# EMT-B starting IVs



## combiguy (Jun 17, 2013)

I know some places have EMTs that can start IVs. Why is this not done everywhere?


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## Mariemt (Jun 17, 2013)

National standards do not have EMT B s starting IVs,  I believe they must have further training to do so.


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## combiguy (Jun 17, 2013)

Yea I know... Im looking for why people think it has not been made a national standard. I know some places in Ohio have emts start IVs


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## STXmedic (Jun 17, 2013)

A really brief search turned up this for your perusal.

http://www.emtlife.com/archive/index.php/t-29763.html


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## DesertMedic66 (Jun 17, 2013)

Because its not needed everywhere


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## combiguy (Jun 17, 2013)

Guess I worded my search wrong. Could only find where EMTS could start IVs.


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## xrsm002 (Jun 17, 2013)

Texas EMS are delegated meaning our individual services medical director can train and sign off on basics doing skills outside of their level. I volunteered at a service that allowed basics to start an IV on certain types of calls only after they had been there a year.


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## xrsm002 (Jun 17, 2013)

The basics at the service I'm at now can do IN narcan


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## chaz90 (Jun 17, 2013)

Colorado allows EMTs to do IVs after an IV add on class of around 20 hours. Most hospitals there have their EMT techs start lines in the ED as well. Every 911 service I know of in the state requires the IV endorsement before they hire an EMT.


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## Akulahawk (Jun 17, 2013)

EMT-B's aren't allowed to start IV's because many times they're not needed and additional education is needed before they'd be allowed to start one. While starting a line isn't normally dangerous, it's not entirely a benign thing to do. While most of the time people can handle a full liter of fluid (because they're down that much fluid) some people aren't and if you inadvertently drop in a liter of fluid because you forgot to TKO the line, it very easily could result in pulmonary edema. 

The other reason is that EMT-B's aren't allowed to give any meds through the IV route. D50 would be one thing that might be a good thing to allow, but that stuff kills tissue if it gets out of the vascular space. D10? Well, it's not as bad... but in either case, they'd also need the ability to check blood glucose, which is it's own additional education. So, what you're ending up with is something more like an AEMT with less education. 

Also, since it's not in the national scope and not everywhere needs to have the EMT-B start lines, it's probably better if the EMT-B is trained to the same national level and let the local EMS agencies decide to add-on those additional skills. Later, if it's beneficial locally, then perhaps it could be added to the state or national scopes.


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## wanderingmedic (Jun 17, 2013)

In AZ EMT's can start an IV with online medical direction and additional training at the discretion of their medical director. Most juridictions do not allow it (i'm not immediately aware of any that do).


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## Carlos Danger (Jun 17, 2013)

combiguy said:


> I know some places have EMTs that can start IVs. *Why is this not done everywhere?*



Why WOULD an EMT be allowed to start IV's?

An IV is simply a route of administration for fluids or medications. If the EMT can't administer fluids or medications - which is the case in most states - they have no need to establish IV access.

The places do allow EMT's to start IV's and give fluids or meds are the exception, not the rule.

FWIW, I would estimate that about 1% of the IV's started prehospital are actually necessary to the positive outcome of the patient.


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## Christopher (Jun 17, 2013)

Akulahawk said:


> Well, it's not as bad... but in either case, they'd also need the ability to check blood glucose, which is it's own additional education.



You're not an EMT if you cannot check a BGL.

We need to start shaming States that disallow this practice for any level of provider.


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## Tigger (Jun 17, 2013)

As stated, with an add on training class, 10 successful starts under supervision, and approval of the service's medical director, EMTs can start IVs in Colorado. In addition we can hang fluids as well as push dextrose, Narcan, and frontline cardiac arrest drugs at a paramedic's direction. 

I will say that it is useful, however I wish we would just increase the minimum certification to staff an ambulance to AEMT. I think a longer class would legitimize the providers a bit more, as well as make them more useful. The IV certification has two purposes, to make EMTs more useful to their paramedic partner, and to allow very rural services to deal with some common calls without waiting for ALS.

That said in my experience, the rural volunteers that we run with do not often have a good understanding of when an IV and/or fluid is indicated and when it is not. They also rarely get a chance to start them, which means that they either do not at all, or do not do a great job with them. If they blow the AC before we show up, that can be a problem. They'll also start fluids on almost everyone. More than once I've asked one of them to stop rooting through our med bag looking for a bag of fluid to spike. This is not a knock on volunteers mind you, it's just a comment that when EMTs are left to their own devices with minimal education, the results are questionable. I start an IV when my paramedic partner tells me too, and that's about the extent of it. 

As for making the EMT more useful to a paramedic partner, here is where the certification is useful. While the paramedic interprets the monitor and starts getting meds ready, I can get access. During an arrest, he or she can run the monitor and manage the airway while I get access and push frontline cardiac arrest meds. I don't think it's essential for EMTs to be able to do these things, but having worked in systems that do not allow this, I find that scenes are definitely run more efficiently. I would still like to see a bridge to AEMT, mostly so that IO access could be added for arrests and that the lowest level provider would actually have some degree of useful education.


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## combiguy (Jun 17, 2013)

Christopher said:


> You're not an EMT if you cannot check a BGL.
> 
> We need to start shaming States that disallow this practice for any level of provider.



Michigan removed glucometer use from EMTs last year... kind of ridiculous.


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## Handsome Robb (Jun 17, 2013)

Tigger said:


> I would still like to see a bridge to AEMT, mostly so that IO access could be added for arrests and that the lowest level provider would actually have some degree of useful education.



I don't understand why the EMT-IV class doesn't include IO access as well. They're easier to do than IVs. Make it so its only in the presence of cardiac arrest or if the medic orders it on a pt in extremis. 

You basically described how my arrests go. I do the airway, run the monitor and ask for a basic story (events leading up complaints, last seen, recent hospitalizations, illness, meds, trauma), partner does stickies, pads, IO, meds, FFs do CPR/BGL/spike a bag, fire captain gets the more in depth story, demographics, history, allergies and medications, deals with family, LZ if needed, gear to package the patient if we get ROSC (partner does this too once I've got the airway done and the vent connected because they know where stuff is in the unit rather than fire digging through everything trying to find something and I can run the monitor and push drugs while they're gone.)

Makes it WAY easier than me having to do everything except CPR and information gathering.


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## Arovetli (Jun 17, 2013)

Robb said:


> I don't understand why the EMT-IV class doesn't include IO access as well. They're easier to do than IVs. Make it so its only in the presence of cardiac arrest or if the medic orders it on a pt in extremis.



Because its not called the EMT-IVIO class.

That is probably the extent of the logic employed.

A more serious response would be as a mean to funnel folks into AEMT.


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## Akulahawk (Jun 17, 2013)

Christopher said:


> You're not an EMT if you cannot check a BGL.
> 
> We need to start shaming States that disallow this practice for any level of provider.


While it's an easy thing to do, not all states allow the EMT-B to do it. I, personally, would be a whole lot happier allowing the Basics to check the BGL than I'd be with them starting a line.


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## Jim37F (Jun 17, 2013)

And here I was thinking EMT-IV was an EMT 4 (as in the Roman numeral) figuring it was what some state called a Basic or Intermediate. Silly me 

In Army Combat Life Saver we used to always do IVs. That's generally a week or two course, designed for Soldiers without any medical training. In most of the CLS courses I we t through we'd spend a day getting instructed on how to start an IV, and then practice on each other. However in the CLS course I just went through we didn't do IVs at all. The rationale of the instructors (who were all experienced Paramedics) was that Soldiers would want to start IVs on a casualty before the ABCs were secured (well, MARCH is the acronym CLS uses, Massive Hemorrhage, Airway, Respirations, Circulatory, Head Injury/Hypothermia). Yet we still spent a full day on chest needle decompression (is it Needle Thoracostomy? I could never spell it). So after 120 hours of training LA County won't trust me with a Glucometer yet after 4 days the Army'll trust me to stick a 3.75" 18 gauge needle in your chest. Go figure 

I can easily see an overexcited Basic here in the States starting an IV before fully securing the ABCs. I'd personally feel a bit more comfortable leaving that up to an Intermediate or Medic, or in a rural area where you only have two guys/gals on the ambulance treating you, a Basic doing it under supervision. However, the folks here from Colorado keep saying an IV trained EMT works well in their system, so I guess if it works, don't try and fix it.


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## Akulahawk (Jun 17, 2013)

Jim37F said:


> And here I was thinking EMT-IV was an EMT 4 (as in the Roman numeral) figuring it was what some state called a Basic or Intermediate. Silly me
> 
> In Army Combat Life Saver we used to always do IVs. That's generally a week or two course, designed for Soldiers without any medical training. In most of the CLS courses I we t through we'd spend a day getting instructed on how to start an IV, and then practice on each other. However in the CLS course I just went through we didn't do IVs at all. The rationale of the instructors (who were all experienced Paramedics) was that Soldiers would want to start IVs on a casualty before the ABCs were secured (well, MARCH is the acronym CLS uses, Massive Hemorrhage, Airway, Respirations, Circulatory, Head Injury/Hypothermia). Yet we still spent a full day on chest needle decompression (is it Needle Thoracostomy? I could never spell it). So after 120 hours of training LA County won't trust me with a Glucometer yet after 4 days the Army'll trust me to stick a 3.75" 18 gauge needle in your chest. Go figure
> 
> I can easily see an overexcited Basic here in the States starting an IV before fully securing the ABCs. I'd personally feel a bit more comfortable leaving that up to an Intermediate or Medic, or in a rural area where you only have two guys/gals on the ambulance treating you, a Basic doing it under supervision. However, the folks here from Colorado keep saying an IV trained EMT works well in their system, so I guess if it works, don't try and fix it.


You just highlighted something... CLS and EMT are two different knowledge and skill-sets. They're designed with different purposes in mind... It's also not too difficult to understand why they removed IV's from the basic CLS skill-set.


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## Aprz (Jun 17, 2013)

Christopher said:


> You're not an EMT if you cannot check a BGL.
> 
> We need to start shaming States that disallow this practice for any level of provider.


+1

We need to start shaming them with a lot more than just checking BGL. :[


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## Akulahawk (Jun 17, 2013)

Aprz said:


> +1,000,000
> 
> We need to start shaming them with a lot more than just checking BGL. :[


Too true... starting with lack of general education....


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## Tigger (Jun 17, 2013)

Arovetli said:


> Because its not called the EMT-IVIO class.
> 
> That is probably the extent of the logic employed.
> 
> A more serious response would be as a mean to funnel folks into AEMT.



The curriculum has never changed as far as I can tell. It was designed well before widespread IO use.


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## Arovetli (Jun 17, 2013)

Tigger said:


> The curriculum has never changed as far as I can tell. It was designed well before widespread IO use.



Huh?

Right, there's no sense to nickel and dime little additions to basic EMT and try to push a new provider level simultaneously.


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## Tigger (Jun 17, 2013)

Arovetli said:


> Huh?
> 
> Right, there's no sense to nickel and dime little additions to basic EMT and try to push a new provider level simultaneously.



Just pointing out that the IV add on certification is a very old (well for EMS) class in Colorado and has seen no updates, which explains why IO is not included. I agree that it serves to potentially prevent the widespread adoption of AEMT.


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## Arovetli (Jun 17, 2013)

Tigger said:


> Just pointing out that the IV add on certification is a very old (well for EMS) class in Colorado and has seen no updates, which explains why IO is not included. I agree that it serves to potentially prevent the widespread adoption of AEMT.



ah i got ya.


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## chaz90 (Jun 18, 2013)

Tigger said:


> Just pointing out that the IV add on certification is a very old (well for EMS) class in Colorado and has seen no updates, which explains why IO is not included. I agree that it serves to potentially prevent the widespread adoption of AEMT.



My old service in CO was considering taking all their EMTs to AEMT when I left. Scope wise, the only additions from CO EMT-IV would be Glucagon, IM Epi, IO access, and using their own NTG. They already have D50, Narcan, Albuterol, and King airways. The additional education would have been a lovely boon for the EMTs as well.


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## TheLocalMedic (Jun 18, 2013)

IMHO, I simply do not see the benefit in having an EMT who can start IVs on an ambulance.  Sure, you could delegate IV starts to them, but to what end?  So you can stand there and watch them do it?  I think someone said that they could talk to the patient further about history and meds while the EMT starts an IV, but I have never had a problem talking and working with my hands at the same time...

Besides, after seeing the volly departments around here, I can't imagine letting them play with needles.  Whoever said that they'd go right for the IV before assessing the patient or checking the ABCs is right on.  Do you know how many times I've walked in and the only report they have given me was the pulse ox reading?  No BP, no pulse, no respirations...  just staring at that little box stuck to their finger like it's some kind of divining rod that will magically tell them whether the patient is really sick.  

If an EMT wants to upgrade to AEMT, great!  Let them start IVs and push some of the commonly used meds and drop King tubes.  But always stress that all of the ALS procedures come after a good exam and BLS interventions.


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## Arovetli (Jun 18, 2013)

TheLocalMedic said:


> Sure, you could delegate IV starts to them, but to what end?  So you can stand there and watch them do it?



Less work for me. I excel at delegation and supervision.


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## Tigger (Jun 18, 2013)

On your garden variety calls my partner puts the patient on the monitor and reads the strip or 12 lead while I get an IV. I don't know anyone who can do both of this things simultaneously. 

Truthfully I would prefer EMT-IVs to work only with a higher level provider but I think I would settle for more medical director scrutiny in who gets authorized and who doesn't. Technically the medical director must individually approve each of their providers however it most cases if you're hired and have the card, then you're good to go.


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## txmedic5 (Jun 18, 2013)

xrsm002 said:


> Texas EMS are delegated meaning our individual services medical director can train and sign off on basics doing skills outside of their level. I volunteered at a service that allowed basics to start an IV on certain types of calls only after they had been there a year.



This! Emts can do king tubes where I work. No ivs though, don't really see a need for it.


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## MTEMTB (Jun 18, 2013)

Depends upon transport time and whether we can get the helicopter in to our scene.
We have an IV endorsement here signed off by our medical director. We are to check blood sugar before starting any fluids.
Also depends upon pt's condition.


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## AlphaButch (Jun 18, 2013)

Our EMTs get signed off on IVs after training. This allows for BLS transport of patient's who have IV access. It also speeds up scene times for those patients that may need access in the field (as they can do either the 12 lead placement or IV start while their partner does the other). The phlebotomy course (part of the IV training) is also for the other services we provide (such as PD draws, stat labs during transport, etc).


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## medic2100 (Jul 3, 2013)

Here in Tennessee every EMT is trained initially to the EMT-I level. We are licensed as As an EMT-IV state of TN and EMTB NR. Under Tennessee guidelines we are allowed to establish IV access, hang NS or LR as indicated, administer D50, BGL, ntg tablet or SL, ASA, albuterol neb, epi 1:1000, combitube, and king airway. With the new AEMT upgrade they say we will be able to so narcan, IO, nitrox, and possibly CPAP. 

As to the OP, it is not uncommon for a ift service to run a handful of basic trucks and just a couple als trucks. The service I work for has a 911 contract and we usually run a basic and an ALS truck in the city. The bls truck can transport things that do not require als skills. It is not uncommon for two EMT-ivs to run a patient to the hospital if there isn't an als unit available.


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## Lolli2 (Jul 3, 2013)

In Wisconsin we can start them but we have to first be a Basic, then take the IV Tech course. We had to do a bunch of clinical time in an ER and get so many successful sticks before we could pass the course.


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## rednecksoccer (Aug 22, 2013)

*IVs for basics*

I work for a very rural 911 service where sometimes we don't have a choice but to run double basic with an on call medic who doesn't ride out unless ALS assistance is required. In the time it takes for the medic or helicopter to get there we can have an IV inserted and ready even if we aren't giving meds. However with extra training, our basics are allowed to administer certain medications. We also use the King Airway at the basic level.


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## unleashedfury (Aug 22, 2013)

I can see this going both ways. here 

My opinion having a EMT-Basic starting IV's with no fluid challenges, No med administration, and placing a Saline lock for just putting it there. Kinda useless IMO. 

OTOH, I can see where it can be beneficial, A lot of ALS units in the State of PA well probably most of them run a Basic, and a Paramedic per truck. So under the supervision of a paramedic could a EMT perform invasive procedures Sure I don't see why not especially if its a critical patient and an extra set of hands to provide additional interventions would be great. 

I strongly believe that BLS should be upgraded to the AEMT level. which seems to be kicked around everywhere but no initiative is taken. 

My final rant about PA State BLS guidelines, State requirement is to have oral glucose present on your trucks.. 45grams. But Glucometers are not part of the BLS scope of practice.  Lets run with this one. So a EMT can believe that a patient is experiencing a Hypoglycemic emergency and administer 1 tube of oral glucose under standing orders. But never know what the patients Blood sugar is at the present moment. So what if your patient is experiencing a head bleed.... the symptoms AMS. noted diaphoresis pale ashen appearance are all too similar.
King LT, Combi-tube, and LMA's are also BLS skills.  but we save them for a "last chance airway" if the ETT was unsuccessful, Intra Nasal Narcan is handed out at Needle clinics for junkies,, Yet as a provider you cannot utilize it at a BLS level. 

IMHO - I believe that as the EMS system evolves we should be moving the BLS side of things to a EMT-I or AEMT level at which EMT's would be initiating IV therapy, and administering a short list of medications within the scope of practice as a BLS provider.

So should a BLS provider be able to perform some advanced skills under the supervision of a paramedic, Sure...... The biggest problem I could see is what was stated earlier, tunnel vision. Its been proven that BLS skills have been most effective in SCA, so instead of worrying about getting IV access immediately keep on the chest. Older medics can remember the days of dumping the drug box on a code. Now we narrowed it down to effective CPR and early defibrillation. 

that's my nickel.. Used to be 2 cents but I increased for inflation.


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## bonesaw (Aug 22, 2013)

unleashedfury said:


> I can see this going both ways. here
> 
> My opinion having a EMT-Basic starting IV's with no fluid challenges, No med administration, and placing a Saline lock for just putting it there. Kinda useless IMO.
> 
> ...



+1 to this

Do away with EMT-B, I, P, I89 etc...

Make it Paramedic and EMT, 
( Do away with basic...make EMT the scope of I, I99, advanced etc.)


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## Handsome Robb (Aug 22, 2013)

Umm...pretty sure the NREMT already basically did that with the EMT, AEMT and Paramedic designators when they redid everything...


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## PaulEMT (Aug 23, 2013)

EMTBs can't start IV lines because it's not in our scrope. If you try to start an IV line as an EMTB then you're action is out of scope. and you can be subject to disciplinary action.


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## STXmedic (Aug 23, 2013)

PaulEMT said:


> EMTBs can't start IV lines because it's not in our scrope. If you try to start an IV line as an EMTB then you're action is out of scope. and you can be subject to disciplinary action.



Your scope can change depending on where you work, bud.


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## Akulahawk (Aug 23, 2013)

PaulEMT said:


> EMTBs can't start IV lines because it's not in our scrope. If you try to start an IV line as an EMTB then you're action is out of scope. and you can be subject to disciplinary action.


Usually, you are correct. Some EMT-Bs are able to because they have taken the right class to add the skill and their local protocols authorize them to start a line. If you're one of those EMT-Bs, you'll know if you're authorized to start an IV.


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## PaulEMT (Aug 23, 2013)

I dont know how you can be authorized to start an IV line and be an EMTB because it's not part of the scope of practice.


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## Handsome Robb (Aug 23, 2013)

PaulEMT said:


> I dont know how you can be authorized to start an IV line and be an EMTB because it's not part of the scope of practice.



The NREMT scope is a national guideline states/counties can set their own scopes. In some areas (ie Texas) the medical director sets the scope of practice for those working under his/her license.


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## rmabrey (Aug 23, 2013)

PaulEMT said:


> I dont know how you can be authorized to start an IV line and be an EMTB because it's not part of the scope of practice.



Indiana as well, the scope can be expanded by the Medical Director if "proper training is provided"


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## Akulahawk (Aug 23, 2013)

PaulEMT said:


> I dont know how you can be authorized to start an IV line and be an EMTB because it's not part of the scope of practice.


Each State/County/Local (whatever) EMS agency has authority to set their own scope of practice for their providers. It means that while someone is certified as an EMT-B through the NREMT, if the person has taken the appropriate additional education, that person may be locally accredited to perform that additional procedure/skill. That's separate from what the NREMT certifies. 

In short, it's possible for an EMT to be accredited to start IV lines, intubate, give IM injections, give/assist with certain medication administration and so on. It all just depends upon what's allowed in that area. 

In California, the State EMS Authority and the local EMS agencies set the scope of practice for EMT-Bs for each area. The EMT scope can be a bit different from county to county - even if they're neighboring counties or EMS systems.


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## PaulEMT (Aug 24, 2013)

Sounds to me that those "services" are going beyond what the federal gov't allows. Not a good idea.


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## Wheel (Aug 24, 2013)

PaulEMT said:


> Sounds to me that those "services" are going beyond what the federal gov't allows. Not a good idea.



There is no federal governing body for ems. States choose what they allow a service to do.


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## DesertMedic66 (Aug 24, 2013)

PaulEMT said:


> Sounds to me that those "services" are going beyond what the federal gov't allows. Not a good idea.



As it was already stated before your scope of practice can change depending on the state, county, and agency you work for.


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## chaz90 (Aug 24, 2013)

PaulEMT said:


> Sounds to me that those "services" are going beyond what the federal gov't allows. Not a good idea.



The federal government doesn't make any rules regarding provider scope. You'll note that you are neither licensed nor credentialed by any federal agency.


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## Akulahawk (Aug 24, 2013)

PaulEMT said:


> Sounds to me that those "services" are going beyond what the federal gov't allows. Not a good idea.


Well, if you want to know, the Federal Government employs EMT-Bs and teaches them a LOT of stuff that go way beyond any normal EMT-B course or scope of practice. Here's a hint: it's the US Military and they're part of the Federal Government. The Army 68W (for example) gets to do a LOT of stuff. They're just certified as EMT-B. Nothing more. Their scope depends upon their training and what their medical officer signs off...


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