# Accessing Delicate Veins



## atticrat (Aug 23, 2010)

Any ancient chineese secrets for sticks into delicate veins?

Here are mine, 

Go as High as possible, -forearm instead of hand, ac instead of forearm....

Go as big as possible, vein not cath.

Bevel Down with cath.

Flush very slowly.


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## socalmedic (Aug 23, 2010)

if you can try not to use a tourniquet that little bit extra can save the vein from blowing.


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## medicRob (Aug 23, 2010)

atticrat said:


> Any ancient chineese secrets for sticks into delicate veins?
> 
> Here are mine,
> 
> ...



+1 for Bevel Down.


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## MylesC (Aug 23, 2010)

atticrat said:


> Any ancient chineese secrets for sticks into delicate veins?
> 
> Here are mine,
> 
> ...


Heat packs if you got them. Of course they usually take forever to heat up... but why bevel down? Shouldnt it be up?


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## LucidResq (Aug 24, 2010)

I've heard of bevel down for peds but was not given a reason.


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## MylesC (Aug 24, 2010)

I hit send by mistake. I was always taught bevel up in my CPT class. is there a hidden trick of the trade that im missing? (oh do tell)

Maybe the bevel down makes sure you dont go right through a weak vein?


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## socalmedic (Aug 24, 2010)

i do bevel down on any 22 or 24, the thought behind that is the length of the bevel is the same as the diameter of the catheter. it is hard for me to explain but with the bevel down you can advance further in with out going through the vein. also if you hit the bottom of the vein with bevel down it will do less damage and hopefully just slide along the inside of the vein instead of piercing it.


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## MylesC (Aug 24, 2010)

Right on that makes perfect sence... thanks SOCAL ill try that on the next PT that comes through needing a draw B)


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## atticrat (Aug 24, 2010)

MylesC said:


> Heat packs if you got them. Of course they usually take forever to heat up... but why bevel down? Shouldnt it be up?



Yes on typical pt's it is always bevel up. But with elderly, peds, tiny, and easy to blow veins I've had succees with the bevel down. Pretty much what socal said, it decreases the chance of advancing the cath through the other side of the vein blowing it out.

It's not a text book method as far as I know. I was shown the technique by a phenominal old school medic, and it's been in my tool bag since.


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## mgr22 (Aug 24, 2010)

socalmedic said:


> i do bevel down on any 22 or 24, the thought behind that is the length of the bevel is the same as the diameter of the catheter. it is hard for me to explain but with the bevel down you can advance further in with out going through the vein. also if you hit the bottom of the vein with bevel down it will do less damage and hopefully just slide along the inside of the vein instead of piercing it.



The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.


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## atticrat (Aug 24, 2010)

mgr22 said:


> The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.



You adjust the angle of approach a bit so you penetrate with the bevel, think steeper angle. Then as soon as you are in drop the angle to advance.

Easier to show someone than type out instructions.

I've used it multiple times and it does work.


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## medicRob (Aug 24, 2010)

mgr22 said:


> The OP asked about delicate veins, not small veins. I haven't tried it, but I'm wondering if bevel-down might be more likely to tear, rather than pierce a delicate vein.



An online friend of mine, Kelly Grayson, Critical Care Paramedic and column writer for ems1.com wrote an interesting article on using the bevel-down technique.  He explains the way the angles can change with bevel down and what that means for us with regard to IV therapy. 

http://www.ems1.com/ems-training/articles/804343-The-bevel-down-technique/


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## mgr22 (Aug 24, 2010)

Atticrat, that actually does make sense. Thanks.

MedicRob, thanks for the article. I'll try it.


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## medicRob (Aug 24, 2010)

Also, check out his article on the estimation of CVP based on assessment of jugular venous distention. Most medical textbooks show the angle of Louis to be 5 cmH20, However he is starting above the clavicles at 10 cmH20 (A bit on the high side of normal). This article particularly reminded me of the way to locate the angle of louis using 2 Q tips. 

Anyways, here it is:

http://www.ems1.com/ems-products/me...ty-Fair-Evaluating-jugular-venous-distension/


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## alphatrauma (Aug 24, 2010)

For those of you who are advocating and/or practicing this bevel down technique, I would give you this as food for thought:

You are using an invasive device in a way that it was not designed to be used. There are SCIENTIFIC clinical studies, published in medical journals, which show that bevel up is SUPERIOR to bevel down. If there are devices designed and approved by the manufacturer for both techniques, that is an entirely different situation. 

If there is an adverse outcome as a result of an IV start, what will you tell your Chief.... or worse yet, the jury? You decided to go bevel down? Based on what clinical education or instruction? You read about it on EMT Life?


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## medicRob (Aug 24, 2010)

alphatrauma said:


> For those of you who are advocating and/or practicing this bevel down technique, I would give you this as food for thought:
> 
> You are using an invasive device in a way that it was not designed to be used. There are SCIENTIFIC clinical studies, published in medical journals, which show that bevel up is SUPERIOR to bevel down. If there are devices designed and approved by the manufacturer for both techniques, that is an entirely different situation.
> 
> If there is an adverse outcome as a result of an IV start, what will you tell your Chief.... or worse yet, the jury? You decided to go bevel down? Based on what clinical education or instruction? You read about it on EMT Life?



Tell ya what. I will message Kelly, the writer of the article and ask him if he would like to come here and weigh in on the advantages and disadvantages of using bevel down. 

Also, I am quite sure that wrappers weren't meant to be used as occlusive dressings either, but they work great. This is one of those old school tricks and tons of nurses
and Paramedics know this. As far as I know, the Pediatric IV Insertion bevel up vs down study by Black, et al was the only study of bevel up vs down and one shouldn't
dismiss something over 1 study. If I am not mistaken it was 33% bevel up success vs 30% bevel down. I would like to hear what Veneficus' opinion is on this matter.


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## rhan101277 (Aug 24, 2010)

socalmedic said:


> if you can try not to use a tourniquet that little bit extra can save the vein from blowing.



I do this for old folks.


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## alphatrauma (Aug 24, 2010)

medicRob said:


> Tell ya what. I will message Kelly, the writer of the article and ask him if he would like to come here and weigh in on the advantages and disadvantages of using bevel down.



I read Kelly's blog, and have nothing but the utmost respect for his experience in the profession... but it stops there, when it comes to off label use of invasive devices. 



medicRob said:


> Also, I am quite sure that wrappers weren't meant to be used as occlusive dressings either, but they work great.



Not even close to being in the same realm or comparable to intravenous therapy. 



medicRob said:


> As far as I know, the Pediatric IV Insertion bevel up vs down study by Black, et al was the only study of bevel up vs down and one shouldn't
> dismiss something over 1 study. If I am not mistaken it was 33% bevel up success vs 30% bevel down. I would like to hear what Veneficus' opinion is on this matter.



I would argue, if bevel down is so effective (which it currently isn't), why are we not learning it in nursing school, paramedic school, etc... 

Here is the same study - 75% vs 60% and 58% vs 42%, 1st and 2nd attempts respectively. The 33% and 30% you reference were related to infants weighing less than 5kg

Pediatric Emergency Care: Pediatric Intravenous Insertion

Veneficus' opinion would be just that, an opinion... which would not lend any credibility or validity to sanctioning the bevel down technique as accepted formal practice.


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## medicRob (Aug 24, 2010)

alphatrauma said:


> I read Kelly's blog, and have nothing but the utmost respect for his experience in the profession... but it stops there, when it comes to off label use of invasive devices.
> 
> 
> 
> ...



I was taught bevel down in nursing school for pediatrics. It was never covered in Paramedic school, however.. but neither is patellar percussion, tactile vocal fremitus, and other useful skills. Just because it is not commonly taught in EMS or Nursing programs doesn't mean it isn't effective.


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## Shishkabob (Aug 24, 2010)

Taken from the same study you posted, in the conclusion:




> The bevel-down technique might be useful in small infants.






Might / might not.


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## medicRob (Aug 24, 2010)

Linuss said:


> Taken from the same study you posted, in the conclusion:
> Might / might not.



This would be a great prehospital research topic.


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## alphatrauma (Aug 24, 2010)

medicRob said:


> I was taught bevel down in nursing school for pediatrics. It was never covered in Paramedic school, however.. but neither is patellar percussion, tactile vocal fremitus, and other useful skills. Just because it is not commonly taught in EMS or Nursing programs doesn't mean it isn't effective.



I work in a pediatric ER, and bevel down is something I have yet to see or hear of anyone performing. To give a little perspective, it is not an adult hospital with a pediatric ER section. It is a stand alone pediatric hospital with it's own ER, ICU, PICU, NICU, OR, Critical Care Transport... and much more. On a daily basis the place is crawling with pediatric ER attendings, residents, orthopods, intensivists, neonatologists, radiologists and any other pediatric specialty that you could think of. Bevel down IV insertion is not anywhere in our standards of practice. 

Who knows, maybe it's a regional thing? I will make it a point to inquire with my ED medical director to get her views on the matter, and will report back.


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## MasterIntubator (Aug 24, 2010)

In the 80's a few flight medics and thier medical director taught me about the bevel trick, but it was with a cut down ( and we used to do many of those... but have dropped out of favor these days ).... but honestly, in the field it really has not made any difference for me.... although, if in a pickle and I need to try a different approach I would try it again.  I just seemed to have the same success either way.

I prefer to use a BP cuff for all my IV sticks...  I can get the BP, then leave it there for the restricting device.   Lets say the BP was 146/92.   Over 146 mmHg was too restricting, under 92 mmHg was not enough venous back pressure.   Sooooo, depending on what I see and feel... I adjust it accordingly.   If that vein is rock hard at 130 mmHg, I tone down the pressure until that vein is "semi-squishy". 
BP cuffs also work well for shocky folks as well.


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## Smash (Aug 24, 2010)

Double post sorry


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## Smash (Aug 24, 2010)

alphatrauma said:


> If there is an adverse outcome as a result of an IV start, what will you tell your Chief.... or worse yet, the jury? You decided to go bevel down? Based on what clinical education or instruction? You read about it on EMT Life?



I'm fortunate enough to not live in fear of litigation. However, regardless of the efficacy or otherwise if the technique, if you are facing a jury I would suspect that something more significant than holding a cannula upside down has occurred. Maybe some perspective is in order.


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## MylesC (Aug 25, 2010)

Once again this is why they call it "Practicing Medicine"? Somethings there just isnt a for-sure way of doing things. Great information guys I checked out all those articles and they were very cool/enlightening. 
I personally was never shown the bevel down. In fact it was frowned at maybe because [the teachers] wanted to get better basics down?
Anyway. Awesome. This forum just got a thumbs up 

:beerchug:


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## alphatrauma (Aug 25, 2010)

Smash said:


> I'm fortunate enough to not live in fear of litigation.



A laudable testament to say the least. 

One does not have to succumb to fear in order to acknowledge it. Litigation is real, whether we choose to recognize it or not.



Smash said:


> However, regardless of the efficacy or otherwise if the technique, if you are facing a jury I would suspect that something more significant than holding a cannula upside down has occurred.



I would be wary of potentially trivializing the improper use of an angiocath. Most would not consider extravasation, necrosis, phlebitis, thrombosis, or extended hospital stays, that can be attributed to deliberate misuse of said device, insignificant. Yes, all of these can occur with the proper use... but why add additional unnecessary risk to the patient, or your career? If you find yourself having trouble with  IV starts on peds (or any other age group), try enrolling in an approved course or the like. Why start experimenting [on patients] with techniques that you have no formal education or training in?

*Wesley Snipes*
_Performing a daring maneuver in any situation in which a daring maneuver is completely and utterly unnecessary. - _Urban Dictionary



Smash said:


> Maybe some perspective is in order.



Perspective is an illusion... one that can be twisted and distorted to create one's own reality. I'll take facts over perspective most days of the week.


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## Shishkabob (Aug 25, 2010)

alphatrauma said:


> I would be wary of potentially trivializing the improper use of an angiocath. Most would not consider extravasation, necrosis, phlebitis, thrombosis, or extended hospital stays, that can be attributed to deliberate misuse of said device, insignificant. Yes, all of these can occur with the proper use... but why add additional unnecessary risk to the patient



Any evidence that flipping the bevel 180* has any more of a chance of complications than if you kept it normal?


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## 8jimi8 (Aug 25, 2010)

Alpha isn't trying to prove it is wrong.  He has the design of the device as approved by the manufacturers on his side.  I have to admit that at first reading of this thread, I was excited about the fact that I would have a new tool in the box... despite my excitement, I've realized that Alpha's "perspective" is quite correct.


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## mgr22 (Aug 25, 2010)

alphatrauma said:


> I would be wary of potentially trivializing the improper use of an angiocath. Most would not consider extravasation, necrosis, phlebitis, thrombosis, or extended hospital stays, that can be attributed to deliberate misuse of said device, insignificant. Yes, all of these can occur with the proper use... but why add additional unnecessary risk to the patient, or your career? If you find yourself having trouble with  IV starts on peds (or any other age group), try enrolling in an approved course or the like. Why start experimenting [on patients] with techniques that you have no formal education or training in?



I don't think what we're discussing here constitutes misuse of angiocaths. Consider the following quote from the 2002 PALS Provider Manual: "During catheter insertion in patients with trauma, shock, or cardiopulmonary arrest, some providers prefer to aim the bevel of the needle down. Aiming the bevel down may facilitate entrance into constricted veins." I'm not a lawyer, but I would think that this sort of statement from a recognized authority on prehospital care (the AHA) would tend to defuse an argument that a bevel-down IV attempt was negligent.

I think our topic is much more about style than protocol.


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## medicRob (Aug 25, 2010)

mgr22 said:


> I don't think what we're discussing here constitutes misuse of angiocaths. Consider the following quote from the 2002 PALS Provider Manual: "During catheter insertion in patients with trauma, shock, or cardiopulmonary arrest, some providers prefer to aim the bevel of the needle down. Aiming the bevel down may facilitate entrance into constricted veins." I'm not a lawyer, but I would think that this sort of statement from a recognized authority on prehospital care (the AHA) would tend to defuse an argument that a bevel-down IV attempt was negligent.
> 
> I think our topic is much more about style than protocol.



Also, Kelly himself said he learned this technique from an experienced neonatal intensivist in a PALS class in the article I just sent him a message asking if he would like to perhaps come weigh in on the issue. I am interested in hearing his opinion, even if it is in favor of alphantrauma's views. After all, we are all learning new things every day.


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## Ambulance_Driver (Aug 25, 2010)

medicRob said:


> Also, Kelly himself said he learned this technique from an experienced neonatal intensivist in a PALS class in the article I just sent him a message asking if he would like to perhaps come weigh in on the issue. I am interested in hearing his opinion, even if it is in favor of alphantrauma's views. After all, we are all learning new things every day.



I'm on the road now, in a highway rest stop in Texas and running late for my shift, but I'll try to weigh in with my thoughts later this evening. Both sides make some good points.


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## medicRob (Aug 25, 2010)

Ambulance_Driver said:


> I'm on the road now, in a highway rest stop in Texas and running late for my shift, but I'll try to weigh in with my thoughts later this evening. Both sides make some good points.



Looking forward to it, thanks.


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## Ambulance_Driver (Aug 25, 2010)

*Is it really an off-label use?*

Those of you who read my EMS1 columns know that every other month I try to post a clinical tip not commonly found in textbooks or current clinical practice. Sometimes, like in auscultatory percussion or in assessing tactile vocal fremitus, are well-received, while others (*cough* palpating BP using a the pleth waveform *cough, cough*) saw me spanked pretty hard in comments.

I appreciate the discussion nonetheless, even when you point out how I didn't carefully think through some of those tips.

Regarding the bevel-down IV technique, I find it works well with tiny little veins, on peds or geriatric patients. Piercing the skin is no harder, although a little more skin traction is sometimes necessary on elderly patients with slack skin.

I noted in my column that studies do not show an increased success rate with bevel-down insertion. However, the unquantifiable variable in such studies is always the skill level of the providers in the study. Teach someone a new technique, and until they gain mastery of it, they'll feel uncomfortable and have limited success when compared to their old way of doing things. 

Take the Gausche pediatric intubation study in L.A. years back: many of the medics in that study didn't feel comfortable doing pediatric intubation compared to BVM, and it's no wonder they felt that way - peds intubation was a new skill for them.

Still, that doesn't mean learning an additional trick is a waste of effort even if your old tricks have served you well. Tiger Woods totally reworked his golf swing when he was already the best golfer in the world. He saw a way to be better, and he took it, and saw a dip in his game until he mastered the new swing. When he did, he was better than ever.

Regarding the bevel-down technique as being off-label use, consider what other things we have done in EMS that are off-label uses - intranasal midazolam, rectal diazepam (at least until Diastat was introduced), endotracheal drug administration, sublingual Procardia, SQ terbutaline as a tocolytic agent... the list goes on. Heck, last time I checked, the package insert for amiodarone has no mention of IV bolus administration, or a 300 mg dose...

... yet we still use it, do we not?

So much of what we do is purely dogma. There's a simple reason you were taught the bevel-up technique in class: because that's the way your *instructors* learned it.

Doesn't necessarily mean it's the *right* way, though.

Case in point: Why were we all taught never to retract the needle from the catheter and re-insert it? Risk of catheter shear, right?

Have you ever TRIED to shear a catheter that way? It takes a 90 degree bend in the cath, and a very delicate 360 degree rotation of the needle, all while *inside* someone's vein.

In other words, not likely. You may bugger up a cath, but it is highly unlikely that you will ever shear off a piece. That particular admonition is a holdover from the days of through-the needle catheters. Doesn't apply to modern equipment.

Ultimately, I think the bevel-down technique is one of those tricks you keep in your bag and use infrequently, but still effective once you've gotten the hang of it.

Kind of like traction splints - rarely needed, but mighty handy when they are.


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## MylesC (Aug 25, 2010)

Just to throw it out there... I had a long discussion with my mom whos been a nurse for the last 30 years.
She was perplexed by the bevel down method.
I heard from , maybe medic rob that this was an "old school medic" technique?
I showed her that article with the guy talking praise about it (EMT bevel down something something had the 2 pencil drawings with the cath and the vein)
And what region are you guys in as well.
Im here in Cali.

I just want to say again I find this awesome. Im not bagging at all.
Thanks guys


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## medicRob (Aug 25, 2010)

MylesC said:


> Just to throw it out there... I had a long discussion with my mom whos been a nurse for the last 30 years.
> She was perplexed by the bevel down method.
> I heard from , maybe medic rob that this was an "old school medic" technique?
> I showed her that article with the guy talking praise about it (EMT bevel down something something had the 2 pencil drawings with the cath and the vein)
> ...



Myles, the reason I called it an "Old school medic" trick is because it seems to be one of those tips you get from seasoned veterans rather than being presented with in a textbook, a trick of the trade if you will. I probably chose the wrong wording in that, I certainly didn't mean that all the old school medics endorse it or that it is something that was taught in a textbook then but not now. What did your mom have to say about it after she read the article? Did she see how it could be beneficial or did she think it wasn't worth the effort? I am very interested to know, especially since she has been a nurse for 30 years. 


As far as the article you speak of, Ambulance_Driver is Kelly Grayson, the writer of that article.


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## abckidsmom (Aug 26, 2010)

Having been an EMS educator, I can agree that the main reason the bevel up technique is taught in class is because that's the way the instructor learned it.

Very interesting discussion, plenty of things to research here.

And I'll throw in another vote for this not being an off-label use.


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## socalmedic (Aug 26, 2010)

last i checked there was no "directions for use" for the catheter. i checked the box, the wrapper, the safety cath itself, hell i even read the whole pamphlet that comes in the box printed in 20 different languages. Nowhere did it say there was a specific way to use it and that is the only approved way. I spoke with a few more medics and they all said that they have tried it before, some had no idea about the bevel and had apparently never thought about the orientation, they just knew that the "button on the thingy" goes up. so i am sticking with my bevel down technique, if it comes up in a court of law "I cant recall how i performed the intravenous canalization" remember they have to responsibility of incriminating you. further more i have to agree with whoever said if you are in court defending yourself you probably have bigger things to worry about than which way the bevel was facing.


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## MrBrown (Aug 26, 2010)

harden up and stick a 14 in his cube


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## Melclin (Aug 26, 2010)

socalmedic said:


> last i checked there was no "directions for use" for the catheter. i checked the box, the wrapper, the safety cath itself, hell i even read the whole pamphlet that comes in the box printed in 20 different languages. Nowhere did it say there was a specific way to use it and that is the only approved way. I spoke with a few more medics and they all said that they have tried it before, some had no idea about the bevel and had apparently never thought about the orientation, they just knew that the "button on the thingy" goes up. so i am sticking with my bevel down technique, if it comes up in a court of law "I cant recall how i performed the intravenous canalization" remember they have to responsibility of incriminating you. further more i have to agree with whoever said if you are in court defending yourself you probably have bigger things to worry about than which way the bevel was facing.



None of the guns I've owned have ever come with instructions either. Doesn't mean there isn't a right and a wrong way of using them. And legal/ethical implications for their incorrect use. 

Not commenting on the bevel down technique. Just questioning the "it didn't say so on the label" logic.


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## 8jimi8 (Aug 26, 2010)

socalmedic said:


> last i checked there was no "directions for use" for the catheter. i checked the box, the wrapper, the safety cath itself, hell i even read the whole pamphlet that comes in the box printed in 20 different languages. Nowhere did it say there was a specific way to use it and that is the only approved way. I spoke with a few more medics and they all said that they have tried it before, some had no idea about the bevel and had apparently never thought about the orientation, they just knew that the "button on the thingy" goes up. so i am sticking with my bevel down technique, if it comes up in a court of law "I cant recall how i performed the intravenous canalization" remember they have to responsibility of incriminating you. further more i have to agree with whoever said if you are in court defending yourself you probably have bigger things to worry about than which way the bevel was facing.



Dude, i hope your instructors don't read this site.  You need to think about some ethics before you pass your NREMT.  

so you say you'll just lie?  Get out of this profession, please.


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## Sasha (Aug 26, 2010)

8jimi8 said:


> Dude, i hope your instructors don't read this site.  You need to think about some ethics before you pass your NREMT.
> 
> so you say you'll just lie?  Get out of this profession, please.



Plus one. If you caused harm to a patient, man up and take responsiblity. Don't lie to cover your own butt. If you'll be dishonest to save your skin, then you really have no business being in EMS, or health care for that matter. Or really any profession that deals directly with people.


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## medicRob (Aug 26, 2010)

Melclin said:


> None of the guns I've owned have ever come with instructions either. Doesn't mean there isn't a right and a wrong way of using them. And legal/ethical implications for their incorrect use.
> 
> Not commenting on the bevel down technique. Just questioning the "it didn't say so on the label" logic.



Every thing comes back to bite you in the butt eventually. There is a certain karma that exists in EMS & Fire that doesn't seem to exist in other professions. If you lie, the universe will in some how and in some way ensure that something comes up that brings that lie out. I have seen it all too many times. Usually, it is just little inconsequential things, but if it involves patient care that is far from inconsequential. You have a responsibility to your patients to treat them to the best of your ability and to maintain the honesty and integrity of your profession. Get with it.


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## Melclin (Aug 26, 2010)

medicRob said:


> Every thing comes back to bite you in the butt eventually. There is a certain karma that exists in EMS & Fire that doesn't seem to exist in other professions. If you lie, the universe will in some how and in some way ensure that something comes up that brings that lie out. I have seen it all too many times. Usually, it is just little inconsequential things, but if it involves patient care that is far from inconsequential. You have a responsibility to your patients to treat them to the best of your ability and to maintain the honesty and integrity of your profession. Get with it.



Ahhh...I agree, but not sure what that has to do with my post. 

Click on the wrong reply link?


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## 8jimi8 (Aug 26, 2010)

Either that, or he agreed with your point.


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## socalmedic (Aug 26, 2010)

wow this thread is in left field now. maby we can move the last 4 pages to the med/legal section. to jim i never meant to imply lieing or dishonesty. to the OP i guess we have decided that you will just have to go without an iv as it is unethical to think outside the box. i guess its a good thing we have IO now because god forbid you use the IV needle upside down to get a vein. i guess the easy thing to do would be to ask my Med director for permission.


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## MediMike (Aug 26, 2010)

Easy solution! Lets someone contact the manufacturers of said angiocaths and ask if there is some detrimental effect produced by inserting bevel down!

And to everyone jumping SoCal's case regarding this hypothetical court situation, what harm do you see being done with the bevel down?

Just curious


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## 8jimi8 (Aug 26, 2010)

socalmedic said:


> if it comes up in a court of law "I cant recall how i performed the intravenous canalization" remember they have to responsibility of incriminating you.



Socal, I don't see any way you can interpret this as being honest.  I understand you may be backpedaling now, but the way to do that is to admit you were wrong, not deny what you stated.  I didn't put any words in your mouth.  People are reacting to your intent to be dishonest, we aren't in left field.  PLEASE don't misrepresent yourself as a professional, if you can't even be honest.


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## MasterIntubator (Aug 26, 2010)

MediMike said:


> Easy solution! Lets someone contact the manufacturers of said angiocaths and ask if there is some detrimental effect produced by inserting bevel down!
> 
> And to everyone jumping SoCal's case regarding this hypothetical court situation, what harm do you see being done with the bevel down?
> 
> Just curious



There will be no harm.  You can "what if" any situation long enough.   The catheter folks probably won't endorse chest decompressions either, as it is an off label use and there are better devices.  But heck.... it works.


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## zzyzx (Aug 27, 2010)

"Case in point: Why were we all taught never to retract the needle from the catheter and re-insert it? Risk of catheter shear, right? Have you ever TRIED to shear a catheter that way? It takes a 90 degree bend in the cath, and a very delicate 360 degree rotation of the needle, all while *inside* someone's vein. In other words, not likely. You may bugger up a cath, but it is highly unlikely that you will ever shear off a piece. That particular admonition is a holdover from the days of through-the needle catheters. Doesn't apply to modern equipment."

Are you sure about this? I have also wondered how that could really happen. But perphaps it is possible to break off a small piece? I never re-insert the needle, but I have seen a few nurses using this technique. It would certainly be helpful to use if you could be 100% sure that there is no risk of breaking off any part of the catheter.


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## Ambulance_Driver (Aug 27, 2010)

8jimi8 said:


> Socal, I don't see any way you can interpret this as being honest.  I understand you may be backpedaling now, but the way to do that is to admit you were wrong, not deny what you stated.  I didn't put any words in your mouth.  People are reacting to your intent to be dishonest, we aren't in left field.  PLEASE don't misrepresent yourself as a professional, if you can't even be honest.



Since when are lawsuits about honesty? They're about blame.

It's not unusual at all for a defense attorney to coach his client to state "I don't recall" in response to the questions that can't be proven.

The plaintiff's attorney is going to *let* you tell the *truth.* He's only going to ask/let you answer questions that strengthen his case. Your attorney will do the same.


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## Ambulance_Driver (Aug 27, 2010)

zzyzx said:


> Are you sure about this? I have also wondered how that could really happen. But perhaps it is possible to break off a small piece? I never re-insert the needle, but I have seen a few nurses using this technique. It would certainly be helpful to use if you could be 100% sure that there is no risk of breaking off any part of the catheter.



You may poke the stylet *through* the cath, and thus bugger it up, but it's not going to shave off a piece. Of course, buggering it up makes it more difficult/traumatic to remove the cath when you discontinue the IV, but there is little danger of a catheter shear and resulting embolus. 

In the early days of intravenous therapy, through-the-needle catheters were used, and the earliest of those devices lacked any protective guides to prevent catheter shear - hence the admonition never to withdraw the stylet and then re-insert it. Doing so in those catheters posed a risk of shaving off a piece of the catheter with the sharp bevel of the needle.

Through-the-needle catheters are only used these days for central line insertion, and have built-in safeguards such as breakaway or splittable needles, or catheter guides to limit the potential for catheter shear.

Of course, I can't provide a specific cite, but Judy Hankins book "Infusion Therapy in Clinical Practice" is an excellent source with plenty of historical background on intravenous therapy. It may well be where I first read of this.


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## 8jimi8 (Aug 27, 2010)

Ambulance_Driver said:


> Since when are lawsuits about honesty? They're about blame.
> 
> It's not unusual at all for a defense attorney to coach his client to state "I don't recall" in response to the questions that can't be proven.
> 
> The plaintiff's attorney is going to *let* you tell the *truth.* He's only going to ask/let you answer questions that strengthen his case. Your attorney will do the same.



Courtroom tactics aside.  Honesty is black and white.  Your ok with a student who intends to lie to cover himself as a professional?  This thread has been hijacked enough.  I'm interested in any further discussion, clarification concerning the bevel down.  I thought someone was going to contact the manufacturer?


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## Ambulance_Driver (Aug 27, 2010)

8jimi8 said:


> Courtroom tactics aside.  Honesty is black and white.  Your ok with a student who intends to lie to cover himself as a professional?  This thread has been hijacked enough.  I'm interested in any further discussion, clarification concerning the bevel down.  I thought someone was going to contact the manufacturer?



I wasn't the one who hijacked the thread, but I take your point. I just doubt that any plaintiff's attorney is ever going to ask which way a bevel was oriented in court, and whether it is capable of causing injury. It's akin to asking if your needle was at 90 degrees or 75 during your IM injection.

I'd also be interested in what the manufacturer says, but I'll take bets that you won't get a firm answer, and if you do, it will be some reiteration of their package insert.


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## 8jimi8 (Aug 27, 2010)

Ambulance_Driver said:


> I wasn't the one who hijacked the thread, but I take your point. I just doubt that any plaintiff's attorney is ever going to ask which way a bevel was oriented in court, and whether it is capable of causing injury. It's akin to asking if your needle was at 90 degrees or 75 during your IM injection.
> 
> I'd also be interested in what the manufacturer says, but I'll take bets that you won't get a firm answer, and if you do, it will be some reiteration of their package insert.



agreed!  
Thanks for posting up to weigh in!


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## socalmedic (Aug 27, 2010)

8jimi8 said:


> I thought someone was going to contact the manufacturer?



smiths medical (maker of the jelco ProtectIV) has been contacted. two clinical support representatives (James, and Kathy) have stated that they see no reason why you cant use the device any what you wish, and they they are not certified for a particular technique. to who was asking about thoracic decompression, they again to that "use it any way you feel clinically necessary". they have however refered my question to their "equipment specialist" and he should get back to me within a week as to if their is a design reason as to why to use bevel up.


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## zzyzx (Aug 27, 2010)

SoCal Medic: Thanks for taking the time to do all that!

If you get a chance to talk to the rep, ask him about the possiblity of shearing off part of the catheter if you advance the needle through the catheter after you have drawn it back.


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## MasterIntubator (Aug 27, 2010)

Yeah.. that was me... about the thoracocentesis.   As you found out... there are many 'multi-taskers' in our toolbox.  And the catheter is one of them.  

Back in the day when those IV catheters were made of a more ridid plastic, ( especially the Insytes - catheter within the stylus ), there was more concern.  The teflon stuff and other exotic plastics are super resilient to tearing and shearing.  Take one out and play with it... stretch it... poke it.  I would be quite impressed if it sheared on first or second F-up.

Another lost art trick when re-treading the stylus, was to turn the stylus bevel down so it would glide along with the sheath curveture, instead of piercing it.  Many manufactures would put a mark/logo/indent on the flash chamber so you would know when the bevel was up... just turn it 90 deg ( Terumo had a "T", angiocath had a dot, etc etc etc )


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## Ambulance_Driver (Aug 29, 2010)

MasterIntubator said:


> Many manufactures would put a mark/logo/indent on the flash chamber so you would know when the bevel was up... just turn it 90 deg ( Terumo had a "T", angiocath had a dot, etc etc etc )



Watch a doc inserting a central line, and you'll often see them take great pains when attaching a syringe to their needle, and for the same reasons - so they can look at the syringe markings and know what way the bevel is oriented.


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## Hockey (Aug 29, 2010)

Bevel down works.  Great in some cases.  I was really against it at first, until I tried it on a next to impossible start and it worked


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## socalmedic (Aug 29, 2010)

hahahaahahaha, awesome pics


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## 8jimi8 (Aug 29, 2010)

ok two points!

I had a guy who was a terrible start. The night before i blew an 18 and a 20.  Like as soon as the vein was pierced, the ivs blew.  So having resolved that the manufacturer did not forbid bevel down, thanks for your efforts Socal, I tried the bevel down.  I had terrible luck, it felt really awkward piercing the skin, like it got hung up somehow and the vein blew as soon as i pierced it.  (Hence admonitions about having to be good at it...)  

Next what happened.... I pierced the skin with a 22 on a guy with really "Tight" skin.  He was quite edematous (non-pitting) and the veins were visible, barely palpable, but deceptively  large.  Somehow I missed on the first pass, i didn't feel the pop, i could see visually that i was past my landmark... so I backed the catheter up, when i pulled it back, the needle slid out about 1mm from the catheter, so i secured the catheter hub, and re-advanced the needle, i encountered resistance as I advanced the needle and thinking I had hit a valve, I pulled the whole array.


What did i find?

I found that the catheter had kinked while inside the the patients arm and the freaking needle had pierced the plastic, exactly 1 mm below the tip of the plastic catheter.

To whomever said that shearing off a piece of the catheter was MERELY a danger  from the PAST...

you are WRONG.  I didn't do it on purpose, but lo and behold, something that has never happened to me before, happened, when I had exactly ZERO fear that it ever could with our modern devices.

I will find out the name of the catheters that we use, so that you all can have a more complete picture.  Going to work here in about an hour.  So look out for my repost.

jimi


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## 8jimi8 (Aug 29, 2010)

just wanted to note, the second guy. i went bevel up.  on call. so i'll get that name of the angiocath before long


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## 8jimi8 (Aug 29, 2010)

*BD Insyte Autoguard (non winged)*

http://bricomedicalsupplies.net/brochures/BD%20Insyte%20IV%20Catheter.pdf


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## MasterIntubator (Aug 29, 2010)

8jimi8 said:


> To whomever said that shearing off a piece of the catheter was MERELY a danger  from the PAST...
> 
> you are WRONG.  I didn't do it on purpose, but lo and behold, something that has never happened to me before, happened, when I had exactly ZERO fear that it ever could with our modern devices.




That may have been me... but I still stand by my statement.  Piercing any part of the catheter with the stylus will MOST likely NOT sheer it off.  They are designed to be tough and have stretching/flexing properties.  Piercing the catheter is a risk when re-inserting the stylus at any point in over-the-stylus catheters, whether on purpose or not.
It happens, I have had it happen several times in the past as well, and it has ONLY happened to me when re-inserting it.  Not saying that it can not happen to any of you unexpectedly, but if it did.... somwhere along your venipuncture, the styus was re-thread within the catheter causing that. ( especially if you are not in the habit of holding the stylus and catheter hub together as you fish for that vein, and backing up can separate the two. ) .... technique my friend... technique.

Around my area, they teach to "break" the seal of the catheter and stylus before doing venipuncture ( I suppose so you don't have such a hard time threading it once you get flash ), but that initial hesitation is most likely there so the catheter does not prematurely start leaving the rigid support of the stylus causing a freak accident.  I do not break that seal. I want it there.

Not something to have a bad hair day about.


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## slb862 (Sep 2, 2010)

*Tricks of the trade...*

For hard starts (pediatrics, elderly, etc.) in the field or in the ED, No matter what gauge I use, and if time permits, I go slow and when I get flash, I allow the chamber to fill, the I then advance slowly.  I have had great success with this manuver.  For some reason this works for me.  B)


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## Ambulance_Driver (Sep 20, 2010)

8jimi8 said:


> To whomever said that shearing off a piece of the catheter was MERELY a danger  from the PAST...
> 
> you are WRONG.  I didn't do it on purpose, but lo and behold, something that has never happened to me before, happened, when I had exactly ZERO fear that it ever could with our modern devices.
> jimi



May have been Master Intubator who said that, but could have just as easily been me.

I never said it was impossible to pierce the catheter with modern through-the-needle catheters, I said it was nigh impossible to *shear it off.*

Big difference there.


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## Shishkabob (Sep 20, 2010)

Jimi and I are at a pediatric hospital for a PEPP class today... should ask this question and see their views.


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