# IVs for EMT-B



## musicislife (May 4, 2012)

I heard that they do it, or that they may add it in NJ, is that true?


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## Medic Tim (May 4, 2012)

musicislife said:


> I heard that they do it, or that they may add it in NJ, is that true?



There are a few areas that have expanded scope emts. As a general rule though a basic does no do anything invasive.


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## mycrofft (May 4, 2012)

Feds are trying to rein in the continued blurring and expansion of scopes of practice. No teeth in it, though.


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## Milla3P (May 6, 2012)

I feel as though I've seen some state that allowed Bs to transport IVs but not initiate them (Washington?). Rhode Island just took ET Intubation away from basics (good move).


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## HMartinho (May 6, 2012)

I can't see any benefit in EMT's can start IV lines.

It is a procedure that requires practice, and is not as easy as it looks like.


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## DesertMedic66 (May 6, 2012)

Milla3P said:


> I feel as though I've seen some state that allowed Bs to transport IVs but not initiate them (Washington?). Rhode Island just took ET Intubation away from basics (good move).



Alot of states/counties will allow for EMTs to transport patients with IV lines but not start them (my county included).


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## exodus (May 6, 2012)

I'd rather have EMT's be able to start IO under the supervision and order of a paramedic. Very useful for cases like full arrests.


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## rwik123 (May 6, 2012)

HMartinho said:


> I can't see any benefit in EMT's can start IV lines.
> 
> It is a procedure that requires practice, and is not as easy as it looks like.



Really? I can see plenty of benefit for basics being able to start IVs. Its really not rocket science. Basics could easily learn how to do it....I just think they'd lack the clinical judgment and overall physiology behind IV therapy. Theres a fine line between allow basics to establish a lock on the patient and allowing them to initiate fluid therapy.


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## Backwoods (May 6, 2012)

With how little training a basic has, I don't think it would be a good idea to cram IV skills into their scope. They can learn that when they go to medic school.


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## STXmedic (May 6, 2012)

rwik123 said:


> Really? I can see plenty of benefit for basics being able to start IVs. Its really not rocket science. Basics could easily learn how to do it....I just think they'd lack the clinical judgment and overall physiology behind IV therapy. Theres a fine line between allow basics to establish a lock on the patient and allowing them to initiate fluid therapy.



If they can't do anything with it, then what's the point? I can understand basics doing IOs in cardiac arrests (our basics do it here), but I see no purpose of a basic starting a lock other than to increase the patients risk for infection.

Edit: I agree it's not a difficult skill to perform. However with them not being able to use it, and it likely to still be an uncommon skill to perform, why not just let the more experienced nurse at the ED start one in a slightly more aseptic environment.


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## NYMedic828 (May 6, 2012)

EMTs starting IVs comes up a lot. I know some members here have EMT-IV next to their name. NY has no such title. But honestly, starting an IV just to have a lock does nothing. Its what you can do with it that requires further knowledge and understanding that comes with an advanced provider course. Even normal saline has its serious risks.

Here on Long Island we have critical care and paramedic ALS providers. CCs basically a little higher than EMT-I but even they have to call medical control to give fluid challenges. Medics don't. 



Milla3P said:


> I feel as though I've seen some state that allowed Bs to transport IVs but not initiate them (Washington?). Rhode Island just took ET Intubation away from basics (good move).



NY allows for this, well at least in NYC you can. Not sure about the state.

Intubation will definitely never be a basic skill in NY.



HMartinho said:


> I can't see any benefit in EMT's can start IV lines.
> 
> It is a procedure that requires practice, and is not as easy as it looks like.



I'd have to disagree. Some patients with garbage for veins, sure. But quite honestly, most patients it isn't much of a technical skill. You put the needle into the tube and push it in. Pretty hard to not understand the procedure itself.




exodus said:


> I'd rather have EMT's be able to start IO under the supervision and order of a paramedic. Very useful for cases like full arrests.



Yes and no. It has its place if the medic is tubing or something but in many places the EMT is doing CPR and the medic is doing the other things. Someone has to do CPR. (considering meds are nonsense anyway and have no proven benefits in cardiac arrest.)


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## rwik123 (May 6, 2012)

PoeticInjustice said:


> If they can't do anything with it, then what's the point? I can understand basics doing IOs in cardiac arrests (our basics do it here), but I see no purpose of a basic starting a lock other than to increase the patients risk for infection.



I never said they should just have locks in their scope. Obv locks alone would do no good. I'm saying the skill of the IV isn't that complicated but would be useless if they didn't have the ability to give fluids...but lack the educational knowledge to apply that skill correctly...sorry I wasn't explicit in my first post. I was talking about the skill of initiating a lock not that they should have the skill without fluids.


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## rwik123 (May 6, 2012)

PoeticInjustice said:


> If they can't do anything with it, then what's the point? I can understand basics doing IOs in cardiac arrests (our basics do it here), but I see no purpose of a basic starting a lock other than to increase the patients risk for infection.
> 
> Edit: I agree it's not a difficult skill to perform. However with them not being able to use it, and it likely to still be an uncommon skill to perform, why not just let the more experienced nurse at the ED start one in a slightly more aseptic environment.



Meh, I wouldn't want basics doing IOs in an arrest. The last thing we need is giving them all a fancy tool and focus on that instead of doing good BLS CPR. The drugs are mostly bs as we all know.


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## STXmedic (May 6, 2012)

rwik123 said:


> Meh, I wouldn't want basics doing IOs in an arrest. The last thing we need is giving them all a fancy tool and focus on that instead of doing good BLS CPR. The drugs are mostly bs as we all know.



If it was a small team working the arrest, I'd agree. Many things would take precedence over that. However, here we have an over abundance of resources (EMT-Bs) on any full arrest, with not near as many medics. So instead of having two to three guys twiddling their thumbs, our medical director decided to give them something fairly low-risk and easy to do to make them more productive and time-saving while waiting for the medics to get there.

Ours can also place king tubes in an arrest. Again, a lot of idle hands given an easily performed skill.

Yes, I agree the drugs are not proven to do much of anything. That doesn't change the fact that our medical director wants them administered.


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## rwik123 (May 6, 2012)

PoeticInjustice said:


> If it was a small team working the arrest, I'd agree. Many things would take precedence over that. However, here we have an over abundance of resources (EMT-Bs) on any full arrest, with not near as many medics. So instead of having two to three guys twiddling their thumbs, our medical director decided to give them something fairly low-risk and easy to do to make them more productive and time-saving while waiting for the medics to get there.
> 
> Ours can also place king tubes in an arrest. Again, a lot of idle hands given an easily performed skill.
> 
> Yes, I agree the drugs are not proven to do much of anything. That doesn't change the fact that our medical director wants them administered.



Sounds like a very progressive system. I like the King protocol.


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## STXmedic (May 6, 2012)

rwik123 said:


> Sounds like a very progressive system. I like the King protocol.



We're definitely getting there. We're about halfway through of a several year swing from being an archaic taxi service to one of the more progressive systems in the country.


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## HMartinho (May 6, 2012)

In my opinion, is much more useful allow an EMT-B to insert an laryngeal mask or king tube, when it's indicated.


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## Tigger (May 6, 2012)

HMartinho said:


> In my opinion, is much more useful allow an EMT-B to insert an laryngeal mask or king tube, when it's indicated.



There's no reason that an EMT cannot do both, it's not like those to skills are somehow incompatible with one another.

As a basic in Colorado, I can start IVs and give fluid challenges without med control. Same goes for D50 and Narcan. Honestly, while I feel like I am competent in these areas, the additional training is not long enough for most EMTs. I took the times to look up the physiology (basic mind you) on my own time. I did get plenty of practice though, so it's not the actual skill I'm worried about.

For most systems in Colorado it's a fairly useful certification though. Most ambulances are P/B so the basic is usually just doing what the medic asks while the medic does something else. As mentioned it's useful for codes, medic does the airway and monitor, basic gets IV access and pushes epi under the medics direction (which is allowed for under state protocol). Someone else does CPR, if there is no else then the basic just does CPR. 

For a double basic truck I am not so sure that allowing IVs is the greatest idea, it seems like it would be too easy for EMTs without proper training to jump to the IV when there are other more pressing issues that need to be dealt with. I think the military has some experience with this?


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## firecoins (May 6, 2012)

Transporting an I've is widely allowed because Medicare rules allow it. It doesn't have anything to with EMT-b scope of practise or treatments.


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## pa132399 (May 6, 2012)

the problem with giving emt's the skill to do iv's is it is just a skill like said before its the actual effects and why. A monkey if trained correctly could probably start an iv better yet my three year old could as well but neither would no why. basically you would have a bunch of whacker emt's with a skill and tons of bls pt who didnt need a line coming in with a lock just because they can do it. BAD IDEA

GOOD IDEA like the king/ lma stuff that was talked about not that hard to understand why and not a hard skill to learn.

just my $.02


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## Nohero (May 6, 2012)

As Tigger explained we can start IV's up here in Colorado, but I'll have to add that it requires a totally seperate class...I believe mine was 24 hours total plus ten successful sticks in the clinical setting.  So you can be a Basic in Colorado and NOT have authorization to start IV's.  You can also be a Basic WITH IV approval, but it requires the extra class and clinical time.


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## Achilles (May 6, 2012)

What about IO and IM?


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## wildmed (May 6, 2012)

Nohero said:


> As Tigger explained we can start IV's up here in Colorado, but I'll have to add that it requires a totally seperate class...I believe mine was 24 hours total plus ten successful sticks in the clinical setting.  So you can be a Basic in Colorado and NOT have authorization to start IV's.  You can also be a Basic WITH IV approval, but it requires the extra class and clinical time.



I also am from co. Emt -iv is pretty much the standard here. It has been very Successful but I'm guessing it may be phased out by the integration of AEMT in the next 5 years. As someone who initiates iv access on very small children on a daily basis and has at least 1000+ ivs under his belt, id say it has been is a very  appropriate add on for EMTs here. I must admit that with the first bunch of AEMT students rotating through my ED, I am fully convinced that this should be the entry level to EMS, and a lot of the EMS leaders in the frontrange seem to agree.


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## the_negro_puppy (May 6, 2012)

Little point if they can't give anything through it. Even if they had a limited scope such as in cardiac arrests etc to help prep for ALS- they would not be performing the skill enough to remain proficient


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## NYMedic828 (May 6, 2012)

pa132399 said:


> the problem with giving emt's the skill to do iv's is it is just a skill like said before its the actual effects and why. A monkey if trained correctly could probably start an iv better yet my three year old could as well but neither would no why. basically you would have a bunch of whacker emt's with a skill and tons of bls pt who didnt need a line coming in with a lock just because they can do it. BAD IDEA
> 
> GOOD IDEA like the king/ lma stuff that was talked about not that hard to understand why and not a hard skill to learn.
> 
> just my $.02



Thank goodness for you grammar and understanding of the english language is not a requirement of EMS.

But yes, this is the main argument against the protocol.




the_negro_puppy said:


> Little point if they can't give anything through it. Even if they had a limited scope such as in cardiac arrests etc to help prep for ALS- they would not be performing the skill enough to remain proficient




The less people that could potentially slow CPR to administer vasopressors the better. The last thing we need is more people racing to shoot someone up with 5mgs of epi.


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## Achilles (May 6, 2012)

Still waiting for an answer....


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## usalsfyre (May 6, 2012)

Achilles said:


> Still waiting for an answer....



Our service allows deep IM injection of epi for anaphylaxis (because epi pens are $100+), but I see ZERO reason to give Basics IO access...


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## Shishkabob (May 6, 2012)

usalsfyre said:


> but I see ZERO reason to give Basics IO access...



To start IOs.  ^_^


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## NYMedic828 (May 6, 2012)

Achilles said:


> Still waiting for an answer....



What do you intend to do with the IO once you insert it? Just because I can tell anyone to press the button on a cordless screwdriver doesn't mean I should.

IM has the same issues of understanding of medications. Only real difference is I don't need an IV in place which is preferable regardless. Sure many people can pick up on it and all will be well but not all people. You can't do something in the light of some people when the ultimate group is far larger.

Even narcan the simplest of drugs has its potentially lethal side effects.


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## Achilles (May 6, 2012)

NYMedic828 said:


> What do you intend to do with an IO over an IV? Just because I can tell anyone to press the button on a cordless screwdriver doesn't mean I should.
> 
> And IM has the same issues of understanding of medications. Sure many people can pick up on it and all will be well, but you can't do something in the light of some people when the ultimate group is far larger.
> 
> Even narcan has its potential major side effects.



You can't always get into a vein, you can almost always get into the femur.


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## Shishkabob (May 6, 2012)

Achilles said:


> You can't always get into a vein, you can almost always get into the femur.



Except we typically don't do IOs in the femur.


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## usalsfyre (May 6, 2012)

Achilles said:


> You can't always get into a vein, you can almost always get into the femur.



What life-saving heroics are you going to perform with said vascular access?


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## NYMedic828 (May 6, 2012)

Achilles said:


> You can't always get into a vein, you can almost always get into the femur.



You are 100% correct. We can't. Thats why the IO is the last resort. It is not the first. And the fact still remains that once you have an IO, what do you plan to do with it? A patient better be circling the drain or already down the pipes if you decide to start an IO. At that point, we have bigger concerns than just "having access."

I don't know how things are done by you. But that statement by me would be digging your own grave on the matter. The sternum in some areas is accepted and everywhere else I know of goes for the tibial site. The femur is not accepted anywhere I know of pre-hospitally. You would need a specialized set to do it to begin with. (longer needle)


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## Shishkabob (May 6, 2012)

NYMedic828 said:


> Thats why the IO is the last resort. It is not the first.



This is where I disagree.  I don't label things as "first" or "last", but as needed.  I have no issue jumping to IO right off the bat, and although my medical director doesn't like IOs and prefers IVs, the protocols he wrote specifically state that if IV access is deemed to be difficult, to skip right to the IO.


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## NYMedic828 (May 6, 2012)

Linuss said:


> This is where I disagree.  I don't label things as "first" or "last", but as needed.  I have no issue jumping to IO right off the bat, and although my medical director doesn't like IOs and prefers IVs, the protocols he wrote specifically state that if IV access is deemed to be difficult, to skip right to the IO.



Sorry I probably could have worded that better. I don't mean last resort in the sense that I wasted 5 minutes trying to stick someone 10 times without success so I finally grabbed the IO. I meant that if we can easily get an IV instead, we should. If my patient is still alive id prefer not to drill a hole in their bone if I don't need to.

I certainly have looked at a patients arm/neck and decided to go right for the IO. It definitely saves time and effort but that still adds no viability at the EMT level.


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## Achilles (May 6, 2012)

NYMedic828 said:


> You are 100% correct. We can't. Thats why the IO is the last resort. It is not the first. And the fact still remains that once you have an IO, what do you plan to do with it?
> 
> I don't know how things are done by you. But that statement by me would be digging your own grave on the matter.
> 
> The femur isn't the primary IO site. You would need a specialized set to do it to begin with. (longer needle)



I will let you know what I plan to do with as soon as I become a para-magician.
Btw, Michigan btw.
I'm also just a basic, so i was just asking a question.


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## usalsfyre (May 6, 2012)

Achilles said:


> I will let you know what I plan to do with as soon as I become a para-magician.
> Btw, Michigan btw.
> I'm also just a basic, so i was just asking a question.



IO access as a medic, useful. As a basic? Pointless.


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## NYMedic828 (May 6, 2012)

Achilles said:


> I will let you know what I plan to do with as soon as I become a *para-magician*.
> Btw, Michigan btw.
> I'm also just a basic, so i was just asking a question.



Smoke and mirrors my friend.

You were defending your argument so we defended ours. No harm done we are all here to learn from one another.


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## Achilles (May 6, 2012)

NYMedic828 said:


> I certainly have looked at a patients arm/neck and decided to go right for the IO. It definitely saves time and effort but that still adds no viability at the EMT level.


The OP is an MFR, do you think he should be starting IV's?


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## NYMedic828 (May 6, 2012)

Achilles said:


> The OP is an MFR, do you think he should be starting IV's?



No... I thought that was made pretty apparent by this point. :unsure:


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## Tigger (May 7, 2012)

usalsfyre said:


> IO access as a medic, useful. As a basic? Pointless.



I think there is some merit in basics starting IOs during a code with a medic partner. I was taught IOs during my IV class for this reason, and there is at least one service in Colorado that is already doing that. If anything IO access is likely "easier" to gain than IV, no? 

I do not support putting IOs on BLS trucks even if the providers in question can hang fluids, there is not enough oversight in that environment.


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## usalsfyre (May 7, 2012)

Tigger said:


> I think there is some merit in basics starting IOs during a code with a medic partner. I was taught IOs during my IV class for this reason, and there is at least one service in Colorado that is already doing that. If anything IO access is likely "easier" to gain than IV, no?
> 
> I do not support putting IOs on BLS trucks even if the providers in question can hang fluids, there is not enough oversight in that environment.



Why not have the focus on performing really good non-invasive airway management or chest compressions?


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## Handsome Robb (May 7, 2012)

Tigger said:


> I think there is some merit in basics starting IOs during a code with a medic partner. I was taught IOs during my IV class for this reason, and there is at least one service in Colorado that is already doing that. If anything IO access is likely "easier" to gain than IV, no?
> 
> I do not support putting IOs on BLS trucks even if the providers in question can hang fluids, there is not enough oversight in that environment.


 
IOs are ridiculously easy. It's literally like drilling a wood screw into a wall. That's exactly what it feels like too. 

My problem with them and fluids on BLS trucks is the lack of understanding of acid-base balance along with physiology and pathophysiology. I'd be afraid of a basic running a liter of fluid wide-:censored::censored::censored::censored:ing-open into granny and fluid overloading her.


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## DesertMedic66 (May 7, 2012)

usalsfyre said:


> Why not have the focus on performing really good non-invasive airway management or chest compressions?



All depends on how many people you have on scene. If you have multiple EMTs on scene then airway and compressions are already being handled. Why not use one of the EMTs to place an IO instead of standing around doing nothing?


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## Tigger (May 7, 2012)

usalsfyre said:


> Why not have the focus on performing really good non-invasive airway management or chest compressions?





firefite said:


> All depends on how many people you have on scene. If you have multiple EMTs on scene then airway and compressions are already being handled. Why not use one of the EMTs to place an IO instead of standing around doing nothing?



I think firefite has the right idea here, and that's one of the intents of the Colorado EMT-IV program. There are lots of basics in Colorado (like everywhere), lets make them more useful given the scarcity of medics in some areas. A volunteer in a rural area can take this class in a fairly short amount of time and hopefully make him or herself more useful when ALS is called. Like most rural areas it is not uncommon for there to only be one or two medics available county-wide and the idea is not to tie both of them up on the same call. Obviously the best solution is to have more medics available but that's not always going to be possible.

I don't think the intent of the IV program is to get BLS ambulance crews to start IVs on their own, or at least I hope it is not.


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## the_negro_puppy (May 7, 2012)

If an EMT-B wants to start IVs then they should do more than the 120 hours of education and become a medic.


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## NYMedic828 (May 7, 2012)

the_negro_puppy said:


> If an EMT-B wants to start IVs then they should do more than the 120 hours of education and become a medic.



Lets try to avoid starting a battle.

Why dont we try to just sum up this thread.

Is an IV technically an advanced invasive procedure? Yes.

Is an IV relatively easy to perform? Yes.

Is an IV practical at a BLS level? Not really. An IV is simply a purchase point for what may really be needed. Medications. Simply having access is worthless without the knowledge and experience that comes along with what to do after.

An IO is even easier to perform than an IV but it still lacks the same ultimate use at a BLS level.

An IM any monkey can perform. But again the knowledge base lacks.

On the other hand does an EMT/paramedic crew now serve purpose with an EMT-IV? To an extent absolutely.


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## OzAmbo (May 7, 2012)

the_negro_puppy said:


> If an EMT-B wants to start IVs then they should do more than the 120 hours of education and become a medic.



[YOUTUBE]http://www.youtube.com/watch?v=MjoMQJf5vKI[/YOUTUBE]


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## Bullets (May 7, 2012)

To the original poster, IVs for EMTs gets tossed about every few years, then goes no where, just like the EMT-I/AEMT. 

We have been "trialing" king/combi/LMA in one of the northern counties for what seems like 20 years now, and nothing has comes. In a state like NJ where we have an over-saturation of ALS there is no impetus to expand the EMT scope outside of changing small things, like oxygen administration, aspirin, ect


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## exodus (May 7, 2012)

Tigger said:


> I think firefite has the right idea here, and that's one of the intents of the Colorado EMT-IV program. There are lots of basics in Colorado (like everywhere), lets make them more useful given the scarcity of medics in some areas. A volunteer in a rural area can take this class in a fairly short amount of time and hopefully make him or herself more useful when ALS is called. Like most rural areas it is not uncommon for there to only be one or two medics available county-wide and the idea is not to tie both of them up on the same call. Obviously the best solution is to have more medics available but that's not always going to be possible.
> 
> I don't think the intent of the IV program is to get BLS ambulance crews to start IVs on their own, or at least I hope it is not.



My exact reasoning behind it. The basic can initiate the access, and the medic can use it. Many people missed the part of my post where I said, "Under order and direct supervision of a medic." So, no. There will NOT be IV / IO's on a BLS truck. In many systems, you have several extra EMT's just standing there, but the medics are always doing something.


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## fast65 (May 7, 2012)

exodus said:


> My exact reasoning behind it. The basic can initiate the access, and the medic can use it. Many people missed the part of my post where I said, "Under order and direct supervision of a medic." So, no. There will NOT be IV / IO's on a BLS truck. In many systems, you have several extra EMT's just standing there, but the medics are always doing something.



I'm liking your idea, I know it would come in handy for me quite often. I'm usually the only medic on scene, and I will very rarely have an EMT-I from the FD. So if I could have a basic start a line under my order/supervision, it would make my job that much easier on occasion.


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## bstone (May 7, 2012)

I'd like to give props and congratulate the OP for using the proper pluralization of EMT. Other than that, I am mostly against EMT-Bs being allowed to start IVs. I simply don't think their education is long or comprehensive enough for that.


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## Tigger (May 7, 2012)

bstone said:


> I'd like to give props and congratulate the OP for using the proper pluralization of EMT. Other than that, I am mostly against EMT-Bs being allowed to start IVs. I simply don't think their education is long or comprehensive enough for that.



I don't think anyone is arguing that IVs be added to the present curriculum. I can only start them because I took another class so it isn't like I don't know anything about them or fluid balances. I'd like to know more but given it's use I'd say the course length (20 hours) is about sufficient.

Is medic school's IV section longer? I'm sure it is, but an EMT-IV and a Paramedic are learning them for different reasons, or at least they should be.


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## NYMedic828 (May 7, 2012)

Tigger said:


> I don't think anyone is arguing that IVs be added to the present curriculum. I can only start them because I took another class so it isn't like I don't know anything about them or fluid balances. I'd like to know more but given it's use I'd say the course length (20 hours) is about sufficient.
> 
> Is medic school's IV section longer? I'm sure it is, but an EMT-IV and a Paramedic are learning them for different reasons, or at least they should be.



Paramedic IV skills aren't necessarily longer so much as they are referred back to countless times throughout the program.

I think I did around 300 IVs on patients in the ER by the end of my program. Countless more on the manikins during skills.

20 hours is more than sufficient for the skill itself and explanation of iso/hypo/hyper solutions but being able to fully comprehend the right situations to actually give those fluid challenges is what really needs more clinical and classroom experience.

And quite honestly, when I first hit the street out of my program I was iffy on which patients deserved IVs as a precautionary measure. It just comes with time and experience.


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## Tigger (May 7, 2012)

NYMedic828 said:


> Paramedic IV skills aren't necessarily longer so much as they are referred back to countless times throughout the program.
> 
> I think I did around 300 IVs on patients in the ER by the end of my program. Countless more on the manikins during skills.
> 
> ...



I agree, and am personally not confident initiating fluid therapy on my own. That's what scares me about the EMT-IV program, there are no doubt BLS services with EMTs giving everyone a bag of NS because they can.:unsure:

Fortunately for me, college athletes have to be one of the healthier patient populations out there so it's a bit less of an issue. It's likely that I will only be starting IVs on significantly dehydrated players whose symptoms are fairly obvious. I also have my athletic trainer boss and our physician oversight to consult prior to starting any therapies, considering the breadth of his experience I think we will not have an issue with pointless IVs.


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## bstone (May 8, 2012)

Tigger said:


> I don't think anyone is arguing that IVs be added to the present curriculum. I can only start them because I took another class so it isn't like I don't know anything about them or fluid balances. I'd like to know more but given it's use I'd say the course length (20 hours) is about sufficient.
> 
> Is medic school's IV section longer? I'm sure it is, but an EMT-IV and a Paramedic are learning them for different reasons, or at least they should be.



I am certain that 20 hours is enough to teach the academic portion of starting IVs but it's nowhere near enough to actually becoming proficient in it. I would suggest the minimal standard be something like 20 hours + 50 successful lines in the ER + 50 successful lines on an ambulance. Anything less than this and I just don't see proficiency. If this could be done then I would sign off on supporting IVs for basics.


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## Tigger (May 8, 2012)

bstone said:


> I am certain that 20 hours is enough to teach the academic portion of starting IVs but it's nowhere near enough to actually becoming proficient in it. I would suggest the minimal standard be something like 20 hours + 50 successful lines in the ER + 50 successful lines on an ambulance. Anything less than this and I just don't see proficiency. If this could be done then I would sign off on supporting IVs for basics.



Yea, I wish that were the case. Instead we just needed 10 successful sticks in the ER, plus whatever we got in class, so around 15. Not enough really.


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## bstone (May 8, 2012)

Tigger said:


> Yea, I wish that were the case. Instead we just needed 10 successful sticks in the ER, plus whatever we got in class, so around 15. Not enough really.



Agreed, not really enough. After doing 100 successful sticks you're going to be really competent. 10-15 just isn't enough to even get your feet wet.


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## OzAmbo (May 8, 2012)

bstone said:


> Agreed, not really enough. After doing 100 successful sticks you're going to be really competent. 10-15 just isn't enough to even get your feet wet.



I think theres another issue you have to look at as well.

For arguments sake this gets legs and you get some select EMTS into hospital where they get their 100 venipunctures in both th IV and "taking bloods" (which is a different animal) and then you stick them out on the road with a restrictive rotocol that allows them to IV only time critical patients which are hard to get at the best of times and sometimes few and far between, especially in low call areas and you'd have to wonder if the guys involved can maintain competency in this without having some extensive clinical governance over it.

If the other option you guys talked about is where an EMT and a Paramedic are at a job and the Pt needs an IV (and i can say this with forst hand experience) my BLS partner doesn't place it, nor do i need them to place it as i have enough brains to delegate some duties which frees me up to do it myself.

Personally i think the priority here is a little screwed up. With calls for analgesia making up such a large proportion of EMS calls i would have though you would be after some non-invasive effective analgesia of some kind, its reprehensible that in this day and age pre-hospital care in 1st world countries still allows this unhumane practice, so i dont see the relevence of IV placement systems where the "basic" level of care doesn't cover the basics.


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## ZootownMedic (May 14, 2012)

Here in Colorado Springs to even get hired you have to have your IV certification as a Basic. Basic's being able to start IV's is nothing short of awesome. It makes life MUCH easier for the medics. And for those saying "they need more practice" well whats the harm in on the job training? As long as they are being safe then having them practice on the rig or in the patients home is only beneficial. If it is a time sensitive patient or one of the RARE patients who absolutely needs a line NOW then just let the Paramedic do it. Other than that let the Basic stick away. We all miss sometimes and we all started somewhere. There really is no downside from what I can see.


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## WolfmanHarris (May 14, 2012)

bstone said:


> I am certain that 20 hours is enough to teach the academic portion of starting IVs but it's nowhere near enough to actually becoming proficient in it. I would suggest the minimal standard be something like 20 hours + 50 successful lines in the ER + 50 successful lines on an ambulance. Anything less than this and I just don't see proficiency. If this could be done then I would sign off on supporting IVs for basics.



I am consistently amused by the wide range in education times in different jurisdictions. Here we sit discussing whether a provider with ~120 hrs of training should or should not have IV cannulation and what level of instruction is sufficient.

At the same time, I'm taking a short study break from cramming in the last bits of review I can do before writing a two hour exam tomorrow at work in order to take the IV enhancement being offered to Primary Care Paramedics. The funny thing is, we have to take the test and pass with a minimum 70% due to our Base Hospital Program dropping the Ministry of Health mandated 100 hours of didactic plus clinical down to 24 hours didactic, 12 hours hospital clinical and 12 hours riding third. The test is to prove requisite knowledge for the condensed course. 

Of course just about every PCP graduate for the last 5+ years has already learned all the material covered in the course as part of their two years of college to enter practice, but this hasn't been adapted as a mandatory part of the scope of practice yet in the province, hence the extra course requirement.


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## ZootownMedic (May 14, 2012)

WolfmanHarris said:


> I am consistently amused by the wide range in education times in different jurisdictions. Here we sit discussing whether a provider with ~120 hrs of training should or should not have IV cannulation and what level of instruction is sufficient.
> 
> At the same time, I'm taking a short study break from cramming in the last bits of review I can do before writing a two hour exam tomorrow at work in order to take the IV enhancement being offered to Primary Care Paramedics. The funny thing is, we have to take the test and pass with a minimum 70% due to our Base Hospital Program dropping the Ministry of Health mandated 100 hours of didactic plus clinical down to 24 hours didactic, 12 hours hospital clinical and 12 hours riding third. The test is to prove requisite knowledge for the condensed course.
> 
> Of course just about every PCP graduate for the last 5+ years has already learned all the material covered in the course as part of their two years of college to enter practice, but this hasn't been adapted as a mandatory part of the scope of practice yet in the province, hence the extra course requirement.



What is the 'IV enhancement'? Here the EMT's literally take a 16 hour course, get 10 sticks in the ER, and go about their merry way. There is only so much you can learn about starting an IV. Getting GOOD at it is a whole other thing but that is what practice is for. I don't see how it can get too complicated. Here they are just doing simple peripheral access but unless you are starting central lines I still don't see the need for that much classroom instruction. Its similar to intubation....the skill itself isn't incredibly hard on most patients. Practicing and becoming good at it as well as knowing when it needs to be done is the difficult part

As a side note, do you know whats even MORE scary? I was at Denver Children's last month on my last clinical for Paramedic school and there was a nursing student on her last clinical before graduating with a BSN. A 6 year old boy with meningitis came in and needed an IV so me and her went in to start it. I asked her if she wanted to do it and she turned about as red as a tomato. I asked her what was wrong and she said that she had only started 2 IV's. I was so stunned I just stared at her in disbeleif as I slipped a 20 in his little AC......I know we as EMS providers get knocked for education but how are you going to have a bachelors in Nursing and have started 2 IV's! Thats how many IV's a EMT has before they start their IV 'school' clinical haha. Crazy.....


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## Tigger (May 15, 2012)

SmokeMedic said:


> What is the 'IV enhancement'? Here the EMT's literally take a 16 hour course, get 10 sticks in the ER, and go about their merry way. There is only so much you can learn about starting an IV.



Maybe it only takes 16 hours to learn to cannulate a vein, but surely you don't think 16 hours is enough time to learn that and the pharmacology behind NS/LR, Narcan, and D50? Never mind learning iso/hyper/hypotonic and acid/base balance? These are things that those administering these medications _should_ know but most of our EMT-B/Ivs do *not*.


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## ZootownMedic (May 15, 2012)

Tigger said:


> Maybe it only takes 16 hours to learn to cannulate a vein, but surely you don't think 16 hours is enough time to learn that and the pharmacology behind NS/LR, Narcan, and D50? Never mind learning iso/hyper/hypotonic and acid/base balance? These are things that those administering these medications _should_ know but most of our EMT-B/Ivs do *not*.



Yeah I agree that the training is mainly focused on the skill itself and not so much the practical application of it. I think it takes PRACTICE to learn how to cannulate a vein and it is measured more in experience and not so much in hours. I think that the level a EMT-B needs to know the pharmacology of Narcan/D50/NS/LR is pretty much covered as is most of the tonicity of the solutions. The reason that they can push Narcan and D50 via IV is that those are two drugs that are relatively harmless and can save lives. It is a good thing that our state allows it since it has actually probably saved lives.

 At the same time though the EMT's around here are USUALLY either starting IV's under the supervision of a Paramedic or in the ER as a tech. Either way they are not gonna be giving any drugs without the medic's say so and I don't know if they really need to understand the acid/base balance to start an IV. I think in the end it is more of a easy remedy so on BLS calls that may require an IV the Medic doesn't HAVE to be in the back. I have been into HUGE arguments with certain EMT's who think that everyone needs an IV and I always argue that most patients do not. If the patient isn't sick, isn't getting meds or fluid, and I don't think I am gonna need it at any point why do it? I have heard many say "because they are gonna get one in the hospital anyways." To which I just bang my head. Either way, I agree that the education is on the skimpy side. I do like the fact that they have the skill though. I think it does far more good than harm and in the end only elevates and progresses our profession. Just my .02 cents.


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## Tigger (May 15, 2012)

Here's my position in short: 
I support allowing EMT-Bs with additional training to start IVs under the direction of a higher level provider. 

I do not support EMT-Bs starting IVs on their own, nor do I support them administering medications on their own. It's the D50 I have the biggest issue with considering the risk of tissue necrosis associated with an improperly placed line. Nasal Narcan via MAD is as effective as IV. 

I could support IV access and fluids following medical control consult, but I think this brings up an additional set of issues.

I really enjoyed my class and found it well done and useful, but I couldn't help think the whole thing was kind of Micky Mouse, just a stopgap measure more than anything else. If someone wants to start IVs, maybe they should just take an AEMT course. I took it mostly because you need it to get hired anywhere else besides my current gig, it was cheap, and it will be somewhat useful where I currently work.


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## mycrofft (May 15, 2012)

I support making IV's a watershed between EMT-B and EMT-P. The slope gets very slippery after that.

That is why I started a thread about making everyone get their EMT-P and eliminating professional medical responders below it. That and drugs, airways, pleural decompression, open chest heart massage....

If you want to put holes in people, get the whole education, not just the Idiot's Guide/Cliff Notes add-on certificate. Your employer would be only to happy to use you like (not as) a paramedic and pay you as an EMT_B.


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## NYMedic828 (May 15, 2012)

I have no problem with EMTs doing IM/IN/IV under supervision of a higher trained person be it a medic/intermediate/RN/MD.

It takes 5 minutes of training to teach the procedure for IN/IM. If it takes more than that you should find a new field.

Not really sure where the acid/base knowledge comes into play with d50, narcan and NS. 

Narcan can have major side effects via withdrawel symptoms. Aspiration is a serious deal. Many people who don't use the stuff too often don't realize that 0.4mg is actually a substantial dose. The wrong person could cause serious side effects by slamming the entire amp in carelessly.

D50 isn't really going to hurt anyone as long as you know your IV is patent but id rather see IM glucagon kits to play it safe.


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## Christopher (May 15, 2012)

NYMedic828 said:


> Narcan can have major side effects via withdrawel symptoms. Aspiration is a serious deal. Many people who don't use the stuff too often don't realize that 0.4mg is actually a substantial dose. The wrong person could cause serious side effects by slamming the entire amp in carelessly.



Yeah...with IM and IN Narcan available, no need for an EMT-B to give it IV. If they're so far gone as to need IV narcan, they likely should have ALS coming to play as well.



NYMedic828 said:


> D50 isn't really going to hurt anyone as long as you know your IV is patent but id rather see IM glucagon kits to play it safe.



I think the IV patency issue is pretty important w.r.t. D50. If anything they should use D10W or D25W bags as BLS (and us as ALS providers).

As for IM glucagon, I worry if they don't have somebody coming who can give IV dextrose they may sit around and wait for some improvement that never happens 

Otherwise, I don't see any reason EMT-B's couldn't start IV's. I don't know that I'd give them any medications to push via IV besides dextrose. Instead I'd see it more as a Paramedic-extender role (that sounds familiar, isn't EMS already a Physician-extender?).


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## mycrofft (May 15, 2012)

So the benefit is that the paramedic can use the EMT-B as "Medic-Helper"?







PS: agreed, not good to equate GLucagon with Dextrose. I saw the results of trying to mainline D50 right into the antecubital and missing....$10,000 of 1992 dollars in plastic surgery, physical then occupational therapy to repair the crater it left in the distal insertion of the bicep.


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## ZootownMedic (May 15, 2012)

mycrofft said:


> I support making IV's a watershed between EMT-B and EMT-P. The slope gets very slippery after that.
> 
> That is why I started a thread about making everyone get their EMT-P and eliminating professional medical responders below it. That and drugs, airways, pleural decompression, open chest heart massage....
> 
> If you want to put holes in people, get the whole education, not just the Idiot's Guide/Cliff Notes add-on certificate. Your employer would be only to happy to use you like (not as) a paramedic and pay you as an EMT_B.



I agree with you to an extent but EMT-B's or soon to be just EMT's, and AEMT's are NEVER going to go away. There are way to many areas and jurisdictions that cannot afford Paramedics and the bottom line is there are just not enough to go around. I always love how some people say that EMS is underecducated and then they say that we should take our current highest level provider and make everyone that level. It makes no sense. CNA's have a place in the hospital just as EMT's have a place in EMS. I see no reason why they can't be trained to safely administer IV's. In our system, they are....and it works great.


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## KnightVision (May 15, 2012)

I have a cert in Phleb, veins are tricky lil pains. And an IV placement can add to the headache (in some cases - shorter needle, smaller gauge, hard vein). Def too much to squeeze into a B class - but a useful skill.  AND, if properly taught later, CEUs?, the ability of just giving a port to expedite fluids/meds in the ED - well, I see it as a time saving bonus and great patient care.  Thoughts??


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## Boomerthedog (May 16, 2012)

As another poster alluded to, many services in Colorado actually require EMT-Bs to be IV certified to even be considered.  Thus, I just got my NREMT certification and subsequently completed my IV course.   Now I just need to get 10 successful sticks in the ER this Friday.  Can anyone give me some advice for my clinical?  I had four sticks on classmates last week, but that was easy because it was a very controlled setting.

I'm a lot more nervous for Friday than I was expecting, so any tips for my first few live patient sticks would be much appreciated.  My instructor said my biggest weakness is that I try to be too gentle. 

Thanks in advance!


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## Christopher (May 16, 2012)

Boomerthedog said:


> As another poster alluded to, many services in Colorado actually require EMT-Bs to be IV certified to even be considered.  Thus, I just got my NREMT certification and subsequently completed my IV course.   Now I just need to get 10 successful sticks in the ER this Friday.  Can anyone give me some advice for my clinical?  I had four sticks on classmates last week, but that was easy because it was a very controlled setting.
> 
> I'm a lot more nervous for Friday than I was expecting, so any tips for my first few live patient sticks would be much appreciated.  My instructor said my biggest weakness is that I try to be too gentle.
> 
> Thanks in advance!



You will miss some, you will make some. You're going to cause some pain. Take every opportunity you can to start an IV, and don't be shy to ask for some guidance.

You can get the steps down with an IV arm and vocalizing each step during practice. I reckon it takes about 50 sticks on an IV arm to be proficient at the steps itself.

After you know the steps, now you just need experience. You'll need another 400-500 sticks to be 0-dark-30 proficient.

Experience comes with stabbin' people, so if you're hesitant to start IV's you'll never become proficient.


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## mycrofft (May 17, 2012)

Well then, give EMT's red cards like wildland firefighters to show what they have a "ticket" (current qualification) to do in as many techniques as they can learn.
A frontier or really rural tech might have benefit of more advanced techniques, but suburban and metropolitan services don't need the added hassle.

I just remembered why we don't want techs doing stuff under our guidance if at all avoidable. I lost a perfectly OK job because a LVN did something minority wrong, I signed it off (I was handed the slip after the pt had left  so no way to check), and was held responsible for her action. You want me to supervise, make me a supervisor and pay me the differential.


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## systemet (May 17, 2012)

120 hours is a really short time for an EMT training program.

Where I worked, the EMTs had six months of training, and IV initiation and D50W were in their scope.  This has since expanded further.  I've heard some people suggest that their training is closer to a US EMT-I than an EMT-B.  I'm not sure whether this is the case.

The world didn't explode because BLS was able to start IVs.  I'm not sure it did a lot to help, although a few septic patients may have benefited, it might have ameliorated some anaphylaxis or hypotension in overdose patients.  But I doubt that it had a large impact.  

For the hypoglycemic diabetics, having the option for D50W was great.  I can't say that I ever saw real statistics or any published work on the complication rate.  I would be concerned that the skill level of some EMTs was less than a paramedic, but I think this more relates to individual experience levels (paramedics are after all, mostly more experienced EMTs), and the call volume in centers running BLS.

The major positives, as I saw it, were that if I backed up a BLS crew, they often had an IV started.  If I ran ALS with an EMT partner, which was most of the time, I could usually trust them to get the IV, and do something else myself.  This was also great on the days when I was just going to miss.

I think the bigger issue here is not whether you can train someone to start an IV in 20 hours or 3 hours or six months.  I'm pretty convinced you can show someone how to physically start an IV (very poorly) in about 10 minutes.  It's about whether we seek to be technicians, or practitioners.

If we really want to have ownership of our field, and aspire to become a profession, then we need to understand what we're doing and why.  Otherwise we're just calling rampart for the IV of D5W.  

So here's a few things that I think it might be good to understand if you're starting an IV:

* The concept of osmolarity / tonicity, and the properties of the commonly given IV solutions, and the effects that they have in vivo (e.g. why D5W is chemically hypertonic, but has effects on plasma electrolytes similar to administering a hypotonic solution).

* Serum electrolytes, and how IV therapy can change them, particularly regarding things like treatment and causation of hyponatremia / hypernatremia.

* The regulation of fluid balance in the human body.  How we lose fluid across various organs, how this becomes changed in disease states, and how it's affected by different medications that a patient may be taking, with a particular consideration of situations in which fluid administration may be detrimental.  

* The pathophysiology of hemorrhagic shock, and the role of hypothermia, hemodilution, coagulopathy, etc., and the appropriate use of volume resuscitation.

* A little bit about fluid dynamics, e.g. Poiseuille's law.  

We still have real problems at the ALS level that we don't really understand why we do what we do, and how this affects the human body.  A large part of this is due to the current state of EMS education, especially when it comes to physiology.  These problems are compounded at the BLS level.


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## medic417 (May 17, 2012)

systemet said:


> We still have real problems at the ALS level that we don't really understand why we do what we do, and how this affects the human body.  A large part of this is due to the current state of EMS education, especially when it comes to physiology.  These problems are compounded at the BLS level.



Exactly.  There is not enough true education given at the ALS level for the skills including the simple IV  so how in the heck can we expect proper education to be given for it at the BLS level.  Yes the actual skill is easy just like doing an appendectomy is easy its all the liitle things we don't know that make it dangerous.


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## mycrofft (May 17, 2012)

As I tell my CPR classes, holding up a business card, "I can print on this how to do CPR and you could leave with that information. ON the other side I could print the basic five steps of landing an airliner, but neither is going to work unless you have the critical knowledge to know when and how and how much".


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## CrackerBDingus (May 17, 2012)

As illegal as it is I've been told that if your company is stationed in-house with fire and the medics trust you they'll teach you how to start IV and on calls requiring tons of different interventions they will have you start it. No administering the fluids or making the decisions though. And again, it's only if they REALLY trust you.


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## mycrofft (May 17, 2012)

They used to treat LVN's that way at a hospital I worked at. Unless you run fluid the start becomes a clotted off site, which no one can use.

Like many other "save seconds" expedient moves, the potential for stuff not working and looking silly later is fairly high.


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## CrackerBDingus (May 17, 2012)

Well, considering basics can set-up the bags for IV, makes sense if the medic just tells them what to use and all the other stuff and just has the basic stick 'em. Wouldn't know personally though, I am not in-house with fire.


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## Christopher (May 17, 2012)

CrackerBDingus said:


> Well, considering basics can set-up the bags for IV, makes sense if the medic just tells them what to use and all the other stuff and just has the basic stick 'em. Wouldn't know personally though, I am not in-house with fire.



I work as a medic for a fire department that routinely runs P/B with a 3rd person rider (student or newbie of some kind). We're busy and we run a decent amount of real-ALS (we don't have RSI). I've yet to find a patient where I can't do the essential ALS on my own while my EMT partner handles something else. Paramedics working without other paramedics just need to learn to prioritize...and an IV is usually low on the list.

At my hospital service we run double medic, are insanely busy, and have RSI. Usually one of the medics is doing the essential ALS while the other is performing something an EMT could do instead. Unless we're doing an RSI, there aren't practical cases where two paramedics need to be performing simultaneous ALS interventions.

If the EMT's are doing their jobs well, a single Paramedic can handle the ALS side. If the EMT's aren't doing their jobs well, then they don't need to be doing things like IV's 

I don't see the utility in adding the additional liability to save time that isn't needed to be saved...


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## mycrofft (May 17, 2012)

...and if the EMT makes a mistake, who is responsible?.....h34r:

Sort of like pushing rope. Sometimes it works (like when it is frozen solid) but many other times, too much likelihood of kinks.


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## CrackerBDingus (May 17, 2012)

I'm not saying it is safe, or even that it should be done. But it is of huge debate in the socal area. Doctor's ambulance even has an interview question about whether or not you would start one if the medic you're running with has his hands tied and asks you too.


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## mycrofft (May 17, 2012)

Like asking if you would steal due to necessity on a JC Penney's job application.


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## ksmith3604 (May 17, 2012)

I actually laugh to myself when I read most of this thread as it seems that most EMT's are solely ambulance drivers.....thats too bad.  I work in a very progressive system (el paso county, CO) and our EMT's play a huge role on the ambulance and in the FD.  Our protocols include IV, fluid administration, dextrose and narcan all without calling in for orders.  IV and those drugs are standing orders from our medical directors.  Combitube is actually VERY standard and expected practice from EMT's.  Our city FD has recently moved to the "team" approach on all codes.  Basically, the first responding ALS engine with have 3 basics and 1 medic.  The medic is in charge of the monitor and scene choreography.  So....if you are following along that leaves 3 BLS providers to do EVERYTHING else.  Our BLS providers sink a combitube, start IV's.  Our EMTs push all meds directed by the lead paramedic.  When the medic shows up from the transporting ambulance they take over drug admin and intubation PRN with ROSC.  I agree EMTs need to know pathophys and be able to justify their interventions, not just do it for the hospital or just do it because they can.  However, there have been very valid reasons presented here for the EMT-B provider to have more advanced scopes.


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## Handsome Robb (May 17, 2012)

ksmith3604 said:


> I actually laugh to myself when I read most of this thread as it seems that most EMT's are solely ambulance drivers.....thats too bad.  I work in a very progressive system (el paso county, CO) and our EMT's play a huge role on the ambulance and in the FD.  Our protocols include IV, fluid administration, dextrose and narcan all without calling in for orders.  IV and those drugs are standing orders from our medical directors.  Combitube is actually VERY standard and expected practice from EMT's.  Our city FD has recently moved to the "team" approach on all codes.  Basically, the first responding ALS engine with have 3 basics and 1 medic.  The medic is in charge of the monitor and scene choreography.  So....if you are following along that leaves 3 BLS providers to do EVERYTHING else.  Our BLS providers sink a combitube, start IV's.  Our EMTs push all meds directed by the lead paramedic.  When the medic shows up from the transporting ambulance they take over drug admin and intubation PRN with ROSC.  I agree EMTs need to know pathophys and be able to justify their interventions, not just do it for the hospital or just do it because they can.  However, there have been very valid reasons presented here for the EMT-B provider to have more advanced scopes.



We have the same thing here. Except we don't use basics. Only Medics and Intermediates.  Fire has basics but all fire really does for us during a code is CPR and bagging until the intermediate can drop a KING and set up the vent. Then it's just CPR, maybe gathering meds and checking a sugar while the I drills an IO and starts pushing drugs as directed by the medic.


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## Christopher (May 18, 2012)

ksmith3604 said:


> I actually laugh to myself when I read most of this thread as it seems that most EMT's are solely ambulance drivers.....thats too bad.



The last bit you were reading was in reference to EMT-B's without IV training starting IV's "off the record".

NC EMT's have a pretty broad scope themselves, just shy of starting IV's. I think they could have IO's added for cardiac arrests, but otherwise with only 200 hours of initial education I don't see the utility in adding IV's for EMT-B's.

When we make it 1000 hours for EMT-B, I'm all in favor of IV's, 3/12-Leads, etc  But that is another post for another day.


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## Kavsuvb (May 26, 2012)

Just my 2 cents here, In the federal area, they allow EMT-B's to start IV's and in the federal area, they follow the NREMT-B standards to the letter and every line the NREMT-B standards. Maybe it's why the Feds are pushing for a uniform standard for all states and a standard for all EMT's, regardless of where your from.


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## Tigger (May 26, 2012)

Kavsuvb said:


> Just my 2 cents here, In the federal area, they allow EMT-B's to start IV's and in the federal area, they follow the NREMT-B standards to the letter and every line the NREMT-B standards. Maybe it's why the Feds are pushing for a uniform standard for all states and a standard for all EMT's, regardless of where your from.



Please prove that "federal EMTs" (I assume you mean Coast Guard EMTs) can start IVs.


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## Kavsuvb (May 26, 2012)

Tigger said:


> Please prove that "federal EMTs" (I assume you mean Coast Guard EMTs) can start IVs.



Go talk to the Combat Medics in the US Army, Air force (AKA, Pararescue, flight medics and combat medics). The Hospital Corpsmen in the US Navy & US Coast Guard. The rescue swimmers which are (AST = Aviation survival technician) They all follow the NREMT standards, line by line. If you Google the US Coast Guard EMT school, you can see the NREMT standards that they follow to the letter.


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## JakeEMTP (May 26, 2012)

Kavsuvb said:


> Go talk to the Combat Medics in the US Army, Air force (AKA, Pararescue, flight medics and combat medics). The Hospital Corpsmen in the US Navy & US Coast Guard. The rescue swimmers which are (AST = Aviation survival technician) They all follow the NREMT standards, line by line. If you Google the US Coast Guard EMT school, you can see the NREMT standards that they follow to the letter.



No. Combat Medics, 68W and Navy Corpman do not follow the NREMT to the letter and for that I am thankful.  

The NREMT also does not set the stanards. It only tests on the material from the US Department of Transportation National Standard Curriculum

68W trains for at least 16 weeks vs the civilian EMT which is about 3 weeks if you go to one of the civilian boot camps. Combat Medics can be trained to provide whatever is necessary in frontline combat or where they are needed. That includes not just starting an IV but doing a cutdown for venous access. It also can include inserting a chest tube. There would be little use for the equivalent of the civilian EMT in combat. 

Corpsmen can also be trained for whatever needed. This includes anything from xrays, labs to pharmarcy. No civilian EMT is going to work in those areas. 


They can still take the civilian equivalent training to be NREMT-I and P.


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## rwik123 (May 26, 2012)

Kavsuvb said:


> Go talk to the Combat Medics in the US Army, Air force (AKA, Pararescue, flight medics and combat medics). The Hospital Corpsmen in the US Navy & US Coast Guard. The rescue swimmers which are (AST = Aviation survival technician) They all follow the NREMT standards, line by line. If you Google the US Coast Guard EMT school, you can see the NREMT standards that they follow to the letter.



Line medics are trained to an EMT-B in whiskey school but have tons of interventions that are no where near the scope of emts in the civilian world. Don't go comparing the civilian and military world. They are two different beasts. Military are generally healthy young men dealing with traumatic injuries, and the medics protocols reflect this. 

PJs and flight designated 68wFs are not basics, they are paramedics so that argument doesn't work either.

Edit: I'm not sure if flight designated medics are paramedics... But they def have more experience than the grunt ground medic and do not "follow the nremt standards"


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## Kavsuvb (May 26, 2012)

JakeEMTP said:


> No. Combat Medics, 68W and Navy Corpman do not follow the NREMT to the letter and for that I am thankful.
> 
> The NREMT also does not set the stanards. It only tests on the material from the US Department of Transportation National Standard Curriculum
> 
> ...



Well How come you have Reserve and National Guard 68Wiskey Medics who are trained to the NREMT standards. Military EMS protocols would allow EMT-Bs to do IV and I have seen a AST in the US Coast Guard who is an NREMT do IV lines.


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## Kavsuvb (May 26, 2012)

rwik123 said:


> Line medics are trained to an EMT-B in whiskey school but have tons of interventions that are no where near the scope of emts in the civilian world. Don't go comparing the civilian and military world. They are two different beasts. Military are generally healthy young men dealing with traumatic injuries, and the medics protocols reflect this.
> 
> PJs and flight designated 68wFs are not basics, they are paramedics so that argument doesn't work either.
> 
> Edit: I'm not sure if flight designated medics are paramedics... But they def have more experience than the grunt ground medic and do not "follow the nremt standards"



Here's the US Coast Guard's AST training
The 18-week AST 'A' School is followed by three weeks of emergency medical technician training at a training center in Petaluma, California
Link http://www.uscg.mil/hq/cg1/attc/training/ast.asp

Here's the US Coast Guard's EMT school
The EMT course is seven weeks long, and is meets or exceeds the requirements of the DOT and National Registry of Emergency Medical Technicians (NREMT) for certification and registration.  EMT Recertification and Transition is a three day course which fulfills the core hours required for recertification, and also transitions the current EMT-Basic to the new NREMT standards. 
http://www.uscg.mil/hq/cg1/TracenPetaluma/HS_School/EMS/default.asp

US Coast Guard's HS school
http://www.uscg.mil/hq/cg1/TracenPetaluma/HS_School/default.asp


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## JakeEMTP (May 26, 2012)

Kavsuvb said:


> Well How come you have Reserve and National Guard 68Wiskey Medics who are trained to the NREMT standards. Military EMS protocols would allow EMT-Bs to do IV and I have seen a AST in the US Coast Guard who is an NREMT do IV lines.



NREMT is a test. It is not the standards.

There are liason schools to make civilian certifications available in the military.

The Combat Medic does not function with the scope of a civiliian EMT. Show me where an EMT can do a cutdown for a vein or insert a chest tube. Civilian Paramedics can not do that. The military exceeds that by far and in may ways. You can still test out to be an EMT-B once you enter civilian life. Centers that teach to the civilian US Department of Transportation National Standard Curriculum may give credit to the military trained person to help them gain a civilian cert.  Your civilian cert will mean next to nothing if you want to be a Combat Paramedic or PJ.


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## Kavsuvb (May 26, 2012)

JakeEMTP said:


> NREMT is a test. It is not the standards.
> 
> There are liason schools to make civilian certifications available in the military.
> 
> The Combat Medic does not function with the scope of a civiliian EMT. Show me where an EMT can do a cutdown for a vein or insert a chest tube. Civilian Paramedics can not do that. The military exceeds that by far and in may ways. You can still test out to be an EMT-B once you enter civilian life. Centers that teach to the civilian US Department of Transportation National Standard Curriculum may give credit to the military trained person to help them gain a civilian cert.  Your civilian cert will mean next to nothing if you want to be a Combat Paramedic or PJ.



That would be an 18D Special forces medical Sergent. Here's what they get at the end of 8 month Special Forces medical school at Ft. Bragg, NC

SOCM (W1's) Credentials include:

EMT Basic
EMT Paramedic
ATLS
BTLS/PHTLS (Basic Trauma Life Support/Prehospital Trauma Life Support)
ACLS (Advanced Cardiac Life Support)
PALS (Pediatric Advanced Life Support)
SOCOM ATP (Advanced Tactical Practitioner)

Their are some SOCOM medics that do work as flight medics for the 160th SOAR.

Also US Air force, Air force reserve and Air National Guard Pararescue are paramedics who are trained to SOCOM medic standards.

Here's the link for the Air Force Pararescue training
http://www.specialtactics.com/paramedic.shtml

http://en.wikipedia.org/wiki/United_States_Air_Force_Pararescue

Here's a link to what the SOCOM ATP (Advanced Tactical Practitioner) entails
http://www.military-medical-technol...nced-tactical-practitioner-certification.html

http://www.jems.com/article/operations-protcols/advanced-tactical-practitioner

Also SOCOM ATP (Advanced Tactical Practitioner) is being consider as a template for what street paramedics will be doing 20 yrs down the road.


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## JakeEMTP (May 26, 2012)

The links you have provided say exactly what we have been saying. 
You can take the EMT-B and EMT-P test after completing some of the military training. But did you look at the prerequisites to get into some of the military programs and what military medical personnel who might have the label as medic or Paramedic do? No civilian Paramedic or EMT is going to make incisions, clamp bleeders, insert chest tubes and do some other very impressive intervention.  The civilian EMT and Paramedic are very different from teh military.  A civilian EMT or Paramedic must go through the military training.  Think of it as saying the UK Paramedic is the same as the American Paramedic. Some things are similar but many are not.


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## Tigger (May 26, 2012)

As stated, I think you're misinterpreting the way the military trains its medical personnel. Yes, many of them do take the NREMT test, but that is no way the "end" of their training. 

I was not aware that ASTs could start IVs, I though they were "just" EMT-Bs. I known that HS techs can, but those are two different positions, no?


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## tanner72 (Jun 10, 2012)

*EMT/IV Tech*

In Maryland, Saint Mary's County, we do have an EMT-B (changing to EMT) IV Tech level certification, this is in part due to long transport times and is closely monitored by the County Medical Director. This certification is re-certified every six-months, AND there has to be a specific number of "sticks" over that six-month period. The MD reviews all cases during the QA meetings. If an IV is started specific reasons have to be detailed.


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## usalsfyre (Jun 10, 2012)

tanner72 said:


> In Maryland, Saint Mary's County, we do have an EMT-B (changing to EMT) IV Tech level certification, this is in part due to long transport times and is closely monitored by the County Medical Director. This certification is re-certified every six-months, AND there has to be a specific number of "sticks" over that six-month period. The MD reviews all cases during the QA meetings. If an IV is started specific reasons have to be detailed.



How does an IV of NS help with "long transport times"?


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## tanner72 (Jun 10, 2012)

The time comment is tied to the patient's complaint and condition and the location of the patient. We have some areas that are a 35-45 minute drive to the nearest medical facility. One example would be if we as a BLS transport have a stroke patient, the medic unit is not available or is to be met en-route, the objective would be to have an IV in place for the medic to use or for when we transfer that patient to the ER, that would be one less step to take.


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## Handsome Robb (Jun 10, 2012)

tanner72 said:


> The time comment is tied to the patient's complaint and condition and the location of the patient. We have some areas that are a 35-45 minute drive to the nearest medical facility. One example would be if we as a BLS transport have a stroke patient, the medic unit is not available or is to be met en-route, the objective would be to have an IV in place for the medic to use or for when we transfer that patient to the ER, that would be one less step to take.



Stroke patients get 3 lines. One TKO and two locks.


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## usalsfyre (Jun 10, 2012)

So are your basics versed in appropriately sized and located lines for diagnostic imaging and neuro resuscitation?


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## zmedic (Jun 10, 2012)

NVRob; said:
			
		

> Stroke patients get 3 lines. One TKO and two locks.



Why? Now they get to the ER and they still need to draw blood, a patient who likely will get anticoagulated and now has been stuck at least 4 times. 

I think very few patients need 3 lines in the field.


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## Ghostnineone (Jun 11, 2012)

Not an EMT but this thread made me curious about something, if EMT's can do king tubes and laryngeal masks why can't they do ET tubes? From my limited googling it seems like you could easily put a king tube down the wrong hole, maybe not a LM though. 

Also, why would you use one over the other?

Being able to start an IV but not put anything in it seems like putting AED pads on a PT but not being allowed to shock.


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## JPINFV (Jun 11, 2012)

King tubes are made to go down the "wrong" hole, and laryngeal masks don't go down either of the two holes.


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## Handsome Robb (Jun 11, 2012)

zmedic said:


> Why? Now they get to the ER and they still need to draw blood, a patient who likely will get anticoagulated and now has been stuck at least 4 times.
> 
> I think very few patients need 3 lines in the field.



One line to draw labs off of, one line to push contrast through, one line for med/fibrinolytic administration. 

That's 3 pokes last time I checked...

They get 3 lines in the hospital, if we can get three good lines in the field why shouldn't we? I'm not dumb, I'm not going to go fishing around for lines that I'm not confident I can get all the way to the ER just to poke holes in someone.


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## Christopher (Jun 11, 2012)

Ghostnineone said:


> Not an EMT but this thread made me curious about something, if EMT's can do king tubes and laryngeal masks why can't they do ET tubes? From my limited googling it seems like you could easily put a king tube down the wrong hole, maybe not a LM though.



Yeahhhh, but no. Paramedics largely are intubation-incompetent and have 8-10 times the training of an EMT.

It would be tough to legitimately place a King in the trachea. Combitube happens occasionally (Kelly Grayson recently blogged about his first ever experience) to find its way into the trachea. LMA's can't go fully into the glottic opening, but they could block it.

That being said, EMT's with *waveform ETCO2* and bougies or tube exchangers could probably place a supraglottic airway (e.g. a KingLT, Air-Q, i-Gel, or LMA-FastTrach) and convert it to an ETT with sufficient training.

Do I think it is necessary? No.

A properly placed SGA is perfectly fine for almost any length of transport that an EMT would be with a critical patient.



Ghostnineone said:


> Also, why would you use one over the other?



One SGA over one another, or ETI over SGA? They're all equivalent when properly used. But this is horribly off topic.



Ghostnineone said:


> Being able to start an IV but not put anything in it seems like putting AED pads on a PT but not being allowed to shock.



I'd agree. No practical help with EMT IV starts.


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## zmedic (Jun 11, 2012)

NVRob; said:
			
		

> One line to draw labs off of, one line to push contrast through, one line for med/fibrinolytic administration.
> 
> That's 3 pokes last time I checked...
> 
> They get 3 lines in the hospital, if we can get three good lines in the field why shouldn't we? I'm not dumb, I'm not going to go fishing around for lines that I'm not confident I can get all the way to the ER just to poke holes in someone.



You can push the meds through the same line you just pulled the labs off of. So 2 lines. In the hospital we tend not to draw labs off existing IVs because they tend to be hemolyzed or diluted. Also are you drawing labs in the field? If you are great. But lots of ambulances don't draw labs so the patient needs to be stuck again at the hospital.


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## Christopher (Jun 11, 2012)

zmedic said:


> You can push the meds through the same line you just pulled the labs off of. So 2 lines. In the hospital we tend not to draw labs off existing IVs because they tend to be hemolyzed or diluted. Also are you drawing labs in the field? If you are great. But lots of ambulances don't draw labs so the patient needs to be stuck again at the hospital.



We draw in the field and only stick twice on STEMI/CVA. 3 IV's seems much when the ED could easily butterfly labs around 2 existing lines.


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## Bullets (Jun 12, 2012)

tanner72 said:


> The time comment is tied to the patient's complaint and condition and the location of the patient. We have some areas that are a 35-45 minute drive to the nearest medical facility. One example would be if we as a BLS transport have a stroke patient, the medic unit is not available or is to be met en-route, the objective would be to have an IV in place for the medic to use or for when we transfer that patient to the ER, that would be one less step to take.



I see this argument as attempting to make a responsibility for EMTs where there its no need. Or to make EMTs feel more important. You really don't need medics on a stroke patient, you need a hospital. Plus I feel starting lines in an ambulance causes the patient unnecessary exposure to infection which can be managed in the hospital. 

Around here the hospitals view field IVs as "dirty" and are quickly replaced


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## Tigger (Jun 12, 2012)

Bullets said:


> I see this argument as attempting to make a responsibility for EMTs where there its no need. Or to make EMTs feel more important. You really don't need medics on a stroke patient, you need a hospital. Plus I feel starting lines in an ambulance causes the patient unnecessary exposure to infection which can be managed in the hospital.
> 
> Around here the hospitals view field IVs as "dirty" and are quickly replaced



Studies show that there is lite difference in infection rates  between IVs started in and out of hospital. Hospital, better know as a large building full of sick people.


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## Handsome Robb (Jun 12, 2012)

zmedic said:


> You can push the meds through the same line you just pulled the labs off of. So 2 lines. In the hospital we tend not to draw labs off existing IVs because they tend to be hemolyzed or diluted. Also are you drawing labs in the field? If you are great. But lots of ambulances don't draw labs so the patient needs to be stuck again at the hospital.



3 is our protocol for CVAs, and two for STEMIs. That's how the hospitals want it, so we do what we can to make it happen. One TKO and two NS locks, preferably 18s or 20s.

There's been talk about us drawing labs on STEMIs/ACS symptoms and CVAs in the field but it hasn't been implemented yet. It's a tough one with our generally short transport times. The hospitals here all draw labs off of our field IVs on a regular basis, I've seen nurses get grumpy when a line will flow but wont draw.


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## rmabrey (Jun 12, 2012)

NVRob said:


> 3 is our protocol for CVAs, and two for STEMIs. That's how the hospitals want it, so we do what we can to make it happen. One TKO and two NS locks, preferably 18s or 20s.
> 
> There's been talk about us drawing labs on STEMIs/ACS symptoms and CVAs in the field but it hasn't been implemented yet. It's a tough one with our generally short transport times. The hospitals here all draw labs off of our field IVs on a regular basis, I've seen nurses get grumpy when a line will flow but wont draw.



I haven't seen a medic draw labs in 8 months here. One hospital quit requiring it when they found out the nurses were throwing our blood draws away anyway, so everyone just quit doing it period


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## NomadicMedic (Jun 12, 2012)

Only one hospital in our county pulls field IVs. The others all use our lines and expect bloods to be drawn if we have a line up. 

It's different everywhere you go.


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## ZootownMedic (Jul 4, 2012)

Just for the record too.....2 of my best friends are SOCM qualified. They both were 18D's out of 10th Special forces group. For the record they are NOT tested at the NREMT-P level. The one went to Paramedic school and the other had to do Practicals and then national registry. They are authorized to test through Ft. Bragg however as long as they still have their NREMT-B. Then they can take the NREMT-P practicals and written exam. They are really great guys and are definitely very well trained. For the record though....their cardiology SUCKS.


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## Doczilla (Jul 5, 2012)

Yes, a SOCM medics cardiology leaves much to be desired. However, they do know enough to perform prehospital ACLS-- and most of them are humble enough to use a reference when needed. 

But they will run circles around you in trauma. And not just "military" trauma. They can transition from "keep them alive until you get to the hospital" to "keep them alive, you ARE the hospital "quite easily.


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## ZootownMedic (Jul 11, 2012)

Doczilla said:


> Yes, a SOCM medics cardiology leaves much to be desired. However, they do know enough to perform prehospital ACLS-- and most of them are humble enough to use a reference when needed.
> 
> But they will run circles around you in trauma. And not just "military" trauma. They can transition from "keep them alive until you get to the hospital" to "keep them alive, you ARE the hospital "quite easily.



Oh I know....their trauma is great. Trauma is just one branch of the tree that is emergency medicine however. Keep in mind that 2 of these guys are my really good friends but.....how many 6 year old asthma patients have they ran? How many 88 year old PE/chest pain/SOB? how many COPD exacerbations? I am not knocking their skills but the bottom line is that they were trained to operate in a combat environment. The streets of the USA are full of sick, ungrateful, unhealthy, old, young, fat, and weird people. Not the poster cut-out 18-35 year old male. Its just a fact that they will have to accept and they don't seem to want to. Their medicine has suffered for it on the streets.


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## Pavehawk (Jul 12, 2012)

Like all medical professionals, SOCOM types never stop learning their trade. Not all military medicine is trauma under fire, and not all SOCOM missions involve blazing gun battles in far away places. Ask any 18D who has been the "family practice doc" for a remote villiage (or several of them). You might be surprised at the depth of knowlwdge these guys pick up during training and then after they get to their units.


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## Tigger (Jul 12, 2012)

SmokeMedic said:


> Oh I know....their trauma is great. Trauma is just one branch of the tree that is emergency medicine however. Keep in mind that 2 of these guys are my really good friends but.....how many 6 year old asthma patients have they ran? How many 88 year old PE/chest pain/SOB? how many COPD exacerbations? I am not knocking their skills but the bottom line is that they were trained to operate in a combat environment. The streets of the USA are full of sick, ungrateful, unhealthy, old, young, fat, and weird people. Not the poster cut-out 18-35 year old male. Its just a fact that they will have to accept and they don't seem to want to. Their medicine has suffered for it on the streets.



But they don't practice medicine on "the streets of the USA." I see no issue with training someone to preform a specific role so long as everyone is aware of what that role is and what its limitations are. I have a hard time believing that these guys are not smart enough to realize that.


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