EMTs starting IV

[bstone]

usalsfyre is correct. This is why we need a LOT more education and higher standards.

 

[jrm818]

What acts faster? IV saline or tap water absorbed though osmosis?

Sure IV is a bit faster to reach the intravascular space, but I bet the time difference is on the order of minutes and is clinically insignificant except for an extremely volume depleted patient. I have a hard time believing that these patients present to any system in large numbers (though I could be wrong). For any patient IV access is not innocuous and neither is playing with body fluids.

Control of body fluid homeostasis is incredibly complex, and require much more consideration than "patient lost fluid, me give him some." The body responses are different depending on source and speed of fluid loss, whether the fluid that was lost was isotonic/isoosmolar or something different, how severe the fluid loss was, etc. Proper replacement of fluid in a super sick patient should probably include monitoring of a number of parameters (plamsa Na, K, glucose, protein conc, h&h, etc) that can't be done in the field.

Multiple body systems (nearly every one, really) are involved in control of this stuff, and it strikes me as irresponsible and dangerous to start tinkering with physiology that isn't properly understood.

 

[Cohn]

So then why not replace the bags of fluid with bottles of water?

When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?


What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?

 

[Bullets]

Emergent situation for "border patrol needs you"? Maybe. True emergent patient presentations? I doubt it.

Saline would replace sodium, and nothing else. There are better fluids for rehydration. Even better than pumping them full of fluid that will make their number look great for an hour or two before leaking out of the vascular space is gentle rehydration using something like gatorade and water half and half over several hours/days as well as a meal. It's realisticlly going to take a few days to rehydrate these people, not a matter of a liter or two. Learn how to calculate water defecit and you will see exactly how staggering of a loss it can be. Dumping fluid in the vascular space is sometimes the answer, but having uneducated EMTs with a merit badge (or for that matter, uneducated paramedics) doing it is asking for trouble.

If you had bothered to look up the condition I was speaking of, it's a warning as to why you don't replace sodium TOO FAST. There's a lot to consider when messing with these things.

I was thinking emergent as in, we have a guy who just walked across a 100 degree desert for multiple days with no food or water, is possibly U/R.


What condition? Dehydration? I'm aware that long term care requires gradual replenishment of fluids, but I'm not keeping him in my ambulance got 10 days, I just want to start treatment for the time it takes to get to an LZ, and get the patient flown to an ICU

If this was your patient, what would you have done? All you've fine so far is tell me how giving a dehydrated patient is bad.

I'm not stupid, I've taken the time to understand the science behind out interventions we administer. Im basing my "give fluids" on the assumptions that a.) I made a decent assessment and determined that this is the proper course of action and b.) Because this is a forum of what I assume is somewhat educated people I didn't have to spell out every medical complication and contraindication for every thing we do

 

[bstone]

Would it be good for an EMT-B to have a patient completely prepped (including IV) for ALS when they arrive? Yes.

Does an EMT-B have the required training in order to do this? I don't think so. If the EMT-B cirriculum was to add an additional 40 hours simply for IV therapy and fluid theory then I would be more inclined. As it is EMT-B is a crashcourse of emergency medicine and it simply isn't in depth enough.

 

[Bullets]

Would it be good for an EMT-B to have a patient completely prepped (including IV) for ALS when they arrive? Yes.

Does an EMT-B have the required training in order to do this? I don't think so. If the EMT-B cirriculum was to add an additional 40 hours simply for IV therapy and fluid theory then I would be more inclined. As it is EMT-B is a crashcourse of emergency medicine and it simply isn't in depth enough.

I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology

 

[CAOX3]

When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?


What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?

You should be concentrating on effective compressions, that's going to save more lives then an emt putting a line in someone.

 

[EMS49393]

I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology

I agree let's educate people. Complete a paramedic program, preferably one that has a degree and all the associated classes required for said degree, THEN you can perform invasive patient care.

This "going half-way" with education is nonsense. Go big or go home. This profession is never going to get out of the dark ages until we stop half-***ing our education.

 

[Bullets]

I agree let's educate people. Complete a paramedic program, preferably one that has a degree and all the associated classes required for said degree, THEN you can perform invasive patient care.

This "going half-way" with education is nonsense. Go big or go home. This profession is never going to get out of the dark ages until we stop half-***ing our education.

But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%? lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.

 

[usalsfyre]

When they do go to the hospital they are going to start a IV on the pt with dehydration anyway... Why wait?


What if we had a cardiac arrest and it takes the medic 45 mins to get down to us wouldn't it be nice if your line was already started so you can push your drugs?

Maybe because there will be people present who understand the pitfalls associated with fluid resucitation?

 

[EMS49393]

But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%? lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.

I do not understand your logic. Perhaps that is because I attend every one of my patients from start to finish and have since I became a paramedic. As a matter of fact, my last service had a charter that specified that the paramedic attend every patient, regardless of complaint, findings, or how badly they might want to "bls" them.

Your demolition expert and locksmith argument makes absolutely no sense. They are two different occupations entirely. You'll demolish your car because you locked your keys in the ignition? That's just insane and frankly has nothing to do with medicine. Regardless, both have many more educational hours behind them than the EMT-B.

 

[Bullets]

I do not understand your logic. Perhaps that is because I attend every one of my patients from start to finish and have since I became a paramedic. As a matter of fact, my last service had a charter that specified that the paramedic attend every patient, regardless of complaint, findings, or how badly they might want to "bls" them.

Your demolition expert and locksmith argument makes absolutely no sense. They are two different occupations entirely. You'll demolish your car because you locked your keys in the ignition? That's just insane and frankly has nothing to do with medicine. Regardless, both have many more educational hours behind them than the EMT-B.

In NJ evey call for ems gets a bls truck, als only comes if our dispatcher determines the need, bls makes an assesment and may cancel medics if they aren't indicated

 

[usalsfyre]

I was thinking emergent as in, we have a guy who just walked across a 100 degree desert for multiple days with no food or water, is possibly U/R.

Different situation than the guy that's not. Not the mention probably the minority of patients encountered.

What condition? Dehydration? I'm aware that long term care requires gradual replenishment of fluids, but I'm not keeping him in my ambulance got 10 days, I just want to start treatment for the time it takes to get to an LZ, and get the patient flown to an ICU

Is waiting 10 minutes to start treatment clinically significant at this point? If he's unresponsive, a liter isn't going to even START to replace what he's lost. Why not wait for the crew who is familiar with all aspects?

If this was your patient, what would you have done? All you've fine so far is tell me how giving a dehydrated patient is bad.

Never said I wouldn't give fluid. In the unresponsive patient I'd start fluid resus quickly if I thought it was the right course. But it wouldn't be with NS, and there's other things the unresponsive dehydration patient needs beside fluid.

I'm not stupid, I've taken the time to understand the science behind out interventions we administer. Im basing my "give fluids" on the assumptions that a.) I made a decent assessment and determined that this is the proper course of action and b.) Because this is a forum of what I assume is somewhat educated people I didn't have to spell out every medical complication and contraindication for every thing we do

NONE of this is covered in basic class. Not one iota. It's not even really adaquately covered in paramedic school. So to assume the lower levels have any mastery of this material without extensive self (i.e. non-mandated) study is patently false.

 

[Lola99]

But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%? lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.

Not every call requires a medic, but that doesn't mean basics shouldn't be educated as much as possible/willing, does it?

So I have this question (and I know it's not the same thing), but back home I work for a BLS service, NOT 911. We do emergent and non-emergent transports, though. Anyway... in the summer, we're contracted, for several years now, to work a local dirt track every weekend. We take two trucks (a local volunteer FD has a truck there too) and play standby until someone rolls or track personnel decide we need to be down there. Our crews are either basic/driver or basicx2. We have one medic, but since it's only a BLS service, he can't really play medic. He's one of those guys that hangs around until a "good" call comes up, then wants to play. I'm a basic. If we were called to the track (only one truck goes at a time unless it's obviously more than one can handle or the first truck down calls for assistance) and found a patient in need of transport to ER, should the medic take over simply because he's a medic or does it matter since it's only a BLS service to begin with?

 

[usalsfyre]

I totally agree on both counts, but lets do it, lets educate these people so they know what they are doing and HOW its working. make the "basic"class longer, 240 hours with more pharmacology

240 hours is a joke. Heck, the 770 that is the minimum for paramedic in Texas is a joke.

 

[usalsfyre]

But we don't need everyone to be a paramedic, how many calls really require all that medics have to offer? 50%? lets send a person a demolition expert when all we need is a locksmith? even the good doc brown admits we don't need medics on everything.

And yet, everyone of those people will see a physician, or at least a midlevel at the end of the line.

 

[EMS49393]

In NJ evey call for ems gets a bls truck, als only comes if our dispatcher determines the need, bls makes an assesment and may cancel medics if they aren't indicated

Well that is certainly fair for the patient. Good thing they're going to the ER.

Dispatchers base their calls on information provided from the call, which is often incorrect or incomplete. It's fallible, and patients have suffered.

Your class is 120 hours long, how much assessment did you actually learn? Enough to determine if a patient is sick enough for a paramedic? I doubt that. I couldn't do it when I was an EMT.

The system is flawed, period. Every patient deserves the highest level of assessment and care. Increasing your little EMT class a few hours so you can do some "cool" skills is not the answer.

So far I haven't read one valid argument in this thread for why a patient needs that IV as performed by a basic. I have read more than one valid argument for why they need a higher level of care.

 

[usalsfyre]

Why do ya'll have the desire to start administering fluids without the educational background?

 

[mikie]

EMT's Starting IV's around here...

Come to Baltimore county and become an "IV-Tech"

2 8(?) hour classes & 10 IV attempts at a local hospital will get you a little certificate saying your a basic that can start a line, KVO, Lactated Ringers (only fluid we carry in the county) or locks in peripheral veins. Won't waist my time taking the class since I'm already a paramedic student doing IV's in the clinical/field setting and have learned about phlebotomy though my paramedic curriculum.

In my opinion, it shouldn't be taught in the basic curriculum, but like that of certain skills, should be a certifiable adjunct skill depending on your REGION. (not that I particularly like the IV tech program in BaCo; there's a hospital or ALS provider <5 minutes away, however an EMT with an hour + transport time, in rural Wyoming might need that access. Hell, can't they do IO's as basics (w/ a supplemental course)?

 

[Veneficus]

Where to begin?

I know:

http://www.youtube.com/watch?v=PJy9FKh0OIs

Why don't we just have basics take about 40 hours of watching this, and then they can do that on a STEMI alert so they don't have to wake up a surgeon? Afterall, they have seen IV fluids given many times without knowing the physiology behind it.

Sounds stupid doesn't it?

Many people have already offered that fluid and electrolyte balance is complex. But rather than echo their statements, let me offer some perspective in simple words?

The body conserves sodium when sweating, only a very small amount is actually lost. This helps pull intracellular fluid into the vascular space.

In dehydration, without intake, the kidneys then start reabsorbing larger amounts of salt.

(See the salt increasing? because the water is decreasing?)

Now your plan is to introduce salt water into the vasculature? Which is going to increase the salt further. Remember NaCl is only mostly isotonic under physiologic conditions. But it is hard to know that just watching the end point of IV starts.

Are you planning to further dilute your normal saline to 1/2 normal or carry 1/2 normal or something more expensive like a colloid mix, in order to increase watercontent under these pathologic conditions?

How will you know when to do that?

If a paramedic starts an IV and runs NS on severely dehydrated patients, they are wrong.

In as few words as possible: hypernatremia -> arryhthmia -> vfib -> cardiac arrest.

Now the basic is going to need to intbate and push drugs because the medic is still 45 minutes out.

Let me address the drugs. Unless there is a specific etiology identified, drugs usually have no measurable effect in cardiac arrest.

I would rather a medic take a few minutes while CPR continues to try and identify a reversible cause than to rapidly follow an algorythm based on epidemiology and if the patient doesn't fall in the parameters, too bad, so sad.

One of the most important things any healthcare provider anywhere can do is not make the situation worse. If you do not make the situation worse and just transport to somebody who can help, you have done not only the right thing, but a great thing.

Please, EMS does not perform surgery on trauma patients because it is rather complex decison making. (a butcher could do the physical skills, and probably has enough experience) Why is anyone advocating trying to balance fluid and electrolytes without the same level of decision making?

The reason we do not put insulin on EMS units is because it takes a knowledgable and skilled practicioner to slowly bring things into balance.

If there was a hyperthermic patient would you advocate dousing them in icewater and hope they didn't become hypothermic? If they did, too bad, so sad?

Of course not, in the severly hyperthermic we reduce temperature in a controlled way. So as to prevent rebound hypothermia.

Any idiot can perform skills, it doesn't take an EMT. But just like we make people go to a doctor to get the proper medicine prescribed, just like we make them go to a pharmacist to dispense it to them, we don't want the local street dealer deciding what your ailment needs, mixing product, and handing it out to anyone who comes across his service.

What makes letting an EMT-B do it without the education and knowledge different?

If the only difference is intent, keep in mind there is more than 1 "herbal remedy" dealer who has the best of intentions dolling out what they think should help without sound education behind it.

Teaching Basics to cannulate a vein/draw blood etc. is rather easy and not a very significant skill.

However, once you start adding medications to the mix, (Saline is by the board of pharmacy a medication) then it is no longer a skill and becomes clinical decisoon making.

Making decisons requires appropriate education.

If some whacker came on here, said they had no medical education and asked where they could get IV supplies to take on his camping trip "just incase," even the basics here would be jumping all over him.

Does knowing CPR somehow put Basics on a higher plane? What if our would be hero knows CPR too?

Would you be ok with the LPN initiating Pressors, sedatives, or neuromuscular blockers because he works in the ICU and sees it all the time? How about defibrillating, placing a chest tube, or termnating efforts?

What do yo think? Add on 40 hour course to determine when efforts should be terminated?