History of IV therapy in EMS

[Bieber]

Wendy, thanks for the reply. A couple of things:

I agree with you that not every patient needs IV therapy, my question about withholding it or delaying it when it is known (or suspected with good reason) that the patient will need IV access at the hospital (even if we ourselves will not give fluid or medications) was where the reasoning in that lied.

I agree that we shouldn't start a reason simply because we can, and that there should be a reason behind establishing IV access. I'm confused, however, by what you mean when you say we shouldn't start an IV when we think we should? I'm sure you didn't mean that in the way it came out.

Im sure you didn't mean your list of EMS indications to be exhaustive, so I'll move on to the next and final point you made, and that is that the IV could "wait" if we don't plan on pushing any medications. Do you mean to imply that even when it is known that the patient will receive an IV at the hospital, we should not establish IV access unless we specifically plan to give fluids or medications during our portion of patient care? Can you explain the rationale behind that?

[Eydawn]

I meant "Oh look, I've got IV stuff and time, I guess I should start an IV because (we can bill for it) (they might need it later) (the ER nurse will yell at me if I don't)" for the "just because we think we should."

I do mean to state that even if you know the patient will need IV access, if you won't be using it, there is no reason for you to initiate it unless you have the time and you know the hospital system likes your IVs. How do you know this patient will *need* IV access? Are you sure? Are you positive they will be admitted, and need IV therapy instead of orals for medications? Can you justify your field start, as opposed to an in hospital, more controlled environment?

I'm going to tell you, I trust our EMS system's IVs, but I pull IV's every day as part of my current gig, and the ones that have the most complications (bent catheters, shear, infiltration) have been almost without exception field starts. That may be just my area, but I doubt it.

So, if you will not be the person pulling the lab draw, or initiating fluid or medication therapy, I am saying yes, you should possibly hold off depending on the overall status of the patient and the way you interface with your hospital systems. If they expect you to draw lab samples in the field, or expect to have that patient ready for draws/meds, then yes, you should start it. If that's not the expectation, why are you starting it?

Wendy

CO EMT-B

RN-ADN Student

[thrutheashes]

Post deleted due to reconsideration of request to lock

Edited July 30, 2012 by thrutheashes

[Bieber]

I do mean to state that even if you know the patient will need IV access, if you won't be using it, there is no reason for you to initiate it unless you have the time and you know the hospital system likes your IVs.

The anticipated need for IV access isn't enough? If the patient will get an IV anyway, and we can reasonably be sure of this, we should defer establishing that IV access for... what purpose, exactly?

How do you know this patient will *need* IV access? Are you sure? Are you positive they will be admitted, and need IV therapy instead of orals for medications? Can you justify your field start, as opposed to an in hospital, more controlled environment?

Controlled in what way? What parts of the hospital are more controlled than the back of an ambulance? The lighting? The temperature? The mood?

I'm going to tell you, I trust our EMS system's IVs, but I pull IV's every day as part of my current gig, and the ones that have the most complications (bent catheters, shear, infiltration) have been almost without exception field starts. That may be just my area, but I doubt it.

Well, if we're going to accept that IV's are not being magically bent by IV gremlins who simply don't exist in the hospital, there must be a reason why field IV's are presenting "messier" than in hospital IV's. What reason do you think is the source of those IV shortcomings? Is it training? Is it that folks aren't taking enough time when they start their IV's? Are they being encouraged to get IV's em route or being discouraged from taking their time getting them? Are they being discouraged from starting IV's in the field and are not getting enough experience doing them?

So, if you will not be the person pulling the lab draw, or initiating fluid or medication therapy, I am saying yes, you should possibly hold off depending on the overall status of the patient and the way you interface with your hospital systems. If they expect you to draw lab samples in the field, or expect to have that patient ready for draws/meds, then yes, you should start it. If that's not the expectation, why are you starting it?

Isn't it part of the job of EMS to adequately prepare patients for hospital care? We take 12-leads even though we cannot perform field angioplasty, for example.

[Eydawn]

Mods, I respectfully beg that the thread be allowed to continue, as thrutheashes has their answer and there is a good nugget to pursue here that I do not feel needs its own thread...

Wendy

CO EMT-B

RN-ADN Student

A 12 lead provides pertinent diagnostic information in a time-sensitive condition. IV access does no such thing. You can't kill someone by screwing up a 12 lead... and time is tissue. If your patient is critical enough, you will be starting that IV. In those non-critical, more stable patients, I don't see a need to hurry up and wait on an IV... especially since they must be dc'd within 48-96 hours (depending on your system). The earlier you start it before it needs to be used, the earlier it gets pulled and the patient gets stuck again for a different access site.

I respectfully offer that a hospital room, with the resources at hand and good lighting, on a non-moving bed and with extra hands/eyes to assist with the IV start is a more controlled environment than the back of the most progressive ambulance... especially if said ambulance is moving.

What is making the field starts messier? I don't know. I'm not there. But I have a pretty good guess... I'm guessing that to minimize scene/transport times, most interventions are being performed in a moving vehicle. EMS still emphasizes "load and go" over "stay and play" regardless of the type of patient... leading to lots of things being done in a moving vehicle.

No, the anticipated need for IV access isn't enough UNLESS that is the expected standard for your particular area and it really does improve the patient's care as soon as they come into the hospital... in many areas, there's no reason to start an IV in the field. Scotty's post shows that they've moved to that model, and I very strongly agree with it.

Wendy

CO EMT-B

RN-ADN Student

[thrutheashes]

Seeing as we are talking about when/where to start IV's, I came accross this study in my research that I found interesting......http://www.ncbi.nlm.nih.gov/pubmed/21367376

[Eydawn]

That's different when you're talking about a rural trauma patient. As they didn't show a mean transport time, and only on scene time, we can only begin to guess how long they had in the ambulance en route to the hospital. When you're driving for 45 minutes, and not in stop and go city traffic, it's a different environment...

Also, I wonder how they classified trauma patients? Anyone with any sort of traumatic injury? Trauma alerts?

Not enough meat there to satisfy this gal...

Wendy

CO EMT-B

RN-ADN Student

[Bieber]

A 12 lead provides pertinent diagnostic information in a time-sensitive condition. IV access does no such thing. You can't kill someone by screwing up a 12 lead...

Oh, I'd beg to differ, but that's a whole other thread entirely.

In those non-critical, more stable patients, I don't see a need to hurry up and wait on an IV... especially since they must be dc'd within 48-96 hours (depending on your system). The earlier you start it before it needs to be used, the earlier it gets pulled and the patient gets stuck again for a different access site.

I'd first argue that the amount of time we spend with a patient as well as the amount of time they may be waiting on an IV will prove to be non-significant when it comes to the timeframe on changing IV's. Also, if the patient is stable, why NOT wait to get the IV? If the patient is going to get an IV eventually, does it matter that EMS gets it and not the ER?

I respectfully offer that a hospital room, with the resources at hand and good lighting, on a non-moving bed and with extra hands/eyes to assist with the IV start is a more controlled environment than the back of the most progressive ambulance... especially if said ambulance is moving.

To be honest, lighting has never been an issue in getting an IV for me. The back of the truck has terrific lighting. Also, having additional hands to start an IV makes the hospital more resourceful, not controlled. Finally, if there is a lack of control due to the ambulance being in motion, that's a problem easily mitigated with the gear shift.

What is making the field starts messier? I don't know. I'm not there. But I have a pretty good guess... I'm guessing that to minimize scene/transport times, most interventions are being performed in a moving vehicle. EMS still emphasizes "load and go" over "stay and play" regardless of the type of patient... leading to lots of things being done in a moving vehicle.

In that case, we should be advocating for EMS to perform their interventions before transport, since that is the real problem--not that they're starting IV's. What would that do to complication rates? Would it put them on par with the hospital? We don't know.

No, the anticipated need for IV access isn't enough UNLESS that is the expected standard for your particular area and it really does improve the patient's care as soon as they come into the hospital... in many areas, there's no reason to start an IV in the field. Scotty's post shows that they've moved to that model, and I very strongly agree with it.

Is it preferable to delay IV access until it is truly needed and possibly impossible by the (i.e. if the patient deteriorates, etc)? Is emergency IO access better than early IV access? Will restricting IV access drop its use to the point that paramedics are no longer able to competently perform the skill reliably, such as ET intubation? And are the benefits of maintaining that skill an performing it early worth the risks of complications? What about nursing workload? Is there a benefit to paramedics starting IV's over nurses so that they have less to do? Is there any particular reason why an IV that will be needed is better off being started later on by a nurse rather than early on by a paramedic?

Good discussion...

Also, sorry for a the spelling errors. I'm posting this all from my phone at work.

[KyleKIR]

Kinda off-topic but on the topic of inserting an IV when not neccessary. I played patient about a month ago when I went to the ER via ambulance for intense stomach pain. (I'm better now). Id say my pain was 10/10. When we got in the ambulance there was a Paramedic Intern along with 2 other medics. They literally sat there for about 5 minutes with the ambulance off while this intern was putting an IV in my arm and then taking my B/P. He got the IV in after the 2nd try. I tried to tell them how much pain I was in and wanted to get to the hospital but they didn't seem to care? I mean I couldn't even walk to the ambulance. Anyways, I wasn't given pain med or anything. I assume the IV was just to have it in before I get to the ER and so that he could practice. They also questioned him about what he thought could be wrong (appendicitis, etc) which is fine..but yeah I thought the whole sitting there was inappropriate. I was in too much pain at the time to say more or complain.

Edited August 2, 2012 by KyleKIR

[Bieber]

Kyle, it's more than appropriate to take a couple of minutes on scene to provide good patient care. Probably the biggest source of errors that I've seen in EMS--and one which my organization has been really trying to correct--is when crews rush to get to the hospital instead of sitting on scene for a bit to provide good, quality care. We've got to get it out of our heads that our primary goal is to get people to the hospital and get it in there that our primary goal is to provide patient care. Especially when it comes to treating pain (which you said they didn't do, which is unfortunate but I wasn't there so I can't speak for their reasons).

Out of curiosity, what happened when you got to the hospital? Like, did they immediately give you something for pain? How long did you have to wait for pain management? For tests? For a diagnosis? For other treatment?