About EMT intermediate

[Ridryder911]

Wow, you guys are brutal around here, aren't you?

For those who had my back...thanks.

For the others...no, it doesn't take two semesters to learn how to take the catheter and stick it in the vein. As a matter of fact, we probably covered that in about two classes including practice sticks on each other.

But, it's not just about the invasive procedure. It's knowing how to choose the correct size catheter for the job. It's knowing when and when not to start a line. It's knowing how much or how little fluid to infuse...and which fluid type you should be using. It's knowing how to ensure that you've not caused further damage by infiltrating the vein or by shearing the catheter.

But, to clarify...the two semesters is the length of time required to become an intermediate and all that implies....not the length of time it took to learn this one skill.

Side note...even phlebotomists spend a single semester in training here in Texas.

Amazing, not one Intermediate discussed osmotic gradient changes or hypertonic fluids and cellular shifts with fluids? Yes, it takes more than the 60 hours to really know about the job.

R/r 911

 

[EMTinNEPA]

Unfortunately, Pennsylvania just took a step backwards and is apparently preparing an "Advance EMT" level. :glare:

 

[dragonjbynight]

We have intermediates here in the rural areas, which is pretty much every thing outside Chicago and the surrounding metropolitan area. EMT-Is are very rare where I'm at, it's all or nothing, Chicago Fire Dept. *might* take an intermediate, not totally sure on that (they were the only ones taking the EMT-I exam at testing). I personally don't understand why one would get an EMT-I over going straight for paramedic, just seems like an unnecessary step.

I went straight from basic to paramedic school and the only thing I would recommend is that if you struggle with A&P, then take a course, it will help in medic school.

One reason to get your I, something I am personally considering once done basic is here in Indiana, you can't take a medic program without being sponsered in by an ALS provider....Which is beyond my ability to understand, but thats the way it was told to me when I signed up for basic. I would rather go Medic...but unfortunately, I don't have the backing yet.

 

[fortsmithman]

Why not get rid of basic and intermediate and just go paramedic.

 

[TransportJockey]

Why not get rid of basic and intermediate and just go paramedic.

This what I hope to eventually come about.

 

[daedalus]

You really think you need 2 semesters of school to learn how to start an IV?

Two semesters to cannulate someone? No. Two semesters (at least) to learn when fluids are needed and how much? Not even close enough to what is needed.

With the latest research from Iraq and Afghanistan, we are learning more and more about fluid resuscitation and EMT-Is are not qualified to determine which patients should receive an IV let alone fluids.

 

[daedalus]

Amazing, not one Intermediate discussed osmotic gradient changes or hypertonic fluids and cellular shifts with fluids? Yes, it takes more than the 60 hours to really know about the job.

R/r 911

And what about auto-resuscitation and hematocrit? What about abdominal compartment syndrome? What about clotting factors and the coagulation cascade? What about cardiovascular physiology, ICP, CPP, and edema? What about plasma proteins? What about diffusion, osmosis, ionic dissociation, colloids, suspensions, and crystalloids? Acid base balance? Compartments?

What about the fact that a patient can live or die by the level of understanding of physiology in trauma situations? I dare these people who say EMT-Is should be giving fluids to visit a surgical ICU.

 

[ResTech]

Two semesters to cannulate someone? No. Two semesters (at least) to learn when fluids are needed and how much? Not even close enough to what is needed.

Disagree. It does not take two semesters to learn which patients need fluid and how much and why. You can easily learn the positives and negatives of fluid administration in less than two semesters... especially when you also are required to take A&P. Were not studying to be surgeons... just Paramedics! Chastise me all you want for that comment.... but pre-hospital fluid resuscitation is not that complicated!

In the middle of a trauma.... Daedalus yell's to his partner... "I think were giving too much fluid... quick, what's the hematocrit???" non-degreed Paramedic partner replies.. "boy, wtf you talk'n about"... Daedalus then goes on... "I think we have some ionic dissociation occurring and plasma proteins are expanding".... stat, hand me the ottoscope"... lol...

EMT-I's have been safely giving IV fluids for decades.

 

[ResTech]

Unfortunately, Pennsylvania just took a step backwards and is apparently preparing an "Advance EMT" level

I'm still undecided if this is to be considered a step backwards. Advanced EMT is a cert level included in the National EMS Scope of Practice. Can't be worse than the majority of ambulances rolling out BLS only in South Central, PA. Least with Advanced EMT, some increased level of care will be onboard.

It's yet to be seen how EMS systems in PA will incorporate them. If Paramedic units still respond along with them I see it as a good thing.

 

[Flight-LP]

Disagree. It does not take two semesters to learn which patients need fluid and how much and why. You can easily learn the positives and negatives of fluid administration in less than two semesters... especially when you also are required to take A&P. Were not studying to be surgeons... just Paramedics! Chastise me all you want for that comment.... but pre-hospital fluid resuscitation is not that complicated!

In the middle of a trauma.... Daedalus yell's to his partner... "I think were giving too much fluid... quick, what's the hematocrit???" non-degreed Paramedic partner replies.. "boy, wtf you talk'n about"... Daedalus then goes on... "I think we have some ionic dissociation occurring and plasma proteins are expanding".... stat, hand me the ottoscope"... lol...

EMT-I's have been safely giving IV fluids for decades.

A couple of points:

A. A&P is not required for the majority of Intermediate students.
B. Its We're, not were. Not going to chastise you, but will point out your inappropriate grammar useage since we are on the education subject.
C. ........just Paramedics. How can you honestly write those words yet blow smoke about supporting advancing the education needed to be a proficient provider?
D. Maybe the degree does matter. I possess a degree and would not respond "wtf", I'd run a 'crit on the IStat. Sorry for the sarcasm, but you really "wow" me sometimes in your inconsistent stand on the topic.

So bring the evidence. Show us the statistics of safety in fluid administration from EMT-Intermediates. My suspicion is that you will not be able to produce the statistics just as I would not be able to present the statistics covering the number of patients who experienced a negative outcome from the hands of the same population. Am I incorrect?

 

[VentMedic]

... just Paramedics!

As long as this attitude exists amongst those who are EMS providers, at any level, and the education/training for the Paramedic remains at just a few hundred hours, EMS may never know what what it can accomplish.

 

[ResTech]

Its We're, not were.

This would be considered a typo not a grammatical error.

.... just Paramedics. How can you honestly write those words yet blow smoke about supporting advancing the education

"just Paramedics" was not intended in anyway to minimize their role... I intentionally antagonize sometimes because a few seem to micro-advocate and think "out here" is the same as being in a hospital... and its not. As I have commented before, I do believe it is possible to do too much in the field and over think patients. If people want to do a full 360 from start to finish with their patients care, than EMS is prob not for them. Become something that allows you to work in a hospital.

I'd run a 'crit on the IStat

This is the micro-advocating I mentioned above.. using an IStat in the field is the exception, not the rule. Do we even have time to consider using an IStat in the 15-20mins we have a patient?

I don't have statistics on EMT-I's and fluid administration just anecdotal observation and reading.

 

[VentMedic]

I don't have statistics on EMT-I's and fluid administration just anecdotal observation and reading.

Were these observations made as an EMT-B and before you started Paramedic school?

Once you finish Paramedic school and hopefully continue your education with college level classes, your observations will probably be very different.

 

[daedalus]

Actually restech, I was speaking about developing a fund of knowledge on the structure and function of blood, not getting field hematocrits. Knowledge of the concept of hematocrit is needed because you are changing it with fluid administration. Initially after acute hemorrhage, hematocrit is normal, however as time passes and the body engages in "auto-resuscitation", it refills the vascular space with fluid, which produces a drop in the hematocrit. Same thing will happen if saline is infused into the blood after hemorrhage.

I will never agree with letting people alter homeostasis with drugs and procedures unless they have a good foundational knowledge of physiologic concepts that allow them to base their decisions on science.

** also bet you didnt know that your fluid administration practices can adversely affect the patient down the road as they fight for their life in the ICU. When I become a medical director, people with sarcasm towards serious issues in trauma resuscitation like yours will not be tolerated in my system.

 

[ResTech]

D... I was just messing with ya... its all good.. I do like to push buttons now and then

 

[daedalus]

I knew you couldn't possible be serious with the otoscope comment, but I did find it slightly humorous to imagine myself yelling at my partner for an otoscope in an emergency.

By the way, as a teaching point for all, supra-normal fluid bolus in trauma patients is associated with an increased incidence of abdominal compartment syndrome, increased amounts of returns to the OR, and increased incidence of death. This is not as simple as running some saline to correct the blood pressure. When my family is in trouble, I want the prehospital provider to know about this before they blindly start an IV because they got the skill from a 10 hour cert class. As for further reading on this, Acute Care Surgery by Britt and Trunkey is my reference, however you can also listen to Dr. Guy's podcasts as he likes to hit this point home.

 

[ResTech]

This is not as simple as running some saline to correct the blood pressure.

The same can also be said about oxygen use. I have had preceptors tell me with almost conviction like tone that all MI or ACS patients get 15lpm of O2 no questions. Unless a patient has hypoxemia, why are we wasting oxygen? Oxygen has no clot busting capability. I got my ACLS manual in the mail today and was flipping through it and happened to read the part where they recommend ACS patients only getting 4lpm unless other factors present like hypoxemia, cardiogenic shock, etc.

And they recommended no oxygen to little oxygen for CVA patients... unless signs of hypoxia. The high-flow O2 thing is a pet peeve I have. If its needed give it... don't give it just because

Good point though D.

 

[MrBrown]

The same can also be said about oxygen use. I have had preceptors tell me with almost conviction like tone that all MI or ACS patients get 15lpm of O2 no questions. Unless a patient has hypoxemia, why are we wasting oxygen? Oxygen has no clot busting capability. I got my ACLS manual in the mail today and was flipping through it and happened to read the part where they recommend ACS patients only getting 4lpm unless other factors present like hypoxemia, cardiogenic shock, etc.

And they recommended no oxygen to little oxygen for CVA patients... unless signs of hypoxia. The high-flow O2 thing is a pet peeve I have. If its needed give it... don't give it just because

Good point though D.

When I first read our procedures around oxygen i thought they where whacky as; but oxygen in high concentrations causes blood vessels to constrict and this reduces blood supply to organs, particularly organs that already have a reduced blood supply.

There is nothing ‘magic’ about oxygen and in general we give oxygen to many patients that do not need it, usually using flows in excess of what is required

 

[FireResuce48]

When I first read our procedures around oxygen i thought they where whacky as; but oxygen in high concentrations causes blood vessels to constrict and this reduces blood supply to organs, particularly organs that already have a reduced blood supply.

There is nothing ‘magic’ about oxygen and in general we give oxygen to many patients that do not need it, usually using flows in excess of what is required

Do you have any links about the negative effects of high flow o2. I would like to read that.

My area doesn't overuse o2 that much but unfortunately thats because we have a whole lot of lazy providers.

 

[daedalus]

Do you have any links about the negative effects of high flow o2. I would like to read that.

My area doesn't overuse o2 that much but unfortunately thats because we have a whole lot of lazy providers.

I am no expert on oxygen therapy (we do have a resident expert who I hope will chime in), however the science of o2 therapy is not exact and in fact we still do not know what the best practices are for some situations (oxygen can be harmful)

I think it is safe to say that oxygen therapy should be guided by the clinical condition of your patient and pulse oximetry. A patient with chest pain with no dyspnea and a normal spO2 probably does not need 15 liters.