# EMTs starting IV



## lampnyter (Nov 23, 2010)

Im pretty sure ive read something about this here but I honestly think EMT-B should be able to start a line but not give any medication to help the medic/nurse. I think if we took a short class just on starting a line we should be allowed to do it.


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## medic417 (Nov 23, 2010)

Yes there is a short IV class it's called Paramedic.


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## lampnyter (Nov 23, 2010)

ha ha very funny. but seriously, is starting an IV that big of a deal?


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## Shishkabob (Nov 23, 2010)

lampnyter said:


> ha ha very funny. but seriously, is starting an IV that big of a deal?



If it isn't that "big of a deal" then why have EMTs start it?


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## lampnyter (Nov 23, 2010)

Linuss said:


> If it isn't that "big of a deal" then why have EMTs start it?



what?

EDIT: What i mean by big deal is that its not that complicated and it would help save time.


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## medic417 (Nov 23, 2010)

:deadhorse:


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## Shishkabob (Nov 23, 2010)

Don't get me wrong, I think there are some things EMTs should be able to do that are "advanced", but not because they are "no big deal".



And really, if time were of the essence, the medic better be placing an IO rather than having someone with minimal practice with IVs trying to get the stick.


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## EMT11KDL (Nov 23, 2010)

:nosoupfortroll: and the lovely debate opens up once again.  Ill give you my .02 on the subject though.  It depends on your area! If the basics are going to be able to get sticks, than I do not see a problem with Basics having IV.  If the Basics are only going to get one or two sticks a month than NO! they should not have IV access.  

Also, if they are running with a Medic.  And the only thing the Basic is doing is establishing the IV.  Than I do not have a problem with it.  

I volunteer for a BLS county.  Would I like to see IV access granted to us.  Of course I would. Do I see it happening NO.  If you do not practice and get to use your skills, they go bye bye.  Same goes with Medications that IV's allow and understanding why medications are being given.  The 21 hour class (I believe that is the length of the basic iv class now) is not long enough to get a true understanding of the basic drugs that you will most likely be allowed to push.

Now after this being said, use the search... this has been debated so many times!!! I believe the troll Is full, and might be to full to eat during thanksgiving


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## TransportJockey (Nov 23, 2010)

In some places they can (like Colorado) but they don't have the knowledge to know what they're doing a majority of the time. Hell an Intermediate usually doesn't have all the proper knowledge and education needed to know all of why and how they're doing it.


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## medic417 (Nov 23, 2010)

lampnyter said:


> what?
> 
> EDIT: What i mean by big deal is that its not that complicated and it would help save time.



And your edit shows why basics should not be doing IV's.


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## lampnyter (Nov 23, 2010)

I dont think IV's themselves are no big deal, i think the actual procedure isnt as "advanced" as they are said to be.


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## lampnyter (Nov 23, 2010)

medic417 said:


> And your edit shows why basics should not be doing IV's.



Because i misread something? Thats mature.


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## medic417 (Nov 23, 2010)

lampnyter said:


> Because i misread something? Thats mature.



No because it shows how little you know about the skill you are suggesting giving to basics.


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## EMT11KDL (Nov 23, 2010)

http://www.emtlife.com/showthread.php?t=10871
http://www.emtlife.com/showthread.php?t=5445
http://emtlife.com/showthread.php?t=8588


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## goodgrief (Nov 23, 2010)

An emt who can do Iv's is a very well trained EMT-I 

Honestly I am not to sure what the scope of practice is for an EMT-B, because we dont have B's in georgia. When we went through the B class it seemed to be how to stop bleeding and splinting.


Ive never understood why there are so many different levels in all the different states.I do know in Tenn their B's can start IVs.


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## bstone (Nov 23, 2010)

There is a short course, about 140 hours long, that teaches an EMT-Basic to do IVs. It's called EMT-Intermediate (aka Advanced EMT).


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## medic417 (Nov 23, 2010)

UGH give me sharp pointy thing.  I shove it in skin and hope get red stuff come out.  I pour clear stuff back in.  It so simple a cave man can do it.  

But in defense of the basics on here sadly many Paramedics do not fully grasp what they are doing and the risks to the patients when they shove sharp pointy thing in.


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## Chimpie (Nov 23, 2010)

EMT11KDL said:


> Also, if they are running with a Medic.  And the only thing the Basic is doing is establishing the IV.  Than I do not have a problem with it.



If an IV needs to be started, the medic can do it.  I'm sure there are other things that need to be done that's in a Basic's scope of practice.


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## bstone (Nov 23, 2010)

Chimpie said:


> If an IV needs to be started, the medic can do it.  I'm sure there are other things that need to be done that's in a Basic's scope of practice.



Or an Intermediate.


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## Chimpie (Nov 23, 2010)

bstone said:


> Or an Intermediate.



Right.


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## Aprz (Nov 23, 2010)

I don't think a lot of EMT-Basics are even good at being Basics.


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## Chimpie (Nov 23, 2010)

Aprz said:


> I don't think a lot of EMT-Basics are even good at being Basics.



This is *not *going to turn into a Basics vs Intermediates vs Paramedics thread.


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## Shishkabob (Nov 23, 2010)

Honestly, I don't get enough chances at an IV myself, so regardless of whether or not my partner can do IVs (or in the case of Intermediates, tubes) doesn't matter.  I get first go.  And second.  And maybe third.


I needs the excitement!!!


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## bstone (Nov 23, 2010)

Chimpie said:


> This is *not *going to turn into a Basics vs Intermediates vs Paramedics thread.



It's already turned into another Basic IV thread, which there are no shortage of.


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## WolfmanHarris (Nov 23, 2010)

PCP's start IV's in various jurisdictions in Canada.
In Alberta it's part of their scope.
In Ontario some services have implemented a program expanding the PCP scope to include IV starts, D50, gravol, independently. This is usually done in Counties without ACP. In some areas PCP's can start IV's, but only when on scene with an ACP.

Keep in mind though that IV starts or not, PCP education covers fluid balance as part of the A&P courses.

I understand the desire on the part of Basics to want to push their scope forward to better care for their patients, but the skill without the background is cart before the horse thinking.


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## TransportJockey (Nov 23, 2010)

WolfmanHarris said:


> PCP's start IV's in various jurisdictions in Canada.
> In Alberta it's part of their scope.
> In Ontario some services have implemented a program expanding the PCP scope to include IV starts, D50, gravol, independently. This is usually done in Counties without ACP. In some areas PCP's can start IV's, but only when on scene with an ACP.
> 
> ...



Apples to Oranges comparison, since EMT-Bs are completely undereducated, even for what little they have in their scope, especially when you compare them to any other developed country's EMS


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## medic417 (Nov 23, 2010)

jtpaintball70 said:


> Apples to Oranges comparison, since EMT-Bs are completely undereducated, even for what little they have in their scope, especially when you compare them to any other developed country's EMS



Heck even underdeveloped countries.  In fact many countries lowest level has a higher education required than our highest level which is Paramedic.


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## Shishkabob (Nov 23, 2010)

jtpaintball70 said:


> Apples to Oranges comparison, since EMT-Bs are completely undereducated, even for what little they have in their scope, especially when you compare them to any other developed country's EMS


Meh.  I'm tired of hearing another country has better EMS education in comparison to ours when they cannot be compared.


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## medic417 (Nov 23, 2010)

Linuss said:


> Meh.  I'm tired of hearing another country has better EMS education in comparison to ours when they cannot be compared.



Education can be compared.  Most require much more actual education.  Now in the field it seems USA allows it's lesser educated more skills that are reserved for doctors elsewhere.


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## WolfmanHarris (Nov 23, 2010)

jtpaintball70 said:


> Apples to Oranges comparison, since EMT-Bs are completely undereducated, even for what little they have in their scope, especially when you compare them to any other developed country's EMS



That was my point. The skill can be taught in a few hours, the knowledge base required to understand it and implement it requires a greater education then can be provided as part of a 120 hour course.

I used to run into this quite a bit when I was still active on the board for the Association of Campus Emergency Response Teams (ACERT; like NCEMSF, but much smaller). Teams trained to the FR or EMR level would get together at conferences and many of them would all want to add new toys to their toy box; whether it was pulse ox, epi, etc. While I had no control over the actual decision within their team I'd always ask the person "Cool. Explain to me how it works."


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## bstone (Nov 23, 2010)

America is the best damn country in the world....except when it comes to education standards of our EMS professionals.


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## Shishkabob (Nov 23, 2010)

We're often demanding science based medicine, but I've yet to see a single study showing higher survival rates, or lower morbidity / mortality when comparing the US system to another country's 'more educated' providers of the equivalent level.  


"Their" PCP might have more education but does it make a difference when they can do the exact same (minimal) skill set?


Heck, on average, you could argue that a British Paramedic has more education than an American Paramedic, but when I'm having a cardiac episode, I want someone who can actually do stuff for it, which, right or wrong, the US outpaces many other country's on our interventions in the cardiac arena.    Yes, 'skills' don't mean everything, but having knowledge, without the ability to intervene, is edging on uselessness.  In an emergency, I'd rather have a Paramedic that can do what they do, than an MD from another country who can't do anything but go "Oh, he has ______, to which he would be given ______... too bad you have to wait since I can't practice"


And before someone gets their panties in a bunch--- yes, education should match our interventions we provide.



I'm the first to say we need more education... but there is also a limit to where you go "Ok, you learned enough" (no, I dont think we are quite there yet).  There has to be a soft-limit on the education required to do our job, the rest learned with time and experience.  If there wasn't, then EVERYONE in medicine would have to be a doctor, which just isnt realistic.


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## 18G (Nov 23, 2010)

I'm kinda in the middle on the question of EMT's being allowed to do IV's. IV's are simple and really just take practice so it's not about rather or not they would be capable of doing them. 

I would have to look at the benefit. How would patients be better served by having an EMT-Basic start an IV? I agree it could add some efficiency to the field with Paramedic/EMT teams but in how many situations is it really gonna matter if the EMT can start the line?

So I would have to say I'm not really for it or against it.... Basics around here cannot do IV's. I'm fine with it either way.


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## Pittma (Nov 23, 2010)

EMT11KDL said:


> :nosoupfortroll: and the lovely debate opens up once again.  Ill give you my .02 on the subject though.  It depends on your area! If the basics are going to be able to get sticks, than I do not see a problem with Basics having IV.  If the Basics are only going to get one or two sticks a month than NO! they should not have IV access.
> 
> Also, if they are running with a Medic.  And the only thing the Basic is doing is establishing the IV.  Than I do not have a problem with it.
> 
> ...



The overall perfect answer for any question or debate regarding "Do you think...should be allowed to..." should always be "depends". One size fits all doesn't work! In a rural area like mine, IV's- YES! In Boston, maybe not so much...ALS will be right there.


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## EMT11KDL (Nov 23, 2010)

Pittma said:


> The overall perfect answer for any question or debate regarding "Do you think...should be allowed to..." should always be "depends". One size fits all doesn't work! In a rural area like mine, IV's- YES! In Boston, maybe not so much...ALS will be right there.



even in rural area. I still have to go with depends. What is ur call volume. Will you get enought sticks in each month to keep ur skill level up? If one or two sticks a month. Than no. But if ur area requires iv access on a daily bases. you area might want to look at putting a  higher level of care in place


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## lampnyter (Nov 23, 2010)

8/10 calls an IV is started


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## WolfmanHarris (Nov 23, 2010)

lampnyter said:


> 8/10 calls an IV is started



Really? Why? Not one of those gain IV access just in case things is it?


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## jjesusfreak01 (Dec 2, 2010)

18G said:


> I would have to look at the benefit. How would patients be better served by having an EMT-Basic start an IV? I agree it could add some efficiency to the field with Paramedic/EMT teams but in how many situations is it really gonna matter if the EMT can start the line.



Exactly...I would like someone to point out a situation where there is a need to start an IV and the paramedic is busy with a more complicated procedure. Other than intubation, I can't think of anything, although I think EMTs should he able to intubate, especially if a medic is there to confirm placement afterwards. You aren't going to be defibrillating while a medic is starting a line, so that's out. If you are working a cardiac arrest, the medic will probably be skipping the iv and going to the io, while the EMT will be doing compressions. In most other situations, time is probably not so critical that the EMT needs to be doing something above their skillset. The EMT can be getting a history or doing a thorough exam, or just assisting the medic with whatever they are doing. So, what i'm really saying here is that although I think many EMTs could handle IVs just fine, there is very little reason for them to need that skill when working with a medic.


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## Shishkabob (Dec 2, 2010)

Wait wait wait wait....


You don't want EMTs doing IVs, but you want them doing endotracheal intubation?


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## Amber2313 (Dec 2, 2010)

jjesusfreak01 said:


> Exactly...I would like someone to point out a situation where there is a need to start an IV and the paramedic is busy with a more complicated procedure. Other than intubation, I can't think of anything, although I think EMTs should he able to intubate, especially if a medic is there to confirm placement afterwards. You aren't going to be defibrillating while a medic is starting a line, so that's out. If you are working a cardiac arrest, the medic will probably be skipping the iv and going to the io, while the EMT will be doing compressions. In most other situations, time is probably not so critical that the EMT needs to be doing something above their skillset. The EMT can be getting a history or doing a thorough exam, or just assisting the medic with whatever they are doing. So, what i'm really saying here is that although I think many EMTs could handle IVs just fine, there is very little reason for them to need that skill when working with a medic.



Out of all that, I see your EMT is always with a medic. That's not true. For my county, we have one working medic. The other is commissioner and doesn't go out very often, if at all. I'm not saying basics should absolutely, hands-down be able to start IVs (frankly, I don't see it happening, but for the sake of conversation...), but I would always err on the side of education. If it were an option, I'd feel comfortable with them learning, but as I see it now, go advanced or hands off the needles.


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## LonghornMedic (Dec 3, 2010)

lampnyter said:


> 8/10 calls an IV is started



What? Where'd you pull that BS stat from?


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## the_negro_puppy (Dec 3, 2010)

LonghornMedic said:


> What? Where'd you pull that BS stat from?



I think he is sayign that he starts IVs in 8/10 of his calls


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## MrBrown (Dec 3, 2010)

Thats because IV fluid or at least a cannulae is like high flow oxygen, it helps everybody right?


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## Bullets (Dec 3, 2010)

MrBrown said:


> Thats because IV fluid or at least a cannulae is like high flow oxygen, it helps everybody right?



Or, like in or system, medics do the blood draws en-route to the hospital. Every patient that comes in ALS is supposed to have a line started, even if drugs wer'nt pushed or fluids hung, labs go straight from the ER to pathology through one of those bank vacuum tube things


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## CAOX3 (Dec 3, 2010)

What's the rationale behind that?

Never been on scene and thought, I wish I could put a line in this guy.  Its useless at the bls level unless you work with a paramedic even still the times are miniscule that the medic is going need the basic to start a line.

Back when I started medics were hard to come by,there was a need for expanded scopes today you can throw a rock and have it bounce off three medics. Leave the als skills to the paramedics.


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## Minnick27 (Dec 3, 2010)

That's how it is in my area. If the medic doesn't have anything to do but ride they will almost always start a line and draw bloods for the hospital


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## Bullets (Dec 3, 2010)

CAOX3 said:


> What's the rationale behind that?
> 
> Never been on scene and thought, I wish I could put a line in this guy.  Its useless at the bls level unless you work with a paramedic even still the times are miniscule that the medic is going need the basic to start a line.
> 
> Back when I started medics were hard to come by,there was a need for expanded scopes today you can throw a rock and have it bounce off three medics. Leave the als skills to the paramedics.



Maybe where you work, but we always get, "FA1, respond to 410 bank street for chest pain, medics pending" or "medic 2 responding from  XX station, eta 15 minutes" so we have to decide is it worth waiting or hoping an als unit frees up, or do we sh oot and scoot? If I could push d50 I could cx micu on a lot of calls, or if the patient is hypovolemic with no other complaint, I could hang fluids and go. 

All I want is d50, nebulize, fluids, maybe a 3 lead. It would cut our dependancy on MICs and speed up calls


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## Cohn (Dec 3, 2010)

or when you have a dehydrated UDA just came from walking in the desert for 3 days with little to no fluids taken in and the next ALS unit is 45 minutes away... Yes, yes you need basics starting lines.


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## TransportJockey (Dec 3, 2010)

Cohn said:


> or when you have a dehydrated UDA just came from walking in the desert for 3 days with little to no fluids taken in and the next ALS unit is 45 minutes away... Yes, yes you need basics starting lines.



I'm still trying to figure out why oral rehydration wouldn't work on a patient like that. Now, granted I don't live in AZ, but I've treated my fair share of dehydration patients in the high deserts of NM (and the mountains for that matter too, mostly offroaders who got lost or mexicans wandering in illegally, which I'm assuming is what your UDA means), and I can think of maybe one or two that actually needed IV hydration instead of PO.


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## TransportJockey (Dec 3, 2010)

Bullets said:


> Maybe where you work, but we always get, "FA1, respond to 410 bank street for chest pain, medics pending" or "medic 2 responding from  XX station, eta 15 minutes" so we have to decide is it worth waiting or hoping an als unit frees up, or do we sh oot and scoot? If I could push d50 I could cx micu on a lot of calls, or if the patient is hypovolemic with no other complaint, I could hang fluids and go.
> 
> All I want is d50, nebulize, fluids, maybe a 3 lead. It would cut our dependancy on MICs and speed up calls



Are you willing for the state/NR to increase mandatory education to gain those skills?

EDIT: Wait, nebs aren't in the basic scope there?


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## wyoskibum (Dec 3, 2010)

*Really???*



Cohn said:


> or when you have a dehydrated UDA just came from walking in the desert for 3 days with little to no fluids taken in and the next ALS unit is 45 minutes away... Yes, yes you need basics starting lines.




No, you need more ALS providers.


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## Bullets (Dec 3, 2010)

jtpaintball70 said:


> Are you willing for the state/NR to increase mandatory education to gain those skills?
> 
> EDIT: Wait, nebs aren't in the basic scope there?



Nope, we don't get anything but o2 in NJ, just what's in the text book. 

If they allowed us to start iv with fluids, d50, and neb, I would only want it if we got the appropriate pharmacology instruction along with the practical skills instruction as well. Otherwise its useless

And we don't need more ALS providers, if they expanded the basic scope, or eliminated basics from the 911 system in favor of intermediates, there would be less demand placed on ALS, and the increase in training would not be exceptional. Patients would get the same level of care, and ALS could do more calls that truly require them. Let basics handle simple diabetic calls that only lead to RMAs and stop tying up ALS while cardiac or respiratory calls are hanging


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## Cohn (Dec 3, 2010)

jtpaintball70 said:


> I'm still trying to figure out why oral rehydration wouldn't work on a patient like that. Now, granted I don't live in AZ, but I've treated my fair share of dehydration patients in the high deserts of NM (and the mountains for that matter too, mostly offroaders who got lost or mexicans wandering in illegally, which I'm assuming is what your UDA means), and I can think of maybe one or two that actually needed IV hydration instead of PO.



We don't carry jugs of water and who ever find them, mostly BP does not carry water for them.


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## MrBrown (Dec 3, 2010)

Oh damn it to the bowels of bloody hell Brown feels like throwing this one (and all the others like it) into the friggin tail rotor .... scurge of the earth man seriously!

You do not need more ALS (Advanced/Intensive Care/Paramedic) what you need is a base level of adequately educated and dexterious practitioners who do not need to run off to mummy [Advanced/Intensive Care/Para]medic everytime you need to put in a drip or give some salbutamol or adrenaline.

*Brown smashes his head on the desk repeatedly, stops and figures getting into his helicopter and flying far, far away is a better idea ....

City traffic, Medivac airborne, below 1,000 northbound


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## usalsfyre (Dec 3, 2010)

Cohn said:


> We don't carry jugs of water and who ever find them, mostly BP does not carry water for them.



So then why not replace the bags of fluid with bottles of water?


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## Bullets (Dec 3, 2010)

usalsfyre said:


> So then why not replace the bags of fluid with bottles of water?



What acts faster? IV saline or tap water absorbed though osmosis?


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## usalsfyre (Dec 3, 2010)

Bullets said:


> What acts faster? IV saline or tap water absorbed though osmosis?



Look at what is lost via sweat in this particular case of dehydration. Now look at what your using to replace everything lost. The general rule of dehydration is baring an emergent issue, you should rehydrate only as fast as you dehydrate. Speed is not always a desirable trait (look up sodium replacement and central pontine mylinolysis, although not aplicable if your only using NS, it is an example of what happens when you start messing with fluid balance and electrolytes).


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## Bullets (Dec 3, 2010)

usalsfyre said:


> Look at what is lost via sweat in this particular case of dehydration. Now look at what your using to replace everything lost. The general rule of dehydration is baring an emergent issue, you should rehydrate only as fast as you dehydrate. Speed is not always a desirable trait (look up sodium replacement and central pontine mylinosis, although not aplicable if your only using NS, it is an example of what happens when you start messing with fluid balance and electrolytes).





The fact that we drive an ambulance out into the deserts of arizona indicates to me that this is an emergent issue, and wouldn't the saline replace sodium list during extensive perspiration better then an equal volume of tap water?


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## Amber2313 (Dec 3, 2010)

jtpaintball70 said:


> Are you willing for the state/NR to increase mandatory education to gain those skills?
> 
> EDIT: Wait, nebs aren't in the basic scope there?



I think most would be absolutely willing if they had the chance. Nebs aren't basic here, either.




CAOX3 said:


> Back when I started medics were hard to come by,there was a need for expanded scopes today you can throw a rock and have it bounce off three medics. Leave the als skills to the paramedics.



Whoa! There is only one working ALS medic for my county's EMS, and three total. One works BLS only and the other is a county commissioner and RARELY goes out on trucks.We used to have another active one, but he left due to travel time. Recieved Medic of the year, too, for giving O2 to a pt's dog after a house fire.


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## usalsfyre (Dec 3, 2010)

Bullets said:


> The fact that we drive an ambulance out into the deserts of arizona indicates to me that this is an emergent issue, and wouldn't the saline replace sodium list during extensive perspiration better then an equal volume of tap water?



Emergent situation for "border patrol needs you"? Maybe. True emergent patient presentations? I doubt it. 

Saline would replace sodium, and nothing else. There are better fluids for rehydration. Even better than pumping them full of fluid that will make their number look great for an hour or two before leaking out of the vascular space is gentle rehydration using something like gatorade and water half and half over several hours/days as well as a meal. It's realisticlly going to take a few days to rehydrate these people, not a matter of a liter or two. Learn how to calculate water defecit and you will see exactly how staggering of a loss it can be. Dumping fluid in the vascular space is sometimes the answer, but having uneducated EMTs with a merit badge (or for that matter, uneducated paramedics) doing it is asking for trouble. 

If you had bothered to look up the condition I was speaking of, it's a warning as to why you don't replace sodium TOO FAST. There's a lot to consider when messing with these things.


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## bstone (Dec 3, 2010)

usalsfyre is correct. This is why we need a LOT more education and higher standards.


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## jrm818 (Dec 3, 2010)

Bullets said:


> What acts faster? IV saline or tap water absorbed though osmosis?



Sure IV is a bit faster to reach the intravascular space, but I bet the time difference is on the order of minutes and is clinically insignificant except for an extremely volume depleted patient.  I have a hard time believing that these patients present to any system in large numbers (though I could be wrong).  For any patient IV access is not innocuous and neither is playing with body fluids.

Control of body fluid homeostasis is incredibly complex, and require much more consideration than "patient lost fluid, me give him some."  The body responses are different depending on source and speed of fluid loss, whether the fluid that was lost was isotonic/isoosmolar or something different, how severe the fluid loss was, etc.  Proper replacement of fluid in a super sick patient should probably include monitoring of a number of parameters (plamsa Na, K, glucose, protein conc, h&h, etc) that can't be done in the field. 

Multiple body systems (nearly every one, really) are involved in control of this stuff, and it strikes me as irresponsible and dangerous to start tinkering with physiology that isn't properly understood.


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## Cohn (Dec 3, 2010)

usalsfyre said:


> So then why not replace the bags of fluid with bottles of water?



When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?


What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?


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## Bullets (Dec 3, 2010)

usalsfyre said:


> Emergent situation for "border patrol needs you"? Maybe. True emergent patient presentations? I doubt it.
> 
> Saline would replace sodium, and nothing else. There are better fluids for rehydration. Even better than pumping them full of fluid that will make their number look great for an hour or two before leaking out of the vascular space is gentle rehydration using something like gatorade and water half and half over several hours/days as well as a meal. It's realisticlly going to take a few days to rehydrate these people, not a matter of a liter or two. Learn how to calculate water defecit and you will see exactly how staggering of a loss it can be. Dumping fluid in the vascular space is sometimes the answer, but having uneducated EMTs with a merit badge (or for that matter, uneducated paramedics) doing it is asking for trouble.
> 
> If you had bothered to look up the condition I was speaking of, it's a warning as to why you don't replace sodium TOO FAST. There's a lot to consider when messing with these things.



I was thinking emergent as in, we have a guy who just walked across a 100 degree desert for multiple days with no food or water, is possibly U/R. 


What condition? Dehydration? I'm aware that long term care requires gradual replenishment of fluids, but I'm not keeping him in my ambulance got 10 days, I just want to start treatment for the time it takes to get to an LZ, and get the patient flown to an ICU

If this was your patient, what would you have done? All you've fine so far is tell me how giving a dehydrated patient is bad.

I'm not stupid, I've taken the time to understand the science behind out interventions we administer. Im basing my "give fluids" on the assumptions that a.) I made a decent assessment and determined that this is the proper course of action and b.) Because this is a forum of what I assume is somewhat educated people I didn't have to spell out every medical complication and contraindication for every thing we do


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## bstone (Dec 3, 2010)

Would it be good for an EMT-B to have a patient completely prepped (including IV) for ALS when they arrive? Yes.

Does an EMT-B have the required training in order to do this? I don't think so. If the EMT-B cirriculum was to add an additional 40 hours simply for IV therapy and fluid theory then I would be more inclined. As it is EMT-B is a crashcourse of emergency medicine and it simply isn't in depth enough.


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## Bullets (Dec 3, 2010)

bstone said:


> Would it be good for an EMT-B to have a patient completely prepped (including IV) for ALS when they arrive? Yes.
> 
> Does an EMT-B have the required training in order to do this? I don't think so. If the EMT-B cirriculum was to add an additional 40 hours simply for IV therapy and fluid theory then I would be more inclined. As it is EMT-B is a crashcourse of emergency medicine and it simply isn't in depth enough.



I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology


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## CAOX3 (Dec 3, 2010)

Cohn said:


> When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?
> 
> 
> What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?



You should be concentrating on effective compressions, that's going to save more lives then an emt putting a line in someone.


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## EMS49393 (Dec 3, 2010)

Bullets said:


> I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology



I agree let's educate people.  Complete a paramedic program, preferably one that has a degree and all the associated classes required for said degree, THEN you can perform invasive patient care.

This "going half-way" with education is nonsense.  Go big or go home.  This profession is never going to get out of the dark ages until we stop half-***ing our education.


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## Bullets (Dec 3, 2010)

EMS49393 said:


> I agree let's educate people.  Complete a paramedic program, preferably one that has a degree and all the associated classes required for said degree, THEN you can perform invasive patient care.
> 
> This "going half-way" with education is nonsense.  Go big or go home.  This profession is never going to get out of the dark ages until we stop half-***ing our education.



But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%?  lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.


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## usalsfyre (Dec 3, 2010)

Cohn said:


> When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?
> 
> 
> What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?



Maybe because there will be people present who understand the pitfalls associated with fluid resucitation?


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## EMS49393 (Dec 3, 2010)

Bullets said:


> But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%?  lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.



I do not understand your logic.  Perhaps that is because I attend every one of my patients from start to finish and have since I became a paramedic.  As a matter of fact, my last service had a charter that specified that the paramedic attend every patient, regardless of complaint, findings, or how badly they might want to "bls" them.  

Your demolition expert and locksmith argument makes absolutely no sense.  They are two different occupations entirely.  You'll demolish your car because you locked your keys in the ignition?  That's just insane and frankly has nothing to do with medicine.  Regardless, both have many more educational hours behind them than the EMT-B.


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## Bullets (Dec 3, 2010)

EMS49393 said:


> I do not understand your logic.  Perhaps that is because I attend every one of my patients from start to finish and have since I became a paramedic.  As a matter of fact, my last service had a charter that specified that the paramedic attend every patient, regardless of complaint, findings, or how badly they might want to "bls" them.
> 
> Your demolition expert and locksmith argument makes absolutely no sense.  They are two different occupations entirely.  You'll demolish your car because you locked your keys in the ignition?  That's just insane and frankly has nothing to do with medicine.  Regardless, both have many more educational hours behind them than the EMT-B.



In NJ evey call for ems gets a bls truck, als only comes if our dispatcher determines the need, bls makes an assesment and may cancel medics if they aren't indicated


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## usalsfyre (Dec 3, 2010)

Bullets said:


> I was thinking emergent as in, we have a guy who just walked across a 100 degree desert for multiple days with no food or water, is possibly U/R.



Different situation than the guy that's not. Not the mention probably the minority of patients encountered. 




Bullets said:


> What condition? Dehydration? I'm aware that long term care requires gradual replenishment of fluids, but I'm not keeping him in my ambulance got 10 days, I just want to start treatment for the time it takes to get to an LZ, and get the patient flown to an ICU



Is waiting 10 minutes to start treatment clinically significant at this point? If he's unresponsive, a liter isn't going to even START to replace what he's lost. Why not wait for the crew who is familiar with all aspects?



Bullets said:


> If this was your patient, what would you have done? All you've fine so far is tell me how giving a dehydrated patient is bad.



Never said I wouldn't give fluid. In the unresponsive patient I'd start fluid resus quickly if I thought it was the right course. But it wouldn't be with NS, and there's other things the unresponsive dehydration patient needs beside fluid. 



Bullets said:


> I'm not stupid, I've taken the time to understand the science behind out interventions we administer. Im basing my "give fluids" on the assumptions that a.) I made a decent assessment and determined that this is the proper course of action and b.) Because this is a forum of what I assume is somewhat educated people I didn't have to spell out every medical complication and contraindication for every thing we do



NONE of this is covered in basic class. Not one iota. It's not even really adaquately covered in paramedic school. So to assume the lower levels have any mastery of this material without extensive self (i.e. non-mandated) study is patently false.


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## Amber2313 (Dec 3, 2010)

Bullets said:


> But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%?  lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.



Not every call requires a medic, but that doesn't mean basics shouldn't be educated as much as possible/willing, does it?

So I have this question (and I know it's not the same thing), but back home I work for a BLS service, NOT 911. We do emergent and non-emergent transports, though. Anyway... in the summer, we're contracted, for several years now, to work a local dirt track every weekend. We take two trucks (a local volunteer FD has a truck there too) and play standby until someone rolls or track personnel decide we need to be down there. Our crews are either basic/driver or basicx2. We have one medic, but since it's only a BLS service, he can't really play medic. He's one of those guys that hangs around until a "good" call comes up, then wants to play. I'm a basic. If we were called to the track (only one truck goes at a time unless it's obviously more than one can handle or the first truck down calls for assistance) and found a patient in need of transport to ER, should the medic take over simply because he's a medic or does it matter since it's only a BLS service to begin with?


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## usalsfyre (Dec 3, 2010)

Bullets said:


> I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology



240 hours is a joke. Heck, the 770 that is the minimum for paramedic in Texas is a joke.


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## usalsfyre (Dec 3, 2010)

Bullets said:


> But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%?  lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.



And yet, everyone of those people will see a physician, or at least a midlevel at the end of the line.


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## EMS49393 (Dec 3, 2010)

Bullets said:


> In NJ evey call for ems gets a bls truck, als only comes if our dispatcher determines the need, bls makes an assesment and may cancel medics if they aren't indicated



Well that is certainly fair for the patient.  Good thing they're going to the ER.

Dispatchers base their calls on information provided from the call, which is often incorrect or incomplete.  It's fallible, and patients have suffered.

Your class is 120 hours long, how much assessment did you actually learn?  Enough to determine if a patient is sick enough for a paramedic?  I doubt that.  I couldn't do it when I was an EMT.  

The system is flawed, period.  Every patient deserves the highest level of assessment and care.  Increasing your little EMT class a few hours so you can do some "cool" skills is not the answer.  

So far I haven't read one valid argument in this thread for why a patient needs that IV as performed by a basic.  I have read more than one valid argument for why they need a higher level of care.


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## usalsfyre (Dec 3, 2010)

Why do ya'll have the desire to start administering fluids without the educational background?


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## mikie (Dec 3, 2010)

*EMT's Starting IV's around here...*

Come to Baltimore county and become an "IV-Tech"

2 8(?) hour classes & 10 IV attempts at a local hospital will get you a little certificate saying your a basic that can start a line, KVO, Lactated Ringers (only fluid we carry in the county) or locks in peripheral veins. Won't waist my time taking the class since I'm already a paramedic student doing IV's in the clinical/field setting and have learned about phlebotomy though my paramedic curriculum.

In my opinion, it shouldn't be taught in the basic curriculum, but like that of certain skills, should be a certifiable adjunct skill depending on your REGION. (not that I particularly like the IV tech program in BaCo; there's a hospital or ALS provider <5 minutes away, however an EMT with an hour + transport time, in rural Wyoming might need that access.  Hell, can't they do IO's as basics (w/ a supplemental course)?


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## Veneficus (Dec 3, 2010)

*Where to begin?*

I know:

http://www.youtube.com/watch?v=PJy9FKh0OIs

Why don't we just have basics take about 40 hours of watching this, and then they can do that on a STEMI alert so they don't have to wake up a surgeon? Afterall, they have seen IV fluids given many times without knowing the physiology behind it.

Sounds stupid doesn't it?

Many people have already offered that fluid and electrolyte balance is complex. But rather than echo their statements, let me offer some perspective in simple words?

The body conserves sodium when sweating, only a very small amount is actually lost. This helps pull intracellular fluid into the vascular space. 

In dehydration, without intake, the kidneys then start reabsorbing larger amounts of salt.

(See the salt increasing? because the water is decreasing?)

Now your plan is to introduce salt water into the vasculature? Which is going to increase the salt further. Remember NaCl is only mostly isotonic under physiologic conditions. But it is hard to know that just watching the end point of IV starts.

Are you planning to further dilute your normal saline to 1/2 normal or carry 1/2 normal or something more expensive like a colloid mix, in order to increase watercontent under these pathologic conditions?

How will you know when to do that?

If a paramedic starts an IV and runs NS on severely dehydrated patients, they are wrong.

In as few words as possible: hypernatremia -> arryhthmia -> vfib -> cardiac arrest.

Now the basic is going to need to intbate and push drugs because the medic is still 45 minutes out.

Let me address the drugs. Unless there is a specific etiology identified, drugs usually have no measurable effect in cardiac arrest. 

I would rather a medic take a few minutes while CPR continues to try and identify a reversible cause than to rapidly follow an algorythm based on epidemiology and if the patient doesn't fall in the parameters, too bad, so sad.

One of the most important things any healthcare provider anywhere can do is not make the situation worse. If you do not make the situation worse and just transport to somebody who can help, you have done not only the right thing, but a great thing.

Please, EMS does not perform surgery on trauma patients because it is rather complex decison making. (a butcher could do the physical skills, and probably has enough experience)  Why is anyone advocating trying to balance fluid and electrolytes without the same level of decision making?

The reason we do not put insulin on EMS units is because it takes a knowledgable and skilled practicioner to slowly bring things into balance. 

If there was a hyperthermic patient would you advocate dousing them in icewater and hope they didn't become hypothermic? If they did, too bad, so sad?

Of course not, in the severly hyperthermic we reduce temperature in a controlled way. So as to prevent rebound hypothermia. 

Any idiot can perform skills, it doesn't take an EMT. But just like we make people go to a doctor to get the proper medicine prescribed, just like we make them go to a pharmacist to dispense it to them, we don't want the local street dealer deciding what your ailment needs, mixing product, and handing it out to anyone who comes across his service. 

What makes letting an EMT-B do it without the education and knowledge different?

If the only difference is intent, keep in mind there is more than 1 "herbal remedy" dealer who has the best of intentions dolling out what they think should help without sound education behind it.

Teaching Basics to cannulate a vein/draw blood etc. is rather easy and not a very significant skill. 

However, once you start adding medications to the mix, (Saline is by the board of pharmacy a medication) then it is no longer a skill and becomes clinical decisoon making. 

Making decisons requires appropriate education.

If some whacker came on here, said they had no medical education and asked where they could get IV supplies to take on his camping trip "just incase," even the basics here would be jumping all over him.

Does knowing CPR somehow put Basics on a higher plane? What if our would be hero knows CPR too?

Would you be ok with the LPN initiating Pressors, sedatives, or neuromuscular blockers because he works in the ICU and sees it all the time? How about defibrillating, placing a chest tube, or termnating efforts? 

What do yo think? Add on 40 hour course to determine when efforts should be terminated?


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## Bullets (Dec 3, 2010)

usalsfyre said:


> Why do ya'll have the desire to start administering fluids without the educational background?



I want the education, but my state doesnt allow it, make basic an associates degree! Take the onus on education out of the individuals hands and require more, acls, phtls, peeps, all should be required for certification, I agree the education is lacking. I want more, but the state only allows me to do so much and I can't go into a medic perform right now


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## Amber2313 (Dec 3, 2010)

I've been following this thread pretty closely and here's what I've come up with.

At first I thought heck yes, the more you know the more you're worth, why not let basics start IV? Then the more I read these I thought heck, if a basic wants to start IVs, go advanced (or whatever that would be in their area). Doing IVs requires more education. That's obvious. But isn't that why we have the different levels? (EMT-B, -A, -I, -P here) 
If you want to play with needles, go get educated, eh?


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## wyoskibum (Dec 3, 2010)

mikie said:


> In my opinion, it shouldn't be taught in the basic curriculum, but like that of certain skills, should be a certifiable adjunct skill depending on your REGION. (not that I particularly like the IV tech program in BaCo; there's a hospital or ALS provider <5 minutes away, however an EMT with an hour + transport time, in rural Wyoming might need that access.  Hell, can't they do IO's as basics (w/ a supplemental course)?



Even in rural Wyoming, EMT basics do not do more than the National Standard Curriculum.  Wyoming does have an aggressive EMT-I level. They can start IV's, administer fluids & meds, intubate, etc.., but there is a lot of oversight by medical control and they need to get orders for certain interventions.


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## LonghornMedic (Dec 3, 2010)

Bullets said:


> I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology



It's called EMT Intermediate.


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## Bullets (Dec 3, 2010)

LonghornMedic said:


> It's called EMT Intermediate.



Add it to the list of things Jersey doesn't allow. Bass ackwards ems since 1921


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## jrm818 (Dec 3, 2010)

Veneficus said:


> In dehydration, without intake, the kidneys then start reabsorbing larger amounts of salt.
> 
> (See the salt increasing? because the water is decreasing?)
> 
> Now your plan is to introduce salt water into the vasculature? Which is going to increase the salt further. Remember NaCl is only mostly isotonic under physiologic conditions. But it is hard to know that just watching the end point of IV starts.



Agree with all of your post, but if I you don't mind a brief hijack,

If serum Na+ is increased (say to 160 meq/L), 0.9% saline (154 meq/L Na+) is actually relatively hypotonic.   Despite the addition of salt to the body, there will be a water gain such that there is net sodium dilution with NS administration (assuming serum Na+ is above 154).  Obviously this will be a slower way of restoring volume than more dilute fluid, and 154 meq/L is a bit higher than normal sodium level, but even with those drawbacks, I don't understand how NS would actually worsen hypernatremia.  What am I missing?


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## Veneficus (Dec 3, 2010)

jrm818 said:


> Agree with all of your post, but if I you don't mind a brief hijack,
> 
> If serum Na+ is increased (say to 160 meq/L), 0.9% saline (154 meq/L Na+) is actually relatively hypotonic.   Despite the addition of salt to the body, there will be a water gain such that there is net sodium dilution with NS administration (assuming serum Na+ is above 154).  Obviously this will be a slower way of restoring volume than more dilute fluid, and 154 meq/L is a bit higher than normal sodium level, but even with those drawbacks, I don't understand how NS would actually worsen hypernatremia.  What am I missing?



The amount of free water (and as I honestly forgot, the compensatory electrolyte balance)

Also for your reading:

http://emedicine.medscape.com/article/766683-overview


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## jrm818 (Dec 3, 2010)

So I think I'm still missing something.

from the emed "treatment" section:

http://emedicine.medscape.com/article/766683-treatment
"Using isotonic sodium chloride solution, stabilize hypovolemic patients who have unstable vital signs before correcting free water deficits because hypotonic fluids quickly leave the intravascular space and do not help to correct hemodynamics. Once stabilization has occurred, free water deficits can be replaced either orally or intravenously."

A desert dehydrated patient will be hypovolemic as well as hypernatremic.  0.9 NS does little to correct the water deficit, I understand that.  But I still don't see how it could increase serum Na+....and the eMed advice is to give NS to correct hypovolemia before worrying about the free water.


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## jgmedic (Dec 3, 2010)

EMS49393 said:


> I do not understand your logic.  Perhaps that is because I attend every one of my patients from start to finish and have since I became a paramedic.  As a matter of fact, my last service had a charter that specified that the paramedic attend every patient, regardless of complaint, findings, or how badly they might want to "bls" them.
> 
> Your demolition expert and locksmith argument makes absolutely no sense.  They are two different occupations entirely.  You'll demolish your car because you locked your keys in the ignition?  That's just insane and frankly has nothing to do with medicine.  Regardless, both have many more educational hours behind them than the EMT-B.



This. A demo expert is most likely not trained as a locksmith. However, as a medic, I have been trained to and past the EMT-B level.


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## Veneficus (Dec 3, 2010)

jrm818 said:


> But I still don't see how it could increase serum Na+....and the eMed advice is to give NS to correct hypovolemia before worrying about the free water.



If you have compensatory increase in intracellular cation, When you add another one like NA++ it is not going to rapidly diffuse into the cell. The NA can be in either the intravascular or extra cellular space, but the point is it is not in the cell. Which brings you to hypervolemic/hypernatrium and the water not being in the cell where it needs to be to ultimately "fix" the person.

If I understand as well, the emed article is based around treatment for acute hypernatremia, in the scenario given, the potential patients may likely have been suffering for days.  

I think more importantly:

"Hypernatremia should not be corrected at a rate greater than 1 mEq/L per hour."

http://emedicine.medscape.com/article/766683-media

Based on that are you advocating NS wide open for the chronically dehydrated as was postulated in the original argument?


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## jrm818 (Dec 3, 2010)

Veneficus said:


> If you have compensatory increase in intracellular cation, When you add another one like NA++ it is not going to rapidly diffuse into the cell. The NA can be in either the intravascular or extra cellular space, but the point is it is not in the cell. Which brings you to hypervolemic/hypernatrium and the water not being in the cell where it needs to be to ultimately "fix" the person.
> 
> If I understand as well, the emed article is based around treatment for acute hypernatremia, in the scenario given, the potential patients may likely have been suffering for days.
> 
> ...



OK, did some reading/remembering and I think I'm almost with you.  I had forgotten about the compensatory increase in intracellular cations, and never knew about the increase in intracellular organic osmoles, but do now.  My last hang up is that as cations and other osmoles increase in the cellular space, the cellular interior becomes progressively hyperosmotic compared to NS, leading to increased water movement into the cells when NS is administered.

Obviously dilute fluids would lead to more water entry into cells, but NS should lead to _some _water moving in, shouldn't it?  And actually, if we're concerned about too rapidly increasing intracellular volume, wouldn't we be more worried about more dilute IV fluids too rapidly moving water into cells?

As for the last question, I don't think I'd consider myself qualified at this point to be trying to empirically rehydrate/osmotically balance a patient like this, so really I wouldn't say I'd "advocate" for anything.  

That said, even before my increase in understanding I wouldn't have thought that wide open anything was a good plan.  I would have thought "OK" to controlled boluses if we're looking at a really sick patient, but for most patients I would have been inclined to maybe do some oral rehydration and let the hospital do anything more drastic with bloodwork to guide them.

Much thanks for the input.  I appreciate it.


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## Bullets (Dec 3, 2010)

Gentleman, thank you to both, that is an excellent article and I learned a bunch. As always, this place is a wealth of knowledge.


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## Bubz628 (Dec 3, 2010)

I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)


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## the_negro_puppy (Dec 3, 2010)

Bubz628 said:


> I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)


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## anestheticmedic (Dec 3, 2010)

IVs aren't that hard, but neither is acls so might as well learn that too if u can start IVs. etc etc just go get your medic. I understand what the OP means but then the paragods had to jump in and overanalyze the whole thing and act like it's a highly advanced skill that only us super awesome medics should get.


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## JPINFV (Dec 3, 2010)

Chimpie said:


> This is *not *going to turn into a Basics vs Intermediates vs Paramedics thread.



Can I still laugh at the people posting, "This is mine, not yours. You can't have because it's mine," posts that presents no rational argument? Sure, there are legitimate and rational arguments for and against EMTs doing IVs under the direct supervision of a paramedic. On it's face, "Take a few months and get a higher license" is not one of them.


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## MrBrown (Dec 3, 2010)

Bubz628 said:


> I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)



But but but he has at least 12 weeks of training!


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## JPINFV (Dec 3, 2010)

lampnyter said:


> 8/10 calls an IV is started



So? Are you going to say that 8/10 calls also are so critical that the minute or so it takes the paramedic to prep and place an IV makes a difference in the outcome? Similarly, how much of that time could be taken by a well trained EMT assisting with getting the supplies out, and if fluids are going to be ran, spiking the bag and priming the IV line?


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## JPINFV (Dec 3, 2010)

Bullets said:


> All I want is d50, nebulize, fluids, maybe a 3 lead. It would cut our dependancy on MICs and speed up calls



How much additional education are you planning on adding to the EMT program in order to provide a sufficient education background on both the interventions listed (including rhythm interpretation for the 3 lead), as well as both the diseases that those interventions treat and the common diseases that presents similarly?


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## JPINFV (Dec 3, 2010)

jtpaintball70 said:


> EDIT: Wait, nebs aren't in the basic scope there?



Not all places allows EMTs to administer albuterol nebs, and some of those that do are so restricted that they might as well not be in place.


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## JPINFV (Dec 3, 2010)

ems.amber911 said:


> Out of all that, I see your EMT is always with a medic. That's not true. For my county, we have one working medic. The other is commissioner and doesn't go out very often, if at all. I'm not saying basics should absolutely, hands-down be able to start IVs (frankly, I don't see it happening, but for the sake of conversation...), but I would always err on the side of education. If it were an option, I'd feel comfortable with them learning, but as I see it now, go advanced or hands off the needles.




The problem is that the IV itself solves very little in most patients. Most patients don't need fluids, so what's the point of establishing a medication route when you lack the ability to administer any medications via that route? At least in a paramedic/EMT ambulance, the paramedic can use the IV. A pure EMT ambulance, not so much.


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## Bullets (Dec 3, 2010)

JPINFV said:


> How much additional education are you planning on adding to the EMT program in order to provide a sufficient education background on both the interventions listed (including rhythm interpretation for the 3 lead), as well as both the diseases that those interventions treat and the common diseases that presents similarly?



However long it takes to properly educate and cover the material if it takes 40 hours, fine, 100 then fine, I don't know a specific number


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## EMS49393 (Dec 4, 2010)

Bullets said:


> However long it takes to properly educate and cover the material if it takes 40 hours, fine, 100 then fine, I don't know a specific number



I spent somewhere in the neighborhood of 3000 hours over a little more than two years obtaining my paramedic.  Are you ready to engage in that much education?  If so, there is no time like the present.

Do you see how ridiculous an additional 40 or even 100 hours of training seems to someone that has over 3000 hours under their belt?  

It has nothing to do with being better than you in life, it has to do with patient care and what is in that patient's best interest.  Invasive skills performed by those that do not understand them is dangerous and is likely to cause more harm then good.  Understand this very important point that was drilled into me during my time in the classroom:

Screw up, you WILL be sued.  Don't try to use the "I didn't know" argument because it will not work and you'll be handed to the wolves (judge and jury).

Be responsible, get an education, understand what you are doing, then proceed with all your "cool skills."  I bet they'll seem much less cool when you truly understand the consequences of everything you do for a patient.


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## Bullets (Dec 4, 2010)

EMS49393 said:


> I spent somewhere in the neighborhood of 3000 hours over a little more than two years obtaining my paramedic.  Are you ready to engage in that much education?  If so, there is no time like the present.
> 
> Do you see how ridiculous an additional 40 or even 100 hours of training seems to someone that has over 3000 hours under their belt?
> 
> ...



I don't think I need 3000 hours to learn how to start an IV and draw blood labs. 
Maybe in york, als is used more. And if I had to take a patient from new oxford or berlin to gettysburg, I'd want als for that transport. But where I operate, Als is only needed on about 20% of all the calls the hospital gets. 

We don't need more als providers in our area we already have a good system, probably the only good thing about nj ems. I also don't think put patient need to get an $1100 bill just because "everyone should get medics" for the 5-10 minute ride to the hospital after a jammed finger or bad gas. We rarely get a bad dispatch that requires medics when they weren't requested, I literally can't recall a time when that was an issue

A 2 tiered system can work, we just need to work on it. As a profession, and as a medical field we are a baby, we are growing and beginning to understand that there is something better out there. We aren't far removed from fire departments fighting in the streets over who puts out a fire, we just fight on line and at conferences instead. We wil get there, it will take time


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## Veneficus (Dec 4, 2010)

jrm818 said:


> OK, did some reading/remembering and I think I'm almost with you.  I had forgotten about the compensatory increase in intracellular cations, and never knew about the increase in intracellular organic osmoles, but do now.  My last hang up is that as cations and other osmoles increase in the cellular space, the cellular interior becomes progressively hyperosmotic compared to NS, leading to increased water movement into the cells when NS is administered..



I don't understand what the hang up is? Yes there would be some movement of water into the cells. But you still have excess solute.



jrm818 said:


> Obviously dilute fluids would lead to more water entry into cells, but NS should lead to _some _water moving in, shouldn't it?  And actually, if we're concerned about too rapidly increasing intracellular volume, wouldn't we be more worried about more dilute IV fluids too rapidly moving water into cells?.



I think the idea is oral fluids being best in somebody capable of drinking it. Then you are adding no solutes, and the body is regulating absorbtion. As for more dilute IV, yes, it would move water faster so the regulation become the amount and speed administered by the provider.


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## Cohn (Dec 4, 2010)

I got a better question whose protocols allows eating a drinking in the box?


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## AustinNative (Dec 4, 2010)

Chimpie said:


> This is *not *going to turn into a Basics vs Intermediates vs Paramedics thread.


 Have you seen that video of the trooper and the EMT???


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## Shishkabob (Dec 4, 2010)

AustinNative said:


> Have you seen that video of the trooper and the EMT???



What does that have to do with anything?


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## Chimpie (Dec 4, 2010)

AustinNative said:


> Have you seen that video of the trooper and the EMT???





Linuss said:


> What does that have to do with anything?



Nothing.  So let's keep this on topic.  Thanks.


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## Amber2313 (Dec 4, 2010)

Cohn said:


> I got a better question whose protocols allows eating a drinking in the box?



-raises hand- ...but that's BLS transport, not lights and sirens. Actually one of our ex-employees was fired for not letting a patient (or pt's family member, I don't remember) bring their water because "it could get spilled in his rig" and he was rude abouit it. 
On second thought, I suppose if it were lights and sirens and our patient wanted to bring something, we'd let them there too, just never had to worry about it.


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## AustinNative (Dec 4, 2010)

Linuss said:


> What does that have to do with anything?



Nothing.  It was a joke about beating a dead horse.  This topic has been flogged more than once.  Relax a bit, eh?


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## Cohn (Dec 4, 2010)

ems.amber911 said:


> -raises hand- ...but that's BLS transport, not lights and sirens. Actually one of our ex-employees was fired for not letting a patient (or pt's family member, I don't remember) bring their water because "it could get spilled in his rig" and he was rude abouit it.
> On second thought, I suppose if it were lights and sirens and our patient wanted to bring something, we'd let them there too, just never had to worry about it.






The big thing about eating and drinking in the box is from what I am told is that its dirty and if the pt needs surgery a full tummy is not ideal.


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## Amber2313 (Dec 4, 2010)

Cohn said:


> The big thing about eating and drinking in the box is from what I am told is that its dirty and if the pt needs surgery a full tummy is not ideal.



BLS transport. In that case I'm usually not taking pt's in for surgeries they don't already know about, and then they would know prior and would be directed by their Dr. not to eat or drink. 
At that company, the rigs are rarely worth worrying about. Private ambulance service usually taking pt's to&from dialysis and running light and sirens mainly when they feel sick and call us because it's familiar. We also have hospital to hospital (hicktown,  own hospital is little more than a bandaid station with cool cameras). 
Anyway... too many examples to explain. I understand, though.


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## HappyParamedicRN (Dec 4, 2010)

The problem is that ems unfortunatly has the highest risk for iv related infections, so why put patients through this if they really do not need it prehospital.  Also a service would not be able to reccoop that money from insurance companies at the bls level.  Also most ERs in this area draw bloods when they put the line....

just my two cents


happy


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## usalsfyre (Dec 4, 2010)

Cohn said:


> The big thing about eating and drinking in the box is from what I am told is that its dirty and if the pt needs surgery a full tummy is not ideal.



Dirtier than a hospital room? How many of your able to orally hydrate dessert walkers need emergent surgery? This is a pretty easy thing to assess for, but again requires more than 3 weeks worth of medical knowledge. 

While not normally a fan of situation specific protocols, this one kinda calls out for one.


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## Shishkabob (Dec 4, 2010)

HappyParamedicRN said:


> The problem is that ems unfortunatly has the highest risk for iv related infections,



No.

I have yet to see a single big study that has shown any major, let alone minor, increase in infection between pre-hospital and hospital initiated IV lines.  Heck, here's just one study.



http://www.annemergmed.com/article/S0196-0644(95)70266-0/abstract

"There was one infection in the prehospital group and four in the in-hospital group (infection rate: .0012 for prehospital patients and .0017 for in-hospital patients"


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## JPINFV (Dec 4, 2010)

Cohn said:


> I got a better question whose protocols allows eating a drinking in the box?




Um, that's more directed at the crew (who is more likely to eat and drink on an ambulance) since the crew is not supposed to eat unless there's a partition between the cab and the back, they change clothes before entering the cab, and they wash their hands. Generally, I've found that unless you're in a station deployment model very few people follow this rule, and even if you are in a station deployment system, then if it's extremely busy the rule isn't followed. Now, the big question is how strictly is this enforced.


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## jrm818 (Dec 4, 2010)

Veneficus said:


> I don't understand what the hang up is? Yes there would be some movement of water into the cells. But you still have excess solute.
> 
> 
> 
> I think the idea is oral fluids being best in somebody capable of drinking it. Then you are adding no solutes, and the body is regulating absorbtion. As for more dilute IV, yes, it would move water faster so the regulation become the amount and speed administered by the provider.



I think I may have misinterpreted your original statement.  I thought you said that NS administration would lead to increased Na+ concentration and baddness because of that increase in concentration.  It will increase total body sodium, but I'm still not seeing how it would increase the actual  concentration since NS is a dilute fluid relative to hypernatremic serum or cells.

I do understand why oral is better and NS isn't the best choice, but I don't see where the actual harm would be from administering it to someone whose sodium is above 154 meq/L.


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## Shishkabob (Dec 4, 2010)

There's a reason why we like to use half-NS when a patient is hypernatremic.  B)


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## Sandog (Dec 4, 2010)

After reading this thread I decided to read up on some of the issues discussed here. I found this really good read on fluid physiology, it is quite comprehensive and I thought it may be of interest to some of you. 

http://www.anaesthesiamcq.com/FluidBook/index.php


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## TraprMike (Dec 5, 2010)

it is up to NO BODY on this board to decide weather or not EMT-B's should start an IV. 

maybe the phrase, " Local Protocol" doesn't exist anymore?


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## JPINFV (Dec 5, 2010)

TraprMike said:


> it is up to NO BODY on this board to decide weather or not EMT-B's should start an IV.
> 
> maybe the phrase, " Local Protocol" doesn't exist anymore?



Well...that's it. Shut down the message board since none of us have the direct power to control anything unless you're in the legislature or a medical director. 
:unsure:


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## ffemt8978 (Dec 6, 2010)

TraprMike said:


> it is up to NO BODY on this board to decide weather or not EMT-B's should start an IV.
> 
> maybe the phrase, " Local Protocol" doesn't exist anymore?



You might want to avoid absolute statements like that.  We have some members that are medical directors for various agencies, and it is absolutely up to them if their EMT-B's can start IV's (subject to state regulations).

Also, local protocols generally must follow what the state and/or licensing agency allows for that level.


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## brentoli (Dec 6, 2010)

Bullets said:


> All I want is d50, nebulize, fluids, maybe a 3 lead. It would cut our dependancy on MICs and speed up calls



Taking a different approach here...

From my limited billing knowledge, Medicare/Medicaid/Insurance won't reimburse for something out of the "average standard of practice" so if they get a bill for a basic truck at the ALS1 level (or wherever a stick, d50, and a 3 lead would fit) they won't pay it. Those things don't come free, so how would you expect to make up your costs?


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## JPINFV (Dec 6, 2010)

brentoli said:


> Taking a different approach here...
> 
> From my limited billing knowledge, Medicare/Medicaid/Insurance won't reimburse for something out of the "average standard of practice" so if they get a bill for a basic truck at the ALS1 level (or wherever a stick, d50, and a 3 lead would fit) they won't pay it. Those things don't come free, so how would you expect to make up your costs?



Reform medicare. 

Balance bill patients when it isn't illegal (illegal for medicare/medicade. Other than that, it's dependent on the contract the service signed with the insurance companies). 

Make EMS 3rd service and supplement it with tax dollars similar to the fire department and law enforcement.


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## TraprMike (Dec 6, 2010)

ffemt8978 said:


> You might want to avoid absolute statements like that.  We have some members that are medical directors for various agencies, and it is absolutely up to them if their EMT-B's can start IV's (subject to state regulations).
> 
> Also, local protocols generally must follow what the state and/or licensing agency allows for that level.



Exactly!  !its up to the Med Dir!!!.. thank you !!!!1111!!:excl:

gesh,,, this place is to intence.. 

and I will not avoid Absolute statements.. ff,emt, webboard nerd.. you are on a bunch of boards, like me, 

oh forget it...


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## CAOX3 (Dec 6, 2010)

Your right its up to your medical director.  I just don't understand the benefit, I have read all thirteen pages, I have operated as an emt for fifteen years, I just can't see it, your patients are not dying or suffering because an emt can't start a line if they are them your whole system needs an overhaul.

You can't replace a medic by teaching a basic a few more tricks.

My opinion.


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## Bullets (Dec 6, 2010)

Because we don't bill on either squad I ride with. One is a police based department and money comes out of tax dollars. The other is a staffed volunteer squad that is a private non-profit and survives on donations and fund raising


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## wyoskibum (Dec 6, 2010)

*lighten up Francis....*



TraprMike said:


> Exactly!  !its up to the Med Dir!!!.. thank you !!!!1111!!:excl:
> 
> gesh,,, this place is to intence..
> 
> ...




The purpose of this forum is to allow EMS related discussion such as this one.  Obviously there has been a lively debate for and against EMT-B's starting IV's.  There are those who are very passionate about their opinions. At some point you have agree to disagree and move forward.

Just my $.02 worth.


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## JPINFV (Dec 6, 2010)

TraprMike said:


> webboard nerd..


I do believe that the proper term is forum trollup.


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## MS Medic (Dec 6, 2010)

This is a topic that is discussed at nauseum (spelling?), both on these boards and in the truck/station. I will admit that when I was a basic, I was on the side of letting basics do it because of a lack of knowledge on the subject. So here it is:

The psycho-motor skill of starting an IV is not that hard. In fact, you could probably train a chimp to do it with enough rote repetition. The problem lies in what you do after the IV is established. IV fluids, in all of its incarnations, are FDA CONTROLLED MEDICATION (caps for emphasis only). Like all medications, IV fluids have negative effects which can be lethal if given incorrectly.
Paramedic pharmacology courses, at bare minimum, will cover the different hypotonic, hypertonic, and isotonic solutions and what effect each will have on the body. There will also be education on disease processes such as ERSD and CHF, so that you understand the effects of fluid administration. The pathophysiology of different types of shock will also be covered so that you know when to give large boluses and when to judiciously control it so the pt does not have pink kool-aid that will not carry O2 in their veins. 
The reason EMT-Bs should not start IVs is because you don't get sufficient education in these areas and the potential consequences of something going wrong outweighs any benefit that might come from a Basic starting an IV to help a nurse or medic.


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## JPINFV (Dec 6, 2010)

MS Medic said:


> The problem lies in what you do after the IV is established. IV fluids, in all of its incarnations, are FDA CONTROLLED MEDICATION (caps for emphasis only). Like all medications, IV fluids have negative effects which can be lethal if given incorrectly.


Most of what is on the ambulance is FDA controlled. You can't just go out and buy medical grade oxygen and administer it all willy nilly either. 


> The reason EMT-Bs should not start IVs is because you don't get sufficient education in these areas and the potential consequences of something going wrong outweighs any benefit that might come from a Basic starting an IV to help a nurse or medic.



However I do agree with this.


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## Veneficus (Dec 6, 2010)

wyoskibum said:


> The purpose of this forum is to allow EMS related discussion such as this one.  Obviously there has been a lively debate for and against EMT-B's starting IV's.  There are those who are very passionate about their opinions. At some point you have agree to disagree and move forward.
> 
> Just my $.02 worth.



EMS is like one big dysfunctional family during the holidays. If we are not arguing it means somebody is sick.


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## MS Medic (Dec 6, 2010)

JPINFV said:


> Most of what is on the ambulance is FDA controlled. You can't just go out and buy medical grade oxygen and administer it all willy nilly either.


Yes, that was my point.


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## TransportJockey (Dec 6, 2010)

Veneficus said:


> EMS is like one big dysfunctional family during the holidays. If we are not arguing it means somebody is sick.



Lol, I'll have to remember that it's so funny and true


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## JPINFV (Dec 6, 2010)

MS Medic said:


> Yes, that was my point.



Sorry, I thought the argument you were making was that EMTs shouldn't start IVs because IV supplies and fluids are FDA controlled.


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## brentoli (Dec 6, 2010)

Bullets said:


> Because we don't bill on either squad I ride with. One is a police based department and money comes out of tax dollars. The other is a staffed volunteer squad that is a private non-profit and survives on donations and fund raising



I dont want to go too far off topic here, but being a non profit doesn't mean you can't bill. In fact one of the problems with EMS is the providers who don't bill. Theres no other facet of healthcare that doesn't bill for its services. What makes EMS diffrent?

[/offtopic]


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## MS Medic (Dec 6, 2010)

JPINFV said:


> Sorry, I thought the argument you were making was that EMTs shouldn't start IVs because IV supplies and fluids are FDA controlled.


No, only pointing out that it is a drug and should only be dispensed with proper training as to the effects and consequences. Sorry if I was not clear.


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## Tigger (Dec 6, 2010)

jtpaintball70 said:


> In some places they can (like Colorado) but they don't have the knowledge to know what they're doing a majority of the time. Hell an Intermediate usually doesn't have all the proper knowledge and education needed to know all of why and how they're doing it.



I would certainly agree that most basics in Colorado do not have requite knowledge to start IVs. That said, in many systems there are no Basic/Basic trucks, but almost all P/B, so at least the Basic is starting the IVs under the direction and supervision of a paramedic that hopefully does have the requisite knowledge surrounding IVs.

Also, current CO protocols have provisions for Basics to push front-line cardiac drugs during arrests under the direction of the medic. Presumably this frees up the medic to intubate and work the monitor. Seems to work ok where I am. Realistically I'm not sure how that happens, at least in my area nearly all calls get a P/B ambulance and a fire unit with at least one paramedic.

Just in case your curious to how the protocols read:

SECTION 4 - Medical Acts Allowed for the EMT-Basic  

4.6   
An EMT-Basic with IV authorization may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications which exceed those listed in Appendices B and D of these rules for an EMT-Basic with IV authorization under the direct visual supervision of an 
EMT-Intermediate or Paramedic when the following conditions have been 
established:  

a) The patient must be in cardiac arrest or in extremis. 

b) Drugs administered must be limited to those authorized by the BME for EMT- Intermediate or Paramedic as stated in Appendices B and D in accordance 
with the provisions of Section 3 of these rules.   

c) The medical director(s) must amend the appropriate protocols and medical continuous quality improvement program used to supervise the EMS 
personnel to reflect this change in patient care.  The medical director(s) and 
the protocol(s) of the EMT-Basic and the EMT-Intermediate or Paramedic, 
must all be in agreement.


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## Veneficus (Dec 6, 2010)

Tigger said:


> Also, current CO protocols have provisions for Basics to push front-line cardiac drugs during arrests under the direction of the medic. Presumably this frees up the medic to intubate and work the monitor. Seems to work ok where I am. Realistically I'm not sure how that happens, at least in my area nearly all calls get a P/B ambulance and a fire unit with at least one paramedic.



Cut for brevity.

Since there is no evidence of the effectiveness of medication in cardiac arrest, giving meds to basics is the capitulation of treating people based soley on epidemiology with all but bogus treatment modalities.  

In my opinion, a fail.


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## Tigger (Dec 6, 2010)

Veneficus said:


> Cut for brevity.
> 
> Since there is no evidence of the effectiveness of medication in cardiac arrest, giving meds to basics is the capitulation of treating people based soley on epidemiology with all but bogus treatment modalities.
> 
> In my opinion, a fail.



Note that I am not attempting to call for the starting of IVs by Basics, but I don't think that the state has "given" the basics the meds in this case, the basic does not decide which drug or when to give it, that's the medic's job. It's just like in the ED, the attending might order epi or the like, but he doesn't physically draw and push it himself, he delegates it to a nurse. 

Am I understanding your argument to be that you do not see the need for pre-hospital use of ACLS drugs? Not a hostile question, merely curious.


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## Veneficus (Dec 6, 2010)

Tigger said:


> Note that I am not attempting to call for the starting of IVs by Basics, but I don't think that the state has "given" the basics the meds in this case, the basic does not decide which drug or when to give it, that's the medic's job. It's just like in the ED, the attending might order epi or the like, but he doesn't physically draw and push it himself, he delegates it to a nurse.
> 
> Am I understanding your argument to be that you do not see the need for pre-hospital use of ACLS drugs? Not a hostile question, merely curious.



My argument is that blindly following an algorythm that uses drugs not demonstrated to have an outcome without the ability to recognize the need for or deviation in a specific patient is not good medicine.

The drugs in the ACLS cardiac arrest algorythm are based on what theorhetically "might help is not shown to harm" for the most common causes of cardiac arrest.

If you are following that drug sequence because it is the sequence, it means that you have not been able to identify a reversible cause of cardiac arrest and are treating it strictly by the numbers.

Without the ability to identify and treat cardiac arrest, following that procedure is simply treating epidemiology. 

There have been several initiatives over the years to create "cardiac techs" who were essentially basics or intermediates who could perform the ACLS arrest algorythms on pulseless apneic patients because "it couldn't hurt." 

I extrapolated that initiative from the idea of basics giving cardiac arrest meds, because it has a similar argument to allowing basics to start IVs because in many cases, it could help and often causes no harm.


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## MS Medic (Dec 6, 2010)

Veneficus said:


> Cut for brevity.
> 
> ...there is no evidence of the effectiveness of medication in cardiac arrest...
> 
> In my opinion, a fail.



That is not entirely true. There is research which seems to show that vasopressin used as the first round for shockable rhythms has some effect.


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## Veneficus (Dec 6, 2010)

MS Medic said:


> That is not entirely true. There is research which seems to show that vasopressin used as the first round for shockable rhythms has some effect.



Can you send me this research?

It shows an improved number of patients discharged neurologically intact from cardiac arrest?


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## MS Medic (Dec 6, 2010)

I will look up the research tomorrow. Its getting to be family time here and I won't be on the computer all night. Rather than post it, I send it to you PM so as not to hijack the thread and get it off topic.


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## TransportJockey (Dec 6, 2010)

MS Medic said:


> I will look up the research tomorrow. Its getting to be family time here and I won't be on the computer all night. Rather than post it, I send it to you PM so as not to hijack the thread and get it off topic.



Can I ask for it as well? I'm interested in this one.


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## TransportJockey (Dec 6, 2010)

Tigger said:


> Snip



Hmmm. ok. I know the service I worked for in the Denver metro I was allowed to do the EMT-B IV drugs, but ACLS drugs were never mentioned. In fact when I asked about it I was flat out told that they didn't let basics do it. The service I worked for didn't use that protocol at all.


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## EMTJUNKIE (Dec 6, 2010)

Tennessee has EMT-IV's.  It is part of our EMT certification.  The basic was discontinued many years ago here.  

As an EMT-IV we mainly establish INT's, but do run fluids if needed.  Our ER's find it helpful when we come in with the PT having an INT established for them.  It cuts down on the time they have to spend or the EDT has to spend.  It means they can start labs sooner or give needed meds quicker.  As a matter of fact, the ER staff gets rather aggravated when we come in without having it established.


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## BuildsCharacter (Dec 6, 2010)

Absolutely yes. I am starting my EMT-B in January but I am in Combat Support Hospital in the Army Reserve. Though I'm not medical i have combat life saver training and they have made it pretty much SOP to start a saline lock so I believe this would be a great idea to have EMT-B's do this on the civilian side. You never know, having that lock in place before things go south means you have they much more of en edge on saving the pt if IV meds are needed.


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## TransportJockey (Dec 6, 2010)

BuildsCharacter said:


> Absolutely yes. I am starting my EMT-B in January but I am in Combat Support Hospital in the Army Reserve. Though I'm not medical i have combat life saver training and they have made it pretty much SOP to start a saline lock so I believe this would be a great idea to have EMT-B's do this on the civilian side. You never know, having that lock in place before things go south means you have they much more of en edge on saving the pt if IV meds are needed.


If the patient is that bad off the medic or intermediate should have already gotten a line, and if not... That's when a good time to drill them would be.
BEsides a basic can't give most IV meds, so if it's a BLS truck, having a line in place when the patient goes south provides no benefit at all.


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## Veneficus (Dec 6, 2010)

BuildsCharacter said:


> Absolutely yes. I am starting my EMT-B in January but I am in Combat Support Hospital in the Army Reserve. Though I'm not medical i have combat life saver training and they have made it pretty much SOP to start a saline lock so I believe this would be a great idea to have EMT-B's do this on the civilian side. You never know, having that lock in place before things go south means you have they much more of en edge on saving the pt if IV meds are needed.



Not to split hairs, but there is considerable difference between the military and civillian medicine.

One is the cost factor. When you start an IV you are billing at medicare rate or higher.

Then you have the issue of having to have somebody monitor this patient, which means they cannot be put into a waiting room without DCing the IV, which you may have to start again when they are finally seen.

Who pays for the occasional complications?

Doing a procedure because you can is not good medicine. 

Sure sometimes things take a turn for the worse, under those circumstances it is good to have a line. But even in the busiest centers those are rare occurances and the staff usually highly capable of dealing with it.


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## MS Medic (Dec 6, 2010)

Now a saline lock and an actual IV with fluids hanging are two entirely different beasts since the saline lock will not introduce more than 10ml of fluid into the system if done properly. So I don't really see that much of a problem with a saline lock. 
Since you don't have to monitor a med, that is the sort of thing that would be between the EMS provider's med director and the local hospitals.


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## NHEMT-I (Dec 6, 2010)

*Possibly ...*

I am assuming you live in a state that does not have intermediates. I have been an EMT for 12 years, 9 of which have been at the intermediate level. I work full time for a small ambulance service which covers 5 towns, and have dabbled in part time work with other services. I have met a myriad of providers, some good, some bad, some that are in between. I have noticed some basics that went on to become intermediates that have excelled, while others did not. I guess what I am saying is that realistically, basics CAN start IV's ... lets face it folks, a trained monkey could do them. What separates the good provider from a bad provider is KNOWLEDGE, good critical thinking skills, the ability to take constructive criticism, the ability to continue learning, solid assessment skills. Intravenous lines very rarely save lives without the coupling of medication and advanced level skills. The ability to start an IV to help a higher level provider may be great ... but the Basic has to learn and understand the reason for starting the IV, what protocol they may be operating under, and what the risks that go along with an evassive procedure ... not "just because I can". I would say that there would have to be stipulations as far as length of service, recomendations from medical directors and service leaders as well as paramedics. It shouldn't be given as a blanket policy, and the candidate should expect a lengthy amount of time to practice before being turned out on their own. Ride time to get used to starting a line in a truck running down the road is much more condusive than sitting in a "perfect setting" ED. Just some thoughts, not trying to deter anyone from furthering their career, but I can tell you from personal experience ... some people just aren't cut out for advanced level skills.


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## jjesusfreak01 (Dec 7, 2010)

Here's something else to think about. Certainly most of us can agree that in the US, the gold standard of pre-hospital care is treatment by a well-trained experienced paramedic. But I have a different perspective on this issue, being that I have spent the better part of the last week having a one-person "Emergency" marathon (thanks Hulu). Now, Johnny and Roy might have been quite good at their job, but they never had to interpret a 12-lead or intubate a patient. In fact, they were allowed to do very little without explicit doctor's orders, however they always had a doctor available to assess the situation and order the appropriate treatments for the patients. 

Even at our EMT-B level, a good bit of our training goes into underlying mechanisms of disease, the pathological aspect behind treatment. Aside from the ability to start IVs, I, as an EMT-Basic, have been trained to a much higher understanding of medicine than the paramedics on "Emergency". With very little additional training, I could do what they do.

So, again, considering that an ideal system includes paramedics on every emergency truck, would there be a problem with training EMTs in the skills necessary to intubate a patient, or to start an IV when under online medical oversight? This thread has spent a lot of time discussing fluid balance and dynamics, but as an EMT, I am not asking to work as an independent licensed care provider, I work under a doctor's licence and usually with a paramedic. If I am performing these skills that have medical implications above my understanding, I do it knowing that I have direct access to a provider who does understand what's going on. 

It would never be my intention to have an EMT who wasn't entirely competent in these skills performing them, but I think if a system is willing to train their EMTs to use a few additional skills and give online medical advice to guide their care, this can allow EMTs to both be more useful to paramedics they are working with as well as provide for more advanced care in systems where it is impractical to have a paramedic in every unit at every corner. 

That is all...


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## MrBrown (Dec 7, 2010)

jjesusfreak01 said:


> Even at our EMT-B level, a good bit of our training goes into underlying mechanisms of disease, the pathological aspect behind treatment. Aside from the ability to start IVs, I, as an EMT-Basic, have been trained to a much higher understanding of medicine than the paramedics on "Emergency".



Is that a crank pipe in your back pocket mate? 

How many of the 120 hours of EMT class is in pathology again?


----------



## wyoskibum (Dec 7, 2010)

MrBrown said:


> How many of the 120 hours of EMT class is in pathology again?



I don't even think the word pathology is defined in the glossary in EMT-B books! ;-D


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## EMS49393 (Dec 7, 2010)

MrBrown said:


> Is that a crank pipe in your back pocket mate?
> 
> How many of the 120 hours of EMT class is in pathology again?



Actually, he probably has much more understanding.  Look at his profile, he's got a BS in biology.

That's it... you can start an IV as a basic if you obtain a BS in biology OR you can go to paramedic school.  Your choice.


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## Veneficus (Dec 7, 2010)

EMS49393 said:


> Actually, he probably has much more understanding.  Look at his profile, he's got a BS in biology.
> 
> That's it... you can start an IV as a basic if you obtain a BS in biology OR you can go to paramedic school.  Your choice.



which begs the question:

Is it his other education that gave him insight to pathology or does he have the same understanding of pathology as every EMT-B?

Because I could support letting an EMT-B who was required to get a BS in biology start and IV. Hell, I would give that person some drugs and autonomy too.


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## jjesusfreak01 (Dec 7, 2010)

MrBrown said:


> Is that a crank pipe in your back pocket mate?
> 
> How many of the 120 hours of EMT class is in pathology again?



That's a valid question. Granted, I have taken anatomy and physiology as well as developmental biology, intro to neurobiology, and cell biology...for starters as part of my degree, but I'm looking over the course outline and textbook for my basic class right now, and I can tell you, it isn't just band-aids 101. Although it spends only a chapter on gross anatomy, the textbook spends a fair deal of time on cardiac anatomy and function as well as the various types of heart diseases and conditions that EMTs might see in the field. My book spends an entire chapter on allergic reaction. Lets be honest here. Is there an easier medical call to diagnose and treat in the field than anaphylaxis? Stridor (breathing difficulty)--check, hives--check, give the epipen! Yet, my textbook starts with an explanation of allergic reactions, covering antibodies, the role of MAST cells, and the role of histamine in reactions. The pharmacology chapters cover the various alpha and beta effects of epinephrine. 

It is my opinion that my EMT class could have taken two weeks or less if all they wanted to do was teach us how to do EMT skills. It seemed to me that instead my instructor spent most of his lecture time teaching us about the mechanisms and pathology of the injuries we would be seeing. I'm attaching my EMT class schedule if anyone wants to take a look. 

My Schedule




Veneficus said:


> which begs the question:
> 
> Is it his other education that gave him insight to pathology or does he have the same understanding of pathology as every EMT-B?
> 
> Because I could support letting an EMT-B who was required to get a BS in biology start and IV. Hell, I would give that person some drugs and autonomy too.


I hear in Texas first responders can intubate if they have a bachelors degree


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## medicRob (Dec 7, 2010)

**Sings to Lambchop Tune**

This is the thread that will not die, 
and I really don't know why..


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## TransportJockey (Dec 7, 2010)

jjesusfreak01 said:


> That's a valid question. Granted, I have taken anatomy and physiology as well as developmental biology, intro to neurobiology, and cell biology...for starters as part of my degree, but I'm looking over the course outline and textbook for my basic class right now, and I can tell you, it isn't just band-aids 101. Although it spends only a chapter on gross anatomy, the textbook spends a fair deal of time on cardiac anatomy and function as well as the various types of heart diseases and conditions that EMTs might see in the field. My book spends an entire chapter on allergic reaction. Lets be honest here. Is there an easier medical call to diagnose and treat in the field than anaphylaxis? Stridor (breathing difficulty)--check, hives--check, give the epipen! Yet, my textbook starts with an explanation of allergic reactions, covering antibodies, the role of MAST cells, and the role of histamine in reactions. The pharmacology chapters cover the various alpha and beta effects of epinephrine.
> 
> It is my opinion that my EMT class could have taken two weeks or less if all they wanted to do was teach us how to do EMT skills. It seemed to me that instead my instructor spent most of his lecture time teaching us about the mechanisms and pathology of the injuries we would be seeing. I'm attaching my EMT class schedule if anyone wants to take a look.
> 
> ...



They can tube if their medical director says they can, no degree needed :S


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## zmedic (Dec 7, 2010)

Wonder how long it will take for that to go away, considering the places that are taking a hard look at not letting medics intubate. I think we're getting close to the point where it will be negligence to intubate without real time capnography to ensure continued tube placement.


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## TransportJockey (Dec 7, 2010)

zmedic said:


> Wonder how long it will take for that to go away, considering the places that are taking a hard look at not letting medics intubate. I think we're getting close to the point where it will be negligence to intubate without real time capnography to ensure continued tube placement.



It won't ever go away with the way TX scope is written. There's a floor that all providers must be competent with, then the medical director has full authority to add whatever they see fit. 
Although on the ETCo2 bit... our two basics at my service use capno for Combi placement, and I use it on either ETT or MLA placement


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## Veneficus (Dec 7, 2010)

jjesusfreak01 said:


> looking over the course outline and textbook for my basic class right now, and I can tell you, it isn't just band-aids 101.



I do not share your optimistic appraisal of the situation.




jjesusfreak01 said:


> Although it spends only a chapter on gross anatomy,.



There is absolutely nothing that can call itself "gross anatomy" in the whole of the EMT or paramedic curriculms nor text books. I have had the opportunity to be a content reviewer prior to publication of several texts, if they got any more basic they would be used in high school health classes.

When I see a muscle table with origin, insertion, innervation, action, synergists and antagonists, I might believe it may have some gross anatomy in it. 

When it describes the anatomical rules, common variances, the parts of the structures, compartments, and evolutionary significance, I might believe there is some gross anatomy in it. 

The newer ones are even worse as the major publishers struggle to make it as spoonfeedable (I think I just invented a word) as humanly possible.

No anatomy class compares to classical human gross anatomy. I have had the pleasure of it both in undergrad and medical school. (for a total of 2 years of it) People don't pass it, they survive it.



jjesusfreak01 said:


> the textbook spends a fair deal of time on cardiac anatomy and function



You really need to check out some of my books before you make statements like that.



jjesusfreak01 said:


> as well as the various types of heart diseases and conditions that EMTs might see in the field.



Even the paramedic texts barely cover them. Some conditions that can be expected are not talked about at all.

Dare I ask to they even mention the NYHA classification scores? The desk copy of EMT I have is a few years old, but somehow I very much doubt it was added considering the recent paramedic texts I have been sent don't.



jjesusfreak01 said:


> My book spends an entire chapter on allergic reaction.



If it is anything like what I have seen, it is a lot of words that barely describes it.



jjesusfreak01 said:


> Lets be honest here. Is there an easier medical call to diagnose and treat in the field than anaphylaxis? Stridor (breathing difficulty)--check, hives--check, give the epipen! Yet, my textbook starts with an explanation of allergic reactions, covering antibodies, the role of MAST cells, and the role of histamine in reactions.



Death?

How about the rest of immunology and hypersensitivity reactions? There is a slight difference between poison ivy and an allergic reaction. (ok maybe not so slight)



jjesusfreak01 said:


> The pharmacology chapters cover the various alpha and beta effects of epinephrine.



I'm sure.

"Alpha is the blood vessles beta 1 is the heart and beta  is the lungs" right?



jjesusfreak01 said:


> It is my opinion that my EMT class could have taken two weeks or less if all they wanted to do was teach us how to do EMT skills.



Then you are lucky your class is exceeding the minimum requirements. They are all not like that. Infact most of them are not.

If I could inquire, what is the name of this textbook?



jjesusfreak01 said:


> It seemed to me that instead my instructor spent most of his lecture time teaching us about the mechanisms and pathology of the injuries we would be seeing.



Did he now? 



jjesusfreak01 said:


> I'm attaching my EMT class schedule if anyone wants to take a look.
> 
> My Schedule



I'd like to see the lecture notes.

Really, I think you seriously overestimate the value of a published EMT text.


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## jjesusfreak01 (Dec 7, 2010)

Veneficus said:


> Really, I think you seriously overestimate the value of a published EMT text.



Absolutely not. Its 1300 pages of unadulterated fluff. The whole thing could be condensed to 300-400 cables while increasing the quality of the text. I'm not going to claim it covers anything in detail, just that the book does more than simply emphasize the necessary monkey skills that the EMT needs. In fact, if all you want to teach is skills, then a book is really an awful way to do it. You would be much better off with videos and hands on workshops. 

To get back on topic...



medicRob said:


> **Sings to Lambchop Tune**
> 
> This is the thread that will not die,
> and I really don't know why..


Somebody started an IV not knowing how to poke,
and they'll continue missing it until their squad is broke...

PS: Brady Prehospital Emergency Care 8th Edition by Mistovich and Karren

PPS: Vene, we were responsible for reading the text, the prof lectured, and the skills were learned hands on...


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