EMTs starting IV

[Bullets]

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

I want the education, but my state doesnt allow it, make basic an associates degree! Take the onus on education out of the individuals hands and require more, acls, phtls, peeps, all should be required for certification, I agree the education is lacking. I want more, but the state only allows me to do so much and I can't go into a medic perform right now

 

[Lola99]

I've been following this thread pretty closely and here's what I've come up with.

At first I thought heck yes, the more you know the more you're worth, why not let basics start IV? Then the more I read these I thought heck, if a basic wants to start IVs, go advanced (or whatever that would be in their area). Doing IVs requires more education. That's obvious. But isn't that why we have the different levels? (EMT-B, -A, -I, -P here)
If you want to play with needles, go get educated, eh?

 

[wyoskibum]

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)?

Even in rural Wyoming, EMT basics do not do more than the National Standard Curriculum. Wyoming does have an aggressive EMT-I level. They can start IV's, administer fluids & meds, intubate, etc.., but there is a lot of oversight by medical control and they need to get orders for certain interventions.

 

[LonghornMedic]

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

It's called EMT Intermediate.

 

[Bullets]

It's called EMT Intermediate.

Add it to the list of things Jersey doesn't allow. Bass ackwards ems since 1921

 

[jrm818]

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.

Agree with all of your post, but if I you don't mind a brief hijack,

If serum Na+ is increased (say to 160 meq/L), 0.9% saline (154 meq/L Na+) is actually relatively hypotonic. Despite the addition of salt to the body, there will be a water gain such that there is net sodium dilution with NS administration (assuming serum Na+ is above 154). Obviously this will be a slower way of restoring volume than more dilute fluid, and 154 meq/L is a bit higher than normal sodium level, but even with those drawbacks, I don't understand how NS would actually worsen hypernatremia. What am I missing?

 

[Veneficus]

Agree with all of your post, but if I you don't mind a brief hijack,

If serum Na+ is increased (say to 160 meq/L), 0.9% saline (154 meq/L Na+) is actually relatively hypotonic. Despite the addition of salt to the body, there will be a water gain such that there is net sodium dilution with NS administration (assuming serum Na+ is above 154). Obviously this will be a slower way of restoring volume than more dilute fluid, and 154 meq/L is a bit higher than normal sodium level, but even with those drawbacks, I don't understand how NS would actually worsen hypernatremia. What am I missing?

The amount of free water (and as I honestly forgot, the compensatory electrolyte balance)

Also for your reading:

http://emedicine.medscape.com/article/766683-overview

 

[jrm818]

So I think I'm still missing something.

from the emed "treatment" section:

http://emedicine.medscape.com/article/766683-treatment
"Using isotonic sodium chloride solution, stabilize hypovolemic patients who have unstable vital signs before correcting free water deficits because hypotonic fluids quickly leave the intravascular space and do not help to correct hemodynamics. Once stabilization has occurred, free water deficits can be replaced either orally or intravenously."

A desert dehydrated patient will be hypovolemic as well as hypernatremic. 0.9 NS does little to correct the water deficit, I understand that. But I still don't see how it could increase serum Na+....and the eMed advice is to give NS to correct hypovolemia before worrying about the free water.

 

[jgmedic]

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.

This. A demo expert is most likely not trained as a locksmith. However, as a medic, I have been trained to and past the EMT-B level.

 

[Veneficus]

But I still don't see how it could increase serum Na+....and the eMed advice is to give NS to correct hypovolemia before worrying about the free water.

If you have compensatory increase in intracellular cation, When you add another one like NA++ it is not going to rapidly diffuse into the cell. The NA can be in either the intravascular or extra cellular space, but the point is it is not in the cell. Which brings you to hypervolemic/hypernatrium and the water not being in the cell where it needs to be to ultimately "fix" the person.

If I understand as well, the emed article is based around treatment for acute hypernatremia, in the scenario given, the potential patients may likely have been suffering for days.

I think more importantly:

"Hypernatremia should not be corrected at a rate greater than 1 mEq/L per hour."

http://emedicine.medscape.com/article/766683-media

Based on that are you advocating NS wide open for the chronically dehydrated as was postulated in the original argument?

 

[jrm818]

If you have compensatory increase in intracellular cation, When you add another one like NA++ it is not going to rapidly diffuse into the cell. The NA can be in either the intravascular or extra cellular space, but the point is it is not in the cell. Which brings you to hypervolemic/hypernatrium and the water not being in the cell where it needs to be to ultimately "fix" the person.

If I understand as well, the emed article is based around treatment for acute hypernatremia, in the scenario given, the potential patients may likely have been suffering for days.

I think more importantly:

"Hypernatremia should not be corrected at a rate greater than 1 mEq/L per hour."

http://emedicine.medscape.com/article/766683-media

Based on that are you advocating NS wide open for the chronically dehydrated as was postulated in the original argument?

OK, did some reading/remembering and I think I'm almost with you. I had forgotten about the compensatory increase in intracellular cations, and never knew about the increase in intracellular organic osmoles, but do now. My last hang up is that as cations and other osmoles increase in the cellular space, the cellular interior becomes progressively hyperosmotic compared to NS, leading to increased water movement into the cells when NS is administered.

Obviously dilute fluids would lead to more water entry into cells, but NS should lead to some water moving in, shouldn't it? And actually, if we're concerned about too rapidly increasing intracellular volume, wouldn't we be more worried about more dilute IV fluids too rapidly moving water into cells?

As for the last question, I don't think I'd consider myself qualified at this point to be trying to empirically rehydrate/osmotically balance a patient like this, so really I wouldn't say I'd "advocate" for anything.

That said, even before my increase in understanding I wouldn't have thought that wide open anything was a good plan. I would have thought "OK" to controlled boluses if we're looking at a really sick patient, but for most patients I would have been inclined to maybe do some oral rehydration and let the hospital do anything more drastic with bloodwork to guide them.

Much thanks for the input. I appreciate it.

 

[Bullets]

Gentleman, thank you to both, that is an excellent article and I learned a bunch. As always, this place is a wealth of knowledge.

 

[Bubz628]

I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)

 

[the_negro_puppy]

I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)

 

[anestheticmedic]

IVs aren't that hard, but neither is acls so might as well learn that too if u can start IVs. etc etc just go get your medic. I understand what the OP means but then the paragods had to jump in and overanalyze the whole thing and act like it's a highly advanced skill that only us super awesome medics should get.

 

[JPINFV]

This is not going to turn into a Basics vs Intermediates vs Paramedics thread.

Can I still laugh at the people posting, "This is mine, not yours. You can't have because it's mine," posts that presents no rational argument? Sure, there are legitimate and rational arguments for and against EMTs doing IVs under the direct supervision of a paramedic. On it's face, "Take a few months and get a higher license" is not one of them.

 

[MrBrown]

I'm not trying to piss in anyone's cereal, but I think it's ridiculous how when a Basic tries to make a simple comment on here just trying to suggest something, a Paramedic just has to come up with the cockiest remark to come back with. Jesus Christ. Let people talk, and don't think just because you have the "P" at the end of your EMT it means you're God. Just sayin'.... B)

But but but he has at least 12 weeks of training!

 

[JPINFV]

8/10 calls an IV is started

So? Are you going to say that 8/10 calls also are so critical that the minute or so it takes the paramedic to prep and place an IV makes a difference in the outcome? Similarly, how much of that time could be taken by a well trained EMT assisting with getting the supplies out, and if fluids are going to be ran, spiking the bag and priming the IV line?

 

[JPINFV]

All I want is d50, nebulize, fluids, maybe a 3 lead. It would cut our dependancy on MICs and speed up calls

How much additional education are you planning on adding to the EMT program in order to provide a sufficient education background on both the interventions listed (including rhythm interpretation for the 3 lead), as well as both the diseases that those interventions treat and the common diseases that presents similarly?

 

[JPINFV]

EDIT: Wait, nebs aren't in the basic scope there?

Not all places allows EMTs to administer albuterol nebs, and some of those that do are so restricted that they might as well not be in place.