EMT-Basic IV

[Afflixion]

...Its often said pre-hospital that an IV never saved anybody... especially in trauma. So other than for efficiency purposes in a PM/EMT crew scenerio, I'm not sure if allowing Basic's to start IV's really offers any better patient care...

I hope you are speaking of no remote area's because I can cite several instances where infusing colloids has saved numerous lives.

It honestly does not take that much time to spike a bag, perform the venipuncture and initiate fluid resuscitation... There is little to no need for basics to perform IVs, the only way I can see it feasible is during an MCI.

 

[Ridryder911]

It honestly does not take that much time to spike a bag, perform the venipuncture and initiate fluid resuscitation... There is little to no need for basics to perform IVs, the only way I can see it feasible is during an MCI.

And in that case fluid resuscitation would be futile anyway.

R/r 911

 

[Afflixion]

Indeed it would. But only time I could see the need for basics to start IVs.

 

[Level1pedstech]

We have an EMT-IV tech program here in Washington. It consists of an additional 56 hours of class and 24 hours of ER time, it is offered after one year of certification as a basic and with the approval of your departments EMS director. In Washington you have to be associated with an EMS agency to be certified through the department of health and practice in the state. This insures that most providers will have some level of experience in pre hospital patient care before moving to the next level. The program is set up and run by the county MPD and is overseen by the state DOH.

I don't see to many ED MD's or ED charge nurses posting on this site so I will take negative comments on the issue with a grain of salt. The ED staff are most likely going to be the ones to chew you a new one if you screw up. Everyone has an opinion but many don't practice in the areas where having an IV Tech is a benefit so their opinions are not based on first hand knowledge of the subject. Providing NS (following protocols) and having med access are always going to be a plus on trauma calls and even critical med patients can benefit having a line placed by an IV tech while a medic takes history and forms a treatment plan. With proper oversight and ongoing education I think the program is a great option for agencies where long response and transport times are the norm.

Having the unique position of working on both sides I am more than willing to share the ER teams thoughts on field providers lines, the most common words I hear are "a 20g are you serious" and "don't bother trying to draw off that PTA line its blown". I'm not putting all pre-hospital providers in this box I just want to point out that most lines started by field providers are either redone or DC'd once in the ER. It has been a real learning experience for me and it has helped to build my field skills hearing what the field providers are doing both right and wrong. With level one and two traumas most PTA lines even when they are viable are never used, trauma teams will always start new large bore lines. Just my two cents.

 

[TransportJockey]

Having the unique position of working on both sides I am more than willing to share the ER teams thoughts on field providers lines, the most common words I hear are "a 20g are you serious" and "don't bother trying to draw off that PTA line its blown". I'm not putting all pre-hospital providers in this box I just want to point out that most lines started by field providers are either redone or DC'd once in the ER. It has been a real learning experience for me and it has helped to build my field skills hearing what the field providers are doing both right and wrong. With level one and two traumas most PTA lines even when they are viable are never used, trauma teams will always start new large bore lines. Just my two cents.

Sounds like your hospitals don't trust the field providers. Here in ABQ, the only thing that happens to PTA lines at the facility is the bags are swapped out to hospital bags (a lot of times from NS to LR), although that is due to an unlabeled Lido bag that was left running open by the hospital because the medic didn't tell them which bag.

 

[VentMedic]

Sounds like your hospitals don't trust the field providers. Here in ABQ, the only thing that happens to PTA lines at the facility is the bags are swapped out to hospital bags (a lot of times from NS to LR), although that is due to an unlabeled Lido bag that was left running open by the hospital because the medic didn't tell them which bag.

Labeling is definitely an issue which is why blood draws from EMS are also frowned upon.

After years of EMS providers bragging how they have to start IVs in dirty places doing it the "EMS way", hospitals have come to just change out field IV within 24 hours. We have also had Paramedics students trying to do their sticks in our EDs as their instructors have taught them the "way it is done in the field" and have basically almost caused their school's programs to lose privileges at our hospitals.

Hospitals will now eat the cost of any infection that is acquired in their facility and that has been made very clear by the insurers. So, unless the EMS providers themselves stop bragging about having no time to clean an IV site because it is "different" in the field, hospitals will continue to be cautious. As well, unless EMS providers can start coming up with consistency in education and competencies for IVs and blood draws, hospitals will also be cautious. CLIA will and have come down hard on labs that accept blood samples from providers that can not provide proof of training that they understand the procedure or the need for labeling.

These issues are not isolated to one hospital in one area but this is part of a nationwide awareness for patient safety.

 

[NVBowhunter]

Here in NV, Basics cannot do IV therapy. Technically, we cannot even take glucose readings, although we were taught how. I have to attend 3 more months of school to obtain my I certification before I get in to that fun stuff.

Starts in Aug B)

 

[daedalus]

an IV Tech is a benefit so their opinions are not based on first hand knowledge of the subject. Providing NS (following protocols) and having med access are always going to be a plus on trauma calls and even critical med patients can benefit having a line placed by an IV tech while a medic takes history and forms a treatment plan.

Really?

From now on in EMS, things like this are going to have to be backed up by cold hard science. Can you produce research that shows EMTs providing IV infusion is beneficial to patient outcomes? And, if none such exists, why let a less educated provider mess around with fluid balances? As many experienced critical care paramedics have stated in this very thread (that do happen to have RN, CCP and/or RRT degrees and work in EDs and/or flight crews), there is no real circumstances where a paramedic should have to have an EMT assistant set up the IV.

 

[Shishkabob]

Where does "set up" equate to "push fluids / drugs"?










Just asking.

 

[daedalus]

You like to ask a whole lot of questions all the time, don't you?

In the case of my post, set up and initiate are meant to mean the same thing.

 

[Shishkabob]

Hey, I'm the chop buster of the forum! ^_^

 

[CAOX3]

Really?

From now on in EMS, things like this are going to have to be backed up by cold hard science. Can you produce research that shows EMTs providing IV infusion is beneficial to patient outcomes? And, if none such exists, why let a less educated provider mess around with fluid balances? As many experienced critical care paramedics have stated in this very thread (that do happen to have RN, CCP and/or RRT degrees and work in EDs and/or flight crews), there is no real circumstances where a paramedic should have to have an EMT assistant set up the IV.

Backed up by cold hard evidence? Let me know when EMS adopts that practise.

 

[usafmedic45]

Backed up by cold hard evidence? Let me know when EMS adopts that practise.

As soon as people drop exactly the attitude you just expressed. The practice will be adopted one person at a time until it becomes a standard. As the saying goes, "Be an example of the change you wish to see in others."

 

[CAOX3]

As soon as people drop exactly the attitude you just expressed. The practice will be adopted one person at a time until it becomes a standard. As the saying goes, "Be an example of the change you wish to see in others."

Thats right together we can change the world.

Attitude? Actually this is evidence based opinion.

Evidence based medicine depends on who you ask. A smart guy like you, should know that.

Sure some systems are progressive, those systems pale in comparison to the ones that cant get out of there own way.

 

[Level1pedstech]

Since I was pulling a shift on the adult side of our facility tonight I thought I would do a little research and ask a few people from different areas of the emergency medicine world thier opinion of lower level field providers starting lines in the field. I explained the additional class room and clinical time above the EMT-B level and that there are IV Tech specific protocols that must be followed. I included two trauma sugeons,two ED docs,two PA students a few RN's and a few medics. The overwhelming response was a thumbs up providing a few rules were followed, mainly that there is ongoing Md oversight,continuing and ongoing education and quality control including follow up when there are problems. Just a little research backed up by some foot work. Im sure it wont change everyones mind but I think it shows there is room for growth in the field.

As far as our facility not trusting field providers, I was careful to not lump all field providers into one bunch. We love our medics and most do a very good job. Vent had a pretty good explanation of how the folks upstairs see things when it comes to policy.

 

[VentMedic]

I explained the additional class room and clinical time above the EMT-B level and that there are IV Tech specific protocols that must be followed. I included two trauma sugeons,two ED docs,two PA students a few RN's and a few medics. The overwhelming response was a thumbs up providing a few rules were followed, mainly that there is ongoing Md oversight,continuing and ongoing education and quality control including follow up when there are problems. Just a little research backed up by some foot work.

Do any of those polled remember when only specially trained RNs were allowed to start IVs in the hospital or why "IV techs" were eliminated? Or what happened to the LVN in the hospital and IVs? Why it was thought an LVN was not appropriate to do IVs because of only have 1 year of education? Those controversies still exist in hospitals throughout this country and are coming back with the infection control issues.

How about the doctors? Why are some allowed to intubate and some aren't? Why can some put in central lines and some can't? Why can some write orders on a tele or ICU floor and some can't? Why can some write orders for Diprivan and some can't? For most it takes a little more than a couple hours of training to get certain privileges even though they seem routine and "easy".

 

[Level1pedstech]

You make some interesting points and its worth a chat with the crew here tonight. We are in slow mode after being slammed pretty hard with traumas since 1900. I dont remember LVN's, I have only been on the inside for four years. You have stated before how different things are on the inside when it comes to procedures, that its skills on the outside and procedures on the inside. I know when it comes to intubation it is almost always an ED doc. Central and art lines can be done by PA students but residents get first shot. I am being asked to point out that RN's can intubate but its not really a procedure RN's do at our facility.

 

[VentMedic]

I am being asked to point out that RN's can intubate but its not really a procedure RN's do at our facility.

There are only a couple of states that do not include intubation for RNs. However, it would be impossible to maintain the skills of RNs if they did intubate in the hospital. Even the smaller ICUs employ over 60 nurses. Larger hospitals can have almost 1000 RNs working just in critical care. As well, who would be fetching all the meds and setting up procedure trays. Believe it or not, doctors and PA students don't always have access to the drug machine and some have not found their way around the storeroom. In an emergency, there should be priorities and job descriptions to avoid confusion.

Our RNs share intubation with the RRTs on all of the transport teams as the RRTs also do some of the procedures that is usually included in their job set. Both must still get 10 intubations in 6 months in addition to the other advanced procedures. Each must also get 25 tubes in their initial training to intubate. Since RRTs are considered primary intubators in Neo, to apply for the transport team they must have no less than 100 intubations and 2 years of NICU experience which it takes 2 years of other RT experience before being accepted into NICU. So you can see how difficult it would be to have the same requirements of a group as large as nursing remain proficient at intubation.

For Flight, if hospital based, the RNs can get their procedures(intubation, central lines etc) in the ED or ICUs. Many also will still work the ICUs on their off days just to maintain proficiency with their RN knowledge and skills since Flight may not give them many patients and medicine changes quickly. They hate to arrive at a facility and pick up a patient who is on a couple of drips they had no idea was even available.

It would also not be feasible to have a Nephrologist have intubation privileges since it is doubtful he/she could meet the requirements to maintain competency. The best person for the procedure should be the one providing it. That also includes the education and what to do after the tube is in. Those who intubate at our hospitals also must know what tube the patient requires and must be thinking about tomorrow and not just one skill at the moment.

I'm sure your hospital has a book or section on their computer intranet that lists all the physicians and what each has been given invasive procedure privileges for. We take the competencies seriously and are allowed to tell a physician to step aside if they are not cleared by the various medical directors and chiefs of medicine or critical care to intubate.

 

[Summit]

There are only a couple of states that do not include intubation for RNs. However, it would be impossible to maintain the skills of RNs if they did intubate in the hospital. Even the smaller ICUs employ over 60 nurses. Larger hospitals can have almost 1000 RNs working just in critical care. As well, who would be fetching all the meds and setting up procedure trays. Believe it or not, doctors and PA students don't always have access to the drug machine and some have not found their way around the storeroom. In an emergency, there should be priorities and job descriptions to avoid confusion.

Our RNs share intubation with the RRTs on all of the transport teams as the RRTs also do some of the procedures that is usually included in their job set. Both must still get 10 intubations in 6 months in addition to the other advanced procedures. Each must also get 25 tubes in their initial training to intubate. Since RRTs are considered primary intubators in Neo, to apply for the transport team they must have no less than 100 intubations and 2 years of NICU experience which it takes 2 years of other RT experience before being accepted into NICU. So you can see how difficult it would be to have the same requirements of a group as large as nursing remain proficient at intubation.

For Flight, if hospital based, the RNs can get their procedures(intubation, central lines etc) in the ED or ICUs. Many also will still work the ICUs on their off days just to maintain proficiency with their RN knowledge and skills since Flight may not give them many patients and medicine changes quickly. They hate to arrive at a facility and pick up a patient who is on a couple of drips they had no idea was even available.

It would also not be feasible to have a Nephrologist have intubation privileges since it is doubtful he/she could meet the requirements to maintain competency. The best person for the procedure should be the one providing it. That also includes the education and what to do after the tube is in. Those who intubate at our hospitals also must know what tube the patient requires and must be thinking about tomorrow and not just one skill at the moment.

I'm sure your hospital has a book or section on their computer intranet that lists all the physicians and what each has been given invasive procedure privileges for. We take the competencies seriously and are allowed to tell a physician to step aside if they are not cleared by the various medical directors and chiefs of medicine or critical care to intubate.

That's very informative... but let me get this straight.

The lesson you are trying to imply, your message, is that starting and monitoring peripheral IVs is equivalent in complexity and consequence to ET intubation and there just aren't enough IV starts in this world to let EMT-B's with IV clearance take these experience opportunities away from RNs and Medics?

I'm not buying it.

 

[VentMedic]

Your argument is that starting and monitoring peripheral IVs is equivalent in complexity and consequence to ET intubation and there just aren't enough IV starts in this world to let EMT-B's with IV clearance take these experience opportunities away from RNs and Medics?

I'm not buying it.

The discussion has moved on.

Read my post before that.

The argument in the hospital for doing IVs was education. Some believed that an LVN with a mere 1 year of education could not do IVs. Hospitals do value the "whys" and education behind each procedure and don't just allow any warm body to poke holes in people. Also the LVN has been removed in many areas from acute care. I don't believe we have any in our system now and that includes the SNF and NH sections.

The discussion you just mentioned was why a hospital could not keep 1000 or even 60 Critical Care RNs proficent in intubation.