IV certification??

[medic417]

Because our under 200 calls a year and many of them BLS doesn't justify changing our agency classification to ALS which requires 24/7 response. That means at least 3 full time medics and their toys. We are too geographically isolated to get that coverage from adjoining areas and have lost 2 of our go-to agencies for ALS support in the past year.

One of the services I work for is ALS 24/7 and has fewer than 200 calls. Just means prioritys need changing. Do whats best for the patients.

 

[BossyCow]

One of the services I work for is ALS 24/7 and has fewer than 200 calls. Just means prioritys need changing. Do whats best for the patients.

Okay for those who haven't read my 2000 posts on the subject..... a recap. I live in an extremely rural, impoverished area where the literacy levels are low, the average education is 'some high school' and the major industries used to be logging and fishing, both of which have tanked. We have continually tried to get ALS to this area but can't pass a levy, don't have the property values to sustain it through tax and most of our real estate is state timberlands, or national parks.

Not only have we been unable to upgrade our system to ALS but two adjoining agencies have dropped their ALS response to BLS. We do what is best for the patients. We do what we can. But telling the WalMart worker how a Caddy is a better ride than his Geo isn't going to make the money appear.

 

[medic417]

Okay for those who haven't read my 2000 posts on the subject..... a recap. I live in an extremely rural, impoverished area where the literacy levels are low, the average education is 'some high school' and the major industries used to be logging and fishing, both of which have tanked. We have continually tried to get ALS to this area but can't pass a levy, don't have the property values to sustain it through tax and most of our real estate is state timberlands, or national parks.

Not only have we been unable to upgrade our system to ALS but two adjoining agencies have dropped their ALS response to BLS. We do what is best for the patients. We do what we can. But telling the WalMart worker how a Caddy is a better ride than his Geo isn't going to make the money appear.

Sad to hear that. We are in same if not worse so again I would argue it can be done. But regardless I disagree with basics doing ALS level procedures. If you want ALS skills get your Paramedic.

 

[BossyCow]

Sad to hear that. We are in same if not worse so again I would argue it can be done. But regardless I disagree with basics doing ALS level procedures. If you want ALS skills get your Paramedic.

But in my state, its not ALS. I do what is legal within my cert.

And as to 'getting my paramedic' I got one.. married him eons ago!

 

[Sasha]

Do whats best for the patients.

They ARE doing what's best for the patient, they're training what service they have to preform more advanced skills and procedures than the national norm.

You can repost the same message, reworded over and over again but the fact of the matter is if there is no money to support it, there is no money to support it. If there is not a high demand, and 200 calls is not a high demand, for something, it's not going to happen.

And as to 'getting my paramedic' I got one.. married him eons ago!

You're so cute!

 

[medic417]

They ARE doing what's best for the patient, they're training what service they have to preform more advanced skills and procedures than the national norm.

You can repost the same message, reworded over and over again but the fact of the matter is if there is no money to support it, there is no money to support it. If there is not a high demand, and 200 calls is not a high demand, for something, it's not going to happen.

Best for the patient care would be all advanced providers so no they are not doing whats best for the patients. They are doing what the city/county/etc claims is best for the budget. Two very seperate things.

In time it will in time it will, yes in time all will be ALS.

 

[Sasha]

Best for the patient care would be all advanced providers so no they are not doing whats best for the patients. They are doing what the city/county/etc claims is best for the budget. Two very seperate things.

In time it will in time it will, yes in time all will be ALS.

They cannot afford to staff ALS trucks. What part of that don't you comprehend? This is not the land of fairy tales where everything works out just because it's for the greater good. Money doesn't just pop up from nowhere. Running an ALS truck costs MONEY. More money than a BLS truck. ALS responders expect better pay then BLS responders. Money makes the world go round, and no money means no ALS. And they don't have a leg to stand on to request a grant or something. 200 calls? When places that run thousands of calls are still using LP10s, don't have ETC02, and there are trucks without a pulse ox? Where would the money do the greater good?

 

[emtbill]

I'll add my perspective to this. I'm a basic-advanced, which in Indiana is considered the lowest level of ALS care. I can intitate peripheral IV access with NS, LR, and D5W, I can check BGLs, and use a 4 lead monitor, manually defibrillating VT and VF. I cannot give any further medications, and I can only recognize 5 basic rhythms per my scope.

I'm not a paramedic replacement. In fact, I'm far closer to a BLS provider.

I consider it BLS, and it really should be BLS. Combine the two courses, and I don't see why we can't have a slightly more advanced basic curriculum. The advanced course is 3 sections, cardiology, trauma, and IV access.

When I work on a medic truck, my skills allow me to expedite the care process by sharing some of the procedural workload.

That's amazing. What if you're not on a medic truck? You can put a patient on a monitor and start an IV? What if they are symptomatic? "Yes mam I see you're in sinus brady with a rate of 35 and BP of 80 systolic, but I really can't do anything for you". That seems almost negligent. Does your state issue certifications or do you recripocate from the NREMT? I know the registry wouldn't certify you competent to read rhythms without being able to correct them.

Why should basics be intubating if a paramedic is on scene?

Provided they have the proper education they should because if the most experienced provider always preforms the procedures no one advances their skills and knowledge.

In regards to the OP's question: It varies from state to state. If you went through an official state-approved EMT class and didn't get training in IV therapy chances are it's not in your scope of practice and you'll need additional training. For example, in Tennessee the lowest level of EMS provider is an IV technician which has little more training than an EMT-B in any other state. On the other hand, in Virginia, the next level of training to start IV's and have expanded pharmaceutical interventions takes an additional 120 hours of training (the same amount as the EMT-B curriculum).

To everyone else: I'm not surprised to see a lot of cynics saying that IV therapy shouldn't be given to BLS providers. It is an ALS skill, but the knowledge required to safely preform it is being exaggerated. The training I was given on the precautions of IV therapy can be summed as follows: 1)Watch for fluid overload by monitoring lung sounds and BP while giving a fluid bolus. If either become abnormal discontinue treatment. 2) Use an aseptic technique and cover the IV site. 3) Monitor IV site for infiltration. 4) Clear the infusion set of air and don't ever advance the catheter past the stylet as to avoid emboli.

Do those precautions really take months of instruction to properly train providers? No. Providers can be taught how to safely start IV's in a weekend, but it will take longer for them to become efficient at it. Providers do not realistically need to be educated in the finer points of osmosis to administer saline. Get real. Do you expect people to be worrying about hypernatremia while bolusing their crashing hypotensive patient? Hyperkalemia? There's not enough potassium in an entire bag of LR to cause any significant cardiac arrhythmias.

Practically every intervention in medicine has risks. For example, oxygen is toxic at elevated partial pressures. Should EMT-B's have to take university level chemistry and physiology to understand gaseous partial pressures and how it affects their patients? No, but one has to consider the risks and benefits of any intervention. In EMS, most of our interventions are clearly beneficial to the patient when they are indicated, and as a result marginal education in the procedures has become accepted. This is evidenced by EMT-B's being allowed a more liberal scope of practice such as the addition of IV therapy and supraglottic airway devices, and standing orders for the administration of nitroglycerin, epinephrine, albuterol, atrovent and glucagon. Is this acceptable? It's debatable, but consider the alternative situation in which a patient is denied an intervention that is clearly indicated such as glucagon in hypoglycemia, the denial of which could cause increased morbidity in lengthy transports. Should the provider be educated in the chemistry of the polypeptide and how it causes conformational changes in protein receptors, thereby activating adenylate cyclase along with several other steps in the pathway, ultimately resulting in an increase in blood sugar levels?

We have to draw the line somewhere, and if patient care becomes compromised when they can't get the care they need than there is a problem. One's education is never complete, however the level to which a provider takes their education is a personal decision. As long as their interventions are safe and appropriate there shouldn't be a problem. Remember, we are technicians, not clinicians, and as such we follow orders from a physician in treating our patients. I would like to see EMS become more respected and autonomous which would require more education. This seems a blatant contradiction to my arguments above, and frankly I'm not sure how to address that. On one hand I do think that the education level of EMS providers as a whole is lacking, but on the other hand I have see too often patients denied the care they need because of unrealistic expectations placed on the provider. The person whom balances this dichotomy will have accomplished a great feat.

 

[vquintessence]

((((snip its))))
To everyone else: I'm not surprised to see a lot of cynics saying that IV therapy shouldn't be given to BLS providers. It is an ALS skill, but the knowledge required to safely preform it is being exaggerated.
Do those precautions really take months of instruction to properly train providers? No. Providers can be taught how to safely start IV's in a weekend
Providers do not realistically need to be educated in the finer points of osmosis to administer saline.

Practically every intervention in medicine has risks. For example, oxygen is toxic at elevated partial pressures. Should EMT-B's have to take university level chemistry and physiology
most of our interventions are clearly beneficial

I would like to see EMS become more respected and autonomous which would require more education. This seems a blatant contradiction to my arguments above, and frankly I'm not sure how to address that.

Well put and agree with what wasn't cut out. You mentioned how we need to be realistic and essentially just know how to do the skills, but on the other hand you want expanded education? Which is it? I wouldn't trivialize which fluid when it comes to the physiology of the body and its response to types of bolus either.

0.9% NS, 0.45% NS, D10w, D5w and LR, oh my!
Would LR be more beneficial to the trauma pt who is likely at least slightly acidotic?
Why do electrolytes matter?
Will giving a hypotensive trauma pt be cured with 3L of saline? Oxygenation?
Do you give a 250cc fluid bolus to a dehydrated child? How much fluid does a Neonate get? Why do they get less?
Why do neonates get D10w instead of D50? How much do they get?
Why do we give isotonic solutions instead of hypo/hypertonic? Does it even matter?

Bill, I am willing to bet that you personally can answer most if not all of the questions above, along with a lot of the EMTs in the forum. The questions weren't a personal attack. The questions are for the average EMT who doesn't pick up a book after (hell during) school/training? The ones gung ho on doing the stuff medics do, cause it looks easy and a monkey CAN do it better.

Disclaimer: Medics aren't exonerated either for being uneducated, but the difference there is that they are expected to know those above, and if they don't, well they don't care along with the system that certifys them. They deserve to get hung when the unfortunate happens and someone gets hurt or dies.

 

[JPINFV]

Provided they have the proper education they should because if the most experienced provider always preforms the procedures no one advances their skills and knowledge.

False dichotomy. It isn't a "well, if they don't preform skills then they'll never advance" because there isn't a requirement of X amount of intubations before starting an EMT-Paramedic course. Furthermore, we don't see RNs or ER techs clamoring to intubate or start chest tubes to "advance." That's because advancing to a higher level is more than learning a handful of skills and throwing them out there. Furthermore, there's the problem of paramedic oversaturation and skill degredation (here's one article on it, I'm trying to find the original study). It doesn't matter if the paramedic is onscene if the paramedic still isn't preforming enough times to maintain competency.

To everyone else: I'm not surprised to see a lot of cynics saying that IV therapy shouldn't be given to BLS providers. It is an ALS skill, but the knowledge required to safely preform it is being exaggerated. The training I was given on the precautions of IV therapy can be summed as follows: 1)Watch for fluid overload by monitoring lung sounds and BP while giving a fluid bolus. If either become abnormal discontinue treatment. 2) Use an aseptic technique and cover the IV site. 3) Monitor IV site for infiltration. 4) Clear the infusion set of air and don't ever advance the catheter past the stylet as to avoid emboli.

What other skills should be lowered to the EMT-B level? How about 12 lead EKGs since there are area that don't require their paramedics to actually interpret the EKG? How about epi and atropine during a cardiac arrest? At what point do we draw the line and either say "We don't need any more of dem dare paramedics?" Alternatively, at what point do we sit here and say a 110 hour advanced first aid course (otherwise known as the 1994 DOT EMT-B curriculum) does not provide enough of a background to preform these interventions?

[3 paragraphs of justifying low education standards including the following quote]
Remember, we are technicians, not clinicians, and as such we follow orders from a physician in treating our patients.

...and that's why EMS will never be a profession and will continue to have things like required base hospital contact in a lot of areas and crap pay.

 

[Shishkabob]

0.9% NS, 0.45% NS, D10w, D5w and LR, oh my!
Would LR be more beneficial to the trauma pt who is likely at least slightly acidotic?
Why do electrolytes matter?
Will giving a hypotensive trauma pt be cured with 3L of saline? Oxygenation?
Do you give a 250cc fluid bolus to a dehydrated child? How much fluid does a Neonate get? Why do they get less?
Why do neonates get D10w instead of D50? How much do they get?
Why do we give isotonic solutions instead of hypo/hypertonic? Does it even matter?

Do I have to say it for the umpteenth time?

We're not asking for all ALS interventions here. We're not asking for all drugs here.

Add on the extra weeks it takes to educate people on how to poke a needle, and about NS. Honestly, if you think it's so hard to teach in the proper time, then why should medics have it too?

I'm not saying give a 4 hour lecture and let them have at it. I'm saying do it in the appropriate amount of time.

 

[vquintessence]

Do I have to say it for the umpteenth time?

We're not asking for all ALS interventions here. We're not asking for all drugs here.

Add on the extra weeks it takes to educate people on how to poke a needle, and about NS. Honestly, if you think it's so hard to teach in the proper time, then why should medics have it too?

I'm not saying give a 4 hour lecture and let them have at it. I'm saying do it in the appropriate amount of time.

It was a question for the guy debating about there being only trivial rammifications behind fluid administration. You work PB. So for few and far between instances where it's absolutely crucial for a simultaneous IV and ETT, can be about the only argument for its use by a basic.

Until the 110 hour cirriculum changes, it doesn't seem wise to have EMT-B units initiating IV alone, when their only option after access is to give nor not give saline, and perhaps understand why. Bossycow cited the only time she can do it is WITH authorization AND when ALS intercept is en route, and even that situation is with long transport times and minimal resources. That could be about the only acceptable situation.

The other part about required education, is, an EMT-I. If basics want IV, then they can get their Int or medic, and hell, after that they can intubate too! Do they want the education involved to get that ability, or do they just want to skill?

 

[VentMedic]

.

The other part about required education, is, an EMT-I. If basics want IV, then they can get their Int or medic, and hell, after that they can intubate too! Do they want the education involved to get that ability, or do they just want to skill?

Why do EMT-Bs put so much time and effort into getting so many "certs" for individual "skills"? It is this type of piece mill stuff that has gotten EMS to the point of 50+ different levels.

It seems that some just want to say they can do the skills of a Paramedic but without the extra responsility the comes with knowing why.

 

[medic417]

Why do EMT-Bs put so much time and effort into getting so many "certs" for individual "skills"? It is this type of piece mill stuff that has gotten EMS to the point of 50+ different levels.

It seems that some just want to say they can do the skills of a Paramedic but without the extra responsility the comes with knowing why.

How true!!!!!!!!!!!!!!!!!! In this day and age of technology there are so many options there is no other legit reasons a person would not go get their Paramedic if they want ALS.

 

[Shishkabob]

I'm all for replacing Bs with Is but nationally it's not trending that way, just the opposite is true.

It seems to me you're against people doing it with the proper education simply because they have a B instead of an I or P.

Again, not looking for another 10 hours added on to the course. Proper education could be an extra 50 hours or 100. But for some reason you have it in your mind that it can't be done.

 

[emtbill]

False dichotomy. It isn't a "well, if they don't preform skills then they'll never advance" because there isn't a requirement of X amount of intubations before starting an EMT-Paramedic course. Furthermore, we don't see RNs or ER techs clamoring to intubate or start chest tubes to "advance." That's because advancing to a higher level is more than learning a handful of skills and throwing them out there.

You misunderstood my statement. It had nothing to do with entrance requirements to a paramedic program. Also, the hospital scenario is moot. There is always a physician in the hospital to do these procedures, however my point was to increase competency of EMS providers. If a patient needs to be intubated, and there's a veteran paramedic and a new paramedic (or even a student) there, no one learns anything if the veteran preforms the skill. Everyone knows he/she is competent, but if the rookie provider doesn't get the experience preforming the skill with the veteran helping him, it could reflect negatively during the rookie's next patient contact without the veteran.

I wholeheartedly agree with you over advancement being more than learning a handful of skills and throwing them out there. A good provider will always be more educated than that. As I was discussing in my OP, however, many procedures have such clear benefit that it might be more beneficial to the patient to give the provider access to the skills liberally.

What other skills should be lowered to the EMT-B level? How about 12 lead EKGs since there are area that don't require their paramedics to actually interpret the EKG?

EMT-B's already obtain 12 leads in my area. See page 13: http://odemsa.vaems.org/index.php?option=com_docman&task=doc_download&gid=8

How about epi and atropine during a cardiac arrest?

BLS providers already do so. See page 50: http://www.western.vaems.org/index.php?option=com_docman&task=doc_download&gid=169

Virginia Enhanced providers are able to start peripheral IV's, place supraglottic airways, etc and can give ASA, NTG, Albuterol, Narcan, Benadryl, Thiamine, Epinephrine, Valium, Morphine, D50, etc. They have no training in reading EKG's and no ACLS training. For this reason they are generally not considered ALS providers as their cardiac assessments are non-diagnostic. Still, in many regions they are allowed to preform paramedic level interventions because the patient will benefit form them.

Do they want the education involved to get that ability, or do they just want to skill?

I think there's a lot of truth to that. There are a lot of whackers out there with the "Hey look what I can do to this patient!" kind of attitude.

 

[Veneficus]

Best for the patient care would be all advanced providers so no they are not doing whats best for the patients. They are doing what the city/county/etc claims is best for the budget. Two very seperate things.

In time it will in time it will, yes in time all will be ALS.

Just my thoughts, but in Bossy's case, I think that providing the care they do is better than no care at all. I do not think basics around the country should be starting IVs. But it sounds to me that her area needs an exception to the rule. (which are more like guidlines anyway ) I do not think simpy having "als" improves care. These same ALS providers would have to be constantly practicing their skills somewhere like a nearby hospital, because they would be using them so infrequently. It is the same situation as having a paramedic on every street corner.

 

[BossyCow]

Why do EMT-Bs put so much time and effort into getting so many "certs" for individual "skills"? It is this type of piece mill stuff that has gotten EMS to the point of 50+ different levels.

It seems that some just want to say they can do the skills of a Paramedic but without the extra responsility the comes with knowing why.

I'm sure there are SOME that are motivated by that, but I'm tired of being tarred with that brush!

 

[Veneficus]

Where to begin....

To everyone else: I'm not surprised to see a lot of cynics saying that IV therapy shouldn't be given to BLS providers. It is an ALS skill, but the knowledge required to safely preform it is being exaggerated. The training I was given on the precautions of IV therapy can be summed as follows: 1)Watch for fluid overload by monitoring lung sounds and BP while giving a fluid bolus. If either become abnormal discontinue treatment. 2) Use an aseptic technique and cover the IV site. 3) Monitor IV site for infiltration. 4) Clear the infusion set of air and don't ever advance the catheter past the stylet as to avoid emboli.

The training you received could be summed up in 4 points. I am not even sure what to say. I seriously pay too much for my education. You really think that’s all there is to it?

Do those precautions really take months of instruction to properly train providers? No. Providers can be taught how to safely start IV's in a weekend, but it will take longer for them to become efficient at it.

the psychomotor skill yes, enough to choose when to use the skill or not which may cause harm, no.

Providers do not realistically need to be educated in the finer points of osmosis to administer saline. Get real. Do you expect people to be worrying about hypernatremia while bolusing their crashing hypotensive patient? Hyperkalemia? There's not enough potassium in an entire bag of LR to cause any significant cardiac arrhythmias..

I clearly spend too much time studying as well. Providers do need to be educated in the finer points of osmosis, otherwise all those MDs and RNs wouldn’t bother with it either. Do you really think that is just information to fill up time in lecture? The patient may already be hyperkalemic before the LR. How does one without a lab or monitor figure that out before the bolus? If you want to save crashing patients adding complications in the rush to provide cookbook medicine will probably not increase the save rate.

Practically every intervention in medicine has risks.

The risks for one patient may be different for others. That is why we practice risk stratification.

For example, oxygen is toxic at elevated partial pressures. Should EMT-B's have to take university level chemistry and physiology to understand gaseous partial pressures and how it affects their patients?

I say yes, then maybe they would stop putting 15L or NRB on every patient, when it makes no difference from a cannula most of the time.

but one has to consider the risks and benefits of any intervention.?

One has to know them to do that.

In EMS, most of our interventions are clearly beneficial to the patient when they are indicated,

Says who? Interventions like fluid for penetrating trauma patients? MAST pants? Spine boards? The plethora of drugs used in cardiac arrest algorithms?

This is evidenced by EMT-B's being allowed a more liberal scope of practice such as the addition of IV therapy and supraglottic airway devices, and standing orders for the administration of nitroglycerin, epinephrine, albuterol, atrovent and glucagon. Is this acceptable

Considering we give those by prescription for patients to administer on themselves? Probably it is a good idea. But that s not an apples to apples comparison. Those are basically treatments that are designed to work for a specific life threatening condition that will probably result in death if left untreated. Fluid therapy is not that specific and rarely will save a life on its own. A pt in cardiogenic shock and a BP of 80/60 will be harmed by fluid. A penetrating trauma patient with a high degree of blood loss or massive wound and a bp of 70/40 will be harmed by fluid. Pt with renal failure, harmed by fluid. Exhausted/dehydrated endurance athletes, sometimes harmed by fluid. (most dramatically usually resulting in death when it happens)

Should the provider be educated in the chemistry of the polypeptide and how it causes conformational changes in protein receptors, thereby activating adenylate cyclase along with several other steps in the pathway, ultimately resulting in an increase in blood sugar levels?

If I need to spend time learning it, why not other providers giving it as well? If for no other reason it might lead to a pay raise? But in my opinion if you are a health care provider administering a drug, you should know why it works. No matter what your level. Not simply if you see X then you do Y.

Remember, we are technicians, not clinicians, and as such we follow orders from a physician in treating our patients.

Why do I bother trying to help EMTs gain professional status with this kind of mindless laborer mentality. No wonder Providers laugh at me when I tell them prehospital providers are more than just ambulance drivers. How long does a radiology Tech need to go to school? I have seen those students do some pretty advanced physics homework to even meet the prereqs.

I would like to see EMS become more respected and autonomous which would require more education. This seems a blatant contradiction to my arguments above, and frankly I'm not sure how to address that. On one hand I do think that the education level of EMS providers as a whole is lacking, but on the other hand I have see too often patients denied the care they need because of unrealistic expectations placed on the provider.

I would take a closer look at "need" and base the care performed by the environment that is involved. (like wilderness, remote, etc) But then I would require education to match the increased scope, understanding that those providers needed a legitimate exception to an established rule of higher education for all providers.

The person whom balances this dichotomy will have accomplished a great feat.

I think the dichotomy is fairly simple. If you are in need of a lower level provider performing treatments (notice I didn’t say skills) then those providers need to be educated (in addition to trained) on what they are doing, why it works, and when not to do it based on medical principles, not time of transport or intercept. I don’t think we need to require basic providers to memorize liver enzymes and functions, but I also don’t think it is too much to ask them to listen to a lecture on how glycogen breaks down into glucose and get the gist of it if they are going to be giving glucagon. (similar idea for other treatments)

 

[Veneficus]

EMT-B's already obtain 12 leads in my area. See page 13: http://odemsa.vaems.org/index.php?option=com_docman&task=doc_download&gid=8..

Big difference between obtain and interpret. But I cannot think of one reason why an EMT-B anywhere shouldn't be able to put on monitor leads and print a strip and transmit it to the hospital, even if they are not providing treatment for it in the field.

BLS providers already do so. See page 50: http://www.western.vaems.org/index.php?option=com_docman&task=doc_download&gid=169

Virginia Enhanced providers are able to start peripheral IV's, place supraglottic airways, etc and can give ASA, NTG, Albuterol, Narcan, Benadryl, Thiamine, Epinephrine, Valium, Morphine, D50, etc. They have no training in reading EKG's and no ACLS training. For this reason they are generally not considered ALS providers as their cardiac assessments are non-diagnostic. Still, in many regions they are allowed to preform paramedic level interventions because the patient will benefit form them..

I noticed reading through the protocols that almost all of the advanced procedures are regarded as psychomotor skills and the decision to perform these skills rests with online medical direction, not the provider in the field. Seems very reasonable to me, but I would not call it an advanced scope until it comes with independant decision making.

I also noticed that paramedics need online direction to administer epi IM to an anaphylactic patient. I seriously hope that is just a misprint.