EMTs starting IV

[Tigger]

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.

 

[Veneficus]

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.

 

[MS Medic]

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.

 

[Veneficus]

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?

 

[MS Medic]

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.

 

[TransportJockey]

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.

 

[TransportJockey]

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.

 

[EMTJUNKIE]

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.

 

[BuildsCharacter]

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.

 

[TransportJockey]

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.

 

[Veneficus]

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.

 

[MS Medic]

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.

 

[NHEMT-I]

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.

 

[jjesusfreak01]

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...

 

[MrBrown]

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]

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

 

[EMS49393]

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.

 

[Veneficus]

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.

 

[jjesusfreak01]

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

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

 

[medicRob]

**Sings to Lambchop Tune**

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