BLS and IV's

[bstone]

Can anyone name one instance where an IV saved a patient's life?





Didn't think so. SNIP

Um...Narcan and D5W save the lives of my PTs daily. Had a PT with a blood sugar of 10. Unresponsive, not in good shape. I do believe the IV D5W saved him.

And Narcan...over and over.

 

[reaper]

Did the EMT do this with the medic there? Who rode with the pt to the hospital?

If the EMT just hung the bag, then they did not "run fluids". The medic was there to make sure what and how much was administered. Do not think that administering NS is no big deal and basics should be able to do it. You can kill a pt with NS, if you have no clue when and why you are giving it.

You are there doing ride alongs to learn the correct way to do things. Don't let people that are working out of their SOP, show the wrong way to do things.

Have fun and learn all you can. But, use your judgement with it too!

 

[triemal04]

Um...Narcan and D5W save the lives of my PTs daily. Had a PT with a blood sugar of 10. Unresponsive, not in good shape. I do believe the IV D5W saved him.

And Narcan...over and over.

Uhm...I'm going to repeat the question: when did an IV save a life? Narcan is not an IV, neither is D50 regardless of how they are given. An IV, meaning a catheter inserted into a vein is an IV. Not the meds that may follow.

I don't have a problem with Intermedietes here (and that only means in my state) starting IV's or giving meds. For what they can do and when they can do it, the course isn't bad. It's cookbook mediecine, but at that level that's pretty much to be expected. (we won't talk about the new scope) But I don't consider them BLS either. (or really ALS...that's also another topic) For BLS providers, basics and first responders...no. Absolutely not. It's to bad for a lot of basic's out there, but there are way more out there that this would be a horrible idea for. The class they take is simple enough that adding a more advanced skill would be stupid; it'd just be a "feel that and poke it" 5 hour class more than likely. Without being able to give any meds, the times when it would really make a difference are extremely limited. The times it could cause problems would be much more common. So no. Basic's get minimal training as it is. Another skill is not needed.

I am sick and disgusted with the amount of people out there who want to look, act, talk like a medic and do medic skills without taking the time to actually become a medic or ALS provider. If you don't like your skill set, go back to school. Do not try and add more skills that you will not be properly trained in or qualified to use. EMT-B's are called BASIC for a reason; they are supposed to be able to provide intial actions until ALS support is reached.

Has anybody ever stopped to think that EMS isn't advancing and getting the respect and acknowledgement it deserves because of #$%^ like this? Untrained people performing skills they should never have had in the first place and causing problems? Low skill levels begging more the "fun" skills even when they don't need them? I'm sorry, but when was the last time you saw a CNA or LPN whining that they should be able to intubate? Never. Won't happen because they have set standards and education levels and the people know that if they want to do more they have to go back to school. Not pitch a hissy fit until someone gives in.

Wow. That felt good.

 

[bstone]

I am an NREMT-Intermediate and 100% ALS provider. I may not have as many skills or the same scope as you, but I am an ALS provider.

There was nothing "cookbook" about my Intermediate program, thank you very much. For every skill we had many hours and presentations on the A&P, biochemical mechanism, pathophysiology, etc etc. In fact our course was not unlike the medic course (same people taught it). We just have fewer skills and less scope so we needed less time, but it was just as rigorous in depth as the medic program.

 

[focal06]

Did the EMT do this with the medic there? Who rode with the pt to the hospital?

If the EMT just hung the bag, then they did not "run fluids". The medic was there to make sure what and how much was administered. Do not think that administering NS is no big deal and basics should be able to do it. You can kill a pt with NS, if you have no clue when and why you are giving it.

You are there doing ride alongs to learn the correct way to do things. Don't let people that are working out of their SOP, show the wrong way to do things.

Have fun and learn all you can. But, use your judgement with it too!

medic was in the jump seat when the EMT-B started the line and administerd fluids. then after that the EMT-B jumped up front and drove to the hospital with the medic and me still in the back. IM not saying an EMT-B should be able to do it with no supervision, that would be wrong, but if a medic is present I dont see why the EMT-B cant lend a helping hand and start the IV. None of our medics around here complain when they get help...call me crazy.

 

[bstone]

There is nothing wrong with an EMT-B starting an IV under the direct supervision of a medic (or Intermediate...or doctor, or nurse, etc). At that point they are acting more like an assistant/tech than a licensed EMT-B.

A medical student assists in surgery, even making the first incision, but does so only under the direct supervision of the attending surgeon. I think it would be a similar guidline for the EMT-B start a line under an EMT-I or P.

 

[Flight-LP]

There is nothing wrong with an EMT-B starting an IV under the direct supervision of a medic (or Intermediate...or doctor, or nurse, etc). At that point they are acting more like an assistant/tech than a licensed EMT-B.

A medical student assists in surgery, even making the first incision, but does so only under the direct supervision of the attending surgeon. I think it would be a similar guidline for the EMT-B start a line under an EMT-I or P.

The absolute saddest part of this whole thread is not the belief that EMT's should be able to perform intravenous cannulation, but the lack of comprehension as to why IT IS NOT BENFICIAL. Therefore, EMT-B's, how can you remotely justify reasoning if you fail to identify it in the first place?????

Med student vs. EMT-B. Apples vs. oranges....................

A Med student assisting in surgery has already completed 2 years of medical school preceded by 4 years of undergraduate studies. They are enrolled in a professional medical prgram. They are covered under the program's liability insurance. And I see very few surgeons who will allow a med student to make any incision, let alone the initial. If there are med students, then there are residents and they are the ones who are there to learn the trade. The med students are there to get a taste of whats to come.

-5 for a horrible analogy, but +20 for taking your education more seriously than most ( another +5 for choosing one of the best educational institutions in the country!)

I leave you with a question though, you mentioned D50 and Narcan save the lives of your pts. daily. Do you routinely give Narcan with D50? and if so why?

 

[bstone]

The absolute saddest part of this whole thread is not the belief that EMT's should be able to perform intravenous cannulation, but the lack of comprehension as to why IT IS NOT BENFICIAL. Therefore, EMT-B's, how can you remotely justify reasoning if you fail to identify it in the first place?????

Med student vs. EMT-B. Apples vs. oranges....................

A Med student assisting in surgery has already completed 2 years of medical school preceded by 4 years of undergraduate studies. They are enrolled in a professional medical prgram. They are covered under the program's liability insurance. And I see very few surgeons who will allow a med student to make any incision, let alone the initial. If there are med students, then there are residents and they are the ones who are there to learn the trade. The med students are there to get a taste of whats to come.

-5 for a horrible analogy, but +20 for taking your education more seriously than most ( another +5 for choosing one of the best educational institutions in the country!)

I leave you with a question though, you mentioned D50 and Narcan save the lives of your pts. daily. Do you routinely give Narcan with D50? and if so why?

I'd be willing to rethink the analogy. It isn't the best one. How about an EMT-B who is in Intermediate or Paramedic school doing IVs under the direct supervision of an Intermediate or Paramedic but not necessarily during their actual clinical times? It would be like informal clinical training. I think many Is and Ps would be cool with this- assuming it was legal and OKd by the med director.

Why do I routinely give D50 and Narcan? Well- I am an Intermediate and where I trained (New Hampshire) our protocols allow for Intermediates to start IVs and based on blood sugar check or positive opiate OD administer D50 or Narcan. We have a lot of protocols that we don't need authorization for, including Epi (1:1000 and 1:10,000), Atropine, Alubterol, Narcan, D50, Oxygen, some of the nerve agent antidotes. Not nearly as many meds as the Medics, of course, but many. We also do 3 lead EKG with dynamic interpretation, manual defibrillation, endotrachael intubation with some meds down the ETT. No traches/crichs, chest decompression, opiates or 12-leads.

Intermediates in New Hampshire most often work with Medics, but many times don't.

I am currently in school so I am taking a break from EMS to concentrate on school, studying for the MCAT and doing well. It is my hope to go to med school, become a great doc and post on these sorts of forums as a resource for information. Communication between EMS providers and physicians is so, so important and not enough of it is done outside the lecture hall or "you're in trouble, take a seat" senario. I hope to change that.

 

[BossyCow]

Here we go again. First of all, I do not have my IV cert yet and am pursuing my EMT-I as soon as I can get into a class.

A lot of the issues I see arising from these types of threads are based on an urban system or EMT-B's who want to play with all the cool toys without an understanding of the possible problems that can result.

In my system, if we are on the western edge of the district, we can have an hour long transport time. Our closest airlift requires at least a half hour lead time so often that hour by ambulance is going to be the fastest route to the hospital for the patient.

My state does have a cert for EMT-B - IV. It is not 'a couple of days' training but an extensive course. It can only be taken with the prior permission of the MPD and he's refused more applicants than he's accepted. Once certified as an EMT-B-IV, you are no longer allowed to recert under the EMT-B training or rules but must take the EMT-I test every three years to recert. as well as send in your list of sucessful sticks.

Once an IV has been started, we must call for ALS support. Our closest ALS is at least 20 minutes out and generally meets us enroute to the hospital. The value of the start of the IV is that it shortens the time spent on the side of the road after we meet up with ALS.

As to saving a life, I do have an instance where it did. We had a traumatic amputation. Crackhead in a car vs old guy on a motorcycle. Took the motorcyclist's leg off right below the hip. We had about 3" of femur and that's was it. He was bleeding from the femeral artery when his buddy who was travelling behind him found him and tied a tourniquet around the stump. The EMT-I who was first on scene started two large bore IV's and called for ALS support. We were lucky to have ALS available and to the west side of their district so the time until rendezvous with ALS was only about 35 minutes. This guy's blood resembled strawberry koolaid by the time he got to the ER. He got 5 units of blood in the ER and everyone was on pins and needles as to whether or not he had enough of his own blood left to make it. He did survive. According to our MPD it was the combination of events that allowed him to survive this event. If his buddy hadn't stopped the bleeding, if the initial fluids hadn't been given, if ALS was not able to meet up with us as rapidly as they did, this guy would not have made it.

Is the best treatment for those kinds of injuries an ALS system? Absolutely! Would I rather have had a Paramedic on scene immediately? You betcha! But it's not going to happen in my lifetime. As a volunteer with a full time job outside of EMS, I am not going to assume the financial burden of training myself to EMT-P so that I can provide care for free. EMT-I is all that is available to me and it is rare. I have to attend the class outside of my county and then prove to my MPD that I can translate that teaching into our protocols by passing his protocol test. Then I have to re-test every 3 years because there are no ILS Oteps provided in my county.

I'm willing to do that because I want to be able to do all I can and all I am allowed to do within my system. I don't want permission to do everything a paramedic can do, but I do want as many certifications as I can earn and as many skills as I can learn.

Not all of us are just whackers thinking "Hey I could do that" after seeing a medic do a skill. Not all of us are trying to be mini-medics. But I want to give every patient I see the best chance of survival.

 

[bstone]

BossyCow, that's very interesting.

Let me just say, however, that Intermediate level is ALS. Just not as many "tools in the toolbox". In New Hampshire I have a lot of tools. States which use I-99 have an even bigger toolbox. States that use I-85 have only a few tools. But they are there.

 

[knxemt1983]

aloow me to clarify. its not that i dont trust basics to start lines. i am a basic. i can start a line, monitor it, push meds through it, dc when necessary. my lack of faith is in the system. i dont believe -iv programs will cover enough of the anciliary information to make it a safe situation. the a/p, fluid/electrolyte balance, med administration, imho, wont be covered. it would(or is in some cases) taught as purely a mechanical skill with none of the medicine behind it.

24hrs in the classroom and 15 starts? we did over 40(maybe more i wasnt counting) and by the time i leave my clinical rotation i will have an average of 300+. thats the diff betweenreal training and just throwing a skill and hoping it sticks.

"I do know Basic services in MA that carry IV supplies and only Basics, but they are ALSO trained either as ER-Techs or Phlebotomists (sp?). Some of the hospitals in the area like to have blood drawn when the patient arrives and TRAINED basics are happy to do this."

it is entirely possible that this type of thing is happening in the western part of the state(illegaly i might add) but there is no way this is going on east of 495. this isnt even a grey area. this is blatantly outside ma bls protocols and is ground for immediate revocation of certification regardless of certification as a phlebotomist or ed tech. these certs do not carry over into mass ems in anyway.

I dont really know how it is done in the rest of the country hut here in Tn we only have emt-iv, which are basics with the a&p od iv's built into the course. Until recently I thought that the course covered it pretty well, and even thought I had a good grasp on the physiology of it, that was until I started paramedic school, and learned about the different types of fluids and the types of fluid shifts, and all the cellular stuff, that they never mentioned in emt school.
With that being said, I think there is a place in some systems for it, but we should really change the requirements for the iv cert. I understand where you are coming from with the skill issue is coming from, we have to start around the same number of iv's before we can get the medic cert, and I haven't done near that many iv's in the past 5 years of ems.

just my 2 cents

 

[triemal04]

I am an NREMT-Intermediate and 100% ALS provider. I may not have as many skills or the same scope as you, but I am an ALS provider.

There was nothing "cookbook" about my Intermediate program, thank you very much. For every skill we had many hours and presentations on the A&P, biochemical mechanism, pathophysiology, etc etc. In fact our course was not unlike the medic course (same people taught it). We just have fewer skills and less scope so we needed less time, but it was just as rigorous in depth as the medic program.

This is a topic for a whole 'nother thread, so I'll just say a few things and then shut up. 1. How long did you spend on A&P, pharmocology, etc etc? 2. Your attitude is quite common it seems and never fails to annoy me. "I'm just as good as a medic even though I don't know as much." YOU probably know more if you're in pre-med now, kuddos on that, but do not forget that that doesn't apply to everyone. 3. Who knows, maybe you had a good program with good instructors. Remember, that also doesn't apply everywhere. EMT-I courses are almost always much shorter than medic school and teach...cookbook mediciene. 4. If you are actually being taught endotracheal intubation, not how to use dual-lumen's or LMA's...you better being doing a whole lot of clinical time, internship time and training otherwise that is very very dangerous. Now I'm goint to stop and try to stay with IV's and BLS providers.

Someone who is in I or medic school and has been taught how to do IV's...it'd depend on the situation and person, but personally that's fine with me. Doesn't apply to the topic at hand though.

Again, you missed the question. Do you routinely give D50 and Narcan together? (you know...add thiamine and you've got the coma cocktail) If so, is that because you are unable to determine an OD from hypoglycemia, your protocolls requie it, or do you not push them together? Oh, and when have you had an IV save a life? And I mean really save a life?

Bossycow...your's is the situation that's a pain. Really the only good solution for you is to do what you're doing and get your Intermediate. (so, is that the EMT-I with airway? With meds? or one of the other 8 intermediate levels WA has? ) It's good that you have a selective program for allowing basics to start IV's, but not everwhere is like that. To many people would be doing the wrong thing because they could without thinking about. It definetly applies to you; if a basic with IV skills starts a line on Joe Blow the average guy because he can and it's rare for him to be able to, that means you have to call an ALS ambulance, right? Even if the pt really didn't need one. If you are going to start an IV YOU MUST KNOW WHEN TO DO IT AND WHEN NOT TO DO IT. If the people in your system are that good, then good for you guys. But I've also seen BLS people sit onscene for 20+ minutes with a critical pt trying to start a line before bringing them to the transport ambulance. As for shortening the time spent on the side of the road...if the medic's can't do the line enroute, that is a whole 'nother problem.

If people want advanced skills, go to school and learn them. Get your intermediate, you'll pick up some skills that are more beneficial than an IV. But as a basic...it's called basic for a reason.

 

[ffemt8978]

Bossy,

I'm in the same situation as you, but in the middle of the state. Nearest hospital is an hour in any direction, nearest ALS is 20-30 minutes in any direction, and Medstar is 35 minutes when available.

Getting back to the call you described, how did the IV itself save the patient? It didn't. Normal saline can not carry oxygen or nutrients to the cells that need them. What saved that patient was a combination of things.

 

[Gbro]

I have a response to all the posters that say; Go To school.
How about you come to the rural area and help us out?

We've had young enthusiastic Highly trained Full timers try and buy our service, after sitting 6-7 days without a call, Guess what?
Ya they were gone, and us Basic's are all thats left.
The only thing we lac in the rural area is Run Volume.
We see sick and injured just as bad as you in Critical Care see, again just not as many.
Why that means those poor folk shouldn't get the best care we can possible give them(without being ALS) is beyond me.
I do fully agree with one of the posters, It is a systems problem.
Our system is required to have everyone equally trained. That is to mean, we must all be proficient in IV"s to carry them.
Now my wife worked in the ER and couldn't start an IV in the field. Why?
B.S. Red tape. that is all.
Like i posted we could go with the training, but i for one have spoken out against it.
We just don't see the volume, To stick someone just for "our" stick count would be wrong. But we do have ALS 20min out for the average call.

 

[triemal04]

I have a response to all the posters that say; Go To school.
How about you come to the rural area and help us out?

We've had young enthusiastic Highly trained Full timers try and buy our service, after sitting 6-7 days without a call, Guess what?
Ya they were gone, and us Basic's are all thats left.
The only thing we lac in the rural area is Run Volume.
We see sick and injured just as bad as you in Critical Care see, again just not as many.
Why that means those poor folk shouldn't get the best care we can possible give them(without being ALS) is beyond me.
I do fully agree with one of the posters, It is a systems problem.
Our system is required to have everyone equally trained. That is to mean, we must all be proficient in IV"s to carry them.
Now my wife worked in the ER and couldn't start an IV in the field. Why?
B.S. Red tape. that is all.
Like i posted we could go with the training, but i for one have spoken out against it.
We just don't see the volume, To stick someone just for "our" stick count would be wrong. But we do have ALS 20min out for the average call.

Hmm. All I can see from this post is that you, even will a very low call volume, still see critical pt's. (which makes me wonder how well you would be able to keep those IV skills up anyway with such a low volume) But you don't want to take the time to go to say...EMT-I school, learn some new pt assessment skills and get a few more skills that will sometimes make a difference. You just want to be able to start IV's because...why? That's the part that is really funny. You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.

Couple suggestions. Think about why you need the skill. Really think about it, and then ask yourself what is best for your community. The able to maybe put a piece of teflon in someones vein, or the ability to perform a little better pt assessment and maybe give a few meds. If you really think that starting an IV is so great, go back and get your EMT-I. You'll learn a few tricks that could help out more than a piece of teflon.

Hate to say it, but this is the type of mentality that makes me so dead set against EMT-B's starting IV's. They want the skills without taking the time to learn them, or learn when/why they should be used and what should go along with them. (if that's clear )

 

[bstone]

This is a topic for a whole 'nother thread, so I'll just say a few things and then shut up. 1. How long did you spend on A&P, pharmocology, etc etc? 2. Your attitude is quite common it seems and never fails to annoy me. "I'm just as good as a medic even though I don't know as much." YOU probably know more if you're in pre-med now, kuddos on that, but do not forget that that doesn't apply to everyone. 3. Who knows, maybe you had a good program with good instructors. Remember, that also doesn't apply everywhere. EMT-I courses are almost always much shorter than medic school and teach...cookbook mediciene. 4. If you are actually being taught endotracheal intubation, not how to use dual-lumen's or LMA's...you better being doing a whole lot of clinical time, internship time and training otherwise that is very very dangerous. Now I'm goint to stop and try to stay with IV's and BLS providers.

My Intermediate program was very indepth. For certain topics which the medics were also being taught we were able to keep up in the conversation. For every topic we learned it was just as in depth as the medics. We just have fewer things.

Again, you missed the question. Do you routinely give D50 and Narcan together? (you know...add thiamine and you've got the coma cocktail) If so, is that because you are unable to determine an OD from hypoglycemia, your protocolls requie it, or do you not push them together? Oh, and when have you had an IV save a life? And I mean really save a life?

Thiamine (100mg IV) is one of our meds. Give it in cases of alcohol DT (Delerium Tremens, Korsokoff's/wernicke). We stick someone's finger and test for blood before giving D50 and determine if they have an actual opiate OD before Narcan. We don't do coma cocktails and have no type protocol for such an unresponsive patient. We actually test and investigate to see what the problem is.

 

[triemal04]

Thiamine (100mg IV) is one of our meds. Give it in cases of alcohol DT (Delerium Tremens, Korsokoff's/wernicke). We stick someone's finger and test for blood before giving D50 and determine if they have an actual opiate OD before Narcan. We don't do coma cocktails and have no type protocol for such an unresponsive patient. We actually test and investigate to see what the problem is.

Good. That makes me happy to be honest. Now be a good sport and answer the question that's really pertinent to this thread and has been asked 3 times. When have you had an IV, and that means just an IV, no meds, really save someones life?

 

[bstone]

Good. That makes me happy to be honest. Now be a good sport and answer the question that's really pertinent to this thread and has been asked 3 times. When have you had an IV, and that means just an IV, no meds, really save someones life?

You mean no fluids of any type, even saline?

Never.

Only saline? Hmmm....dunno. I don't follow up on every PT.

 

[triemal04]

You mean no fluids of any type, even saline?

Never.

Only saline? Hmmm....dunno. I don't follow up on every PT.

That's part of my problem with Basic's and IV's. A straight IV does no good whatsoever. The times when giving saline or ringers will really make a difference (and I do mean really) are pretty rare, and more than likely will be seen in a rural, low volume setting where rapid transport to a ER is not an option.

Which brings me to the bigger problem. In an urban environment, there isn't going to be that much of a need for a basic to start a line. If there is the system is pretty messed up. But in the rural... Most of the skills, the physical skills that medic's perform a monkey could eventually be taught to do. The problem is knowing when to do it, why to do it, when not to do it, and how you do it in adverse situations. With the way the average EMT is trained these days, that would not be taught to basic's, they'd just get the physical skill. And in a low volume system, how long do you think those skills would last before they'd be sticking some 90 year old grandma 6 times and delaying transport because they couldn't get a line? I've seen the downside to rural agencies having advanced skills (and most of the time they've been trained beyond the basic level), there is no need to put more tools in untrained hands. It may be unfair to some responsible people out there, but unfortunately, that's how the game works now. If you want more skills, take the time to learn how to do them properly. That doesn't gaurentee that you'll retain all that knowledge, but at least it's a start.

Now it's time for another gin 'n tonic.

 

[Gbro]

Hmm. All I can see from this post is that you, even will a very low call volume, still see critical pt's. (which makes me wonder how well you would be able to keep those IV skills up anyway with such a low volume) But you don't want to take the time to go to say...EMT-I school, learn some new pt assessment skills and get a few more skills that will sometimes make a difference. You just want to be able to start IV's because...why? That's the part that is really funny. You've started this thread but haven't given one reason why simply starting an IV is a good idea for an EMT-Basic.

Couple suggestions. Think about why you need the skill. Really think about it, and then ask yourself what is best for your community. The able to maybe put a piece of teflon in someones vein, or the ability to perform a little better pt assessment and maybe give a few meds. If you really think that starting an IV is so great, go back and get your EMT-I. You'll learn a few tricks that could help out more than a piece of teflon.

Hate to say it, but this is the type of mentality that makes me so dead set against EMT-B's starting IV's. They want the skills without taking the time to learn them, or learn when/why they should be used and what should go along with them. (if that's clear )

I do hope you are more attentive in your examination of a Pt. in front of you.

Humm?
I am posting this "because(as you can see from the poll) there "ARE" BLS services with IV Protocol's"
Not the service i am with as we elect not to.

I did take the EMT-I years ago. The system wouldn't allow just me(EMT-I or my Wife EMT/RN) because the whole crew wasn't equally trained.
There are some situations today that would make that hurdle lower.
The IV stick count was is a problem where I couldn't keep up my EMT-I. I would have had to work with another service and then who knows?
When I did my clinicals for the I, after 40 hours in the ER, Not one stick.
We did stick each other way too many times...