Our regional guidelines require routine ALS on many of our calls. Routine ALS is defined as IV, 02, monitor. Recently the 02 has been modified to only 02 if patient is short of breath or has a SAT >94%. Now we are looking at the IV part. Do all these patients really need prehospital IVs? And should EMS also consider the fact that some hospitals do not use the EMS IVs unless they absolutely have to?
For years, as a rule I put in an IV in a patient if I thought the hospital was going to do it. I did it for three reasons:
1) I might need it to give the patient fluid or medication
2) The more IVs I did, the better at IVs I became
3) It always made the nurses happy.
I put fewer IVs in patients now than I used to, but the real question remains, Is a prehospital IV always in the best interest of the patient?
When the patient says, “Why are you doing an IV?” And the answer is, “They will do one at the hospital in case you may need it, so we are just getting it done for them.” then that is probably not the best reason to do one. Personally, I think the hospitals probably overdue the IVs as well.
A better rule might be, don’t do an IV unless you plan to use it, or think there is a reasonable possibility that you may have to use it.
If we apply that rule to our prehospital patients, who can be excluded?
Anyone who doesn’t meet this criteria:
Any patient who requires IV fluids
Any patient who requires a medication that can only be given by IV
Any patient who is at moderate risk for dropping their blood pressure, and or requiring IV fluid or a medication that can only be given IV.
Under this criteria, these patient would get an IV:
cardiac chest pain, hypotension, allergic reaction/anaphylaxisis, pulmonary edema, severe asthma, sepsis, severe dehydration
These patients might not:
single seizure, hypertension, swollen legs, flu-like symptoms, mild asthma
Trying to come up with a specific list is difficult and raises the perennial EMS qualifier — “It Depends.”
You can never remove judgement from the guidelines.
With the increase of intranasal meds such as fentanyl and narcan, assuming they work, would we remove fractures, muscle injuries, abdominal pain and opiate ODs from the IV list?
And perhaps you could argue that patients with mild vomiting, instead of getting IV fluid and IV zofran, would do just as well with Zofran ODT and a couple bottles of Gatorade.
And with the backup availability of an EZ-IO, do we need to remove even more IV candidates from the list who we are now doing an IV on in case they get worse and we are unable to get IV access.
I don’t really have the answers. I am curious if any systems out there have well-defined guidelines on who gets a prehospital IV.