annoy me.  "I'm just as good as a medic even though I don't know as much."  YOU probably know more if you're in pre-med now, kuddos on that, but do not forget that that doesn't apply to everyone.  3.  Who knows, maybe you had a good program with good instructors.  Remember, that also doesn't apply everywhere.  EMT-I courses are almost always much shorter than medic school and teach...cookbook mediciene.  4.  If you are actually being taught endotracheal intubation, not how to use dual-lumen's or LMA's...you better being doing a whole lot of clinical time, internship time and training otherwise that is very very dangerous.  Now I'm goint to stop and try to stay with IV's and BLS providers.

Someone who is in I or medic school and has been taught how to do IV's...it'd depend on the situation and person, but personally that's fine with me.  Doesn't apply to the topic at hand though.

Again, you missed the question.  Do you routinely give D50 and Narcan together?  (you know...add thiamine and you've got the coma cocktail)  If so, is that because you are unable to determine an OD from hypoglycemia, your protocolls requie it, or do you not push them together?  Oh, and when have you had an IV save a life?  And I mean really save a life?

Bossycow...your's is the situation that's a pain.  Really the only good solution for you is to do what you're doing and get your Intermediate.  (so, is that the EMT-I with airway?  With meds?  or one of the other 8 intermediate levels WA has? )  It's good that you have a selective program for allowing basics to start IV's, but not everwhere is like that.  To many people would be doing the wrong thing because they could without thinking about.  It definetly applies to you; if a basic with IV skills starts a line on Joe Blow the average guy because he can and it's rare for him to be able to, that means you have to call an ALS ambulance, right?  Even if the pt really didn't need one.  If you are going to start an IV YOU MUST KNOW WHEN TO DO IT AND WHEN NOT TO DO IT.  If the people in your system are that good, then good for you guys.  But I've also seen BLS people sit onscene for 20+ minutes with a critical pt trying to start a line before bringing them to the transport ambulance.  As for shortening the time spent on the side of the road...if the medic's can't do the line enroute, that is a whole 'nother problem.

If people want advanced skills, go to school and learn them.  Get your intermediate, you'll pick up some skills that are more beneficial than an IV.  But as a basic...it's called basic for a reason.


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## ffemt8978 (Sep 25, 2007)

Bossy,

I'm in the same situation as you, but in the middle of the state.  Nearest hospital is an hour in any direction, nearest ALS is 20-30 minutes in any direction, and Medstar is 35 minutes when available.

Getting back to the call you described, how did the IV itself save the patient?  It didn't.  Normal saline can not carry oxygen or nutrients to the cells that need them.  What saved that patient was a combination of things.


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## Gbro (Sep 25, 2007)

I have a response to all the posters that say; Go To school.
How about you come to the rural area and help us out?

We've had young enthusiastic Highly trained Full timers try and buy our service, after sitting 6-7 days without a call, Guess what?
Ya they were gone, and us Basic's are all thats left. 
The only thing we lac in the rural area is Run Volume.
We see sick and injured just as bad as you in Critical Care see, again just not as many.
Why that means those poor folk shouldn't get the best care we can possible give them(without being ALS) is beyond me.
I do fully agree with one of the posters, It is a systems problem.
Our system is required to have everyone equally trained. That is to mean, we must all be proficient in IV"s to carry them. 
Now my wife worked in the ER and couldn't start an IV in the field. Why? 
B.S. Red tape. that is all.
Like i posted we could go with the training, but i for one have spoken out against it.
We just don't see the volume, To stick someone just for "our" stick count would be wrong. But we do have ALS 20min out for the average call.


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## triemal04 (Sep 26, 2007)

Gbro said:


> I have a response to all the posters that say; Go To school.
> How about you come to the rural area and help us out?
> 
> We've had young enthusiastic Highly trained Full timers try and buy our service, after sitting 6-7 days without a call, Guess what?
> ...


Hmm.  All I can see from this post is that you, even will a very low call volume, still see critical pt's.  (which makes me wonder how well you would be able to keep those IV skills up anyway with such a low volume)  But you don't want to take the time to go to say...EMT-I school, learn some new pt assessment skills and get a few more skills that will sometimes make a difference.  You just want to be able to start IV's because...why?  That's the part that is really funny.  You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.

Couple suggestions.  Think about why you need the skill.  Really think about it, and then ask yourself what is best for your community.  The able to maybe put a piece of teflon in someones vein, or the ability to perform a little better pt assessment and maybe give a few meds.  If you really think that starting an IV is so great, go back and get your EMT-I.  You'll learn a few tricks that could help out more than a piece of teflon.

Hate to say it, but this is the type of mentality that makes me so dead set against EMT-B's starting IV's.  They want the skills without taking the time to learn them, or learn when/why they should be used and what should go along with them.  (if that's clear  )


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## bstone (Sep 26, 2007)

triemal04 said:


> This is a topic for a whole 'nother thread, so I'll just say a few things and then shut up.  1.  How long did you spend on A&P, pharmocology, etc etc?  2.  Your attitude is quite common it seems and never fails to annoy me.  "I'm just as good as a medic even though I don't know as much."  YOU probably know more if you're in pre-med now, kuddos on that, but do not forget that that doesn't apply to everyone.  3.  Who knows, maybe you had a good program with good instructors.  Remember, that also doesn't apply everywhere.  EMT-I courses are almost always much shorter than medic school and teach...cookbook mediciene.  4.  If you are actually being taught endotracheal intubation, not how to use dual-lumen's or LMA's...you better being doing a whole lot of clinical time, internship time and training otherwise that is very very dangerous.  Now I'm goint to stop and try to stay with IV's and BLS providers.



My Intermediate program was very indepth. For certain topics which the medics were also being taught we were able to keep up in the conversation. For every topic we learned it was just as in depth as the medics. We just have fewer things.



> Again, you missed the question.  Do you routinely give D50 and Narcan together?  (you know...add thiamine and you've got the coma cocktail)  If so, is that because you are unable to determine an OD from hypoglycemia, your protocolls requie it, or do you not push them together?  Oh, and when have you had an IV save a life?  And I mean really save a life?



Thiamine (100mg IV) is one of our meds. Give it in cases of alcohol DT (Delerium Tremens, Korsokoff's/wernicke). We stick someone's finger and test for blood before giving D50 and determine if they have an actual opiate OD before Narcan. We don't do coma cocktails and have no type protocol for such an unresponsive patient. We actually test and investigate to see what the problem is.


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## triemal04 (Sep 26, 2007)

bstone said:


> Thiamine (100mg IV) is one of our meds. Give it in cases of alcohol DT (Delerium Tremens, Korsokoff's/wernicke). We stick someone's finger and test for blood before giving D50 and determine if they have an actual opiate OD before Narcan. We don't do coma cocktails and have no type protocol for such an unresponsive patient. We actually test and investigate to see what the problem is.


Good.  That makes me happy to be honest.  Now be a good sport and answer the question that's really pertinent to this thread and has been asked 3 times.  When have you had an IV, and that means just an IV, no meds, really save someones life?


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## bstone (Sep 26, 2007)

triemal04 said:


> Good.  That makes me happy to be honest.  Now be a good sport and answer the question that's really pertinent to this thread and has been asked 3 times.  When have you had an IV, and that means just an IV, no meds, really save someones life?



You mean no fluids of any type, even saline?

Never.

Only saline? Hmmm....dunno. I don't follow up on every PT.


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## triemal04 (Sep 26, 2007)

bstone said:


> You mean no fluids of any type, even saline?
> 
> Never.
> 
> Only saline? Hmmm....dunno. I don't follow up on every PT.


That's part of my problem with Basic's and IV's.  A straight IV does no good whatsoever.  The times when giving saline or ringers will really make a difference (and I do mean really) are pretty rare, and more than likely will be seen in a rural, low volume setting where rapid transport to a ER is not an option.

Which brings me to the bigger problem.  In an urban environment, there isn't going to be that much of a need for a basic to start a line.  If there is the system is pretty messed up.  But in the rural...  Most of the skills, the physical skills that medic's perform a monkey could eventually be taught to do.  The problem is knowing when to do it, why to do it, when not to do it, and how you do it in adverse situations.  With the way the average EMT is trained these days, that would not be taught to basic's, they'd just get the physical skill.  And in a low volume system, how long do you think those skills would last before they'd be sticking some 90 year old grandma 6 times and delaying transport because they couldn't get a line?  I've seen the downside to rural agencies having advanced skills (and most of the time they've been trained beyond the basic level), there is no need to put more tools in untrained hands.  It may be unfair to some responsible people out there, but unfortunately, that's how the game works now.  If you want more skills, take the time to learn how to do them properly.  That doesn't gaurentee that you'll retain all that knowledge, but at least it's a start.

Now it's time for another gin 'n tonic.


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## Gbro (Sep 26, 2007)

triemal04 said:


> Hmm.  All I can see from this post is that you, even will a very low call volume, still see critical pt's.  (which makes me wonder how well you would be able to keep those IV skills up anyway with such a low volume)  But you don't want to take the time to go to say...EMT-I school, learn some new pt assessment skills and get a few more skills that will sometimes make a difference.  You just want to be able to start IV's because...why?  That's the part that is really funny.  You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.
> 
> Couple suggestions.  Think about why you need the skill.  Really think about it, and then ask yourself what is best for your community.  The able to maybe put a piece of teflon in someones vein, or the ability to perform a little better pt assessment and maybe give a few meds.  If you really think that starting an IV is so great, go back and get your EMT-I.  You'll learn a few tricks that could help out more than a piece of teflon.
> 
> Hate to say it, but this is the type of mentality that makes me so dead set against EMT-B's starting IV's.  They want the skills without taking the time to learn them, or learn when/why they should be used and what should go along with them.  (if that's clear  )



I do hope you are more attentive in your examination of a Pt. in front of you.

Humm?
I am posting this "because(as you can see from the poll) there "ARE" BLS services with IV Protocol's"
Not the service i am with as we elect not to.

I did take the EMT-I years ago. The system wouldn't allow just me(EMT-I or my Wife EMT/RN) because the whole crew wasn't equally trained.
There are some situations today that would make that hurdle lower.
The IV stick count was is a problem where I couldn't keep up my EMT-I. I would have had to work with another service and then who knows?
When I did my clinicals for the I, after 40 hours in the ER, Not one stick.
We did stick each other way too many times...


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## Gbro (Sep 26, 2007)

> That's part of my problem with Basic's and IV's. A straight IV does no good whatsoever. The times when giving saline or ringers will really make a difference (and I do mean really) are pretty rare, and more than likely will be seen in a rural, low volume setting where rapid transport to a ER is not an option.



Something like this maybe?

http://www.duluthnewstribune.com/articles/index.cfm?id=50780&section=None

A neighboring BLS service had this run a week ago or so,


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## Flight-LP (Sep 26, 2007)

So you have a conscious, alert patient in pain with a pelvis fracture. How does this remotely prove your point? The IV would have been of no immediate necessity other than for pain management, which again, can not be provided by an EMT-B. Since the BLS service was able to transfer him, apparently pain wasn't too much of an issue..............

Bstone - Thats great that you do not give the blind "coma cocktail", but even if you do confirm an opiate OD, what is your criteria for administering the Narcan. For instance if you have someone who is slurring their speech, has sluggish pupils, BP 100/60, P 58, R 14, and an SPO2 of 95%, would you Narcan them? Why or Why not?


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## bstone (Sep 26, 2007)

Flight-LP said:


> Bstone - Thats great that you do not give the blind "coma cocktail", but even if you do confirm an opiate OD, what is your criteria for administering the Narcan. For instance if you have someone who is slurring their speech, has sluggish pupils, BP 100/60, P 58, R 14, and an SPO2 of 95%, would you Narcan them? Why or Why not?



After checking with the current protocols, it states:


Intermediate standing orders 
IV access, obtain blood sample and administer fluids to maintain systolic blood pressure >90 mmhg. 
Suggested narcotic antidotes: naloxone 0.4–2 mg IV push, im, SQ, in or ETT. If no response, 
may repeat initial dose every 5 minutes to a total of 10 mg. 
Consider paramedic intercept.

http://www.nh.gov/safety/divisions/...cuments/2007_nh_patient_care_protocols_v2.pdf


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## Flight-LP (Sep 26, 2007)

Sorry my friend, but this is precisely my point. I'm not interested in what your standing orders have to say, I am seeking your reason and rationale as to why you would or would not provide a treatment. Protocols are only guidlines, not the King James Bible. Narcan should only be administered in a known narcotic OD with RESPIRATORY DEPRESSION. If an airway is patent, there is no reason to give an antagonist that is going to do nothing more that agitate your patient and thus placing them at risk for an increase myocardial workload. Honestly,even with respiratory depression, I rarely ever give it. I'll just intubate them. That way their airway is definately controlled and I don't have an agitated patient pissed off at me for taking away their high. 

This is the thought process that us ALS provders are referring to. If you cannot identify all of the pro's and con's to a treatment, then it shouldn't be given. It is slightly more understood and accepted at the Intermediate level, but this just adds one more justification as to why none of the Intermediate skills should be allowed in an EMT-B's hands............................


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## bstone (Sep 26, 2007)

You asked me what my protocals were, I answered and now you're angry?

Huh?


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## BossyCow (Sep 26, 2007)

ffemt8978 said:


> Bossy,
> 
> What saved that patient was a combination of things.



Absolutely and part of that combination was the initial IV


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## triemal04 (Sep 26, 2007)

Gbro said:


> I do hope you are more attentive in your examination of a Pt. in front of you.
> 
> Humm?
> I am posting this "because(as you can see from the poll) there "ARE" BLS services with IV Protocol's"
> ...


I think I've met you before.  Or at least far to many people like you.  If your service won't allow different levels to work there, maybe you should focus on fixing that problem.  Then you could get some I's working there, (who knows, maybe an off-duty medic) which would be beneficial for the reasons I've listed.  Having Basic who can start IV's (in your service, something you've allready said is an option) is not a good idea for the reasons allready listed.  And if you went 40 hours in the local ER without starting an IV you're proving my point about keeping your skills up.

This bears repeating:
Couple suggestions. Think about why you need the skill. Really think about it, and then ask yourself what is best for your community. The able to maybe put a piece of teflon in someones vein, or the ability to perform a little better pt assessment and maybe give a few meds. If you really think that starting an IV is so great, go back and get your EMT-I. You'll learn a few tricks that could help out more than a piece of teflon.
Of course that means that you woud have to work to change your system, somethin you've allready voted against.  Why was that?  Because you knew you'd be putting advanced skills in peoples hand when they wouldn't get the neccasary practise using them?

Also:
You just want to be able to start IV's because...why? That's the part that is really funny. You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.
And your little example does not qualify.  Basic's in an urban environment won't have this problem, it's services like yours that will.  And shouldn't because...well...that's been done to death, and it even seems like you know that.


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## Flight-LP (Sep 26, 2007)

bstone said:


> You asked me what my protocals were, I answered and now you're angry?
> 
> Huh?




I'm not angry at all..................I asked what your criteria is for determination to administer Narcan. The perception I was going for is when do you deem it appropriate to administer? Its easy to stay within the "protocol box", but what is generally deemed to be a level of proficiency is when the ability to think out of the box comes into play. Sorry to use you as the scapegoat, no hard feelings implied.


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## bstone (Sep 26, 2007)

Flight-LP said:


> I'm not angry at all..................I asked what your criteria is for determination to administer Narcan. The perception I was going for is when do you deem it appropriate to administer? Its easy to stay within the "protocol box", but what is generally deemed to be a level of proficiency is when the ability to think out of the box comes into play. Sorry to use you as the scapegoat, no hard feelings implied.



You asked me how I would use Narcan. If you want to know the exact indications then ask that. <_<


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## disassociative (Sep 26, 2007)

Lord have mercy, we had to go so far as to cover the epidermal strata(stratum corneum, stratum granulosum, stratum basale) the various histology and structures such as pacinian corpuscles, meissner's corpuscles, fluid compartments, electrolytes, basic biology of cell processes, slight bit of chemistry(mainly in regards Acid/Base balance); then we focused on the emergency care.

THIS WAS FOR TN EMT-IV; not paramedic.
TN EMT-IV has NREMT-B with Additional training to hold licensure
in TN. I feel they are adequately prepared. However, I must infer
that medication administration of ALS drugs should not be allowed 
for BLS providers as they are not trained in ACLS or Advanced interventions.

I have put some thought in it, and I am in the process of suggesting that one of the local community colleges go from certificate paramedic to associate; in which the student would have to take pre-nursing courses such as: A & P I, II, Microbiology, Gen Bio, Gen Chem, General Education Courses, Psychology, and dosage calculation.

This way, with the ever-increasing number of Paramedic-RN transition programs, our paramedics would have the appropriate training to enter into RN studies. I am not implying, by any means, that Paramedic should be given any nursing credits with regard to their training--however, I feel their should be a fast-track RN course designed for paramedics, which caters to their medical knowledge.


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## reaper (Sep 26, 2007)

How bout we just get our pay raised to match that education, then most medics won't want to get their RN! Most RN programs are AAS degrees. If we have AAS degrees then why won't our pay match the education? People keep comparing us against RN's, that is apples to oranges. Two different specialties.


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## disassociative (Sep 26, 2007)

Well, yes, it makes sense to think: well if I have an associates of this I should get paid like someone with an associates of that. The actual course work you do in paramedic school is only a small part of the degree process. The main part of any degree, as far as undergraduate is concerned, is comprised of general education curriculum(English, Communications, Math, Natural Science, Physical Science, Organic Chem, Non-Organic Chem, etc). These requirements vary based on major. If we were to begin offering A.A.S. to paramedics; sure their would be extra coursework, but that would equal more informed patient care and would equal more respect to the profession as a whole--not to mention the facilitation of an easy transfer from said degree to RN, A.A.S.--or B.S.N. for that matter. Next time you are out on the street(amongst civilians, not ems or fire personnel) ask them 2 questions. What does a paramedic do?, Job Roles?; then, ask What does a nurse do? Job Roles? Formal credentialing can have a variety of  benefits. 

Ever get sick of the fact that here you spent 3 long semesters + God knows how many hours in clinicals so that a college can tell you--Oh; we can't use that time toward anything...It was special student for credit or non-credit.

Or how about; sorry--this is a non-degree program, we do not offer financial aid nor government aid(even though most of you are government personnel)

Nurses once had to fight for proper credentialing, and now; it is our time.


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## Gbro (Sep 26, 2007)

> Triemal..
> Also:
> You just want to be able to start IV's because...why? That's the part that is really funny. You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.
> And your little example does not qualify. Basic's in an urban environment won't have this problem, it's services like yours that will. And shouldn't because...well...that's been done to death, and it even seems like you know that.



I started this Poll/Thread because there "ARE" BLS services that are IV trained.
They are a necessary part of Rural EMS! As there is no ALS available to them.
We have beat that one to death and you have your opinion on that and "WE" who live and work in the Rural areas know that "YOU" don't know!

There need to be a place for those who do IV's in the BLS setting to be supported, Not told how useless they are and that there is no good that can become of it.
AMEN!


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## Flight-LP (Sep 26, 2007)

disassociative said:


> If we were to begin offering A.A.S. to paramedics...........



Uhhhh, there are quite a few A.A.S. programs and even some B.S. Paramedic programs.................


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## Flight-LP (Sep 26, 2007)

Gbro said:


> They are a necessary part of Rural EMS! As there is no ALS available to them.
> We have beat that one to death and you have your opinion on that and "WE" who live and work in the Rural areas know that "YOU" don't know!



Been there, done that, got the t-shirt.......................

Worked in several rural environments throughout Texas, both on an ambulance and helicopter, and guess what.................Every ambulance had a Paramedic! Guess its not as necessary as you perceive.................. Regardless, I'm through wth this arguement. To each their own.............


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## triemal04 (Sep 27, 2007)

Gbro said:


> I started this Poll/Thread because there "ARE" BLS services that are IV trained.
> They are a necessary part of Rural EMS! As there is no ALS available to them.
> We have beat that one to death and you have your opinion on that and "WE" who live and work in the Rural areas know that "YOU" don't know!
> 
> ...


No, you started this thread with a poll.  At best you could say you wanted to know who had IV's in a BLS service.  At worst you could say you started it with the intent of having this arguement since saying "In previous threads we have heard from some ALS members that BLS services have no business using IV's." is bound to get people's backs up.  Other than seeing who did it, I can't see any reason for this thread, except for you wanting to show how wrong people are when they say that basic's shouldn't use IV's.  So far, you've failed in that regard.

Now first, I'm going to repeat myself in the hope that you can actually answer the questions this time.  Why do you want the ability to start IV's in a BLS service?  You STILL have not given a reason why it's neccasary.  Second, don't you think that getting a overall higher level of training would benefit your community more than just getting the "flash" skills?  When have you had an IV REALLY AND TRULY save a life?

IV's are a part of EMS, rural or not.  If you want them, go out and get the neccasary training and knowledge to use them.  Though if they are so neccasary, why did you yourself vote to not have them in your service?  You neglected to address that.  Just like normal.

I've worked in the rural setting.  And guess what, the people who wanted to really do right by the area went back to school, got their EMT-I and were able to better care for their pt's.  They didn't try and take a shortcut to a skill that they wouldn't be qualified for.  Again, if you think it is such an important skill, why would you not want your own service to have it?  

Now, I've said about all I can.  All my reasons why BLS services should not use IV's have been listed.  There is no point in even responding to you since you pass over most to come back with something that is flat out ridiculous.  

You good sir, are a great example of why EMS is not progressing at the rate it should and getting the respect it deserves.  I hope you are happy with that.


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## ffemt8978 (Sep 27, 2007)

I think we've beat this horse to death...





Thread closed


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