Can EMT-B intubate or start IVs?

hogwiley said:
Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.

Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.

Catheter shear, air embolisms, infection, phlebitis, disease transmission and needle sticks, infiltration, tissue necrosis, forgetting to remove the tourniquet, hitting nerves, tendons or arteries. Its a pretty long list. Not to mention causing the patient unnecessary pain, leaving them with bruises and hematomas, and using up good veins in failed attempts and leaving Paramedics or the ER with nothing.

Then you have to worry about EMT Basics wasting time on scene trying to get an IV and getting tunnel vision. And finally what are they going to do with that IV? EMTs cant give IV meds, and giving fluids can open up the possibility of even more complications, and if given inappropriately can do more harm than good. Do you really want some 19 year old ricky rescues with 2 months of training doing that in an uncontrolled pre hospital environment? LPNs cant even start an IV in most settings and their education far surpasses EMTs.
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I have to disagree with your statement regarding IV. And if you want to say that no basic should be able to start IV because of there lack of education and experience, than it should be taken out of the Paramedic scope also! How many paramedics now are going through zero to hero programs. And also all the complications you state can happen to EMT, Paramedic, RN, PA, NP, DO, MD. So with your logic no one should do IV in 20 to 30 years because by than everyone who is good at starting lines will no longer be practicing medicine. And all the new people coming up shouldn't be allowed to start lines because they have no experience. I have seen paramedics get tunneled vision trying to start a line.

Medications comment, some states basics are allowed to push limited medications, and as a Paramedic it's nice to show up on a scene and have access all ready on that cardiac, altered, or trauma patient. It saves me time and it allows me to focus on other things. And if I have an Emt partner that can start a line for me, even better I can focus my attention to the patient and his or her care and not starting the line.
 
EMT11KDL said:
I have to disagree with your statement regarding IV. And if you want to say that no basic should be able to start IV because of there lack of education and experience, than it should be taken out of the Paramedic scope also! How many paramedics now are going through zero to hero programs. And also all the complications you state can happen to EMT, Paramedic, RN, PA, NP, DO, MD. So with your logic no one should do IV in 20 to 30 years because by than everyone who is good at starting lines will no longer be practicing medicine. And all the new people coming up shouldn't be allowed to start lines because they have no experience. I have seen paramedics get tunneled vision trying to start a line.

Medications comment, some states basics are allowed to push limited medications, and as a Paramedic it's nice to show up on a scene and have access all ready on that cardiac, altered, or trauma patient. It saves me time and it allows me to focus on other things. And if I have an Emt partner that can start a line for me, even better I can focus my attention to the patient and his or her care and not starting the line.
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Id have to agree cuz Washington state where i work has emt-IV tech still and is still hiring them so it is not being phased out like people thought, so it seems that my state think emts can do IV's just fine. I could also say that nurses that started IV's on me personally did not do too well causing pain by having to stick me up to 6 times on both arms, if this were to happen to me while i was starting an IV and I had a critical PT I more than likely would instead go by IM route and TX.
 
RefriedEMT said:
Id have to agree cuz Washington state where i work has emt-IV tech still and is still hiring them so it is not being phased out like people thought, so it seems that my state think emts can do IV's just fine. I could also say that nurses that started IV's on me personally did not do too well causing pain by having to stick me up to 6 times on both arms, if this were to happen to me while i was starting an IV and I had a critical PT I more than likely would instead go by IM route and TX.
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And what about the medications where IM is not an option?
 
DesertEMT66 said:
And what about the medications where IM is not an option?
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The medic would have to take over, simple as that. What I cant do the medic usually can and the county i am going to start working for soon has a requirement that every PT has an ALS eval whether critical or not. Granted most of the units i will be on will have a medic on it all the time similar to clark county in Washington.
 
hogwiley said:
Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.

Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.

Catheter shear, air embolisms, infection, phlebitis, disease transmission and needle sticks, infiltration, tissue necrosis, forgetting to remove the tourniquet, hitting nerves, tendons or arteries. Its a pretty long list. Not to mention causing the patient unnecessary pain, leaving them with bruises and hematomas, and using up good veins in failed attempts and leaving Paramedics or the ER with nothing.

Then you have to worry about EMT Basics wasting time on scene trying to get an IV and getting tunnel vision. And finally what are they going to do with that IV? EMTs cant give IV meds, and giving fluids can open up the possibility of even more complications, and if given inappropriately can do more harm than good. Do you really want some 19 year old ricky rescues with 2 months of training doing that in an uncontrolled pre hospital environment? LPNs cant even start an IV in most settings and their education far surpasses EMTs.
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I'm mixed on this. Here in Colorado, if you're an EMT on an ambulance it's pretty much a guarantee that you also have your IV endorsement and will be starting most of the IVs provided they aren't being done enroute by your paramedic. I start a lot of IVs, usually more than my partner does on any given shift. I'm certainly far from an expert (ask my first patient today, sorry buddy), but I'm far from awful. In Colorado, you attend a 24 hour class and then have a clinical shift at a hospital to get an endorsement. It's certainly the bare minimum, but it does teach you to start them safely. And frankly, it is pretty useful on a medic/EMT ambulance.

But I agree with the ricky rescue comment. I often cringe at our corresponding volley FFs (or career for that matter) IV attempts. Just brutal.
 
I'm surprised at the "EMTS should never start IVs" because it is so final. And the list of reasons why, catheter shear, etc. That can happen, albeit rare, when a medic does it. Doesn't really prove the point. And as to the admittedly retrospective intubation studies, in that it didn't help the outcome, that doesn't mean we shouldn't tube. When you tube a code, they're already dead. You're providing a direct airway and protecting it. Most codes don't survive, period. So I guess we shouldn't do CPR, push meds, and defib either according to that logic.
 
MackTheKnife said:
And as to the admittedly retrospective intubation studies, in that it didn't help the outcome, that doesn't mean we shouldn't tube.
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Actually, that is exactly what it means.

You do know why we do research in the first place, right?

The entire point of research is to identify what helps and what doesn't. Why bother researching anything if we are just going to ignore the findings?

MackTheKnife said:
Most codes don't survive, period. So I guess we shouldn't do CPR, push meds, and defib either according to that logic.
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This statement indicates a fundamental lack of basic resuscitative knowledge, and is exactly why you have no business intubating anyone, even codes.

Even laypersons whose entire clinical education is limited to an 8 hour CPR course know why CPR and defib are more important than an advanced airway.
 
Remi said:
Actually, that is exactly what it means.

You do know why we do research in the first place, right?

The entire point of research is to identify what helps and what doesn't. Why bother researching anything if we are just going to ignore the findings?



This statement indicates a fundamental lack of basic resuscitative knowledge, and is exactly why you have no business intubating anyone, even codes.

Even laypersons whose entire clinical education is limited to an 8 hour CPR course know why CPR and defib are more important than an advanced airway.
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What utter BS.
 
Remi said:
Then enlighten me as to how research really works and why we should keep doing things that don't help patients.
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Tradition Remi, tradition!
 
cprted said:
If you're so keen to start IVs, intubate, and do other ALS interventions, come take an ALS course.
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I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.
 
Actually, researching the effectiveness of various interventions during CPR is one of the more difficult things to undertake.

Because, let's face it, unless you correct the results to specifically focus on people who should survive an arrest (those who meet Utstein Criteria for the most part) there are so goddamn many confounders, especially when talking about prehospitally that it becomes...not a crapshoot...but very hard to really say "yes, this ONE THING made a difference." And then you have to worry about being able to take those results and impose them on what, given the current state of the US EMS system, are potentially very different circumstances/settings...well...just another difficulty.

I mean ****...look at some of the further data from the PRIMED trial; in that setting, in certain circumstances and locations, intubation was actually associated with LOWER overall mortality, and better survival to discharge rates. Of course, all the data for that group came specifically from one area...and sadly isn't going to be reproduceable nationally anytime soon.

Hence the problem, and the failure when it comes to studies that look at CPR.

Or any specific problem really.

You want to know what really works, and what doesn't? You don't set up a study/trial in an area that has average or mediocre results at best, you go to a place that already is doing very good at treating the specific illness you are looking at, and you make THEM change something. Because they are already good at it, and any changes are more likely to be the result of whatever you are studying, and not just a continuation of the previous poor performance.
 
MackTheKnife said:
I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.
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The number of skills you have performed does not change whether intubation is an appropriate intervention in cardiac arrest. Your statement regarding witholding CPR + defib is odd given these interventions have been clearly shown to improve outcomes.

As for EMTs starting IVs and intubating generally : I don't see an issue with IV's. I am curious what medications thse EMTs are trained / educated to administer. Where I used to live this pretty much included normal saline and ACLS drugs. For intubation I wonder how many patients are being intubated without the use of medications (for induction / post intubation sedation etc). If most of the patients intubated are in cardiac arrest it seems like a needless intervention that is most likely to add confusion to the code. That's what Paramedics are for.
 
SeeNoMore said:
As for EMTs starting IVs and intubating generally : I don't see an issue with IV's. I am curious what medications thse EMTs are trained / educated to administer. Where I used to live this pretty much included normal saline and ACLS drugs.
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The Colorado IV-cert allows EMTs to push D-50 and Narcan. There's also an optional albuterol module, but I don't know how many places actually do that. Here's a link to the curriculum: https://www.colorado.gov/pacific/si...rapy-and-Medication-Administration-Course.pdf
 
MackTheKnife said:
I assume this was directed at me. Been there, done that, got all the T shirts. You haven't probably done half the amount of intubations, IVs, chest taps, crics, etc., that I've done.
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I'm curious - what exactly do you do? Are these skills you learned as a corpsman or what? It doesn't sound like you're truly a "basic EMT".
 
jwk said:
I'm curious - what exactly do you do? Are these skills you learned as a corpsman or what? It doesn't sound like you're truly a "basic EMT".
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No problem. My CV is mixed. I was a PM (NREMTP, and VA), and a Hospital Corpsman. Prior to PM I was an EMT-Cardiac (VA designation) then got my PM. Went back in the Navy and worked weapons and antiterrorism/force protection where I got involved in live-tissue TCCC and continued with that as a PMC. Obviously my PM lapsed in the military, that's why my current level is NREMT. My former avatar title said"former EMT-P"
 
MackTheKnife said:
No problem. My CV is mixed. I was a PM (NREMTP, and VA), and a Hospital Corpsman. Prior to PM I was an EMT-Cardiac (VA designation) then got my PM. Went back in the Navy and worked weapons and antiterrorism/force protection where I got involved in live-tissue TCCC and continued with that as a PMC. Obviously my PM lapsed in the military, that's why my current level is NREMT. My former avatar title said"former EMT-P"
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So here's the problem - in the real world, you have to deal with state laws and scope of practice. You MAY have done all these wonderful procedures, but you can't do them now. Do you really think a basic EMT with a 120 hr course - that's just three weeks of full time work - can go from zero to IV's, intubations, etc. and be competent to do all of them in 120 hrs? C'mon. From a quick Google search, corpsman training is 18 weeks. Somehow I'm sure that adds up to way more than 120 hours. Just because you understand and have done a lot of these procedures as a corpsman and/or a paramedic, surely you should be able to understand the difference between those and a basic EMT. The difference in knowledge base is pretty large.

I started out in EMS in it's early days - mid 70's - with a hospital-based service that was out to make a name for themselves with their emergency services. Back then, EMT class was 81 hours - medics were 200. The laws were a little fuzzy, and while medic scope of practice was laid out, there wasn't a hard restriction of what an EMT or medic could NOT do. This place was trying to teach medics to do IJ's and subclavians, and was playing around with placing trans-thoracic pacing wires. So, as a basic EMT, I did tons of IV's in the hospital and in the field (I have no problem with EMT's doing IV's, or at least being able to try once or twice), defibrillated, and even did a couple of intubations and intracardiac injections (very in-vogue back then) and thought I was totally hot sh*t. Now, as a practicing anesthetist for more than 35 years, I look back and think "how friggin stupid was that!". I had no clue of the possible complications from the procedures I was trying - I was simply mimicking what I saw and thought I could do it too. See one, do one, teach one, only without the educational background to back it up. Stupid, stupid, stupid.
 
JWK, appreciate your comment. My thoughts go only to intubation. Yes, I am probably one of a very few who think we can teach EMTs to intubate. I am not advocating the other skills you mentioned. I do remember intracardiac injections as well as the others. Maybe I'm just one of the few who mastered intubation easily and as an ENTJ personality type, think others could do the same. I don't think it is that hard. You have the experience of prehospital and now, clinical as an anesthetist, to see both worlds. As for complications from intubation, what do you see as the biggest one? Is it esophageal intubation? Or something else?
jwk said:
So here's the problem - in the real world, you have to deal with state laws and scope of practice. You MAY have done all these wonderful procedures, but you can't do them now. Do you really think a basic EMT with a 120 hr course - that's just three weeks of full time work - can go from zero to IV's, intubations, etc. and be competent to do all of them in 120 hrs? C'mon. From a quick Google search, corpsman training is 18 weeks. Somehow I'm sure that adds up to way more than 120 hours. Just because you understand and have done a lot of these procedures as a corpsman and/or a paramedic, surely you should be able to understand the difference between those and a basic EMT. The difference in knowledge base is pretty large.

I started out in EMS in it's early days - mid 70's - with a hospital-based service that was out to make a name for themselves with their emergency services. Back then, EMT class was 81 hours - medics were 200. The laws were a little fuzzy, and while medic scope of practice was laid out, there wasn't a hard restriction of what an EMT or medic could NOT do. This place was trying to teach medics to do IJ's and subclavians, and was playing around with placing trans-thoracic pacing wires. So, as a basic EMT, I did tons of IV's in the hospital and in the field (I have no problem with EMT's doing IV's, or at least being able to try once or twice), defibrillated, and even did a couple of intubations and intracardiac injections (very in-vogue back then) and thought I was totally hot sh*t. Now, as a practicing anesthetist for more than 35 years, I look back and think "how friggin stupid was that!". I had no clue of the possible complications from the procedures I was trying - I was simply mimicking what I saw and thought I could do it too. See one, do one, teach one, only without the educational background to back it up. Stupid, stupid, stupid.
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MackTheKnife said:
JWK, appreciate your comment. My thoughts go only to intubation. Yes, I am probably one of a very few who think we can teach EMTs to intubate.
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Your argument for EMT intubation has still not addressed all the problems with outcomes related to prehospital intubation. You know, the actual effects that the intervention has on patients.

Do you think patients intubated by EMT's will have better outcomes than patients intubated by paramedics? Or are you just not concerned with outcomes?

I once heard a funny and interesting quip......."Most American males think they are better than they actually are at two things: driving and making love." Well, IME, and it is pretty clearly reflected in the research, lots of folks in EMS think they are better than they really are at airway management.


 
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