IVs for EMT-B

[WolfmanHarris]

I am certain that 20 hours is enough to teach the academic portion of starting IVs but it's nowhere near enough to actually becoming proficient in it. I would suggest the minimal standard be something like 20 hours + 50 successful lines in the ER + 50 successful lines on an ambulance. Anything less than this and I just don't see proficiency. If this could be done then I would sign off on supporting IVs for basics.

I am consistently amused by the wide range in education times in different jurisdictions. Here we sit discussing whether a provider with ~120 hrs of training should or should not have IV cannulation and what level of instruction is sufficient.

At the same time, I'm taking a short study break from cramming in the last bits of review I can do before writing a two hour exam tomorrow at work in order to take the IV enhancement being offered to Primary Care Paramedics. The funny thing is, we have to take the test and pass with a minimum 70% due to our Base Hospital Program dropping the Ministry of Health mandated 100 hours of didactic plus clinical down to 24 hours didactic, 12 hours hospital clinical and 12 hours riding third. The test is to prove requisite knowledge for the condensed course.

Of course just about every PCP graduate for the last 5+ years has already learned all the material covered in the course as part of their two years of college to enter practice, but this hasn't been adapted as a mandatory part of the scope of practice yet in the province, hence the extra course requirement.

 

[ZootownMedic]

I am consistently amused by the wide range in education times in different jurisdictions. Here we sit discussing whether a provider with ~120 hrs of training should or should not have IV cannulation and what level of instruction is sufficient.

At the same time, I'm taking a short study break from cramming in the last bits of review I can do before writing a two hour exam tomorrow at work in order to take the IV enhancement being offered to Primary Care Paramedics. The funny thing is, we have to take the test and pass with a minimum 70% due to our Base Hospital Program dropping the Ministry of Health mandated 100 hours of didactic plus clinical down to 24 hours didactic, 12 hours hospital clinical and 12 hours riding third. The test is to prove requisite knowledge for the condensed course.

Of course just about every PCP graduate for the last 5+ years has already learned all the material covered in the course as part of their two years of college to enter practice, but this hasn't been adapted as a mandatory part of the scope of practice yet in the province, hence the extra course requirement.

What is the 'IV enhancement'? Here the EMT's literally take a 16 hour course, get 10 sticks in the ER, and go about their merry way. There is only so much you can learn about starting an IV. Getting GOOD at it is a whole other thing but that is what practice is for. I don't see how it can get too complicated. Here they are just doing simple peripheral access but unless you are starting central lines I still don't see the need for that much classroom instruction. Its similar to intubation....the skill itself isn't incredibly hard on most patients. Practicing and becoming good at it as well as knowing when it needs to be done is the difficult part

As a side note, do you know whats even MORE scary? I was at Denver Children's last month on my last clinical for Paramedic school and there was a nursing student on her last clinical before graduating with a BSN. A 6 year old boy with meningitis came in and needed an IV so me and her went in to start it. I asked her if she wanted to do it and she turned about as red as a tomato. I asked her what was wrong and she said that she had only started 2 IV's. I was so stunned I just stared at her in disbeleif as I slipped a 20 in his little AC......I know we as EMS providers get knocked for education but how are you going to have a bachelors in Nursing and have started 2 IV's! Thats how many IV's a EMT has before they start their IV 'school' clinical haha. Crazy.....

 

[Tigger]

What is the 'IV enhancement'? Here the EMT's literally take a 16 hour course, get 10 sticks in the ER, and go about their merry way. There is only so much you can learn about starting an IV.

Maybe it only takes 16 hours to learn to cannulate a vein, but surely you don't think 16 hours is enough time to learn that and the pharmacology behind NS/LR, Narcan, and D50? Never mind learning iso/hyper/hypotonic and acid/base balance? These are things that those administering these medications should know but most of our EMT-B/Ivs do not.

 

[ZootownMedic]

Maybe it only takes 16 hours to learn to cannulate a vein, but surely you don't think 16 hours is enough time to learn that and the pharmacology behind NS/LR, Narcan, and D50? Never mind learning iso/hyper/hypotonic and acid/base balance? These are things that those administering these medications should know but most of our EMT-B/Ivs do not.

Yeah I agree that the training is mainly focused on the skill itself and not so much the practical application of it. I think it takes PRACTICE to learn how to cannulate a vein and it is measured more in experience and not so much in hours. I think that the level a EMT-B needs to know the pharmacology of Narcan/D50/NS/LR is pretty much covered as is most of the tonicity of the solutions. The reason that they can push Narcan and D50 via IV is that those are two drugs that are relatively harmless and can save lives. It is a good thing that our state allows it since it has actually probably saved lives.

At the same time though the EMT's around here are USUALLY either starting IV's under the supervision of a Paramedic or in the ER as a tech. Either way they are not gonna be giving any drugs without the medic's say so and I don't know if they really need to understand the acid/base balance to start an IV. I think in the end it is more of a easy remedy so on BLS calls that may require an IV the Medic doesn't HAVE to be in the back. I have been into HUGE arguments with certain EMT's who think that everyone needs an IV and I always argue that most patients do not. If the patient isn't sick, isn't getting meds or fluid, and I don't think I am gonna need it at any point why do it? I have heard many say "because they are gonna get one in the hospital anyways." To which I just bang my head. Either way, I agree that the education is on the skimpy side. I do like the fact that they have the skill though. I think it does far more good than harm and in the end only elevates and progresses our profession. Just my .02 cents.

 

[Tigger]

Here's my position in short:
I support allowing EMT-Bs with additional training to start IVs under the direction of a higher level provider.

I do not support EMT-Bs starting IVs on their own, nor do I support them administering medications on their own. It's the D50 I have the biggest issue with considering the risk of tissue necrosis associated with an improperly placed line. Nasal Narcan via MAD is as effective as IV.

I could support IV access and fluids following medical control consult, but I think this brings up an additional set of issues.

I really enjoyed my class and found it well done and useful, but I couldn't help think the whole thing was kind of Micky Mouse, just a stopgap measure more than anything else. If someone wants to start IVs, maybe they should just take an AEMT course. I took it mostly because you need it to get hired anywhere else besides my current gig, it was cheap, and it will be somewhat useful where I currently work.

 

[mycrofft]

I support making IV's a watershed between EMT-B and EMT-P. The slope gets very slippery after that.

That is why I started a thread about making everyone get their EMT-P and eliminating professional medical responders below it. That and drugs, airways, pleural decompression, open chest heart massage....

If you want to put holes in people, get the whole education, not just the Idiot's Guide/Cliff Notes add-on certificate. Your employer would be only to happy to use you like (not as) a paramedic and pay you as an EMT_B.

 

[NYMedic828]

I have no problem with EMTs doing IM/IN/IV under supervision of a higher trained person be it a medic/intermediate/RN/MD.

It takes 5 minutes of training to teach the procedure for IN/IM. If it takes more than that you should find a new field.

Not really sure where the acid/base knowledge comes into play with d50, narcan and NS.

Narcan can have major side effects via withdrawel symptoms. Aspiration is a serious deal. Many people who don't use the stuff too often don't realize that 0.4mg is actually a substantial dose. The wrong person could cause serious side effects by slamming the entire amp in carelessly.

D50 isn't really going to hurt anyone as long as you know your IV is patent but id rather see IM glucagon kits to play it safe.

 

[Christopher]

Narcan can have major side effects via withdrawel symptoms. Aspiration is a serious deal. Many people who don't use the stuff too often don't realize that 0.4mg is actually a substantial dose. The wrong person could cause serious side effects by slamming the entire amp in carelessly.

Yeah...with IM and IN Narcan available, no need for an EMT-B to give it IV. If they're so far gone as to need IV narcan, they likely should have ALS coming to play as well.

D50 isn't really going to hurt anyone as long as you know your IV is patent but id rather see IM glucagon kits to play it safe.

I think the IV patency issue is pretty important w.r.t. D50. If anything they should use D10W or D25W bags as BLS (and us as ALS providers).

As for IM glucagon, I worry if they don't have somebody coming who can give IV dextrose they may sit around and wait for some improvement that never happens

Otherwise, I don't see any reason EMT-B's couldn't start IV's. I don't know that I'd give them any medications to push via IV besides dextrose. Instead I'd see it more as a Paramedic-extender role (that sounds familiar, isn't EMS already a Physician-extender?).

 

[mycrofft]

So the benefit is that the paramedic can use the EMT-B as "Medic-Helper"?

PS: agreed, not good to equate GLucagon with Dextrose. I saw the results of trying to mainline D50 right into the antecubital and missing....$10,000 of 1992 dollars in plastic surgery, physical then occupational therapy to repair the crater it left in the distal insertion of the bicep.

 

[ZootownMedic]

I support making IV's a watershed between EMT-B and EMT-P. The slope gets very slippery after that.

That is why I started a thread about making everyone get their EMT-P and eliminating professional medical responders below it. That and drugs, airways, pleural decompression, open chest heart massage....

If you want to put holes in people, get the whole education, not just the Idiot's Guide/Cliff Notes add-on certificate. Your employer would be only to happy to use you like (not as) a paramedic and pay you as an EMT_B.

I agree with you to an extent but EMT-B's or soon to be just EMT's, and AEMT's are NEVER going to go away. There are way to many areas and jurisdictions that cannot afford Paramedics and the bottom line is there are just not enough to go around. I always love how some people say that EMS is underecducated and then they say that we should take our current highest level provider and make everyone that level. It makes no sense. CNA's have a place in the hospital just as EMT's have a place in EMS. I see no reason why they can't be trained to safely administer IV's. In our system, they are....and it works great.

 

[KnightVision]

I have a cert in Phleb, veins are tricky lil pains. And an IV placement can add to the headache (in some cases - shorter needle, smaller gauge, hard vein). Def too much to squeeze into a B class - but a useful skill. AND, if properly taught later, CEUs?, the ability of just giving a port to expedite fluids/meds in the ED - well, I see it as a time saving bonus and great patient care. Thoughts??

 

[Boomerthedog]

As another poster alluded to, many services in Colorado actually require EMT-Bs to be IV certified to even be considered. Thus, I just got my NREMT certification and subsequently completed my IV course. Now I just need to get 10 successful sticks in the ER this Friday. Can anyone give me some advice for my clinical? I had four sticks on classmates last week, but that was easy because it was a very controlled setting.

I'm a lot more nervous for Friday than I was expecting, so any tips for my first few live patient sticks would be much appreciated. My instructor said my biggest weakness is that I try to be too gentle.

Thanks in advance!

 

[Christopher]

As another poster alluded to, many services in Colorado actually require EMT-Bs to be IV certified to even be considered. Thus, I just got my NREMT certification and subsequently completed my IV course. Now I just need to get 10 successful sticks in the ER this Friday. Can anyone give me some advice for my clinical? I had four sticks on classmates last week, but that was easy because it was a very controlled setting.

I'm a lot more nervous for Friday than I was expecting, so any tips for my first few live patient sticks would be much appreciated. My instructor said my biggest weakness is that I try to be too gentle.

Thanks in advance!

You will miss some, you will make some. You're going to cause some pain. Take every opportunity you can to start an IV, and don't be shy to ask for some guidance.

You can get the steps down with an IV arm and vocalizing each step during practice. I reckon it takes about 50 sticks on an IV arm to be proficient at the steps itself.

After you know the steps, now you just need experience. You'll need another 400-500 sticks to be 0-dark-30 proficient.

Experience comes with stabbin' people, so if you're hesitant to start IV's you'll never become proficient.

 

[mycrofft]

Well then, give EMT's red cards like wildland firefighters to show what they have a "ticket" (current qualification) to do in as many techniques as they can learn.
A frontier or really rural tech might have benefit of more advanced techniques, but suburban and metropolitan services don't need the added hassle.

I just remembered why we don't want techs doing stuff under our guidance if at all avoidable. I lost a perfectly OK job because a LVN did something minority wrong, I signed it off (I was handed the slip after the pt had left so no way to check), and was held responsible for her action. You want me to supervise, make me a supervisor and pay me the differential.

 

[systemet]

120 hours is a really short time for an EMT training program.

Where I worked, the EMTs had six months of training, and IV initiation and D50W were in their scope. This has since expanded further. I've heard some people suggest that their training is closer to a US EMT-I than an EMT-B. I'm not sure whether this is the case.

The world didn't explode because BLS was able to start IVs. I'm not sure it did a lot to help, although a few septic patients may have benefited, it might have ameliorated some anaphylaxis or hypotension in overdose patients. But I doubt that it had a large impact.

For the hypoglycemic diabetics, having the option for D50W was great. I can't say that I ever saw real statistics or any published work on the complication rate. I would be concerned that the skill level of some EMTs was less than a paramedic, but I think this more relates to individual experience levels (paramedics are after all, mostly more experienced EMTs), and the call volume in centers running BLS.

The major positives, as I saw it, were that if I backed up a BLS crew, they often had an IV started. If I ran ALS with an EMT partner, which was most of the time, I could usually trust them to get the IV, and do something else myself. This was also great on the days when I was just going to miss.

I think the bigger issue here is not whether you can train someone to start an IV in 20 hours or 3 hours or six months. I'm pretty convinced you can show someone how to physically start an IV (very poorly) in about 10 minutes. It's about whether we seek to be technicians, or practitioners.

If we really want to have ownership of our field, and aspire to become a profession, then we need to understand what we're doing and why. Otherwise we're just calling rampart for the IV of D5W.

So here's a few things that I think it might be good to understand if you're starting an IV:

* The concept of osmolarity / tonicity, and the properties of the commonly given IV solutions, and the effects that they have in vivo (e.g. why D5W is chemically hypertonic, but has effects on plasma electrolytes similar to administering a hypotonic solution).

* Serum electrolytes, and how IV therapy can change them, particularly regarding things like treatment and causation of hyponatremia / hypernatremia.

* The regulation of fluid balance in the human body. How we lose fluid across various organs, how this becomes changed in disease states, and how it's affected by different medications that a patient may be taking, with a particular consideration of situations in which fluid administration may be detrimental.

* The pathophysiology of hemorrhagic shock, and the role of hypothermia, hemodilution, coagulopathy, etc., and the appropriate use of volume resuscitation.

* A little bit about fluid dynamics, e.g. Poiseuille's law.

We still have real problems at the ALS level that we don't really understand why we do what we do, and how this affects the human body. A large part of this is due to the current state of EMS education, especially when it comes to physiology. These problems are compounded at the BLS level.

 

[medic417]

We still have real problems at the ALS level that we don't really understand why we do what we do, and how this affects the human body. A large part of this is due to the current state of EMS education, especially when it comes to physiology. These problems are compounded at the BLS level.

Exactly. There is not enough true education given at the ALS level for the skills including the simple IV so how in the heck can we expect proper education to be given for it at the BLS level. Yes the actual skill is easy just like doing an appendectomy is easy its all the liitle things we don't know that make it dangerous.

 

[mycrofft]

As I tell my CPR classes, holding up a business card, "I can print on this how to do CPR and you could leave with that information. ON the other side I could print the basic five steps of landing an airliner, but neither is going to work unless you have the critical knowledge to know when and how and how much".

 

[CrackerBDingus]

As illegal as it is I've been told that if your company is stationed in-house with fire and the medics trust you they'll teach you how to start IV and on calls requiring tons of different interventions they will have you start it. No administering the fluids or making the decisions though. And again, it's only if they REALLY trust you.

 

[mycrofft]

They used to treat LVN's that way at a hospital I worked at. Unless you run fluid the start becomes a clotted off site, which no one can use.

Like many other "save seconds" expedient moves, the potential for stuff not working and looking silly later is fairly high.

 

[CrackerBDingus]

Well, considering basics can set-up the bags for IV, makes sense if the medic just tells them what to use and all the other stuff and just has the basic stick 'em. Wouldn't know personally though, I am not in-house with fire.