# Poor IV access



## cruiseforever (Apr 22, 2011)

I have found myself not trying to start an IV on pt.s that I cannot find a good site to try.  I hate causing the pt. discomfort when I know my chances of getting a line is just about zero.  If push comes to shove and I need to have an access point, I will use the IO.

I will treat the pt. with IM meds instead.  Is there anyone else that feels the same way?


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## Medic2409 (Apr 22, 2011)

Yep.

Course, there will be people who will jump in with disparaging remarks concerning how any medic should be able to get a line on anybody, and if you can't, you're not a good medic.

Bologna, or Baloney, either way you choose to spell the word. 

IMHO, why waste time hunting an IV site when you can get potentially life saving interventions on board IM or IN, and then continue your hunt for an IV?


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## medicRob (Apr 22, 2011)

cruiseforever said:


> I have found myself not trying to start an IV on pt.s that I cannot find a good site to try.  I hate causing the pt. discomfort when I know my chances of getting a line is just about zero.  If push comes to shove and I need to have an access point, I will use the IO.
> 
> I will treat the pt. with IM meds instead.  Is there anyone else that feels the same way?



We have all been through this at some time or another. Diabetics and dehydration patients are the worst! The key is to practice, practice, practice... but also remember.. there are some people that are impossible to stick.


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## Aidey (Apr 22, 2011)

I have elected not to start an IV more than once. It completely depends on the patient and situation. If I've got 95 year old grandma who is running a fever and has one vein you can stick anything bigger than a mosquito into I may not start an IV knowing the hospital is going to want blood cultures. 

1/2 the time the RNs thank me for being considerate, the other 1/2 of the time they roll their eyes and say "whatever".


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## Shishkabob (Apr 22, 2011)

I'm of the view that if I don't NEED an IV to do something, I either don't do one or limit it to just one try.

If they need an IV, they get a few tries.  If they NEED NEED a line, they will get an IO, which is why I won't really let misses bother me as much.



However, I had an EMT I had never worked with before last shift, go to the station captain complaining about my IV skills (over a single missed IV).  Yes, a single IV, one of 2 that I attempted that day, and on a patient that didn't necessarily need it at that moment.


Obviously I did something to piss him off that day for him to moan about a single IV, I just don't know what.


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## fast65 (Apr 22, 2011)

Linuss said:


> *I'm of the view that if I don't NEED an IV to do something, I either don't do one or limit it to just one try.*
> 
> If they need an IV, they get a few tries.  If they NEED NEED a line, they will get an IO, which is why I won't really let misses bother me as much.
> 
> ...



That's where I pretty much stand as well. I mean, I love starting IV's, but I know it's anything but comfortable for the patient and they already called us because they have a problem, why cause them more pain than necessary.

On a side note, you should really work on your IV skills Linuss, I can't believe you missed one.


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## Combat_Medic (Apr 22, 2011)

What you all have trouble getting IVs?  Come join the army.  We teach you to never miss.  :lol: j/k


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## Shishkabob (Apr 22, 2011)

Combat_Medic said:


> What you all have trouble getting IVs?  Come join the army.  We teach you to never miss.  :lol: j/k



Yes, because starting an IV on a healthy 20 year old is the same as starting an IV on a dehydrated 84 year old.


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## fast65 (Apr 22, 2011)

Linuss said:


> Yes, because starting an IV on a healthy 20 year old is the same as starting an IV on a dehydrated 84 year old.



Eh, tomato, tomato...huh, I guess it doesn't work the same when you type it


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## medicsb (Apr 22, 2011)

I'll second the "go IM [or IN] and continue looking" based on the assumption that the patient actually NEEDS an IV for meds or due to a possible deterioration for which meds may be needed.  But, don't forget the feet or the EJ if you really need an IV.   One of the more unusual stories I have heard was of a medic starting an IV in the dorsal vein of the penis of a cardiac arrest patient.


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## Veneficus (Apr 22, 2011)

cephalic and basilic veins.

Not just terms to memorize for anatomy.


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## CAOX3 (Apr 22, 2011)

Im partial to the venous cutdown.

Of course you need to attend the four hour add on

And your given a new patch, EMT-SAPHENOUS


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## mcdonl (Apr 22, 2011)

When doing my hospital time I started to get discouraged... I was only allowed one attempt (Instead of the two our protocol allows) and I missed on my first two patients... but, when it took TWO nurses who were both 30+ year vets to finally get a line I realized that it happens. Even to the best of providers.

I find that most people who end up in the back of an ambulance have a detailed history and knowledge of their "stick" ability....


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## CTBryan11 (Apr 22, 2011)

Linuss i agree that starting lines on a 20 yr. Old healthy pt may be easier than a 84 yr old dehydrated one.. but at the same time combat medics are EXTREMELY good at starting IVS seeing as how there patients can be wounded from gsw or something worse.. and if they have been in battle for 8-9 hours in the heat of the day they will also be dehydrated and depending on the wound..hypovolemic shock with collapsing veins.. and they can hit on them most the time.. if that fails then they will go IO but its rare


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## Shishkabob (Apr 22, 2011)

Because civilian medics never have GSW patients... or GSW patients who've bled out... or GSW patients that are geriatric.


The same injuries that happen in a warzone could NEVER happen at home.  Nope.  Never.


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## bigbaldguy (Apr 22, 2011)

While doing my ride time we transported an IV drug user. Guy had lit himself on fire in his kitchen. 7 people tried starting a line on the guy, two tries on the bus and 7 tries at the ER. They finally called in a life flight nurse/paramedic to start a EJV line. The whole time the guy was telling us where he might have a vein left, which ones wouldn't work Ect.


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## jwk (Apr 22, 2011)

CTBryan11 said:


> Linuss i agree that starting lines on a 20 yr. Old healthy pt may be easier than a 84 yr old dehydrated one.. but at the same time combat medics are EXTREMELY good at starting IVS seeing as how there patients can be wounded from gsw or something worse.. and if they have been in battle for 8-9 hours in the heat of the day they will also be dehydrated and depending on the wound..hypovolemic shock with collapsing veins.. and they can hit on them most the time.. if that fails then they will go IO but its rare



Starting IV's is a technical skill - the only thing that makes you good/better at it is practice.  There are no deep dark secret IV starting techniques that are known only to a select few.


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## MediMike (Apr 22, 2011)

Linuss said:


> Because civilian medics never have GSW patients... or GSW patients who've bled out... or GSW patients that are geriatric.
> 
> 
> The same injuries that happen in a warzone could NEVER happen at home.  Nope.  Never.



You always crack me up Linuss. Agreed with whoever mentioned the feet. Had numerous pt.'s who say they can't be stuck anywhere, been drilled before etc. etc., pull them socks down and take a gander. Man it stinks sometimes though...


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## CTBryan11 (Apr 22, 2011)

Civilian medics never have gsw pts? Or gsw pts that bleed out?? What perfect town do u work out where there is never a shooting?


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## CTBryan11 (Apr 22, 2011)

And yes jwk I know... but they do practice alot.. which is why they are good.. my dad was a combat medic for 10 yrs and my uncle was a parajumper for 8


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## MrBrown (Apr 22, 2011)

It seems you Americans love to put a drip into anything that moves and Brown thinks the notion of a saline lock and extension set are somehow lost in translation ... perhaps its being reflected back out of the ambulance by that long spine board shielding? 

Seriously tho, Brown is quite conservative and will only cannulate somebody who is crook i.e. needs fluids or medication.  That might mean about 10% of patients, its not like crappy abdo or back pains, "can't breaf", Nana who fell over, little Timmy with the flu or sinusitis or a lot of routine other things needs an IV started.

Now, if the hospital want to start one to get bloods or give medication then let them do it, Brown would rather have the hospital start one anyway, its not like your living room holds up to being clinically clean anyway.


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## firetender (Apr 22, 2011)

cruiseforever said:


> I have found myself not trying to start an IV on pt.s that I cannot find a good site to try.



This sounds more to do with your level of confidence than with the condition of the patient. If your patient needs an IV you don't NOT try. You take your best shot or shots depending on the severity of the case. 

Though I never used one, I understand IO is backup and not a primary approach (I could be wrong; correct me please), and that comes AFTER you've tried, not as something used because you suspect you can't. It's something to use because you couldn't.

Back in the days when we didn't use gloves routinely, if you could feel it you could stick it. Have you ever tried palpating without gloves before giving up?


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## usalsfyre (Apr 22, 2011)

MrBrown said:


> its not like your living room holds up to being clinically clean anyway.


So I probably start more lines than I need to just based on expectations of my service, but I would guess the average living room couch harbors less nastiness than the average resuscitation bay stretcher....


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## usalsfyre (Apr 22, 2011)

firetender said:


> Though I never used one, I understand IO is backup and not a primary approach (I could be wrong; correct me please), and that comes AFTER you've tried, not as something used because you suspect you can't. It's something to use because you couldn't.


Depends. If I have a low likelihood of success and need a line RIGHT NOW (periarrest, unstable airway that needs medication to get control of, ect) then I'll jump straight to IO, as I can do it a lot faster than IV access


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## Veneficus (Apr 22, 2011)

jwk said:


> Starting IV's is a technical skill - the only thing that makes you good/better at it is practice.  There are no deep dark secret IV starting techniques that are known only to a select few.



Why do yo have to take away the mystique? 


There is no need to see veins. As Firetender pointed out, and even with gloves on, you can usually feel for them.

The point I was trying to make earlier is that certain veins are always there given an inch or there about of deviation. 

The ones mentioned are very reliable, especially on heavier folk, no need to see them or feel for them, if you know where they are, no reason not to find one.

As for a saphenous. If you are bent on starting one n the lower extremity, what do you need a cutdown for? Just put the needle in.


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## Aidey (Apr 22, 2011)

I can see my veins fairly clearly, on my R arm they are anatomically correct, on the L they are all screwy. The cephalic is so far lateral it is basically posterior, and the basilic crosses the elbow joint perpendicularly. I know the plural of anecdote is not data, but I highly doubt anyone could hit a vein in that area purely based on supposed anatomical position. I'm sure there are other people equally screwy out there. 

When ever I have blood drawn I love presenting that arm to the Phlebotomists and watching them mentally go "oh damn". ^_^


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## medicsb (Apr 22, 2011)

MrBrown said:


> It seems you Americans love to put a drip into anything that moves and Brown thinks the notion of a saline lock and extension set are somehow lost in translation ... perhaps its being reflected back out of the ambulance by that long spine board shielding?
> 
> Seriously tho, Brown is quite conservative and will only cannulate somebody who is crook i.e. needs fluids or medication.  That might mean about 10% of patients, its not like crappy abdo or back pains, "can't breaf", Nana who fell over, little Timmy with the flu or sinusitis or a lot of routine other things needs an IV started.
> 
> Now, if the hospital want to start one to get bloods or give medication then let them do it, Brown would rather have the hospital start one anyway, its not like your living room holds up to being clinically clean anyway.



Heh, I always am amused when I hear some medics stating how some large percentage (usually a multiple of 20) of their patients "require" ALS.  4 times out of 5 they're lining patients for the sake of lining them and calling it ALS.  I'm kind of surprised that medicare hasn't started denying ALS level payments for stuff like that.  

Moving on, I always preferred to palpate with an ungloved finger, so I'd palpate before gloving up.  If I needed to repalpate, then I'd pull a finger off the glove, clean my finger with an alcohol prep and then wipe the spot again.  Worked for me.

I'll admit that I was never really good at blind sticks, mostly because I rarely encountered situations that called for it.  But when I was in training in Philly, there were some medics in the ED that did it all the time and almost always hit a vein.  It was impressive.


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## 18G (Apr 22, 2011)

If I feel my pt. needs an IV I will at least try. I won't give up before I even attempt. Some pt's. have crappy veins and it takes 4,5,6 or more times to get an IV in the ED. When I try 2 or 3 times and the nurses try 3 or 4 times on certain pt's. I don't feel so bad  But it can hurt your confidence at times especially when you have runs of where it seems like you can't stick anything. 

Where I'm at the hospital appreciates a line already placed especially if they are busy. Our protocols don't define a certain number of attempts but our service policy is no more than 3 attempts per provider. 

To the person who said they only got one try as a student.... that is crappy precepting! I had a great RN as a preceptor in the ED who would stand there and watch me, offer tips on technique, and give me feedback until I got it. If I missed the first attempt, she handed me a second catheter. Her philosophy was the only way your gonna learn is to do it and I am thankful to have had her as a preceptor.

At least the germs in someones living room are their own and the patient has already been exposed to them for years and years. Germs from a hospital are a whole 'nother game.


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## Akulahawk (Apr 22, 2011)

I'm with 18G... I had a great preceptor. Similar mentality. As it turned out, I was unable to cannulate only one patient during my ED time... and nobody else there could get a line in him either. His veins were very fragile. Poke 'em with a needle and they'd just go "pop" like the proverbial balloon... He got stuck many times... Unfortunately, I never did find out what they finally did to get a line in him as he came in right at shift change and care was turned over to the next shift.

I did learn a lot though!


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## Gecko24 (Apr 22, 2011)

EJ.Femoral, or IO.  Yes you can do those on adults, even if they are awake.


Or for those male pts. that tell you that there is no way your can get a IV in them.  Bet them 20 bucks they got one vein you can usually get, but they may not like it much.

Come on, did you really have to think about what vein I was talking about?


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## 18G (Apr 23, 2011)

Akulahawk said:


> Unfortunately, I never did find out what they finally did to get a line in him as he came in right at shift change and care was turned over to the next shift.



I had a patient like this. Nobody could obtain IV access so they put in a central line for the 3-day hospital admission.


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## Akulahawk (Apr 23, 2011)

18G said:


> I had a patient like this. Nobody could obtain IV access so they put in a central line for the 3-day hospital admission.


I heard they were thinking of doing the same thing to my patient... but shift change happened before the doc had actually ordered anything done.


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## cruiseforever (Apr 23, 2011)

firetender said:


> This sounds more to do with your level of confidence than with the condition of the patient. If your patient needs an IV you don't NOT try. You take your best shot or shots depending on the severity of the case.
> 
> Though I never used one, I understand IO is backup and not a primary approach (I could be wrong; correct me please), and that comes AFTER you've tried, not as something used because you suspect you can't. It's something to use because you couldn't.
> 
> Back in the days when we didn't use gloves routinely, if you could feel it you could stick it. Have you ever tried palpating without gloves before giving up?



I am very confident in my ability to start IVs.  The longer I do this the more I question why I do something.  Our standing orders guide us to start IVs on pts. with certain conditions.  If the pt. is stable and has no viens that I cannot see or feel.  I will not try to start one.  I will always look.  If they are sick I will be more aggressive.  Up to an IO.  You should check them out. 

I was just wondering how aggressive other people were to get a line.  When I was new medic it was get that IV, get that tube, do this,do that.  I now look to see if it's a pt. thing or an ego thing.


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## jwk (Apr 23, 2011)

medicsb said:


> One of the more unusual stories I have heard was of a medic starting an IV in the dorsal vein of the penis of a cardiac arrest patient.



I have heard this for years, but honestly wonder if it's more of an urban myth kind of thing.  I've never seen it in 35+ years of in the medical profession, but have always heard stories that one of my classmate's best friend's 2nd cousin's son-in-law actually started an IV there.  Has anyone ACTUALLY seen this?


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## medicRob (Apr 23, 2011)

jwk said:


> I have heard this for years, but honestly wonder if it's more of an urban myth kind of thing.  I've never seen it in 35+ years of in the medical profession, but have always heard stories that one of my classmate's best friend's 2nd cousin's son-in-law actually started an IV there.  Has anyone ACTUALLY seen this?



Here is one that will make you cringe. Back when I worked a paramedic ambulance, there was a frequent flyer, not because he always called us, but because he was always doing something: overdosing, getting hurt, etc. 

Anyways, can you guess where he injected his methamphetamine? I'll give you 2 guesses, but you'll only need 1.


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## fast65 (Apr 23, 2011)

medicRob said:


> Here is one that will make you cringe. Back when I worked a paramedic ambulance, there was a frequent flyer, not because he always called us, but because he was always doing something: overdosing, getting hurt, etc.
> 
> Anyways, can you guess where he injected his methamphetamine? I'll give you 2 guesses, but you'll only need 1.



Into some sort of peripheral vein


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## medicRob (Apr 23, 2011)

fast65 said:


> Into some sort of peripheral vein



He lovingly called it, "hitting the monkey wrench", but sure... we'll say that.


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## fast65 (Apr 23, 2011)

medicRob said:


> He lovingly called it, "hitting the monkey wrench", but sure... we'll say that.



Do I get a prize?h34r:


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## medicRob (Apr 23, 2011)

fast65 said:


> Do I get a prize?h34r:



Sure. You get to bandage the monkey wrench any time you want.


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## fast65 (Apr 23, 2011)

medicRob said:


> Sure. You get to bandage the monkey wrench any time you want.



Yay!!! Wait...dammit


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## rmabrey (Apr 23, 2011)

I've never personally stuck an IV, but during my time in the ER of both our major hospitals and my 13 or so ambulance shifts I quickly learned that discomfort or not, I want the medic doing it......Not an ER nurse. The ER is going to do it anyway if its an ALS patient.


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## medicRob (Apr 23, 2011)

rmabrey said:


> I've never personally stuck an IV, but during my time in the ER of both our major hospitals and my 13 or so ambulance shifts I quickly learned that discomfort or not, I want the medic doing it......Not an ER nurse. The ER is going to do it anyway if its an ALS patient.



Do you mean you would rather have it started on scene or en route, or do you mean you prefer medic, because RNs are quite capable of IV's, trust me.


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## rmabrey (Apr 23, 2011)

medicRob said:


> Do you mean you would rather have it started on scene or en route, or do you mean you prefer medic, because RNs are quite capable of IV's, trust me.


I would prefer to never have an IV started en route, but I would trust any medic I have worked with so far to do it. I would prefer a medic, given my limited experience but I know RN's are quite capable, and I have seen some good ones.....I've also seen a lot more that werent as good.

But in defense of RN's, as I stated previously, if it is an ALS run for the service I have been at, the pt gets IV access, so they dont get as much experience and practice IMO.

ETA: Again my post sounds weird so I'll try to clarify. Rn's here work 8 hour shifts, whereas medics work 12's. In that time a nurse may start 1 or 2 IV's, or if at one particular hospital, they will have a staff medic do it so they may start none. A medic in the field will start ~8 on a normal day


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## medicRob (Apr 23, 2011)

rmabrey said:


> I would prefer to never have an IV started en route, but I would trust any medic I have worked with so far to do it. I would prefer a medic, given my limited experience but I know RN's are quite capable, and I have seen some good ones.....I've also seen a lot more that werent as good.
> 
> But in defense of RN's, as I stated previously, if it is an ALS run for the service I have been at, the pt gets IV access, so they dont get as much experience and practice IMO.
> 
> ETA: Again my post sounds weird so I'll try to clarify. Rn's here work 8 hour shifts, whereas medics work 12's. In that time a nurse may start 1 or 2 IV's, or if at one particular hospital, they will have a staff medic do it so they may start none. A medic in the field will start ~8 on a normal day



I'll agree with you that yes, there are some RN's that aren't as good with IV's, but that is true of every profession, even Paramedicine. As far as nursing goes, we usually work 3 12 hour shifts a week for full time, that is a pretty common schedule, although there are a few variations. 

In an ER emergency unit of a Trauma I, it is not unheard of for an RN to average around 12 sticks per 12 hour shift, not to mention RN's spend more time in clinicals alone than a medic spends in their entire program. RNs that are also members of the IV team can average up to 30 IVs a shift. When I was on a dedicated IV Team, we would stick on every unit. 

In my humble opinion, I would prefer to have an RN start an IV on me, unless I know the medic. However, we do not always get a choice in who sticks us, and if I required IV Fluids, I would be thankful to whomever got a patent IV line in me regardless of their title.


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## usalsfyre (Apr 23, 2011)

One of the most talented folks I've ever seen at starting lines was actually a Basic who went to phlebotomy class and spent the next 10 years teching at a trauma center. That doesn't mean I want him making care decisions, just that he was good at a monkey skill.

If I had to pick, by "group", who I want starting lines in me it would be 1)anethestist of any sort 2) IV team RNs. Both of these sets of people can seemingly put patent lines in diabetic IV drug abusing marble statues with PVD.


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## medicRob (Apr 23, 2011)

usalsfyre said:


> One of the most talented folks I've ever seen at starting lines was actually a Basic who went to phlebotomy class and spent the next 10 years teching at a trauma center. That doesn't mean I want him making care decisions, just that he was good at a monkey skill.
> 
> If I had to pick, by "group", who I want starting lines in me it would be 1)anethestist of any sort 2) IV team RNs. Both of these sets of people can seemingly put patent lines in diabetic IV drug abusing marble statues with PVD.



Well, of course we all want the anesthetist! lol. Anyways, I worked as a Lab Assistant II (Phlebotomy) while in nursing school. I got lots of experience, it did take time to get use to angles and depth when we got to our IV sections. 

I counted in one shift as a Lab Assistant II, 35 sticks. Mind you, some patients you will stick multiple times a day: 6 am labs, STAT labs, Vanc peaks/troughs, updated BMP/CMP, lactate, BNP, you name it.


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## rmabrey (Apr 24, 2011)

medicRob said:


> I'll agree with you that yes, there are some RN's that aren't as good with IV's, but that is true of every profession, even Paramedicine.



Agreed


medicRob said:


> As far as nursing goes, we usually work 3 12 hour shifts a week for full time, that is a pretty common schedule, although there are a few variations.


Most units are that way here, and again it varies by hospital, but the ER  works 8's, I can only assume they prefer "fresh" nurses. The other major hospital is working 12's now that I think about it, but given a choice I would not go to that one anyway.


medicRob said:


> In an ER emergency unit of a Trauma I, it is not unheard of for an RN to average around 12 sticks per 12 hour shift, not to mention RN's spend more time in clinicals alone than a medic spends in their entire program.


Both our major hospitals are Trauma II, and I can only recall seeing a couple sticks by nurses, most were staff medics, students, or the life flight  medic (that was my instructor also). Again it is probably just the particular area.


medicRob said:


> RNs that are also members of the IV team can average up to 30 IVs a shift. When I was on a dedicated IV Team, we would stick on every unit.


Im requesting them, Ill beg if I have to 


medicRob said:


> if I required IV Fluids, I would be thankful to whomever got a patent IV line in me regardless of their title.


Can't argue that.


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## jwk (Apr 24, 2011)

rmabrey said:


> I would prefer to never have an IV started en route, but I would trust any medic I have worked with so far to do it. I would prefer a medic, given my limited experience but I know RN's are quite capable, and I have seen some good ones.....I've also seen a lot more that werent as good.
> 
> But in defense of RN's, as I stated previously, if it is an ALS run for the service I have been at, the pt gets IV access, so they dont get as much experience and practice IMO.
> 
> ETA: Again my post sounds weird so I'll try to clarify. Rn's here work 8 hour shifts, whereas medics work 12's. In that time a nurse may start 1 or 2 IV's, or if at one particular hospital, they will have a staff medic do it so they may start none. A medic in the field will start ~8 on a normal day



I think your assumptions stem from your admittedly limited experience.  Remember that not every ER case is a trauma case or code that comes in by ambulance.  There are lots of people who need IV's for any number of reasons - some for hydration, some for nutrition, some for repeated antibiotics, some for pain meds and PCA's, etc.  The length of shift doesn't really mean much given the ups and downs of both EMS and ER caseloads.


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## rmabrey (Apr 24, 2011)

jwk said:


> I think your assumptions stem from your admittedly limited experience.



That would be a good assumption, and also that I've already said the Techs always end up starting the IV's


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## Anjel (Apr 24, 2011)

rmabrey said:


> That would be a good assumption, and also that I've already said the Techs always end up starting the IV's



I asked an RN who I was tagging along with in our Trauma center and she said she hadn't started an IV in over a month. 

They have medics they hire as techs who go around doing them, That is one of their sole jobs. Even in trauma they have their crap ready and go in if it is needed. 

I really could care less who sticks me. It's really hard to get a good vein on me. Last IV attempt took 7 tries. But 3 different people. I ended up looking like a junkie. It was the anesthesiologist that got it on the very last try. In my hand.


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## medicstudent101 (Apr 24, 2011)

You have paramedics that SUCK at starting lines on pt's.
You have paramedics that are AMAZING at starting lines on pt's.

You have RN's that SUCK at starting lines on pt's. 
You have RN's that are AMAZING at starting lines on pt's.

You have pt's that have CRAPPY veins.
You have pt's that have GREAT veins. 

Any combo of the 3 sections makes for how easy or difficult it's going to be starting a line on someone. Point being, there's a spectrum on both pre-hospital and definitive care as it pertains to how good or bad someone is on starting lines. So we shouldn't be too critical on someone if the situation allows. 

If you're working a code, then by all mean someone that's proficient in IV's should be the one attempting. If you know you're not that great at getting lines then be man(or woman) enough to pass on the task to someone more capable. If you're lacking in the IV department, then PRACTICE. B)


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