# Can EMT-B intubate or start IVs?



## Kaleb Griffin (Mar 4, 2015)

I never thought that they could, but one of my friends that had taken his EMT class said that practiced intubation skills.  I thought it was out of an EMT's scope of practice.


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## OnceAnEMT (Mar 4, 2015)

Intubation, NPA insertion... eh...

Not an EMT skill. That said, I know my class busted into the ALS gear from time to time to get familiar with it and would "practice", but we were never officially instructed on how to intubate a patient. By NREMT standards EMTs can't start IVs, but some states have an EMT-IV licensure (very few) that does have it in their scope.


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## Jim37F (Mar 4, 2015)

Pretty much nope. There are a few select areas that allow EMTs to go to an additional course and get certified to start IV's and some areas allow EMTs to insert King Airways and the like, but as far as actual intubation? Not a chance at the EMT-B level.


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## cruiseforever (Mar 4, 2015)

The EMTs I work with can do IVs and IOs.  But no intubation.


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## cprted (Mar 4, 2015)

EMTs can be trained to ASSIST with an intubation.  Putting a tube in a doll a couple of times does not, in any way shape or form, make someone trained to intubate.


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## Kaleb Griffin (Mar 4, 2015)

Thank you all for your responses.  I did find it a little weird that they were practicing intubations, if they were never going to be able to perform one at the basic level.  It is one of the skills I want to learn, and hope to when I get my dream job of being a flight nurse!


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## NomadicMedic (Mar 4, 2015)

Until 2013, basics in Ohio could intubate pulseless and apneic patients. 

http://www.associationsoftware.com/aws/OACEP/pt/sd/news_article/68293/_PARENT/layout_details/true


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## NomadicMedic (Mar 4, 2015)

... And in Texas, with their physician directed practice, a doc could authorize a basic to intubate.


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## Kaleb Griffin (Mar 4, 2015)

Oh wow.  I wish it was still in our scope...


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## NomadicMedic (Mar 4, 2015)

Kaleb Griffin said:


> Oh wow.  I wish it was still in our scope...



Want to intubate? Become a paramedic.


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## DesertMedic66 (Mar 4, 2015)

DEmedic said:


> Want to intubate? Become a paramedic.


Pretty much my view. Don't just learn a skill. Learn why you are doing it and when you should not due it.


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## akflightmedic (Mar 4, 2015)

My first intubation was as a brand new EMT Basic in South Carolina. It was taught, allowed and expected. However, orotracheal intubation is no longer an EMT Basic skill there, but they can do LMA, King Tube, and Combitube.


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## Ewok Jerky (Mar 4, 2015)

I would ask your friend what exactly "intubation" means I bet he doesn't know.


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## RebelAngel (Mar 4, 2015)

Not in my state.


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## irishboxer384 (Mar 4, 2015)

i-gels _should_ be taught to basics i think, with the background knowledge etc obviously


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## OnceAnEMT (Mar 4, 2015)

irishboxer384 said:


> i-gels _should_ be taught to basics i think, with the background knowledge etc obviously



ATCEMS use to have Basics doing Kings for cardiac arrest, and we just moved to IGels in February.


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## Kaleb Griffin (Mar 4, 2015)

DEmedic said:


> Want to intubate? Become a paramedic.


I plan to....after nursing school.


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## OnceAnEMT (Mar 5, 2015)

Kaleb Griffin said:


> I plan to....after nursing school.



To intubate or to be a paramedic?

Yikes.


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## COmedic17 (Mar 5, 2015)

In some places EMTs can use a supraglottic airway, but I have never heard of EMTs intubating... 

Here in colorado, EMTs can get an IV cert but that's a Seperate certificate then their EMT.


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## EMTinCT (Mar 5, 2015)

Can they? Sure. Will they lose their license? Yup.


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## Underoath87 (Mar 7, 2015)

He probably just meant placing a supraglottic airway.


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## RefriedEMT (Mar 7, 2015)

Yea Oregon can do supraglottic airways, Washington state can train their EMT-Basics to put in IV's after they have had STATE cert for 1 year or they get permission from someone in their company who thinks they can handle it which is considered EMT-IV Tech.


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## PotatoMedic (Mar 7, 2015)

Washington has I believe 7 "different" EMT's.  Basic, IV tech, Airway tech, IV/Airway tech... EDIT.  Never mind.  Washington has gone to just the 4.  First responder, EMT, AEMT, and Paramedic.  Though I do believe they still have some "ad-on classes" but I can't find those.


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## NomadicMedic (Mar 7, 2015)

I didn't think WA was still licensing those levels, that they were just hold overs.


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## LACoGurneyjockey (Mar 7, 2015)

Montana offers an EMT-B Intubation endorsement, basically a merit badge class for highly rural areas with little to no ALS resources. Can't say I think it's a good idea for basics to be placing ETTs, but it does exist. 

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


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## PotatoMedic (Mar 7, 2015)

DEmedic said:


> I didn't think WA was still licensing those levels, that they were just hold overs.


Last year when I was recertifing they still had all 7.  I know that in mid January the DOH updated their EMS system as a whole so I am guessing that is when they dropped those.


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## NomadicMedic (Mar 7, 2015)

We had some IV EMTs in Yakima, but they weren't supposed to act outside the BLS scope. They had the certification, but the medical director hadn't given them authority to practice at that level.


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## RefriedEMT (Mar 7, 2015)

FireWA1 said:


> Washington has I believe 7 "different" EMT's.  Basic, IV tech, Airway tech, IV/Airway tech... EDIT.  Never mind.  Washington has gone to just the 4.  First responder, EMT, AEMT, and Paramedic.  Though I do believe they still have some "ad-on classes" but I can't find those.



Im certain they still have EMT-IV Tech simply because I see posting after posting by AMR looking for full time EMT-IV Techs, last one I saw posted was a month or two ago. Also as far as I know they don't do anything advanced other than putting an IV in. I am not even sure they are allowed to administer any additional medications although they may be able to.


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## PotatoMedic (Mar 7, 2015)

My guess is that they still exist and that some places might still be able to do the classes.  But looking at the website where they used to list all 7.  Now only 4 exist with AEMT taking most of them.


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## RefriedEMT (Mar 7, 2015)

FireWA1 said:


> My guess is that they still exist and that some places might still be able to do the classes.  But looking at the website where they used to list all 7.  Now only 4 exist with AEMT taking most of them.



Then maybe as you say they are in the process of eliminating EMT-IV Tech spots, but to be honest I have no idea. It would not surprise me because Clark County Washington use to require all EMT-Basics to have 1 year exp AND IV Tech cert, but a few months back I was told that the 1 year requirement has been taken out. To further clarify it I have seen EMT-Basic postings for Clark County in the past few months while they NEVER posted for them in the year or so before that.


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## samsbgm (Mar 7, 2015)

I know where I'm at emt's can do IV's, io's, and supraglottic airways. With your iv cert you can give ns, lr, d50, iv narcan. You can also push every medication your medic tells you to From ketamine to epi. You also do blood draws.


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## Jim37F (Mar 7, 2015)

samsbgm said:


> I know where I'm at emt's can do IV's, io's, and supraglottic airways. With your iv cert you can give ns, lr, d50, iv narcan. You can also push every medication your medic tells you to From ketamine to epi. You also do blood draws.


Meanwhile out here they don't even want Basics checking blood sugar because those little tiny finger lancets that people use OTC are too invasive for us or something like that


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## DesertMedic66 (Mar 7, 2015)

Jim37F said:


> Meanwhile out here they don't even want Basics checking blood sugar because those little tiny finger lancets that people use OTC are too invasive for us or something like that


Our protocol used to state that EMTs can only check BGL after directed to do so by the medic. Now it states EMTs can check BGL as long as a paramedic is present haha


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## Jim37F (Mar 7, 2015)

Some medics in our department don't want us even touching them...others straight up hand them to us lol


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## DesertMedic66 (Mar 7, 2015)

The majority of the BGL testing we do is from the IV flash so EMT have always been able to do most of the checks. The way the protocol was written it sounded like if there was already any blood then an EMT can test it lol


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## Jim37F (Mar 7, 2015)

Yeah they've never had a problem with us getting it off the flash...it's just the finger sticks some of our medics don't want us touching (or like I said others will simply hand me the Lancet and glucometer)


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## samsbgm (Mar 8, 2015)

I thought everyone could do a d-stick. In my opinion every emt should be able to do that. How many diabetic problems do we run on? It just makes sense. IV's are a much needed skill for emt's to have to. Most patients get an iv and blood draw.


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## DesertMedic66 (Mar 8, 2015)

samsbgm said:


> I thought everyone could do a d-stick. In my opinion every emt should be able to do that. How many diabetic problems do we run on? It just makes sense. IV's are a much needed skill for emt's to have to. Most patients get an iv and blood draw.


Things vary greatly by system. Here when someone calls 911 they get at least 2 medics so there isn't really a need for EMTs to start IVs.


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## MackTheKnife (Mar 8, 2015)

cprted said:


> EMTs can be trained to ASSIST with an intubation.  Putting a tube in a doll a couple of times does not, in any way shape or form, make someone trained to intubate.


You're right. It's the start. We did the adult/peds intubations on dummies and then had to do three actual in the field or ER to get fully signed off.


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## samsbgm (Mar 8, 2015)

DesertEMT66 said:


> Things vary greatly by system. Here when someone calls 911 they get at least 2 medics so there isn't really a need for EMTs to start IVs.



Where I'm at you always get two medics too. Can emt's attend on a call if someone has an iv? Half the time I'm just getting one enroute.


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## DesertMedic66 (Mar 9, 2015)

samsbgm said:


> Where I'm at you always get two medics too. Can emt's attend on a call if someone has an iv? Half the time I'm just getting one enroute.


For my area if it's a 911 call the paramedic has to attend regardless. If it's an IFT then EMTs are able to transport with an IV line and fluids.


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## triemal04 (Mar 9, 2015)

MackTheKnife said:


> You're right. It's the start. We did the adult/peds intubations on dummies and then had to do three actual in the field or ER to get fully signed off.


Don't hedge on these answers.  

Do you think that made you competent to intubate properly?  Yes or no.

Do you agree with people who have that same amount of training being allowed to intubate?  Yes or no.

Just checking.


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## captaindepth (Mar 9, 2015)

Kaleb Griffin said:


> I never thought that they could, but one of my friends that had taken his EMT class said that practiced intubation skills.  I thought it was out of an EMT's scope of practice.



When I worked in the GOM as an EMT-B/DMT (Diver Medical Technician) we were "taught" how to intubate and start IVs and were allowed to with medical direction. I cant tell you how thankful I am that I never was in a situation where it was needed. There is no way I would have been able to successfully intubate a pt and whats even worse is I probably would not have recognized a misplaced ET tube. Only after working on an ambulance (as a basic) and going through P school do I see how dangerous it was to give EMTs the ability to attempt to place advanced airways.


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## Kaleb Griffin (Mar 9, 2015)

captaindepth said:


> When I worked in the GOM as an EMT-B/DMT (Diver Medical Technician) we were "taught" how to intubate and start IVs and were allowed to with medical direction. I cant tell you how thankful I am that I never was in a situation where it was needed. There is no way I would have been able to successfully intubate a pt and whats even worse is I probably would not have recognized a misplaced ET tube. Only after working on an ambulance (as a basic) and going through P school do I see how dangerous it was to give EMTs the ability to attempt to place advanced airways.


I absolutely understand why you would think that way.  It would pretty much be the same as an RN (even though they can't normally intubate) delegating an intubation to myself (ER tech).


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## COmedic17 (Mar 9, 2015)

samsbgm said:


> Where I'm at you always get two medics too. Can emt's attend on a call if someone has an iv? Half the time I'm just getting one enroute.


Where I'm at its one Medic, my EMT partner, and whoever off the fire truck (EMTs) however nearly all EMTs have an IV cert. but sometimes they don't. So they can't maintain or start an IV.


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## captaindepth (Mar 9, 2015)

Kaleb Griffin said:


> I absolutely understand why you would think that way.  It would pretty much be the same as an RN (even though they can't normally intubate) delegating an intubation to myself (ER tech).



Yeah, it was not a good idea to say the least. There were 2 EMTs/DMTs per job (one per shift), if the **** hit the fan, it would have been the blind leading the blind. 

I am all for EMTs having IV certs when they work with a paramedic partner. Its great experience and is great for when you have critical/multiple pts.


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## jcroteau (Mar 10, 2015)

Up here it's very much the same as you guys have mentioned. Licensed to do Iv starts, supra glottic airways and they get an "orientation" for a class to intubation.....just so they're comfortable around the skill when the medic does it.


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## cprted (Mar 10, 2015)

jcroteau said:


> Up here it's very much the same as you guys have mentioned. Licensed to do Iv starts, supra glottic airways and they get an "orientation" for a class to intubation.....just so they're comfortable around the skill when the medic does it.


Keeping in mind that BLS in Canada is called Primary Care Paramedic (with some regional variations) and is a 8-12 month fulltime program closer to AEMT than EMT-B.


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## emtB123 (Apr 18, 2015)

Kaleb Griffin said:


> I never thought that they could, but one of my friends that had taken his EMT class said that practiced intubation skills.  I thought it was out of an EMT's scope of practice.


In Wisconsin we can do blind intubation at the basic level. King and combi.


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## NomadicMedic (Apr 18, 2015)

emtB123 said:


> In Wisconsin we can do blind intubation at the basic level. King and combi.



Just as a point of order, a BIAD is not commonly referred to as intubation, even though you are, in reality, placing a tube.

The act of placing an endotracheal tube is what we are referencing when we speak of intubation. In most cases this is not, and should not ever be a basic skill.


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## MackTheKnife (Apr 18, 2015)

DEmedic said:


> Just as a point of order, a BIAD is not commonly referred to as intubation, even though you are, in reality, placing a tube.
> 
> The act of placing an endotracheal tube is what we are referencing when we speak of intubation. In most cases this is not, and should not ever be a basic skill.


Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.


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## emtB123 (Apr 18, 2015)

DEmedic said:


> Just as a point of order, a BIAD is not commonly referred to as intubation, even though you are, in reality, placing a tube.
> 
> The act of placing an endotracheal tube is what we are referencing when we speak of intubation. In most cases this is not, and should not ever be a basic skill.


I suppose that's why we always said placing an advanced airway in class. My bad.


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## Flying (Apr 18, 2015)

MackTheKnife said:


> Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.


Can you explain your reasoning for this beyond "it's an uncomplicated airway"?


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## NomadicMedic (Apr 18, 2015)

MackTheKnife said:


> Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.



Right. Nothing complicated at all. 

smh.


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## Amelia (Apr 18, 2015)

We can do Supraglottics as an EMT here, but no IVs. I dont think we can even assist in one?


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## MackTheKnife (Apr 18, 2015)

My reasoning is this: I've done a lot of intubations. On peds in status epilepticus, on codes, etc. Are there difficult intubations? Absolutely, but it's a mechanical skill. If you have good eye hand coordination, and know basic A&P, you can tube. ETs are the proverbial gold standard of airways. That being said, teaching intubation and acquiring the skill is not that hard. I'm not advocating that Basics do RSIs, by the way.


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## NomadicMedic (Apr 18, 2015)

MackTheKnife said:


> My reasoning is this: I've done a lot of intubations. On peds in status epilepticus, on codes, etc. Are there difficult intubations? Absolutely, but it's a mechanical skill. If you have good eye hand coordination, and know basic A&P, you can tube. ETs are the proverbial gold standard of airways. That being said, teaching intubation and acquiring the skill is not that hard. I'm not advocating that Basics do RSIs, by the way.




If you haven't had a failed intubation attempt, you haven't done enough intubations. 
Minimizing intubation as "no big deal" is a dangerous road to head down.


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## TransportJockey (Apr 18, 2015)

DEmedic said:


> Right. Nothing complicated at all.
> 
> smh.


That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general


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## NomadicMedic (Apr 18, 2015)

TransportJockey said:


> That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general



Sorry. I should have used the sarcasm font.


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## TransportJockey (Apr 18, 2015)

DEmedic said:


> Sorry. I should have used the sarcasm font.


Sorry i misquoted.  I know you better than to think you meant that lol. I meant yhe one you quoted.


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## MackTheKnife (Apr 18, 2015)

DEmedic said:


> If you haven't had a failed intubation attempt, you haven't done enough intubations.
> Minimizing intubation as "no big deal" is a dangerous road to head down.


Oh, I've failed a few times. Never said I was batting 1,000. And I'm not minimizing. Some things in life are put on a pedestal, or are made to seem Godlike, as with intubation. It's not complicated or hazardous as say starting a central line or doing a cric to put it into perspective.


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## MackTheKnife (Apr 18, 2015)

TransportJockey said:


> That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general


It's not that kind of thinking. If it is please cite a study, etc. I have read articles in JEMS for instance, about how medics attempting prehospital intubations are experiencing  difficulty and a higher failure rate. And it was being considered to go away from intubation.


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## Carlos Danger (Apr 18, 2015)

MackTheKnife said:


> Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.



Yeah....read much research on prehospital ETI?

Airway management is easy, alright.....until it's not.


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## MackTheKnife (Apr 18, 2015)

Remi said:


> Yeah....read much research on prehospital ETI?
> 
> Airway management is easy, alright.....until it's not.


Remi, you, like some of the other commenters, are missing my point. What I am saying is the skill is easily taught, as the skill set is eye-hand coordination and knowing what you're looking at. Didn't say it was easy for everyone. We had a few medics who had a hard time tubing cause they couldn't recognize the cords since it didn't look the same as in the book or in the dummy. Once they figured it out, they became quite good.
What concerns me is the attitude I am inferring from some of you. You probably weren't around when EMS had to constantly fight to stay viable. Doctors and nurses fought us all the time because they didn't think we could do the things we're doing. Medicine advances despite us. We have PAs, NPs, etc., doing things that doctors once did. Not an exact analogy, I know. But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.
And some didn't bother reading that I have a lot of experience motivating and just made snarky comments.


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## chaz90 (Apr 18, 2015)

MackTheKnife said:


> It's not that kind of thinking. If it is please cite a study, etc. I have read articles in JEMS for instance, about how medics attempting prehospital intubations are experiencing  difficulty and a higher failure rate. And it was being considered to go away from intubation.


How does this support your point in the slightest?


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## chaz90 (Apr 18, 2015)

MackTheKnife said:


> But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.
> And some didn't bother reading that I have a lot of experience motivating and just made snarky comments.



Reason 1: Intubation proficiency requires a significant number of real patient practice to achieve and maintain clinical competency which is likely unachievable and not feasible for a large number of 120 hour BLS providers

Reason 2: It's a low frequency/high risk skill pre-hospitally, particularly if we're talking about rural services with such low call volumes they are using an EMT to intubate since they don't even have any ALS provider or hospital available

Reason 3: Better alternatives exist for EMT airway placement during arrests, IE any number of supraglottic rescue airways

Reason 4: Failing to recognize a misplaced ETT is a fatal error, and most BLS services don't have the equipment, training,  or experience to prevent this from occurring frequently

Shall I continue?


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## NomadicMedic (Apr 18, 2015)

A study of EM residents showed it takes upwards of 70 intubation attempts to become baseline competent, which was identified as securing the airway 90% of the time without outside assistance. Not many paramedics, outside of those in high volume areas, will see that many tubes in 10 years.

Emerg Med J doi:10.1136/emermed-2013-202470

Is that a skill basics should be attempting after a weekend add on module?

Hell, I'm of the opinion that regular street medics shouldn't be performing ETI.


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## Carlos Danger (Apr 18, 2015)

Chaz and DE are both right on.



MackTheKnife said:


> Remi, you, like some of the other commenters, are missing my point.



I'm sorry, but you are the one who is missing the point.



MackTheKnife said:


> You probably weren't around when EMS had to constantly fight to stay viable.



Not sure how this is relevant, but FWIW, I started paramedic school almost 20 years ago.



MackTheKnife said:


> Medicine advances despite us. We have PAs, NPs, etc., doing things that doctors once did.


Medicine does advance and change. The problem with your comparison though, is that the additional parameters being added to mid-level practice is happening because research has shown it to be effective and efficient....blindly adding advanced skills to the scope of unqualified practitioners is not "advancing" by any definition.



MackTheKnife said:


> But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.



I'll add two more reasons to the ones that Chaz and DE already listed:

1) Prehospital intubation by American paramedics has never been shown to affect outcomes positively.....so even without a study, you'll never convince anyone that prehospital intubation by EMT's will be good for patients.

2) The success rates of prehospital intubation without RSI are uniformly ABYSMAL and completely unacceptable. So unless you think EMT's should be pushing sux, the whole idea is a non-starter.

These opinions aren't based on my _feelings_ about the issue, they are based on years of experience and reading the related literature.


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## DesertMedic66 (Apr 18, 2015)

Sure intubation is just a skill, like needle cric, needle thor, IV, and IO. However providers need to know why they are doing the skill, what can go wrong, and what results they are looking for. All of which can not be taught in a 120 hour class, some would argue it's not even really taught in paramedic school. 

Along with these skills the providers should have other tools to verify they skill was done correctly. So for intubation we are talking about ETCO2. Now we have to provide an ETCO2 monitor to the BLS crew, teach them about the different waveforms and different values. 

That is asking a lot for a very entry level position.


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## Shishkabob (Apr 18, 2015)

DEmedic said:


> Hell, I'm of the opinion that regular street medics shouldn't be performing ETI.




You can argue on the efficacy and that'd be a valid argument, but proficiency outside of harm should not be the defining issue.  Don't delay compressions, don't delay transport, and recognize if it's in the esophagus quickly and correct it and it's really a non-issue, all else being equal.

There aren't many studies on the efficacy of surgical crichs in the field, yet the removal of ETI leaves exactly just that: Surgical crichs on the population who ETI has the potential of being beneficial and/or blind insertion airways are unacceptable, such as esophageal varices, smoke inhalation, etc.


Taking a tool out because it's sometimes missed is not the best way of going about medicine and the issue at hand.  Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics.  THAT'S the correct way of fixing the issue of misses / unrecognized misses.


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## Carlos Danger (Apr 18, 2015)

Linuss said:


> Taking a tool out because it's sometimes missed is the absolute worst way of going about medicine and the issue at hand.  Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics.  THAT'S the correct way of fixing the issue of misses / unrecognized misses.


What about the fact that it's never been shown to help, and in fact very often causes harm? Somehow we always seem to gloss over that minor detail.

It's not about the fact that it is "sometimes missed", it's about the fact that even when it isn't missed, it _doesn't help patients.
_
Funny how we are so quick to cite the evidence when it comes to spinal immobilization, yet so quick to dismiss the evidence when it comes to prehospital intubation.

At what point do we finally just admit, "you know what, this just isn't working"?


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## Shishkabob (Apr 18, 2015)

Remi said:


> What about the fact that it's never been shown to help, and in fact very often causes harm? Somehow we always seem to gloss over that minor detail.
> 
> It's not about the fact that it is "sometimes missed", it's about the fact that even when it isn't missed, it _doesn't help patients.
> _
> ...




And like I just said:  Argue the efficacy, not the proficiency.  Proficiency can be increased with minor fixes, thus should not be a bullet-point in the conversation.


Further: Studies say it doesn't always help, however we can't actually say that it actually causes harm with any certainty.   Correlation doesn't mean causation, and we don't exactly know why some people fare worse with ETI (outside of delaying compressions or things of that nature).  Physiologically speaking, a small plastic tube in someones throat shouldn't cause any difference, so what else is going on?  More people who die in the hospital have IVs, however that doesn't mean the IV caused, nor has any correlation, to their death unless it can be attributed to things such as an embolus.

Just like the arguments about Epi in SCA.  Studies show that it increases ROSC... we also know that discharge-intact is not statistically different with Epi.  Instead of pinning it on Epi, why not take a more holistic approach and ask why someone may get ROSC but not maintain it?  Perhaps there's something being missed, something that can be changes, and discarding that viewpoint can prevent further studies in to such and possibly changing medicine in the future.  (The first person to invent a medication that causes systemic vasoconstriction without causing cerebral edema / etc, will be a trillionare).  



With the restrictions placed on studies in emergency medicine, it makes it much harder to do random double-blinded studies, thus we generally have to go off of reviews, conjecture, etc.  Obviously not the best way to do studies, let alone medicine; we have studies contradicting each other all the time.  Luckily we have studies such as ALPS in the pipeline right now which will hopefully help narrow things down in the future.


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## Carlos Danger (Apr 18, 2015)

Linuss said:


> And like I just said:  Argue the efficacy, not the proficiency.  Proficiency can be increased with minor fixes, thus should not be a bullet-point in the conversation.
> 
> 
> Further: Studies say it doesn't always help, however we can't actually say that it actually causes harm with any certainty.   Correlation doesn't mean causation, and we don't exactly know why some people fare worse with ETI (outside of delaying compressions or things of that nature).  Physiologically speaking, a small plastic tube in someones throat shouldn't cause any difference, so what else is going on?  More people who die in the hospital have IVs, however that doesn't mean the IV caused, nor has any correlation, to their death unless it can be attributed to things such as an embolus.
> ...



True that the studies are almost all retrospective, but there are many of them and they are almost unanimous in their findings: prehospital ETI fails to improve or worsens outcomes. The one large prospective study (the Bernard TBI study done in Aus) showed small statistical benefits but they were arguably clinically insignificant - certainly not overwhelmingly positive - and that was even in a system where the paramedics are much better trained than in the US.

Such evidence against a non-sexy intervention would result in widespread calls among paramedics to have it removed from the protocols.

Personally, I think these findings are a result of several subtle but very important factors, of which proficiency with passing the tube through the cords is only one (though obviously a critical and foundational one).

We do need more prospective trials before we know for sure, and they shouldn't be so hard to approve given the current lack of evidence of benefit.

However, the fact is, at the present time, the best evidence we have simply does not support routine prehospital ETI by paramedics, nevermind by EMT's.

What is the ALPS trial?


----------



## Shishkabob (Apr 18, 2015)

Remi said:


> What is the ALPS trial?



ALPS is the Amiodarone, Lidocaine, Placebo Study that the ROC is doing in a few locations (one of which is at my location).  Basically a double-blinded, placebo controlled study for cardiac arrests, determining Amio vs Lido vs nothing.


Believe they are aiming for 1500 enrollments before expanding it, which last I heard will be reached pretty soon.  I have 2-3 myself.


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## triemal04 (Apr 18, 2015)

MackTheKnife said:


> Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.


You know, I was going to ask you to answer this question:


triemal04 said:


> Don't hedge on these answers.
> 
> Do you think that made you competent to intubate properly?  Yes or no.
> 
> ...


But after reading that it's pretty clear what your answer is.  And for those just checking in, attitudes like this is why EMS in the US, as a whole, is a failure.  


TransportJockey said:


> That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general


And truly, it's appropriate for doctors to do things like that with that kind of ignorant, flip attitude.


Linuss said:


> Taking a tool out because it's sometimes missed is not the best way of going about medicine and the issue at hand.  Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics.  THAT'S the correct way of fixing the issue of misses / unrecognized misses.


It's not that "it's sometimes missed" that is pushing the drive to remove endotracheal intubation from the paramedic skillset (which, for the record I agree with, outside individual systems that can actually prove that it is appropriate for them to do), it's the fact that the average paramedic is incompetant from the get go when it comes to intubation.

The initial education on it, the physical hands on training, continued performance to maintain competancy, education on real post-intubation management...all of that is sorely lacking.  And without that, it becomes a skillset that will cause more problems than any potential benefit it could bring.

The other part is that paramedics ARE missing tubes or STILL, in this day and age, placing a tube in the esophageaus and not recognizing it.  With exceptions, when paramedic intubation gets looked at the success rate is dismal; I honestly don't remember the last study that mentioned what the first pass success rate was, but I'd bet it also would be horrifying.  (obviously there are exceptions to this, but for the average paramedic, pretty accurate)


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## Carlos Danger (Apr 18, 2015)

triemal04 said:


> It's not that "it's sometimes missed" that is pushing the drive to remove endotracheal intubation from the paramedic skillset (which, for the record I agree with, outside individual systems that can actually prove that it is appropriate for them to do), it's the fact that the average paramedic is incompetant from the get go when it comes to intubation.
> 
> The initial education on it, the physical hands on training, continued performance to maintain competancy, education on real post-intubation management...all of that is sorely lacking.  And without that, it becomes a skillset that will cause more problems than any potential benefit it could bring.
> 
> The other part is that paramedics ARE missing tubes or STILL, in this day and age, placing a tube in the esophageaus and not recognizing it.  With exceptions, when paramedic intubation gets looked at the success rate is dismal; I honestly don't remember the last study that mentioned what the first pass success rate was, but I'd bet it also would be horrifying.  (obviously there are exceptions to this, but for the average paramedic, pretty accurate)



Success rates with RSI are really generally not that bad (providing you take self-reported data about the attempts at face value); it's really the outcomes that are troublesome. And that's a result of the factors you mentioned in the second paragraph, as well as the unique difficulties inherent to prehospital ETI.


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## MackTheKnife (Apr 18, 2015)

chaz90 said:


> How does this support your point in the slightest?


Didn't say that it did.


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## gotbeerz001 (Apr 18, 2015)

MackTheKnife said:


> Didn't say that it did.


Interesting tactic.


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## RefriedEMT (Apr 19, 2015)

Either way I think supraglottic and blind insertion devices should still be used not only by medics but emts because they IMO are fairly basic.


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## hogwiley (Apr 19, 2015)

Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.

Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.

Catheter shear, air embolisms, infection, phlebitis, disease transmission and needle sticks, infiltration, tissue necrosis, forgetting to remove the tourniquet, hitting nerves, tendons or arteries. Its a pretty long list. Not to mention causing the patient unnecessary pain, leaving them with bruises and hematomas, and using up good veins in failed attempts and leaving Paramedics or the ER with nothing.

Then you have to worry about EMT Basics wasting time on scene trying to get an IV and getting tunnel vision. And finally what are they going to do with that IV? EMTs cant give IV meds, and giving fluids can open up the possibility of even more complications, and if given inappropriately can do more harm than good. Do you really want some 19 year old ricky rescues with 2 months of training doing that in an uncontrolled pre hospital environment? LPNs cant even start an IV in most settings and their education far surpasses EMTs.


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## EMT11KDL (Apr 19, 2015)

hogwiley said:


> Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.
> 
> Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.
> 
> ...



I have to disagree with your statement regarding IV. And if you want to say that no basic should be able to start IV because of there lack of education and experience, than it should be taken out of the Paramedic scope also! How many paramedics now are going through zero to hero programs. And also all the complications you state can happen to EMT, Paramedic, RN, PA, NP, DO, MD. So with your logic no one should do IV in 20 to 30 years because by than everyone who is good at starting lines will no longer be practicing medicine.  And all the new people coming up shouldn't be allowed to start lines because they have no experience. I have seen paramedics get tunneled vision trying to start a line. 

Medications comment, some states basics are allowed to push limited medications, and as a Paramedic it's nice to show up on a scene and have access all ready on that cardiac, altered, or trauma patient. It saves me time and it allows me to focus on other things. And if I have an Emt partner that can start a line for me, even better I can focus my attention to the patient and his or her care and not starting the line.


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## RefriedEMT (Apr 20, 2015)

EMT11KDL said:


> I have to disagree with your statement regarding IV. And if you want to say that no basic should be able to start IV because of there lack of education and experience, than it should be taken out of the Paramedic scope also! How many paramedics now are going through zero to hero programs. And also all the complications you state can happen to EMT, Paramedic, RN, PA, NP, DO, MD. So with your logic no one should do IV in 20 to 30 years because by than everyone who is good at starting lines will no longer be practicing medicine.  And all the new people coming up shouldn't be allowed to start lines because they have no experience. I have seen paramedics get tunneled vision trying to start a line.
> 
> Medications comment, some states basics are allowed to push limited medications, and as a Paramedic it's nice to show up on a scene and have access all ready on that cardiac, altered, or trauma patient. It saves me time and it allows me to focus on other things. And if I have an Emt partner that can start a line for me, even better I can focus my attention to the patient and his or her care and not starting the line.



Id have to agree cuz Washington state where i work has emt-IV tech still and is still hiring them so it is not being phased out like people thought, so it seems that my state think emts can do IV's just fine. I could also say that nurses that started IV's on me personally did not do too well causing pain by having to stick me up to 6 times on both arms, if this were to happen to me while i was starting an IV and I had a critical PT I more than likely would instead go by IM route and TX.


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## DesertMedic66 (Apr 20, 2015)

RefriedEMT said:


> Id have to agree cuz Washington state where i work has emt-IV tech still and is still hiring them so it is not being phased out like people thought, so it seems that my state think emts can do IV's just fine. I could also say that nurses that started IV's on me personally did not do too well causing pain by having to stick me up to 6 times on both arms, if this were to happen to me while i was starting an IV and I had a critical PT I more than likely would instead go by IM route and TX.


And what about the medications where IM is not an option?


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## RefriedEMT (Apr 20, 2015)

DesertEMT66 said:


> And what about the medications where IM is not an option?



The medic would have to take over, simple as that. What I cant do the medic usually can and the county i am going to start working for soon has a requirement that every PT has an ALS eval whether critical or not. Granted most of the units i will be on will have a medic on it all the time similar to clark county in Washington.


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## Tigger (Apr 21, 2015)

hogwiley said:


> Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.
> 
> Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.
> 
> ...


I'm mixed on this. Here in Colorado, if you're an EMT on an ambulance it's pretty much a guarantee that you also have your IV endorsement and will be starting most of the IVs provided they aren't being done enroute by your paramedic. I start a lot of IVs, usually more than my partner does on any given shift. I'm certainly far from an expert (ask my first patient today, sorry buddy), but I'm far from awful. In Colorado, you attend a 24 hour class and then have a clinical shift at a hospital to get an endorsement. It's certainly the bare minimum, but it does teach you to start them safely. And frankly, it is pretty useful on a medic/EMT ambulance.

But I agree with the ricky rescue comment. I often cringe at our corresponding volley FFs (or career for that matter) IV attempts. Just brutal.


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## MackTheKnife (Apr 21, 2015)

I'm surprised at the "EMTS should never start IVs" because it is so final. And the list of reasons why, catheter shear, etc. That can happen, albeit rare, when a medic does it. Doesn't really prove the point. And as to the admittedly retrospective intubation studies, in that it didn't help the outcome, that doesn't mean we shouldn't tube. When you tube a code, they're already dead. You're providing a direct airway and protecting it. Most codes don't survive, period. So I guess we shouldn't do CPR, push meds, and defib either according to that logic.


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## Carlos Danger (Apr 21, 2015)

MackTheKnife said:


> And as to the admittedly retrospective intubation studies, in that *it didn't help the outcome, that doesn't mean we shouldn't tube.*


Actually, that is _exactly_ what it means.

You do know why we do research in the first place, right?

The entire point of research is to identify what helps and what doesn't. Why bother researching anything if we are just going to ignore the findings?



MackTheKnife said:


> Most codes don't survive, period. So I guess we shouldn't do CPR, push meds, and defib either according to that logic.



This statement indicates a fundamental lack of basic resuscitative knowledge, and is exactly why you have no business intubating anyone, even codes.

Even laypersons whose entire clinical education is limited to an 8 hour CPR course know why CPR and defib are more important than an advanced airway.


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## MackTheKnife (Apr 21, 2015)

Remi said:


> Actually, that is _exactly_ what it means.
> 
> You do know why we do research in the first place, right?
> 
> ...


What utter BS.


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## Carlos Danger (Apr 21, 2015)

MackTheKnife said:


> What utter BS.



Then enlighten me as to how research really works and why we should keep doing things that don't help patients.


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## PotatoMedic (Apr 21, 2015)

Remi said:


> Then enlighten me as to how research really works and why we should keep doing things that don't help patients.


Tradition Remi, tradition!


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## cprted (Apr 21, 2015)

If you're so keen to start IVs, intubate, and do other ALS interventions, come take an ALS course.


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## MackTheKnife (Apr 21, 2015)

cprted said:


> If you're so keen to start IVs, intubate, and do other ALS interventions, come take an ALS course.


I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.


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## triemal04 (Apr 21, 2015)

Actually, researching the effectiveness of various interventions during CPR is one of the more difficult things to undertake.

Because, let's face it, unless you correct the results to specifically focus on people who should survive an arrest (those who meet Utstein Criteria for the most part) there are so goddamn many confounders, especially when talking about prehospitally that it becomes...not a crapshoot...but very hard to really say "yes, this ONE THING made a difference."  And then you have to worry about being able to take those results and impose them on what, given the current state of the US EMS system, are potentially very different circumstances/settings...well...just another difficulty.  

I mean ****...look at some of the further data from the PRIMED trial; in that setting, in certain circumstances and locations, intubation was actually associated with LOWER overall mortality, and better survival to discharge rates.  Of course, all the data for that group came specifically from one area...and sadly isn't going to be reproduceable nationally anytime soon.  

Hence the problem, and the failure when it comes to studies that look at CPR.

Or any specific problem really.

You want to know what really works, and what doesn't?  You don't set up a study/trial in an area that has average or mediocre results at best, you go to a place that already is doing very good at treating the specific illness you are looking at, and you make THEM change something.  Because they are already good at it, and any changes are more likely to be the result of whatever you are studying, and not just a continuation of the previous poor performance.


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## SeeNoMore (Apr 22, 2015)

MackTheKnife said:


> I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.


 
The number of skills you have performed does not change whether intubation is an appropriate intervention in cardiac arrest. Your statement regarding witholding CPR + defib is odd given these interventions have been clearly shown to improve outcomes.

As for EMTs starting IVs and intubating generally : I don't see an issue with IV's. I am curious what medications thse EMTs are trained / educated to administer. Where I used to live this pretty much included normal saline and ACLS drugs. For intubation I wonder how many patients are being intubated without the use of medications (for induction / post intubation sedation etc). If most of the patients intubated are in cardiac arrest it seems like a needless intervention that is most likely to add confusion to the code. That's what Paramedics are for.


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## Ensihoitaja (Apr 22, 2015)

SeeNoMore said:


> As for EMTs starting IVs and intubating generally : I don't see an issue with IV's. I am curious what medications thse EMTs are trained / educated to administer. Where I used to live this pretty much included normal saline and ACLS drugs.



The Colorado IV-cert allows EMTs to push D-50 and Narcan. There's also an optional albuterol module, but I don't know how many places actually do that. Here's a link to the curriculum: https://www.colorado.gov/pacific/si...rapy-and-Medication-Administration-Course.pdf


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## jwk (Apr 22, 2015)

MackTheKnife said:


> I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.


I'm curious - what exactly do you do?  Are these skills you learned as a corpsman or what?  It doesn't sound like you're truly a "basic EMT".


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## MackTheKnife (Apr 23, 2015)

jwk said:


> I'm curious - what exactly do you do?  Are these skills you learned as a corpsman or what?  It doesn't sound like you're truly a "basic EMT".


No problem. My CV is mixed. I was a PM (NREMTP, and VA), and a Hospital Corpsman. Prior to PM I was an EMT-Cardiac (VA designation) then got my PM.  Went back in the Navy and worked weapons and antiterrorism/force protection where I got involved in live-tissue TCCC and continued with that as a PMC.  Obviously my PM lapsed in the military, that's why my current level is NREMT. My former avatar title said"former EMT-P"


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## jwk (Apr 23, 2015)

MackTheKnife said:


> No problem. My CV is mixed. I was a PM (NREMTP, and VA), and a Hospital Corpsman. Prior to PM I was an EMT-Cardiac (VA designation) then got my PM.  Went back in the Navy and worked weapons and antiterrorism/force protection where I got involved in live-tissue TCCC and continued with that as a PMC.  Obviously my PM lapsed in the military, that's why my current level is NREMT. My former avatar title said"former EMT-P"


So here's the problem - in the real world, you have to deal with state laws and scope of practice.  You MAY have done all these wonderful procedures, but you can't do them now.  Do you really think a basic EMT with a 120 hr course - that's just three weeks of full time work - can go from zero to IV's, intubations, etc. and be competent to do all of them in 120 hrs?  C'mon.  From a quick Google search, corpsman training is 18 weeks.  Somehow I'm sure that adds up to way more than 120 hours.  Just because you understand and have done a lot of these procedures as a corpsman and/or a paramedic, surely you should be able to understand the difference between those and a basic EMT.  The difference in knowledge base is pretty large.

I started out in EMS in it's early days - mid 70's - with a hospital-based service that was out to make a name for themselves with their emergency services.  Back then, EMT class was 81 hours - medics were 200.  The laws were a little fuzzy, and while medic scope of practice was laid out, there wasn't a hard restriction of what an EMT or medic could NOT do.  This place was trying to teach medics to do IJ's and subclavians, and was playing around with placing trans-thoracic pacing wires.  So, as a basic EMT, I did tons of IV's in the hospital and in the field (I have no problem with EMT's doing IV's, or at least being able to try once or twice), defibrillated, and even did a couple of intubations and intracardiac injections (very in-vogue back then) and thought I was totally hot sh*t.  Now, as a practicing anesthetist for more than 35 years, I look back and think "how friggin stupid was that!".  I had no clue of the possible complications from the procedures I was trying - I was simply mimicking what I saw and thought I could do it too.  See one, do one, teach one, only without the educational background to back it up. Stupid, stupid, stupid.


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## MackTheKnife (Apr 23, 2015)

JWK, appreciate your comment.  My thoughts go only to intubation. Yes, I am probably one of a very few who think we can teach EMTs to intubate. I am not advocating the other skills you mentioned. I do remember intracardiac injections as well as the others. Maybe I'm just one of the few who mastered intubation easily and as an ENTJ personality type, think others could do the same. I don't think it is that hard. You have the experience of prehospital and now, clinical as an anesthetist, to see both worlds. As for complications from intubation, what do you see as the biggest one? Is it esophageal intubation? Or something else?


jwk said:


> So here's the problem - in the real world, you have to deal with state laws and scope of practice.  You MAY have done all these wonderful procedures, but you can't do them now.  Do you really think a basic EMT with a 120 hr course - that's just three weeks of full time work - can go from zero to IV's, intubations, etc. and be competent to do all of them in 120 hrs?  C'mon.  From a quick Google search, corpsman training is 18 weeks.  Somehow I'm sure that adds up to way more than 120 hours.  Just because you understand and have done a lot of these procedures as a corpsman and/or a paramedic, surely you should be able to understand the difference between those and a basic EMT.  The difference in knowledge base is pretty large.
> 
> I started out in EMS in it's early days - mid 70's - with a hospital-based service that was out to make a name for themselves with their emergency services.  Back then, EMT class was 81 hours - medics were 200.  The laws were a little fuzzy, and while medic scope of practice was laid out, there wasn't a hard restriction of what an EMT or medic could NOT do.  This place was trying to teach medics to do IJ's and subclavians, and was playing around with placing trans-thoracic pacing wires.  So, as a basic EMT, I did tons of IV's in the hospital and in the field (I have no problem with EMT's doing IV's, or at least being able to try once or twice), defibrillated, and even did a couple of intubations and intracardiac injections (very in-vogue back then) and thought I was totally hot sh*t.  Now, as a practicing anesthetist for more than 35 years, I look back and think "how friggin stupid was that!".  I had no clue of the possible complications from the procedures I was trying - I was simply mimicking what I saw and thought I could do it too.  See one, do one, teach one, only without the educational background to back it up. Stupid, stupid, stupid.


----------



## Carlos Danger (Apr 23, 2015)

MackTheKnife said:


> JWK, appreciate your comment.  My thoughts go only to intubation. Yes, I am probably one of a very few who think we can teach EMTs to intubate.



Your argument for EMT intubation has still not addressed all the problems with outcomes related to prehospital intubation. You know, the _actual effects _that the intervention has on patients.

Do you think patients intubated by EMT's will have better outcomes than patients intubated by paramedics? Or are you just not concerned with outcomes? 

I once heard a funny and interesting quip......."Most American males think they are better than they actually are at two things: driving and making love." Well, IME, and it is pretty clearly reflected in the research, lots of folks in EMS think they are better than they really are at airway management.


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## MackTheKnife (Apr 23, 2015)

Remi, if the tube is properly situated, it doesn't matter who placed it, now does it?


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## triemal04 (Apr 23, 2015)

MackTheKnife said:


> Remi, if the tube is properly situated, it doesn't matter who placed it, now does it?


It's comments like this that make it very clear that you don't understand what you are talking about.


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## MackTheKnife (Apr 23, 2015)

triemal04 said:


> It's comments like this that make it very clear that you don't understand what you are talking about.


Trivial, i mean triemal04, what is clear is that you have no idea what you are talking about. A properly situated tube is a properly situated tube no matter who placed it. Insert laryngoscope, visualize the cords, insert tube with cuff just past the cords, inflate cuff, and secure tube. See? I do know what I'm talking about.


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## DesertMedic66 (Apr 23, 2015)

MackTheKnife said:


> Trivial, i mean triemal04, what is clear is that you have no idea what you are talking about. A properly situated tube is a properly situated tube no matter who placed it. Insert laryngoscope, visualize the cords, insert tube with cuff just past the cords, inflate cuff, and secure tube. See? I do know what I'm talking about.


Tubes never become dislodged right?
You've never heard someone say "but I saw the cords" when answering why the tube was misplaced?

Once a central line is in place it doesn't really matter who did it right?


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## triemal04 (Apr 23, 2015)

MackTheKnife said:


> Trivial, i mean triemal04, what is clear is that you have no idea what you are talking about. A properly situated tube is a properly situated tube no matter who placed it. Insert laryngoscope, visualize the cords, insert tube with cuff just past the cords, inflate cuff, and secure tube. See? I do know what I'm talking about.


Because all that matters is that the tube is in the trachea.  That's it.  Nothing that came before, during, or after the attempt matters.  Just that a tube is in the trachea.

I feel stupider just for saying that.

But, since you are a highspeed/low drag stud corpsman who has been there and done it all (probably twice) I'll go ahead and bow deferentially to your knowledge and superior wisdom.  You win masterful one, you win!

edit:  this is probably where Mack will mention how long he's been doing this (again) and how he really has done all these cool things (again) and how that obviously makes him an expert and correct in all his statements, what with how superior he is to the rest of the world.  Pardon the vomit on my keyboard...


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## MackTheKnife (Apr 23, 2015)

DesertEMT66 said:


> Tubes never become dislodged right?
> You've never heard someone say "but I saw the cords" when answering why the tube was misplaced?
> 
> Once a central line is in place it doesn't really matter who did it right?


Jeez, why don't we what if this to death? I never said things don't go wrong, no matter what the procedure. You guys who keep on attacking what I said can't be honest and address what I stated: That the skill is not that complicated. I didn't address the what ifs or other issues.


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## DesertMedic66 (Apr 23, 2015)

MackTheKnife said:


> Jeez, why don't we what if this to death? I never said things don't go wrong, no matter what the procedure. You guys who keep on attacking what I said can't be honest and address what I stated: That the skill is not that complicated. I didn't address the what ifs or other issues.


No, the skill it self isn't very complicated. However everything else about the skill gets very complicated Which is what the majority of us are stating.


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## MackTheKnife (Apr 23, 2015)

triemal04 said:


> Because all that matters is that the tube is in the trachea.  That's it.  Nothing that came before, during, or after the attempt matters.  Just that a tube is in the trachea.
> 
> I feel stupider just for saying that.
> 
> ...


You are such a font of wisdom. Of course the other things matter. Like adequately ventilating a pt before attempting an intubation. Having suction ready, etc. In TCCC, the primary airway is an NPA, not an ETT. And thanks for making fun of my experience. I only described my CV when asked. I wish I was a stud but obviously my penis is small compared to yours.


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## epipusher (Apr 23, 2015)

Mack your posts make you seem a little pathetic. True or not it seems as though you are an EMT who so badly wants to be a medic but for some reason have yet to have that P on your card. But as we all know we can be whoever we want to be on the internet.


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## MackTheKnife (Apr 24, 2015)

epipusher said:


> Mack your posts make you seem a little pathetic. True or not it seems as though you are an EMT who so badly wants to be a medic but for some reason have yet to have that P on your card. But as we all know we can be whoever we want to be on the internet.


Dude, go back to school and learn English, or better yet, reading comprehension. I was a "P". National Registry and Virginia. VA # was 17132-L632-1038-P121. Notice the P?  National # MP806346.


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## MackTheKnife (Apr 24, 2015)

epipusher said:


> Mack your posts make you seem a little pathetic. True or not it seems as though you are an EMT who so badly wants to be a medic but for some reason have yet to have that P on your card. But as we all know we can be whoever we want to be on the internet.


Since you have a hard time reading my post, or believing them:


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## Flying (Apr 24, 2015)

Mack the ease of the skill is not the issue we are trying to bring up.

Let's ignore that we have data (courtesy of DEMedic and Google scholar) that very strongly suggests that only a minority of paramedics that perform the skill regularly and often can demonstrate proficiency (a 9/10 success rate as opposed to 3/4). I think you are in this minority given your experience. But we have other problems even after ignoring the fact that the majority of civilian EMTs don't work in high volume systems with low skill dilution.

I hope we can agree that ET intubation is an invasive procedure that has complications ranging from minor to life-threatening.

How is that ever going to translate to the EMT, the level of "training" that does not even cover A&P and the basic sciences?
Are we going to trust people who aren't even obligated to know Boyle's law or the basics of metabolism to understand the consequences of what they are doing?

Maybe, just maybe, EMTs don't have to understand what they do. Maybe we can work out a Protocol that allows them to provide life-saving intervention when people really need it.
But then they just become dogs. That's how we encourage BS like backboarding, the Golden Hour, being safe by "overtreating" with oxygen.


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## MackTheKnife (Apr 24, 2015)

Flying said:


> Mack the ease of the skill is not the issue we are trying to bring up.
> 
> Let's ignore that we have data (courtesy of DEMedic and Google scholar) that very strongly suggests that only a minority of paramedics that perform the skill regularly and often can demonstrate proficiency (a 9/10 success rate as opposed to 3/4). I think you are in this minority given your experience. But we have other problems even after ignoring the fact that the majority of civilian EMTs probably don't work in high volume systems with low skill dilution.
> 
> ...


Appreciate your post and the tone of it.  Thanx for acknowledging that I do have experience and am not blowing smoke up people's arses.  Some here like to go on the attack because of my admittedly controversial post.  Some just like to attack, period. Once again, thanx for the kind words.


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## epipusher (Apr 24, 2015)

Instead of pushing hard for basics to be allowed to intubate, why dont you go after becoming a medic again?


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## MackTheKnife (Apr 25, 2015)

Epi,
Good question. That's exactly what I'm going to do. I'm researching bridge programs now for after I graduate nursing school next year.


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## Tigger (May 1, 2015)

Paramagicz said:


> hey Mack, just wanted to say that don't get too hung up on the attacks..... I've seen worst, for some reason military EMS personnel don't mix well with civilian EMS providers. I have a feeling they think that we are a bunch of gun toting idiots who treat human beings (patients) like a sack of meat or something...



Telling someone to justify their opinion with facts is not attacking them. Let's not insinuate that it has anything to do with anyone's backgrounds.


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## Paramagicz (May 2, 2015)

guys, I don't see a long term logical reason why we all argue over this... I can see both side of your guys opinions..  The paramedics on here thinks that EMT doesn't possess the in-depth knowledge to intubate and can do more harm to the PT than good...

and on Mack's side, I can understand that he see the whole EMT vs Paramedic intubation thing is a blur because in the military, a combat medic can have a really wide range of scope of practice, including people that are working for DOD or in the PMC... and on top of that, in other Countries...Their Arm forces medics can sometimes even goes further with their practice... it really all comes down to if the individual has the ability to pick up the skills.

Personally, I don't see anything wrong with EMT gaining the ability to intubate, going through EMT school.. they always taught us that "airway is king" & "airway comes first!"  etc.

so how is it wrong for future EMTs to learn that extra skill that could help them secure the PT's airway in a better and a more efficient way?  
rather than sticking a combi-tube in and say "Cool, now let's hope ALS get here before this thing fail..." (which from what i heard happens often due incompatible sizing for each individual patient)


Also, I do feel like they are attacks on the poor dude.... because the comments on here attacks the guy's credentials and his opinions rather than seeing that he is just trying to point out the work-load can be divided (which is already happening based on some of the other guy's input coming from other states and counties... like what EMT11KDL said about "giving the paramedic more wiggle room to perform other important procedures"


I mean I can see some folks might be worried that EMT-B might eventually take over prehospital care and push the job market for paramedics over the cliff or something because they are allowed to do everything a paramedic can (eventually) but get pay less (so ambulance companies would definitely pick them up) I can see that happening since it's happening with ICU nurses that tags along with ambulances, they are being pushed out of that line of work because of paramedics. (just for icing on top, I know some medics don't see it this way but more of the "quality" of care for the patient might diminish if we give such vital role to an EMT-B) 

anyways, this ol medic sergeant from my unit used to say "JUST GET that Somah-a-B*tch back on his damn feet so he can go home and see his 300 pounds wife again" lol
all jokes aside, I feel that rings true in a way.


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## Carlos Danger (May 2, 2015)

Paramagicz said:


> Personally, I don't see anything wrong with EMT gaining the ability to intubate, going through EMT school.. they always taught us that "airway is king" & "airway comes first!"  etc.
> 
> so how is it wrong for future EMTs to learn that extra skill that could help them secure the PT's airway in a better and a more efficient way?
> rather than sticking a combi-tube in and say "Cool, now let's hope ALS get here before this thing fail..." (which from what i heard happens often due incompatible sizing for each individual patient)



There are good reasons why the idea of civilian EMT's intubating is ridiculous, and they have been well documented in this thread already. 

The first and most obvious one is initial training: How do you propose EMT's even learn to intubate in the first place? Paramedic programs are many times as long as EMT programs, and even at that, I think most of us would agree that paramedic students don't get enough training in airway management, and it is a fact that they very often struggle to get even the tiny number of live tubes needed to graduate.  

If you can come up with a good way around that, then we can move on to one of the several other important reasons why this would never work.


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## MackTheKnife (May 2, 2015)

I thought this thread was dead, but apparently not.  I find Remi's comment absurd. Some of the comments here show total close-mindedness. I.e., "it'll never work". Pretty final. As Paramagicz said, in the military, who are not paramedics, perform advanced skills. So there goes the " it'll never work" argument. And as for studies, mentioned previously, some are good and some are bad. Just cause there's a study, doesn't mean it's correct.


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## luke_31 (May 2, 2015)

MackTheKnife said:


> I thought this thread was dead, but apparently not.  I find Remi's comment absurd. Some of the comments here show total close-mindedness. I.e., "it'll never work". Pretty final. As Paramagicz said, in the military, who are not paramedics, perform advanced skills. So there goes the " it'll never work" argument. And as for studies, mentioned previously, some are good and some are bad. Just cause there's a study, doesn't mean it's correct.


Part of why it's not as big a deal for the military is that there is a lot more liability in the civilian world for allowing advanced procedures to be done regardless of skill level. In the military there isn't the same level of liability which is why 68w can do a lot more when working with soldiers.


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## Carlos Danger (May 2, 2015)

MackTheKnife said:


> I thought this thread was dead, but apparently not.  I find Remi's comment absurd. Some of the comments here show total close-mindedness. I.e., "it'll never work". Pretty final. As Paramagicz said, in the military, who are not paramedics, perform advanced skills. So there goes the " it'll never work" argument.



Over the course of this 7 page thread, you have been presented with several solid reasons why EMT's intubating is a ridiculous idea.

You have not yet responded to a _single one_.

Present a cogent response ("but, but....back in the AO we did it" does not qualify as cogent), or admit that you do not have one.

Start by addressing the problem of initial training that I outlined in my last post.




MackTheKnife said:


> And as for studies, mentioned previously, some are good and some are bad. Just cause there's a study, doesn't mean it's correct.



Research is how science is done. It is how we know what does and doesn't work in medicine. You don't know _anything _about how an intervention works if you haven't examined it's effects systematically and objectively, and then had other experts look at your work and agree with your methods, findings, and conclusions.

This isn't just "a" study on prehospital intubation. There aren't just 5 studies. Or 10. Or 25. There are probably closer to 50 studies published in peer-reviewed medical journals in just the past 10 years or so. And not a single one that I can think of supports the idea of EMT intubation. Many even question the need for and effectiveness of intubation by paramedics. And in the face of that, you are really going to say "hey y'all, I think we should take people with even LESS training and have them give it a whirl".

You aren't allowed to just ignore published, peer-reviewed research. You can disagree with it if you want, but the onus is on YOU to justify your disagreement, not the other way around.


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## Gurby (May 2, 2015)

Remi said:


> This isn't just "a" study on prehospital intubation. There aren't just 5 studies. Or 10. Or 25. There are probably closer to 50 studies published in peer-reviewed medical journals in just the past 10 years or so. And not a single one that I an think of supports the idea of EMT intubation. Many even question the need for and effectiveness of intubation by paramedics. And in the face of that, you are really going to say "hey y'all, I think we should take people with even LESS training and have them give it a whirl".



This was the first thought that occurred to me, and I'm surprised nobody has mentioned it yet.  I didn't bring it up because I was too lazy to go read the studies myself... But isn't there basically no evidence that says prehospital intubation is a good thing for even medics to be doing?  In cardiac arrest (which is the only scenario I could see EMT-B's being allowed to intubate), patients statistically do better with BLS-only care.  It's suspected that this is because paramedics might waste time worrying about IV's, drugs and airway when what the patient really needs is compressions and electricity, or they interrupt compressions to place a tube, spend too much time on scene, etc.

I don't want to turn this into a debate about whether or not paramedics should be intubating... But the fact that even that's already kind of a gray area makes the idea of adding intubation to EMT-B scope seem pretty silly to me.


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## Carlos Danger (May 2, 2015)

Gurby said:


> This was the first thought that occurred to me, and I'm surprised nobody has mentioned it yet.  I didn't bring it up because I was too lazy to go read the studies myself... *But isn't there basically no evidence that says prehospital intubation is a good thing for even medics to be doing?*  In cardiac arrest (which is the only scenario I could see EMT-B's being allowed to intubate), patients statistically do better with BLS-only care.  It's suspected that this is because paramedics might waste time worrying about IV's, drugs and airway when what the patient really needs is compressions and electricity, or they interrupt compressions to place a tube, spend too much time on scene, etc.



I wouldn't say there is _no _evidence in favor of it, but there is definitely much more unsupportive than supportive, and the supportive ones tend to show minimal benefit.

I definitely would not argue that paramedics should never be intubating, but I do think paramedic airway training and general approach to airway management should probably look quite different than it does now, and I think there is plenty of evidence to support that position.



Gurby said:


> I don't want to turn this into a debate about whether or not paramedics should be intubating... *But the fact that even that's already kind of a gray area makes the idea of adding intubation to EMT-B scope seem pretty silly to me.*



Yep, that's exactly the point, and the main reason (though certainly not the only one) why this whole idea is a non-starter.


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## NomadicMedic (May 2, 2015)

There are a myriad of reasons why EMT basic's should not be allowed to intubate. Here's an important one to consider; when an airway goes bad, it goes very bad. It leaves even experienced paramedics (and other providers) with no option other than a surgical airway, and that's certainly not a skill an EMT basic should have.

Letting a basic intubate is on par with giving a 6 year old rudimentary instruction on driving, neglecting any instruction on how to use the brakes, then throwing them the keys and saying "go for it!"

hey, even experienced drivers crash all the time, but they have _some_ skills to try and mitigate the damage.


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## Chimpie (May 2, 2015)

*This thread has been cleaned up. Some posts have been removed, either because they were off topic or violated one of our rules.

Keep it clean and on topic.*


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## kamran (May 5, 2015)

Hi
in our country,Iran,all EMTs eligible to take IV line,Intubation,and give drugs to the patients


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## LACoGurneyjockey (May 5, 2015)

kamran said:


> Hi
> in our country,Iran,all EMTs eligible to take IV line,Intubation,and give drugs to the patients


How long is the education/training there for someone to be able to start an IV, push meds (oh, and what meds), and intubate?


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## kamran (May 5, 2015)

associate degree is 2 years and bachlore is 4 years.
we can use all of emergency box drugs such as:epinephrin,atropin,naloxan.TNG,hydrochortison,aminophylin,phenytoin,lidocain,chlorpheniramin,dexamethason,asprin,...


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## DesertMedic66 (May 5, 2015)

kamran said:


> associate degree is 2 years and bachlore is 4 years.
> we can use all of emergency box drugs such as:epinephrin,atropin,naloxan.TNG,hydrochortison,aminophylin,phenytoin,lidocain,chlorpheniramin,dexamethason,asprin,...


The normal length of an EMT program in the USA is about 120 hours total...


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## OnceAnEMT (May 5, 2015)

DesertEMT66 said:


> The normal length of an EMT program in the USA is about 120 hours total...



I think there is a little lapse in communication here. Our EMT-Basic program is 120 hours, yes, but there is no way that the EMT-Basic equivalent in Iran is still "Basic" after 2, let alone 4 years, and performing ACLS. @kamran what are the different levels of EMT there, if any?


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## kamran (May 5, 2015)

Here is 3 level of EMT; EMT-B      EMT-I       EMT-p
it depends on your medical knwoledge


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## OnceAnEMT (May 5, 2015)

kamran said:


> Here is 3 level of EMT; EMT-B      EMT-I       EMT-p
> it depends on your medical knwoledge



So just to clarify, are you saying that EMT-B, the lowest level, can execute ACLS protocols?

If yes, my follow up is what on earth is the difference between the 3 levels of EMT in Iran?


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## LACoGurneyjockey (May 5, 2015)

Grimes said:


> So just to clarify, are you saying that EMT-B, the lowest level, can execute ACLS protocols?
> 
> If yes, my follow up is what on earth is the difference between the 3 levels of EMT in Iran?



And to add to that, is the lowest level of EMT still required to go thru 2 years of schooling?
I got my EMT in a 4 week, 5 day a week accelerated program. I wouldn't trust me to have any more than what my meager scope entails with that amount of training.


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## kamran (May 6, 2015)

if a person want to work in EMS‌‌‌‌‌‌,at least should have 2 years academic course at Emergency medicine or anesthology, or 4 years in Emergency medicine, anesthology, nursing. 
at one shift the highest level EMt is responsible and do the invasive procedure, but sometimes 2 basic are in a shift and they give all type of care to the patients.


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## LACoGurneyjockey (May 6, 2015)

What can an EMT-I do that a B cannot, and what can a P do that an I cannot? 
So 2 years is the minimum requirement to work on an ambulance? 
I wish 'murrica would catch onto this eventually


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## kamran (May 6, 2015)

actually, the rules are different between EMt B  and EMt I and EMt p, but they train Acls in 2 years degree because of stuff shortage. 
yes minimum level for working in ambulance is 2years


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## Flying (May 6, 2015)

Are you finding that more foreigners are being hired because of the shortage? What is the average education level of those coming from outside the country?

Has this system been put in place throughout the entire country, or just the large cities?

Are many motorbikes used in your system?

(Admins, it may be best to move these posts to a new thread in international EMS.)


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## kamran (May 6, 2015)

in fact, we haven't foreigner in our EMS system since payment is according our currency, rial, and is very low for foreigners.therefor,Im improving my English language for immigration to Canada or Australia.


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## TimRaven (May 8, 2015)

Here in the Bay Area, CA, we EMT can't "de facto" perform any of mentioned procedures:

While King airway is on the approval list as optional, very few companies/service actually carry them.
Pulse Ox, finger sticks are still not approved in several counties, never mind IV.

One representative from my county EMS office clearly states that he doesn't trust EMT or AEMT (if there is any) even with just oral Aspirin on a suspect MI patient.


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## EMT533 (Feb 17, 2016)

I am in Ultrasound school right now and it is not enough for me. I go into the MA lab and practice drawing drawing blood on my best friend. I know IV is much more difficult considering all the variables. My question is are the mechanics the same? If I can draw blood do I have a basic understanding of an IV?


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## Tigger (Feb 17, 2016)

EMT533 said:


> I am in Ultrasound school right now and it is not enough for me. I go into the MA lab and practice drawing drawing blood on my best friend. I know IV is much more difficult considering all the variables. My question is are the mechanics the same? If I can draw blood do I have a basic understanding of an IV?


Sort of. Place needle in vein like usual (might be holding the catheter differently compared to a butterfly). Hold needle still, thread catheter off. Tamponade vein, remove catheter, place tubing on hub.


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## Akulahawk (Feb 17, 2016)

EMT533 said:


> I am in Ultrasound school right now and it is not enough for me. I go into the MA lab and practice drawing drawing blood on my best friend. I know IV is much more difficult considering all the variables. My question is are the mechanics the same? If I can draw blood do I have a basic understanding of an IV?





Tigger said:


> Sort of. Place needle in vein like usual (might be holding the catheter differently compared to a butterfly). Hold needle still, thread catheter off. Tamponade vein, remove catheter, place tubing on hub.



Actually the technique is slightly different from using a butterfly for lab draws. Getting the needle into the vein isn't really the hard part. It's threading the catheter into the vein. Sure, sometimes the vein is wide and shallow which makes it very easy to go through the "back wall" but I find that more often the trouble is threading the catheter when the patient's skin is very tough. Tough skin can really "grab" the catheter and cause all sorts of havoc with placement, even if you anchor the skin and vein well. One minor caveat to this is some of this difficulty depends upon the type of catheter you're using. I never had this problem when I used the "ProtectIV" catheters because you advanced the hub using the same hand you hold the needle assembly with. This allowed my "free" hand to maintain consistent tension and not have to worry too much about the aforementioned skin toughness-catheter grab problem.


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## EMT533 (Feb 17, 2016)

Ok thank you! I noticed that there are many different types of IV catheters. Is there a 'universal' type of IV the EMT and Paramedics are required to use?


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## chaz90 (Feb 17, 2016)

No. I don't even have the same brand of IV cath in my bag every day. Different hospitals restock different brands, and I've used various other types at different services and hospitals.


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## STXmedic (Feb 17, 2016)

EMT533 said:


> Ok thank you! I noticed that there are many different types of IV catheters. Is there a 'universal' type of IV the EMT and Paramedics are required to use?


Do you mean a universal brand/style? No. Whatever your department decides is the one you'll use.


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## EMT533 (Feb 17, 2016)

You answered my question. It's just based on what he department used. Thank you!


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## EMT533 (Feb 17, 2016)

You answered my question. It's just based on what the department uses. Thank you! Sorry about the misspelled words. I'm typing very fast.


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## Giant81 (Feb 17, 2016)

Not in WI

As a basic I can administer a few medications, none of which are IV since IV is not a basic skill.

As for airways, I cannot intubate, but I can use a superglottic airway (combi/king/igel), OPA, NPA, but no intubation 

To start IV's you need to be an EMT-A or Paramedic level.  intubation is not allowed until paramedic level.


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## EMT533 (Feb 17, 2016)

Same in TX.


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## TransportJockey (Feb 17, 2016)

EMT533 said:


> Same in TX.


Not true. If your medical director says a basic can start IVs and tube, then they can. And a lot of places allow intermediates to tube.


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## EMT533 (Feb 17, 2016)

I know intermediatesame can but I was unaware basics were even trained.


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## EMT533 (Feb 17, 2016)

Intermediates *


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## STXmedic (Feb 17, 2016)

EMT533 said:


> I know intermediatesame can but I was unaware basics were even trained.


They aren't trained in school. It's very agency-specific. Like TJ said, it's up to the medical director. Texas doesn't have a state scope.


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## EMT533 (Feb 17, 2016)

Huh. That's good to know. Thank you very much!


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## COmedic17 (Feb 17, 2016)

EMT's in Colorado can start IV's. They have to take a mandatory IV certification course.


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## chaz90 (Feb 17, 2016)

Are there any agencies in Texas that still allow EMTs to intubate? I understand they can, but I can't imagine it's common with the proliferation of ALS services and supraglottic airways.


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## chaz90 (Feb 17, 2016)

COmedic17 said:


> EMT's in Colorado can start IV's. They have to take a mandatory IV certification course.


I was always a big proponent for this skill set, but only for paid EMTs who see a fairly decent call volume and are assisting their paramedic partner. I loved working with a medic and being able to do this for them on scene or on a BLS transport for a basic saline lock and labs, but I hated going to rural areas and having the vollie EMT blow 5+ IV attempts because they only run a couple calls a year.


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## Carlos Danger (Feb 17, 2016)

chaz90 said:


> Are there any agencies in Texas that still allow EMTs to intubate? I understand they can, but I can't imagine it's common with the proliferation of ALS services and supraglottic airways.



I love supraglottic airways.

Just sayin'......


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## EMT533 (Feb 17, 2016)

Honestly I don't know. I will need to research that and get back to you.


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## STXmedic (Feb 17, 2016)

chaz90 said:


> Are there any agencies in Texas that still allow EMTs to intubate? I understand they can, but I can't imagine it's common with the proliferation of ALS services and supraglottic airways.


I'm sure there are a couple, but it's by no means common. Presidio EMS comes to mind, but they're hardly a common EMS system for any level. King tubes are pretty prevalent at the EMT level, though.


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## EMT533 (Feb 17, 2016)

I took a screen shot off of the NREMT.organization website. It is a download able document so I can't give a link. He is what it says about advanced EMT.


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## STXmedic (Feb 17, 2016)

Did you have a question about AEMT? Just curious as to the reason for posting those.


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## EMT533 (Feb 17, 2016)

I looked for other sources that would be reliable, but I wouldn't trust them. Maybe there are places in Texas that allow intubation by EMT, but I don't want to give false information.


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## chaz90 (Feb 17, 2016)

The source you posted has nothing to do with Texas scope of practice. NREMT minimum scope of practice has no bearing on what individual medical directors may train and license their providers to perform.


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## STXmedic (Feb 17, 2016)

EMT533 said:


> I looked for other sources that would be reliable, but I wouldn't trust them. Maybe there are places in Texas that allow intubation by EMT, but I don't want to give false information.


Texas isn't bound by NREMT, so their standards don't mean much. Texas uses NREMT as a benchmark to reach for initial certification, but that's it.


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## EMT533 (Feb 17, 2016)

Oh wow. That is interesting that is different state to state. I was unaware of that. I was under the impression that the NREMT was IT and that is what needed to be followed to a 'T'. Thank you for answering the question. I was going a little crazy trying to find the answer from a reliable source.


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## STXmedic (Feb 17, 2016)

Nope, all NREMT is is a certifying body. Most states will use their test as the initial certification test, but there are a few states that don't use NREMT at all, in any form or fashion. Even in the states that do use them, you don't always have to maintain NREMT, only your state cert. My NREMT-P lapsed years ago. But my Texas cert is active, which is all I need.


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## EMT533 (Feb 17, 2016)

Oh ok. That's great information. Thank you!


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## TransportJockey (Feb 18, 2016)

chaz90 said:


> Are there any agencies in Texas that still allow EMTs to intubate? I understand they can, but I can't imagine it's common with the proliferation of ALS services and supraglottic airways.


We had two basics in Pecos that could. .. but again,  not a typical agency


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## jwk (Feb 18, 2016)

EMT533 said:


> Oh ok. That's great information. Thank you!


That holds true with pretty much anything.  There is no federal law that relates to scope of practice for physicians, nurses, PA's, paramedics, EMT's, RT's, cosmetologists or interior designers (yes, some states license designers).  Licenses to practice and scope of practice are all functions of the state, not federal government.


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## Giant81 (Feb 18, 2016)

This may be a bit off topic so forgive me, but obviously an EMT/paramedic/RN/etc... .all have to work under the direction of a medical dirctor.  They are also only allowed to work in an area that they are properly credentialed to do so.

When you make it to the MD level, how do those rules change?  Do MD's work under a medical director? is their credentialing limited to the hospital/city/county/state they live in? Are they afforded leeway to treat patients medically anywhere in the US as long as they maintain a valid medical license?  Like if I'm credentialed in WI, and vacationing in FL, and we come up on a bad crash, can I only help at the first aid level, or do I have the ability to use anything at my disposal to help if need be.  And if you're an MD and you do stop to help, does passing care off to a paramedic constitute abandonment since they are not at the same or higher level?  Or, as an MD are you allowed to make the determination that this persons care can adequately be handled by a paramedic transferring to an ED?

Sorry too many questions, but I'm not a doctor nor did I stay at a Holiday Inn last night so I wasn't sure.  My dream job would be to leave my 9-5 desk job, become a paramedic, then work on going to pre-med and medical school to eventually get my MD.  But, at 34, 4 kids, and a wife, my life just can't revolve around school enough to be able to do that.  Neither can I take a pay cut from my tech job, to go become a paramedic yet.  someday...maybe


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## luke_31 (Feb 18, 2016)

Giant81 said:


> This may be a bit off topic so forgive me, but obviously an EMT/paramedic/RN/etc... .all have to work under the direction of a medical dirctor.  They are also only allowed to work in an area that they are properly credentialed to do so.
> 
> When you make it to the MD level, how do those rules change?  Do MD's work under a medical director? is their credentialing limited to the hospital/city/county/state they live in? Are they afforded leeway to treat patients medically anywhere in the US as long as they maintain a valid medical license?  Like if I'm credentialed in WI, and vacationing in FL, and we come up on a bad crash, can I only help at the first aid level, or do I have the ability to use anything at my disposal to help if need be.  And if you're an MD and you do stop to help, does passing care off to a paramedic constitute abandonment since they are not at the same or higher level?  Or, as an MD are you allowed to make the determination that this persons care can adequately be handled by a paramedic transferring to an ED?
> 
> Sorry too many questions, but I'm not a doctor nor did I stay at a Holiday Inn last night so I wasn't sure.  My dream job would be to leave my 9-5 desk job, become a paramedic, then work on going to pre-med and medical school to eventually get my MD.  But, at 34, 4 kids, and a wife, my life just can't revolve around school enough to be able to do that.  Neither can I take a pay cut from my tech job, to go become a paramedic yet.  someday...maybe


My understanding is that MDs need to have a state license for any state that they intend to practice in.


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## twistedMP (Feb 18, 2016)

luke_31 said:


> My understanding is that MDs need to have a state license for any state that they intend to practice in.


Yeah MD'S need to be licensed in each state. The exception being medical strike team's and and at the federal level like VA or BOP


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