14. Expanded Medication Routes, Less IV Emphasis

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.  Expanded Medication Routes, Less IV Emphasis

When I was going through paramedic school (1982), another student told me, if you can’t get an IV, you can’t be a paramedic. If your IV skills are not second nature, you will spend too much time worrying about getting an IV, he said, and not be calm enough to keep the big picture in mind. Plus, he said, if you can’t get the IV, you can’t fully treat the patient or give most of the medications you carry.

I worked hard on my IVs during school, taking many extra shifts on the IV rotation where I accompanied the IV nurse around the hospital and jumping to do every IV I could on my ED rotations. I was already an EMT-Intermediate, but I worked for a small volunteer service and was lucky to get three IVs a month. When I was cut loose as a paramedic (now working for a city 911 ambulance company), I was assigned an EMT-Intermediate as a partner for my first six months as a condition of my medical control. On my calls, I insisted on doing most of the IVs and I put IVs in most of my patients. My reasoning was if the person was going to get an IV in the hospital, I was going to give them an IV in the field. At the time, we also drew four tubes of blood for the hospitals, so bringing in a patient with an IV and labs drawn was a great way to earn nurses’ favors.

Back then, if a patient was in status epilepticus, we had to have an IV to give them Valium. If a patient was in CHF or having an MI, we had to have an IV to give them nitro. If they were in pain, we had to have an IV to give them morphine. Even most heroin ODs got an IV. True, if you had a patient in cardiac arrest, you could give drugs down the tube if you didn’t have an IV, but even then, we did not think that was the most effective way to deliver the drugs. And, of course, trauma patients didn’t just need an IV, they needed two large bore IVs so you could run the fluids wide open.

Things are very different today in 2012. You still need to be good at IV to be an effective paramedic, but there are more drug delievery options, which is better for the paramedic and, most importantly, better for the patient.  Also, the IV has less importance in cardiac arrest and trauma as studies have shown IV meds don’t improve and may worsen outcomes in cardiac arrest and the old practice of pouring fluids into trauma patients was, in fac,t helping kill some of them.

Today with a patient in status epilepticus, we can give Versed not just intramuscularly (IM), but intranasally (IN). Same with patients in pain. IM, or even better IN with Fentanyl. Heroin ODs get Narcan IM or IN as well. We can give patients with chest pain NTG without an IV as long as we use caution. Someone sick and vomiting, we can give Zofran IM, and very soon, we may be able to give it sublingually. With Benadryl we now have a PO option. And for those patients who absolutely need an IV, no more sweating and shaking hands, the eyes of everyone on you as you poke and poke and fail to get an IV on a critical person who continues to deteriorate or who may already be dead, you now have the EZ-IO drill to fall back on.

I want to thank all the thousands of patients who let me put IVs in them over the last twenty years and who helped give me the confidence I have today in my IV skills. I no longer follow the rule that if a patient is going to get an IV in the hospital, they will get one from me in the field. I still do my fair share of IVs – but I now appreciate there may be times when it may be necessary in the ED, but it is not as necessary for us prehospitally to do it. There is also that factor that some hospitals routinely either DC prehospital IVs or put in their own. Some have said it is for infection control reasons, others have said it allows the hospital to add another charge to the bill. I don’t know, but when transporting a patient to a hospital following such a policy, I tend to be more selective about when I establish IV access.

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.Expanded Medication Routes, Less IV Emphasis

 15. Narrower Use of Narcan
16. Increased Standing Orders

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