EMT-Basic IV

[daedalus]

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.

I asked for scientific evidence and this is what you post? It seems like you are evading my question by runnng to a trauma surgeon and asking him I it's ok. Here is a hint, if someone asks for evidence to support your treatment one day and you come back to that person saying so and so said it was ok, you will have lost respect as a provider and you will facv the consequences of whatever you have done.

CAOX3, my county bases many practices on best available medical research. Your attitude is disapponting.

 

[ResTech]

In the hospital I do clinicals, the ED Techs who are trained to do IV's, 12-lead acquisition, BG readings, and foley catheters are a huge help and resource to the RN's. If it wouldnt be for the ED Techs, the nurses would be overwhelmed and the ED wouldn't flow near as smoothly. ANd it would cost the hospital a lot more $$$$$.

The skill of starting an IV is simple... practice makes perfect. As long as medical oversight is provided I don't really see why an ED Tech who is a CNA, EMT or LPN can't start an IV safely. Aseptic technique isn't hard to learn and in some care situations, not all care providers need to have 2 or 4 years of education to do certain skills.

I am all for research based EMS and not EMS based on what appears to work. But take two groups... one group of ED Tech's that are CNA or EMT trained and another group that are all RN. Let them all practice IV venipuncture and at the end of a year compare results from the two groups. Do you really think there would be a higher rate of infection or infiltration in the Tech group? Would an RN have more successful sticks on less attempts? I really do not think you would see any clinical or statistical difference between the two groups. I really don't.

There are RN's who may have a difficult stick and after two try's that can't get it... know who they often call? An ED Tech... because they are experienced in finding veins and getting the catheter where it needs to go.. in the vein.. and that is the primary goal.

I think through time and practice, it is possible to determine that certain treatment modalities can be performed safely by lesser trained personnel with great patient benefit. I don't want to start an albuterol by Basic's debate... but that is an example I would like to cite. Some States allow for Basics to administer albuterol because of the benefit and almost immediate relief of SOB combined with the safety profile of the medication.

If your an asthmatic who lives 20-30 minutes from an ALS unit... are you gonna wanna remain SOB for that time period and possibly worsen or get the medication safely from your local BLS company 5 minutes away? For my family and myself would be from the BLS station. There is a risk versus benefit assessment that must be made. Would albuterol in this scenerio not be good patient care?

Sorry so long

 

[VentMedic]

In the hospital I do clinicals, the ED Techs who are trained to do IV's, 12-lead acquisition, BG readings, and foley catheters are a huge help and resource to the RN's. If it wouldnt be for the ED Techs, the nurses would be overwhelmed and the ED wouldn't flow near as smoothly. ANd it would cost the hospital a lot more $$$$$.

The skill of starting an IV is simple... practice makes perfect. As long as medical oversight is provided I don't really see why an ED Tech who is a CNA, EMT or LPN can't start an IV safely. Aseptic technique isn't hard to learn and in some care situations, not all care providers need to have 2 or 4 years of education to do certain skills.

I am all for research based EMS and not EMS based on what appears to work. But take two groups... one group of ED Tech's that are CNA or EMT trained and another group that are all RN. Let them all practice IV venipuncture and at the end of a year compare results from the two groups. Do you really think there would be a higher rate of infection or infiltration in the Tech group? Would an RN have more successful sticks on less attempts? I really do not think you would see any clinical or statistical difference between the two groups. I really don't.

There are RN's who may have a difficult stick and after two try's that can't get it... know who they often call? An ED Tech... because they are experienced in finding veins and getting the catheter where it needs to go.. in the vein.. and that is the primary goal.

I think through time and practice, it is possible to determine that certain treatment modalities can be performed safely by lesser trained personnel with great patient benefit. I don't want to start an albuterol by Basic's debate... but that is an example I would like to cite.

Some States allow for Basics to administer albuterol because of the benefit and almost immediate relief of SOB combined with the safety profile of the medication.

If your an asthmatic who lives 20-30 minutes from an ALS unit... are you gonna wanna remain SOB for that time period and possibly worsen or get the medication safely from your local BLS company 5 minutes away? For my family and myself would be from the BLS station. There is a risk versus benefit assessment that must be made. Would albuterol in this scenerio not be good patient care?

Sorry so long

Again, you are only measuring skills.

We sorta have a rule in hospitals. Don't screw with what you can not put back in or reverse. If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it. Or, if Plan A for intubation does not work, they have access to Plans B and C. If the albuterol causes a reaction or there is a good probability of causing an adverse reaction judging by the meds a patient is on, the RRT or RN can put the patient on a monitor or give a med to alleviate the symptoms.

Almost any human or animal can be taught "skills". However, skills should be viewed as procedures that also come with a set of guidelines and protocols that goes along with the education of the providers. Just poking a hole in the patient's skin is again a no brainer. What to do when you muck up is another ballgame. Usually you have to yell for another provider with a higher license.

If your an asthmatic who lives 20-30 minutes from an ALS unit

40 + years after it was thought a Paramedic could provide better care in the U.S., we are still relying on EMTs and then this is what happens to the patient. No, they do not need an EMT with another "skill". They need a higher level provider. Period.

 

[Shishkabob]

We sorta have a rule in hospitals. Don't screw with what you can not put back in or reverse. If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it.

And that was the ONLY reasoning I was looking for this whole time... not of that "Not enough A&P" crap, but something that actually makes sense, and is real.


B)

 

[Summit]

Again, you are only measuring skills.

We sorta have a rule in hospitals. Don't screw with what you can not put back in or reverse. If an RN causes an IV infiltrate, he/she can give the medicine immediately that will prevent necrosis. If an RRT accidentally let the ETT fall out when retaping, they can put it back it. Or, if Plan A for intubation does not work, they have access to Plans B and C. If the albuterol causes a reaction or there is a good probability of causing an adverse reaction judging by the meds a patient is on, the RRT or RN can put the patient on a monitor or give a med to alleviate the symptoms.

Almost any human or animal can be taught "skills". However, skills should be viewed as procedures that also come with a set of guidelines and protocols that goes along with the education of the providers. Just poking a hole in the patient's skin is again a no brainer. What to do when you muck up is another ballgame. Usually you have to yell for another provider with a higher license.



40 + years after it was thought a Paramedic could provide better care in the U.S., we are still relying on EMTs and then this is what happens to the patient. No, they do not need an EMT with another "skill". They need a higher level provider. Period.

This should have been your original response in the thread.

 

[ResTech]

So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering?

What about the pilot studies and programs that are conducted prior to widespread implementation of "additional skills"? These studies assess the safety of the skill by Basics, the accuracy of their respiratory assessment, effective administration, and clinical benefit from assessing how well patients improved from Basic administration. Are these pilot programs not reviewed by physicians at the State level? Are these pilot programs not designed to identify major concerns for safety?


Don't get me wrong, I agree with the educational standards and that ALS should be the minimum level of care. I believe that wholeheartedly. But this is EMS, not in-hospital. I've said this before, many dynamics and logistical obstacles exist in EMS and communities across our country that don't exist in the hospital. Hospital methodology doesn't always work out in the field.

Everyone promotes education (as they should) and likes to be critical of EMT's, but I rarely ever hear anyone promoting methods of implementing this higher education model within EMS. It really takes more than graduating from college to make this happen. Many of you from an urban setting have no clue what EMS is like in the rural communities and what obstacles there are.


Now for the questions.....

How do you suppose we staff a 24/7 Paramedic unit within a volunteer station, in a town of 10,000 or less, and without municipal funding? .....when expenses are paid strictly through services provided and bingo and carnivals. Let me tell you, most services don't do much better than break even. It can be done but it isn't easy to get off the ground and keep going.... what about the initial expense of starting such a service?

What about ALS personnel retention? Are degreed Paramedics gonna work in BFE for $11-12hr and only run 3 or 4 calls a week? Or are they gonna be attracted to the city or busier services who can pay more?

Who in the primarily volunteer organization is gonna coordinate the ALS service? Do we now have to pay extra for an ALS Coordinator? Should we offer free tuition for the volunteers to go to College to become Paramedics?

These questions just scratch the surface of things that need considered to provide a higher level of service. Its not as easy as some like to think. It cost money to provide ALS and unfortunately most local governments don't wanna pay nor do the residents that live in the community.

While education is important.... thats only the first step of many.

I look forward to hearing practical plans for taking a BLS station and transitioning them to ALS in a small, rural community.

 

[medic417]

I look forward to hearing practical plans for taking a BLS station and transitioning them to ALS in a small, rural community.

That horse has been beaten to death. I and many others have posted ways that any community can get away from volunteer service and go paid 24/7 Paramedic staffed.

Now if you plan to stay volunteer service not much more annual expense for advanced supply's. Only hold up is people refusing to get education. Now days you can get Paramedic online from reputable colleges distance is no longer an excuse.

And back to dead horse I work in a poverty stricken community of less than 2000 and we are staffed paid Paramedics 24/7.

 

[ResTech]

And back to dead horse I work in a poverty stricken community of less than 2000 and we are staffed paid Paramedics 24/7.

That's awesome... share how it is accomplished in your community. Where does the funding come from to keep it going? Where did the money come from for the start-up costs?

I don't recall reading the threads were this has been a major discussion but I very well could have missed it. Point is... its not always easy.... and maybe more discussion should be shifted to plans of implementation of this higher education model and realizing that EMS isn't the hospital setting.

 

[CAOX3]

. CAOX3, my county bases many practices on best available medical research. Your attitude is disapponting.

You didnt say that, you said "based on cold hard evidence". Which is different from best available research. MAST trousers was based on best available research, how did that work out.

My attitude is disappointing, Im sorry if the truth hurts.

 

[WolfmanHarris]

That's awesome... share how it is accomplished in your community. Where does the funding come from to keep it going? Where did the money come from for the start-up costs?

I don't recall reading the threads were this has been a major discussion but I very well could have missed it. Point is... its not always easy.... and maybe more discussion should be shifted to plans of implementation of this higher education model and realizing that EMS isn't the hospital setting.

Since you asked.
In the year 2000 the Province of Ontario, which previously fully funded and controlled Ambulance Service downloaded it to the Upper Tier Municipalities (Counties or Regional Governments) in the South of the province and to the Social Services Administration Boards in the remote northern areas. At around this time, the province also increased requirements for response times (easy to do when no longer footing the bill).

The UTM's and SSAB found themselves in a pickle. They'd received the responsibility for EMS, with a tentative promise from the Province to maintain 50% of previous funding, increased regulatory requirements placed on the system AND they had to determine how they would operate their services while simultaneous having to renegotiate contracts with all of their Paramedics. Oh and I forgot to mention around this time BLS increased to a two year program which created first a temporary staffing shortage followed by demands for increased wages. (Which just about doubled over this transition period).

How you ask did these rural and remote areas of Ontario manage to provide 24/7 paid EMS? Simple they had the responsibility to provide it and were forced to make it a priority. Amazing what can be made to work when you have no option.

So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering?

The extra training you're arguing for to truly make these skill additions work, including patho and requisite pharmacology would indeed make the addition of albuterol (aka Salbutamol) or IV therapy acceptable. Of course the academic commitment to do it right, even for such small things is a great deal longer then I think you were actually suggesting.

 

[VentMedic]

So instead of allowing an EMT-B with training on the medication and increased education on the respiratory diseases they would be giving albuterol for (again, just example not to open debate... its the principle), lets place ourselves up on the education soapbox and let the patient suffer because of it? Lets have the asthmatic in extremis who is severely hypoxic, become even more hypoxic, agitated, miserable, and scarred while they wait for 30mins for ALS to arrive. Is this fair for the patient to have to experience prolonged suffering?

Read this again and see how ridiculous it sounds to provide such inadequate care. Adding a skill without the ability to do much else is just half arsed. And, if the the patient is asthmatic, they probably already have albuterol, atrovent and a whole cabinet full of meds for their breathing. They need a line, possibly CPAP, possibly corticosteroids, possibly Mag Sulfate and maybe even intubation. One albuterol will NOT fix a patient with a severe asthma attack.

What about the pilot studies and programs that are conducted prior to widespread implementation of "additional skills"? These studies assess the safety of the skill by Basics, the accuracy of their respiratory assessment, effective administration, and clinical benefit from assessing how well patients improved from Basic administration. Are these pilot programs not reviewed by physicians at the State level? Are these pilot programs not designed to identify major concerns for safety?

Maybe the CNAs should do a study if they can replace the RN. NOT! Do you not understand that what these studies are saying is that the EMT can be taught a skill and probably won't kill anyone by allowing them to perform that skill? They have not done estensive studies as to the benefit. When the studies were done to allow EMT-Bs use CombiTubes and ETI, the patients were essentially dead. Yes, states have written that EMT-Bs can do these skills on a patient that has coded. Yes, an EMT-B can start a pretty IV. Then what?

The EMT was NEVER intended to be the primary provider. Again, in the 1960s the founders of modern EMS wanted to upgrade the ambulance attendants to Paramedics. For some reason those in EMS do not want this upgrade and that is what has left some areas in the dark ages for the last 40 years.

Everyone promotes education (as they should) and likes to be critical of EMT's, but I rarely ever hear anyone promoting methods of implementing this higher education model within EMS. It really takes more than graduating from college to make this happen. Many of you from an urban setting have no clue what EMS is like in the rural communities and what obstacles there are.


Now for the questions.....

How do you suppose we staff a 24/7 Paramedic unit within a volunteer station, in a town of 10,000 or less, and without municipal funding?

Oh cry me a river! Florida provides 24/7 to every citizen in the state and that includes communities a lot smaller than 10,000.

My comments might sound harsh but I am just disgusted with hearing excuses from people wanting to stay "BLS" as an EMT-B and just want to learn anotehr skill. And, it is usually the providers who are BLS telling their communities that it will be so bad if strangers come to town to provide ALS or that the FD will be crap at it.

 

[ResTech]

Read this again and see how ridiculous it sounds to provide such inadequate care. Adding a skill without the ability to do much else is just half arsed. And, if the the patient is asthmatic, they probably already have albuterol, atrovent and a whole cabinet full of meds for their breathing. They need a line, possibly CPAP, possibly corticosteroids, possibly Mag Sulfate and maybe even intubation. One albuterol will NOT fix a patient with a severe asthma attack.

The purpose of a Basic in providing albuterol is not to take the place of a primary care provider obviously. It is to fill a void and provide patient relief as early as possible until ALS arrives. Its not that ridiculous of a concept in the context of a system that is not all ALS. And just perhaps, the patient is out and about and forgot their inhaler... so yeah one albuterol may provide significant relief.

Maybe the CNAs should do a study if they can replace the RN. NOT! Do you not understand that what these studies are saying is that the EMT can be taught a skill and probably won't kill anyone by allowing them to perform that skill?

No. I think the study findings in my hypothetical study would say that it is very beneficial to have ED Techs in a hospital be trained to start IV's. They would safely achieve the desired result of IV access, be a great asset for resource management in the ED, and if they encountered a problem, a RN, PA, or Physician is right there. The complication risk of starting an IV is minimal and parameters for safety would be easily implemented.

I am just disgusted with hearing excuses from people wanting to stay "BLS" as an EMT-B and just want to learn anotehr skill.

I don't want to just learn another skill which is why I am going to school. Nor am I advocating any community staying BLS and adding skills. I am however, being prudent in recognizing the problems and obstacles that must be identified and overcome to have an all ALS system. Your talking like its a simple Monday night meeting decision...."listen up everybody, next month were going ALS... we have no clue where the staffing or money is coming from or who is gonna manage it yet, but were going ALS because I have a college degree and am a Paramedic, RN, RRT, and a G.O.D and my education says we must be ALS".

What I am talking about is Systems Development and the obstacles that exist for providing Advanced Life Support in Smalltown, USA.

Yes, sometimes (if not largely) it is a matter of priority and convincing the powers-to-be it is in the best interest of the community to transition to ALS. Until they are convinced, no money is gonna be handed your way.

Vent, you should send your resume to the Pennsylvania Dept of Health and all other States and inform them you have all the answers to their Systems Development problems and you can bring EVERY EMS service up to the Paramedic level and overcome any hurdle that may come your way. Just think of the money they would pay you to solve all their problem... you would be in very high demand!

 

[VentMedic]

The purpose of a Basic in providing albuterol is not to take the place of a primary care provider obviously. It is to fill a void and provide patient relief as early as possible until ALS arrives. Its not that ridiculous of a concept in the context of a system that is not all ALS. And just perhaps, the patient is out and about and forgot their inhaler... so yeah one albuterol may provide significant relief.

If the patient has been doing albuterol all day prior to calling you......

No. I think the study findings in my hypothetical study would say that it is very beneficial to have ED Techs in a hospital be trained to start IV's. They would safely achieve the desired result of IV access, be a great asset for resource management in the ED, and if they encountered a problem, a RN, PA, or Physician is right there. The complication risk of starting an IV is minimal and parameters for safety would be easily implemented.

Yes, ED Techs are useful. But, in the hospital there are continued competencies, QA and numerous chances to do the IV. As well, there will always be an RN in the area to start the meds or fix whatever goes wrong. But, EMS sometimes fails to maintain records for training, QA and continued evaluation for competency.

I don't want to just learn another skill which is why I am going to school. Nor am I advocating any community staying BLS and adding skills. I am however, being prudent in recognizing the problems and obstacles that must be identified and overcome to have an all ALS system. Your talking like its a simple Monday night meeting decision...."listen up everybody, next month were going ALS... we have no clue where the staffing or money is coming from or who is gonna manage it yet, but were going ALS because I have a college degree and am a Paramedic, RN, RRT, and a G.O.D and my education says we must be ALS".

What type of service do your hospitals provide? Are they all staffed with LVNs and the doctors are all GPs? Do you have any specialists or trauma centers in the state? Have you even looked at job listings for other professionals to see what is required in addition to the bare minimum education? Hospitals and other facilities did not accomplish quality by making excuses. Their accrediting agencies would also not fall for excuses and EMS is lucky they have few agencies to please.

.

Vent, you should send your resume to the Pennsylvania Dept of Health and all other States and inform them you have all the answers to their Systems Development problems and you can bring EVERY EMS service up to the Paramedic level and overcome any hurdle that may come your way. Just think of the money they would pay you to solve all their problem... you would be in very high demand!

Why should I send my resume? Doesn't your state have people who have an interest in education and making a difference? I have been part of a movement that accomplished providing EMS throughout my state and while Florida has its faults, the foundation has been laid. Now we can focus on improving the quality of education by at least attempting to accredit the medic mills which might take some doing since we don't use the NREMT for the Paramedic exam.

 

[reaper]

Maybe you need to petition at your state level for all ALS services! If the state mandates it, then your community will have no choice but to figure out how to get it done.

FL is a leader in this phase. Every county in the state has ALS service. These are counties that have less then 10,000 people in the whole county. Some how they get it done and have for years. They retain Paramedics and pay them decent wages. This is all because the state of FL is very involved in EMS and mandates the changes.

I have worked systems in towns of 5000 people in the middle of the Midwest. They seem to be able to have a paid ALS crew in those towns.

So, lets stop the argument that it cannot be done, due to money. It can be done anywhere, if the effort is put forth!

 

[ResTech]

You do make some good points in your last posts.. but for any State to just come in and say... this is the deadline... every station must be ALS... isn't going to work. I could be wrong... maybe that would be the wakeup call and is what it would take. But States are gonna be hesitant to do that because they don't have the millions of dollars budgeted to assist with every licensed BLS service going ALS. At least in PA, its a local level endeavor to go ALS.

 

[Summit]

Not in this economy anyways... oh wait... maybe the Federal government can just majikally make some more money appear out of nowwhere. I approve of the ALS Stimulus Bill!

 

[EMTinNEPA]

A government-run EMS system would be great! Just look at what the government's done for healthcare so far... medicare, medicaid... and let's not forget the stunning job they've done fixing the economy!

 

[Ridryder911]

I ask if is it because the majority of those in EMS, have no real exposure to medicine or is the teaching (or lack of) causing the lack of understanding of medicine?

Why do those in EMS always to refer to the easy way out or wanting to take drastic short cuts? It has been documented, researched and presented that it never works out, patients suffer, the system suffers, yet.. we still continue?

A good example is the intubation procedure. A well needed procedure and research has shown that the success of the procedure has gone down, as the education levels and required knowledge and clinical performance requirements have decreased. Now, even the "more" educated Paramedic lacks enough training and expertise lacks the ability of being successful and we want to "continue focusing on lower levels performing these skills?"
It makes no sense!

Communities exclaim they have no methods of providing emergency medical care. Yes, there are some very remote areas, where the best will always be first responder care. One cannot ever expect much more than that but as states such as Alaska has demonstrated one does not have to compromise care.

Why do we as a so called profession still allow the entry level only to be less than a hundred clock hour course? Then worse, we project to those that have completed this course that they are actually part of the medical community as health care providers? That they actually are educated enough to offer opinions and offer positions to determine the wave and future of EMS? What other profession, would even consider such idiocy?

Could one imagine the nursing profession allowing CNA to determine the future and role of the nursing profession? Entry level trained firefighters determining the future of fire protection? Again asinine!

Do we of those that have obtained a formal education, clinical experience, and further into advanced education and diversity in health care believe we are above others? Maybe. So be it. Each profession base their profession upon experts within that field (except EMS).

What many fail to realize and recognize is that it is scientifically proven the skills of the EMT is very, very basic and crude. Elementary rated skllls that it is considered almost fail safe enough to say that with repetitious practice, no one should ever fail. Again, it is not the action of the skills but the theory and intellect behind the actions.

Hernia repair is supposedly one of the easiest surgical procedures. Yet, I doubt that anyone would want someone to just be taught on how to do the procedure alone to perform this on them. Same analogy.

I find it ironic how compliant those in EMS become. Most would never allow their children to attend a non-accredited public school or University, and I could only imagine the outcries if they were to find that their teacher highest level of education was a GED. Yet, we endorse and even brag ...."how fast, shortcut, cool or instructors have experience not schooling"... Make sense? Of course it does, look at the "type" we attract.

Time we change it!

R/r 911

 

[extant]

http://www.emtlife.com/showthread.php?t=10871&highlight=Basics+starting

http://www.emtlife.com/showthread.php?t=5445&highlight=Basics+starting

This has been covered once or twice (or a hundred times)..........................

Individuals with a 120 hour EMT course +3 day IV class have no business dealing with IV's as it is insufficient time to appropriately learn how easily you can screw things up.

I don't see how starting a saline lock is so easy screwed up. In the Army we were doing IV's every day for months, its easy, we did them in classrooms, in the dirt, in the rain, while the casualty is on a litter. 3 days of training for a saline lock is acceptable, and necessary. Pushing fluids, a much different story.

 

[Ridryder911]

I don't see how starting a saline lock is so easy screwed up. In the Army we were doing IV's every day for months, its easy, we did them in classrooms, in the dirt, in the rain, while the casualty is on a litter. 3 days of training for a saline lock is acceptable, and necessary. Pushing fluids, a much different story.

Again, please try to understand it is not the skill it is the knowledge of starting the intravenous line. The reason the military does as it does is for entirely different reason. It is a prophylactic and methodical type situation. Military verily rarely expects definitions or allows questions in regards of not knowing but more than is expected.

From what expertise do you really have to state that the 3 days of training is adequate? Do you really know the risks involved in intravenous therapy? Not all patients are alike what military profile of healthy 20-30 year olds and no past medical history. Not to ridicule by far but unfortunately, assumption is too often made.

R/r911