# IV advice?



## Porta (Oct 18, 2012)

Today was my first ER rotation. Things went well, I had a good time and felt comfortable interacting with patients, pushing drugs (although I most def need more experience) etc. What I wasn't comfortable with was IVs. I'm okay with missing them, I'm okay with retracting the catheter and seeking the vein, but I'm most concerned with my patient's level of discomfort. Nobody likes to have someone rummage a catheter up and down their arm looking for a vein. 
After the second try I would discontinue my attempts and hand off to my Preceptor to establish the line. 
At what point would you feel it was appropriate to stop trying?
 I understand that this is a tough skill to learn, and I'm not discouraged, I'm more concerned with what other providers feels is an appropriate amount of attempts before handing off to a more experienced provider.


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## Jambi (Oct 18, 2012)

Depending on the patient my threshold was usually 2 trys.  It really depended.

I know that's still vague, but judgement comes down to exerience, so I say keep doing what you're doing and stop worrying. Your preceptors will/should intervene if needed, and your discretion will develop as time goes on.

"stay calm and start IVs" LOL


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## Porta (Oct 18, 2012)

No, no that's not vague to me at all. The nurses also said its patient specific. One of the pts I had tonight was already in enough pain, and I wasn't about to cause them more grief by turning them into a shishkabab.
 After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to. 
Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...


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## STXmedic (Oct 18, 2012)

My typical rule of thumb is two. If they really need access after two attempts, my partner and I will both attempt, or move to an IO. If its an IV for a comfort measure, I'll talk to the patient about whether or not they want me to try again or if they can wait until we get to the hospital. If it's an IV more for hospital ease, or for something simple like addressing a mild dehydration, I won't go past two. Other things will come in to play as well, but that's the gist of it.


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## Jambi (Oct 18, 2012)

Porta said:


> Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...



I do not.  It is against my personal ethics, and I also believe that it falls outside professional conduct standards.  

Pt treatment should always be dictated by Pt condition and need.

I know people that would/will toss in large-bore IVs based on behavior, etc., but that's on them...


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## mycrofft (Oct 18, 2012)

Porta said:


> After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to.
> Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...



That's called battery and malpractice. Churchill said when you're killing a man, being civil to him costs nothing. Same for starting IV's.

Where I worked two tries was the rule of thumb. Rarely we would make multiple tries drawing DNA forensic specimens because, for a time, if a subject didn't yield a specimen they had to wait out the rest of their sentence. I once stuck a willing guy fourteen times for a blood specimen.


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## Tigger (Oct 18, 2012)

My training program allowed us one attempt and then we had to retract the cath and the preceptor or RN gained access. We also had to ask permission as students to gain access.


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## Porta (Oct 18, 2012)

Tigger said:


> My training program allowed us one attempt and then we had to retract the cath and the preceptor or RN gained access. We also had to ask permission as students to gain access.



That's actually one thing I noticed tonight, I was the only one asking if I could physically touch the patient. 

"Hi my name is Porta, I'm an Advanced student, would you mind if I started an IV on you/palpated your abdomen/etc?" 
. 

Thank you all very much for your responses. I feel more comfortable.


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## NYMedic828 (Oct 18, 2012)

Some people claim slapping the vein causes venospasm and may engorge the particular vein a bit but quite honestly it has never done anything for me... See nurses do it all the time but I think its just an old practice...

what does work is a solid, tight tourniquet and a good rub down with the alcohol swap. A tight tourniquet can be uncomfortable for a patient but it won't be as bad as if you have to stick them again. In the field, you can supplement a BP cuff pumped up nice and tight it works even better.


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## JPINFV (Oct 18, 2012)

Porta said:


> That's actually one thing I noticed tonight, I was the only one asking if I could physically touch the patient.
> 
> "Hi my name is Porta, I'm an Advanced student, would you mind if I started an IV on you/palpated your abdomen/etc?"




"Hi, my name is JPINFV, I'm the medical student on the _____ team."

At least at my current hospital, the treatment release that's signed for minimal and basic procedures (IVs and the like, in contrast to say... surgery or central lines) includes a line on the fact that students and residents are involved with the patient's care. Similarly, the consent form for major things (like surgeries) includes a line about students and residents being involved. Gotta learn somehow, and they're free to say no. However, I'm not going to specifically ask if I can do an exam, especially since my exams aren't just extra exams (our notes go into the patient's chart).


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## Porta (Oct 18, 2012)

JPINFV said:


> "Hi, my name is JPINFV, I'm the medical student on the _____ team."
> 
> At least at my current hospital, the treatment release that's signed for minimal and basic procedures (IVs and the like, in contrast to say... surgery or central lines) includes a line on the fact that students and residents are involved with the patient's care. Similarly, the consent form for major things (like surgeries) includes a line about students and residents being involved. Gotta learn somehow, and they're free to say no. However, I'm not going to specifically ask if I can do an exam, especially since my exams aren't just extra exams (our notes go into the patient's chart).



I didn't think of it that way, I was thinking more along the lines of "How would *I* feel?" But now that I see where someone else would be coming from I can understand why my fellow classmates kinda hung back. 

I figured it would bode well for me if I was polite and asked for permission first, rather than just telling them what I was going to do to them. Granted this is in a learning setting, and in a controlled environment. I don't plan on being as polite (I guess you could say) in the field.


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## JPINFV (Oct 18, 2012)

Porta said:


> Granted this is in a learning setting, and in a controlled environment. I don't plan on being as polite (I guess you could say) in the field.




The attitude I approach patient care, as a student, is that I'm a member of a team (which is true). I work with my team to care for you. Yes, you can refuse. Yes, I'm properly supervised for what I'm doing (I don't need someone to watch me take an H&P or do a progress note, for example). Yes, the patient should know who is treating him, including students (one of the reasons I despise the title "Student Doctor JPINFV with _____" and use "JPINFV, the medical student on ___"). 

However I think there's a certain amount of confidence when the student presents himself as legitimately being there and performing a legitimate function instead of a "let me poke and prod you for the sake of poking and proding you." It's not about hanging back. It's about presenting yourself as being as essential as anyone else on the team. Granted, if I know something specifically will be painful, I'll defer to the resident or attendant's exam. There is no sense for causing pain for the sake of causing pain.


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## 18G (Oct 18, 2012)

When I was a Paramedic student I had an awesome RN in the ED who made me keep trying until I got the IV. Her philosophy was if I don't do it in the ED I won't be able to do it in the field. 

Now as a Paramedic, I limit myself to three attempts unless a critical patient then I limit that and move on to another option. I don't usually have an ALS partner to help with an IV so its all me which is why I do three attempts. 

Had a call a few days ago. Pt. intubated and paralytic onboard. Vancomycin infiltrated enoute and had to pull the line. Tried twice in the other arm without success. By this time patient is withdrawling, moving head slightly and sweating. So it came down to IO or EJ. Patient had a nice EJ so stuck that with an 18 no problem and got the Versed and Vecuronium onboard.


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## EMSrush (Oct 19, 2012)

Porta said:


> After the second try I would discontinue my attempts and hand off to my Preceptor to establish the line.
> At what point would you feel it was appropriate to stop trying?
> I understand that this is a tough skill to learn, and I'm not discouraged, I'm more concerned with what other providers feels is an appropriate amount of attempts before handing off to a more experienced provider.



I'd like to preface my response by saying that I believe the answer to your question will differ, depending on who you are talking about. For a student, I say two sticks per Pt max before you hand it off. For an experienced provider, Pt's condition and good clinical judgment will dictate how many attempts and which type of attempt needs to be made.

Regarding sticking Pts /c a large bore due to their behavior, I think that's really bad juju. I'd recommend you ignore those "suggestions" for a multitude of reasons.


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## Handsome Robb (Oct 19, 2012)

People always hate me for saying it but why not practice your large bore IVs on the people that are so inebriated/high/unconscious/drug affected they either wont feel it, remember it, care about it or any combination of the above. When you actually need big bore IVs (read: 14 or 16 gauge) you need it on the first shot and quickly. 

With that said, your treatments should never be punitive. If you're starting a huge line because "this guy is an :censored::censored::censored::censored::censored::censored::censored:" you need to check yourself. 

I'll say it now and everyone can get upset about it, I often place or have my students place 16g IVs in extremely intoxicated people and don't lose any sleep over it. 

As for the max attempts, as a student you get 2 shots unless it's a critical patient that I need access on quickly then it's only one opportunity before I take over. 

I agree with what JP said about identifying yourself as a student.


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## Veneficus (Oct 19, 2012)

NVRob said:


> People always hate me for saying it but why not practice your large bore IVs on the people that are so inebriated/high/unconscious/drug affected they either wont feel it, remember it, care about it or any combination of the above. When you actually need big bore IVs (read: 14 or 16 gauge) you need it on the first shot and quickly.
> 
> With that said, your treatments should never be punitive. If you're starting a huge line because "this guy is an :censored::censored::censored::censored::censored::censored::censored:" you need to check yourself.
> 
> ...



I think I wrote a few volumes on this actually. 

first, in my pseudo scientific experiment the difference in nociceptive pain pain from a large bore and a smaller guage is indistinguishable.
(a coworker and I each tried sticking the other blindfolded with both a 14g and an 18g) In 3 of the 4 cases neither of us could accurately tell. In the 4th my partner in crime actually picked the 18g as more painful.

The real difference is largely psychological. So starting a large bore IV on a drunk patient is probably only going to satisfy the anger of the provider. (Not exactly the moral ethical thing, but it happens.)

The other issue is that it takes a different technique to insert a large bore catheter. Like any skill, if you don't do it regularly, you will not be good at it when it counts. That means somebody, sometime, is going to get a larger needle than they "need." It is sort of like animal testing, at some point, there are acceptable losses.

As for the OP, trouble with IVs on the first ED rotation? I wouldn't worry about it at all. Now after 5 years in the field, well, maybe there is a problem then.

Every place I have been, there is a noncritical understood (not written in policy or the like) of 2 attempts before asking for help.

When the pt. is critical, then all bets are off and "whatever it takes" is the only rule.

Chances are on an ambulance, unless you are giving a med, the patient can make it to the hospital before an IV anyway. 

As for improving, always ask to try to stick the hardest patients at your clinical location. It is the best way to build the skill.

As a hint, practice extensively on the Basilic and cephalic veins. They are not often visible, they are not on a joint, well above shunt placement, and because of human embryological development, have almost no anatomical deviation. Which means whether a newborn or 300kg 90 year old, it is a reliable option.


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## james88 (Oct 19, 2012)

Porta said:


> No, no that's not vague to me at all. The nurses also said its patient specific. One of the pts I had tonight was already in enough pain, and I wasn't about to cause them more grief by turning them into a shishkabab.
> After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to.
> Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...



I was talking to a nurse the other day and she was telling me about a pt that came in with an IV in their forehead. lol


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## Veneficus (Oct 19, 2012)

james88 said:


> I was talking to a nurse the other day and she was telling me about a pt that came in with an IV in their forehead. lol



I saw an anesthesiologist put an IV inder somebody's eyelid to try and challenge himself after EMS and several ED staff couldn't get one. 

I have yet to attempt such myself, but have used everything from the forehead, breast, and varicose veins. 

Once saw a nurse put an IV is the penis after an abusive pt called her a worthless c***.


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## mycrofft (Oct 19, 2012)

"I saw an anesthesiologist put an IV inder somebody's eyelid to try and challenge himself after EMS and several ED staff couldn't get one. "

Hate to see that one sclerose or infiltrate.

Yeah, gauge versus discomfort can be largely due to technician psycholgy. How about times you need a bigger needle, such as to avoid haemolysis? Or to introduce mui-lots-lots fluids STAT? (Mouth wide, here comes foot...  ).


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## 18G (Oct 19, 2012)

Don't know if its true but one of my Paramedic instructors told the class that he knew a medic that placed an IV in someone's penis lol. The topic was get a line where you can when you really need one. 

Hmmm.


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## MSDeltaFlt (Oct 19, 2012)

Porta said:


> Today was my first ER rotation. Things went well, I had a good time and felt comfortable interacting with patients, pushing drugs (although I most def need more experience) etc. What I wasn't comfortable with was IVs. I'm okay with missing them, I'm okay with retracting the catheter and seeking the vein, but I'm most concerned with my patient's level of discomfort. Nobody likes to have someone rummage a catheter up and down their arm looking for a vein.
> After the second try I would discontinue my attempts and hand off to my Preceptor to establish the line.
> At what point would you feel it was appropriate to stop trying?
> I understand that this is a tough skill to learn, and I'm not discouraged, I'm more concerned with what other providers feels is an appropriate amount of attempts before handing off to a more experienced provider.



It depends.  It depends on the severity of their condition and the amount of available veins and whether or not I have an IO.  It also depends on whether I'm having an off day or not.

I was taught by a RN friend of mine who is considered. "big gun" when it comes to IV's, "if you can't feel it don't stick it".

I never stick to be punitive.  Because some of these people are liable to have some weird form of Munchhausen Syndrome and actually enjoy that.

As far as causing too much pain sticking a needle in a pt's arm goes, it doesn't hurt me at all to stick them.  There's a difference between being empathetic towards a pt's condition and being empathetic to the point of choosing to limit your care that the pt really needs.

Basically it boils down to realizing that the point of futility of accessing a vascular line is more fluid than one might think.  And that, my friend, is what you also need to learn if not already doing so.


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## Porta (Oct 19, 2012)

MSDeltaFlt said:


> Basically it boils down to realizing that the point of futility of accessing a vascular line is more fluid than one might think.  And that, my friend, is what you also need to learn if not already doing so.



I'm sorry but I'm not entirely sure what your trying to say. Are you saying I'm just over thinking it?


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## MSDeltaFlt (Oct 19, 2012)

Porta said:


> I'm sorry but I'm not entirely sure what your trying to say. Are you saying I'm just over thinking it?



I think you might be here.  What I'm saying is try and try again UNTIL you realize (or even think) that there is no way you will be able to get the IV.  Then let someone else try.  Then go to the next pt and repeat the process.  

Starting IV's is like any other skill.  They're easy to learn, but hard to master.  That takes experience. And you can't teach experience. So go get it.


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## Porta (Oct 19, 2012)

MSDeltaFlt said:


> I think you might be here.  What I'm saying is try and try again UNTIL you realize (or even think) that there is no way you will be able to get the IV.  Then let someone else try.  Then go to the next pt and repeat the process.
> 
> Starting IV's is like any other skill.  They're easy to learn, but hard to master.  That takes experience. And you can't teach experience. So go get it.



Ah, okay. Roger, wilco.


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## VFlutter (Oct 20, 2012)

MSDeltaFlt said:


> I was taught by a RN friend of mine who is considered. "big gun" when it comes to IV's, "if you can't feel it don't stick it".



That really is some great advice. One of the RNs who trained me literally closed his eyes when looking for veins and would only go off touch. He rarely missed and could get lines in the worst patients. When I first started I was too visual, it took a while to get comfortable feeling veins out. 

Another problem I had when I first started out was not having the tourniquet tight enough, that was the hardest part for me.


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## Porta (Oct 20, 2012)

ChaseZ33 said:


> That really is some great advice. One of the RNs who trained me literally closed his eyes when looking for veins and would only go off touch. He rarely missed and could get lines in the worst patients. When I first started I was too visual, it took a while to get comfortable feeling veins out.
> 
> Another problem I had when I first started out was not having the tourniquet tight enough, that was the hardest part for me.



It is, I'm glad I posted this thread


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## emsred23 (Oct 25, 2012)

In the field you sometimes NEED an IV so you try 2,3,4 times. Depending on protocols then drill em! Once you get lots of practice itll just be smooth. If nothing pops up, know where the veins should be.... aim and guess. You cant get them all...


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## Porta (Oct 25, 2012)

Hey guys, 
Today was my last day of ER clinicals and I was fairly successful on my sticks. Thanks for the input!
- Porta


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## Porta (Oct 25, 2012)

emsred23 said:


> In the field you sometimes NEED an IV so you try 2,3,4 times. Depending on protocols then drill em! Once you get lots of practice itll just be smooth. If nothing pops up, know where the veins should be.... aim and guess. You cant get them all...



Oh, trust me...I had one pt who I stuck 3x...luckily 3rd time was a charm. The guy was a trooper though!


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## blachatch (Oct 25, 2012)

Porta said:


> Oh, trust me...I had one pt who I stuck 3x...luckily 3rd time was a charm. The guy was a trooper though!



I feel your pain had my first IV start today on a 93 y old. I was so nervous I was sweating, I messed up the first time.. but got it the second time after some playing around but the nurse had to take over since we weren't getting any blood flow for blood draws.:unsure:


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## Porta (Oct 26, 2012)

blachatch said:


> I feel your pain had my first IV start today on a 93 y old. I was so nervous I was sweating, I messed up the first time.. but got it the second time after some playing around but the nurse had to take over since we weren't getting any blood flow for blood draws.:unsure:



I have decided I dislike sticking the elderly. They all seem to pray very loudly and scream about the devil...
I think it has more to do with the fact that they all had dementia and I live the the Deep South than my IV skills...

Hopefully.


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## NomadicMedic (Oct 26, 2012)

Haha. You better get used to it. We stick far more old than young.


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## Porta (Oct 26, 2012)

n7lxi said:


> Haha. You better get used to it. We stick far more old than young.



"MA'AM I AM NOT THE DEVIL."

After awhile I just started agreeing with her. 

My only issue was/is the texture of their skin threw me off. I spent the day sticking people who had nice thick skin and then....paper. Kinda threw my new found confidence


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## Jambi (Oct 26, 2012)

Porta said:


> "MA'AM I AM NOT THE DEVIL."
> 
> After awhile I just started agreeing with her.
> 
> My only issue was/is the texture of their skin threw me off. I spent the day sticking people who had nice thick skin and then....paper. Kinda threw my new found confidence



i've been known to toss a little lotion on their skin a few minutes before trying an iv. Traction is also your friend.

And don't be afraid of gnarly looking hands

And don't wear evil clown masks either, it's not nice.


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## Porta (Oct 27, 2012)

Jambi said:


> i've been known to toss a little lotion on their skin a few minutes before trying an iv. Traction is also your friend.
> 
> And don't be afraid of gnarly looking hands
> 
> And don't wear evil clown masks either, it's not nice.



It's not a mask, it's how I do my makeup. 

I'll remember that trick, thanks dude. 

I was a little concerned with the hands bc they're so bony, does that matter?


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## Jambi (Oct 27, 2012)

Porta said:


> I was a little concerned with the hands bc they're so bony, does that matter?



i've never had a problem so long as there are viable veins.


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## Handsome Robb (Oct 27, 2012)

Porta said:


> I was a little concerned with the hands bc they're so bony, does that matter?



Don't start at a 45* angle and you're fine. 

Hands take some practice but I'd honestly rather have a hand IV than one in my AC.


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## blachatch (Oct 27, 2012)

The skin was giving me a hard time to on the older person.. The skin was so loose as i was trying to advance the Catheter I was pushing her loose flappy skin with it and was getting off track of advancing.. It was kind of frustrating even though it was my first time.


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## Porta (Oct 27, 2012)

blachatch said:


> The skin was giving me a hard time to on the older person.. The skin was so loose as i was trying to advance the Catheter I was pushing her loose flappy skin with it and was getting off track of advancing.. It was kind of frustrating even though it was my first time.



thats exactly what happened to myself and my classmate last night.


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## Akulahawk (Oct 27, 2012)

Porta said:


> "MA'AM I AM NOT THE DEVIL."
> 
> After awhile I just started agreeing with her.
> 
> My only issue was/is the texture of their skin threw me off. I spent the day sticking people who had nice thick skin and then....paper. Kinda threw my new found confidence



Regardless of the skin thickness, visualize your target as the inside of a small piece of hollow pasta. You aim for the middle of that lumen and go from there. You start out with a shallow angle and after you have entered the skin, aim for that lumen and just go for it!


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## Porta (Oct 27, 2012)

Akulahawk said:


> Regardless of the skin thickness, visualize your target as the inside of a small piece of hollow pasta. You aim for the middle of that lumen and go from there. You start out with a shallow angle and after you have entered the skin, aim for that lumen and just go for it!



Good analogy!


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## bigbaldguy (Oct 28, 2012)

One thing no one ever really told me in a way I understood was you don't start right in the vein. You start a bit down from it and kind of tunnel up towards it so you don't go through it on entry. Like a gofer who starts out making a new tunnel but then joins that tunnel with an existing one. I was starting mine way too far up. Also I was under the impression that going fast makes it hurt less. It does make it hurt less but you're more likely to miss. Better to drag the pain out an extra 3-5 seconds then to have to try 3 or four times. Now I advance the needle nice and slow and I haven't missed one since.

Hope this helps.


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## the_negro_puppy (Oct 28, 2012)

I still believe site selection is really important. Spend the extra minute or two to have a look at all your options. Find the best vein, don't just settle for the first one you see because you feel rushed. By doing this I virtually get most IV's on first attempt, makes for a happy patient.

- Use traction, pull the skin as taught as possible. This can help with loose skin and prevent veins from rolling away.

- Go in at a shallow angle. Many books say 45 degree then lower but I have never done this. I generally go in at as shallow angle as possible.

- Tapping veins lightly does actually make them more engorged and easier to stick. I use this often. Make sure you are dangling their arm if possible, allow gravity to pool blood in the veins.

- Pt's with chronic health problems usually know where their 'good veins' are. Ask them where they normally receive blood draws etc from.

I always go for the forearm if possible. Seems to hurt less, doesn't prevent use of the hand and wont get kinked by bending at the elbow.

- Practice makes perfect. The only way to get better is just do it over and over again.


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## Porta (Oct 28, 2012)

bigbaldguy said:


> One thing no one ever really told me in a way I understood was you don't start right in the vein. You start a bit down from it and kind of tunnel up towards it so you don't go through it on entry. Like a gofer who starts out making a new tunnel but then joins that tunnel with an existing one. I was starting mine way too far up. Also I was under the impression that going fast makes it hurt less. It does make it hurt less but you're more likely to miss. Better to drag the pain out an extra 3-5 seconds then to have to try 3 or four times. Now I advance the needle nice and slow and I haven't missed one since.
> 
> Hope this helps.



That's actually one thing I was messing up, I was way too high. The IVs that I had success with, I think I was lower and was able to get a little more wiggle room. 

Thank you!


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## Porta (Oct 28, 2012)

the_negro_puppy said:


> I still believe site selection is really important. Spend the extra minute or two to have a look at all your options. Find the best vein, don't just settle for the first one you see because you feel rushed. By doing this I virtually get most IV's on first attempt, makes for a happy patient.
> 
> - Use traction, pull the skin as taught as possible. This can help with loose skin and prevent veins from rolling away.
> 
> ...



Thanks! 
I wish we had more ED time. I start ride time in a few weeks and I know it's going to be a lot harder in the truck than a stable environment like the ED.  
But it's not like I'm the first student to ever be intimidated by sticks.


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## wildmed (Oct 29, 2012)

I usually stop with 2 tries and will allow an attempt to go for 30 sec, this is variable depending on how badly I need a line. If a pt is crumping, Im not going to stop until I have access of some sort.The best trick I have ever learned was from a flight nurse when I was a new ED tech. Instead of advancing just the angiocath once you have a flash; pull just the needle tip back into the catheter so its no longer exposed, and advance the entire unit. This keeps the cath ridged and allows you to have better control while your advancing into the vein, without causing damage to it. It works great for those fragile old veins that have been wrecked by heparin as well as tiny peds veins with strong valves. I also am a big fan of hands for a 1st try because you can hold traction easily, they are usually easy to visualize, and you are leaving superior options for access incase you loose a line. Obviously if your needing to drop bilateral 16-14 this should not be your 1st option. Also dont forget the “handcuff" vein, many people forget its there, but it can be a great option.


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## Porta (Oct 29, 2012)

Handcuff vein? Do you mean this guy?


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## VFlutter (Oct 29, 2012)

http://m.youtube.com/watch?v=_-9tTq53XH8

We had one of these on our floor for a while. It was useful but they decided it was not worth the cost at the time. A decent understanding of common anatomy and thorough palpation did just as well.


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## wildmed (Oct 29, 2012)

The “handcuff” vein is the basilic vein. Its located on the posterior portion of the forearm a few inches distal to the elbow. If your having a hard time finding something, look at your own arms, circulatory anatomy may be slightly different between each person, but the general lay out is the same. Once your confident in your skills it also pays off to be creative,don’t get locked into the arms or EJ as your only two options. I’ve started lines in upper arms, breast tissue, scalps (Neonate),feet, and legs that remained patent for days .


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## Porta (Oct 29, 2012)

wildmed said:


> The “handcuff” vein is the basilic vein. Its located on the posterior portion of the forearm a few inches distal to the elbow. If your having a hard time finding something, look at your own arms, circulatory anatomy may be slightly different between each person, but the general lay out is the same. Once your confident in your skills it also pays off to be creative,don’t get locked into the arms or EJ as your only two options. I’ve started lines in upper arms, breast tissue, scalps (Neonate),feet, and legs that remained patent for days .



Ah, okay. I actually got an IV on that my last rotation. How difficult are EJs? I watched my preceptor try and get one (or two rather) on a woman and it seemed that it would have been easier if he had gone for a vein in one of her breasts or go IO - he stuck her twice with no luck. If you need a central line but can't get an EJ, would an IO be your best bet after that?


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## JDub (Oct 29, 2012)

Porta said:


> Ah, okay. I actually got an IV on that my last rotation. How difficult are EJs? I watched my preceptor try and get one (or two rather) on a woman and it seemed that it would have been easier if he had gone for a vein in one of her breasts or go IO - he stuck her twice with no luck. If you need a central line but can't get an EJ, would an IO be your best bet after that?



Neither an EJ or an IO are central lines. 

If you are in the field, most providers attempt to go for an EJ last, so yes a IO would probably be your only option at point. I would say if you keep looking you could probably find a vein to place an IV in.

If you are at the ER and you attempt an EJ as a last resort and cannot get it, then a doctor will probably place a central line such as in the Internal Jugular (IJ), Subclavian or Femoral.


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## Porta (Oct 29, 2012)

Oh, okay, thank you for the correction. I was under the impression they were considered central lines.


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## Akulahawk (Oct 29, 2012)

Porta said:


> Oh, okay, thank you for the correction. I was under the impression they were considered central lines.


Depending upon where you work, an EJ could be considered a central line or a peripheral line, as far as IV access is concerned. Where I did my ED clinical rotation, they considered the EJ as a central line but the local EMS agency considered it a peripheral line. Just know what your employer considers as a central vs peripheral line. Follow their rules as to what you can place and you'll (usually) have their backing when it comes to IV lines placement.


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## JPINFV (Oct 29, 2012)

Wait... a regular peripheral IV being considered a central line? There's a rather large difference between size, technique, and function of a central line and a peripheral IV, regardless of location.


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## Porta (Oct 29, 2012)

My scope only allows me peripheral lines, which includes an EJ. However, at the ED, the EJ was referred to as a central line.


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## Akulahawk (Oct 29, 2012)

JPINFV said:


> Wait... a regular peripheral IV being considered a central line? There's a rather large difference between size, technique, and function of a central line and a peripheral IV, regardless of location.


Yep. Some places consider an EJ to be a central line. That was pretty much my argument as well when I found out that those places don't consider EJ's to be a peripheral line. :blink:


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## hogwiley (Oct 29, 2012)

When I was in the hospital not too long ago I had students sticking me like a pin cushion. First in the ER there was a student medic. Then later up on the floor and needed a second one started, I got to have a student Nurse do the honors. Later when that line went bad I had an RN start one who was as bad, if not worse than the students, and she left one at a weird angle that hurt like a SOB, but I wasnt about to ask her to take it out and put it somewhere else. I'm a fairly muscular skinny little guy but apparently im a hard stick. 

I can tell you none of them followed the 2 sticks your out rule. I finally had to ask if I did something to these people to make them hate me. I told them next time they needed a line Ill stick the damn thing myself.


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## blachatch (Oct 30, 2012)

wildmed said:


> I usually stop with 2 tries and will allow an attempt to go for 30 sec, this is variable depending on how badly I need a line. If a pt is crumping, Im not going to stop until I have access of some sort.The best trick I have ever learned was from a flight nurse when I was a new ED tech. Instead of advancing just the angiocath once you have a flash; pull just the needle tip back into the catheter so its no longer exposed, and advance the entire unit. This keeps the cath ridged and allows you to have better control while your advancing into the vein, without causing damage to it. It works great for those fragile old veins that have been wrecked by heparin as well as tiny peds veins with strong valves. I also am a big fan of hands for a 1st try because you can hold traction easily, they are usually easy to visualize, and you are leaving superior options for access incase you loose a line. Obviously if your needing to drop bilateral 16-14 this should not be your 1st option. Also don’t forget the “handcuff" vein, many people forget its there, but it can be a great option.



This sounds like a great idea I might try next time.. to prevent damage to the catheter when trying to advance.


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## AtlasFlyer (Nov 3, 2012)

hogwiley said:


> When I was in the hospital not too long ago I had students sticking me like a pin cushion. First in the ER there was a student medic. Then later up on the floor and needed a second one started, I got to have a student Nurse do the honors. Later when that line went bad I had an RN start one who was as bad, if not worse than the students, and she left one at a weird angle that hurt like a SOB, but I wasnt about to ask her to take it out and put it somewhere else. I'm a fairly muscular skinny little guy but apparently im a hard stick.
> 
> I can tell you none of them followed the 2 sticks your out rule. I finally had to ask if I did something to these people to make them hate me. I told them next time they needed a line Ill stick the damn thing myself.



When I was in the hospital in 2005 having my 2nd baby I had a student attempting to start my IV. I admit I have scrawny arms, but this girl could not get the thing started. It was AWFUL. I was already on edge because the baby was being induced 4 weeks early for failure to thrive, and I was quickly reduced to tears by this student sticking me over and over and over and over and over again.

She finally left, in tears herself, and had a supervisor come in and get it going. I felt bad for her, and I know students have to learn on someone, but please not repeated attempts on someone who's already pretty upset.


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## jorgito (Nov 3, 2012)

two tries sounds good;however, on the field its a different story.  You try as many times as you need to, even the most experienced miss, so keep trying.  Practice makes perfect.


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## Akulahawk (Nov 3, 2012)

Personally, my rule is 2 attempts if the IV fits in the category of "nice to have" or I'm in a student role. If the IV is in the "MUST HAVE" then I'll stick as many times as necessary, using whatever route is available to obtain patent vascular access. I'll do 3 peripheral attempts and then consider IO next. While it's nice to _see_ the veins (normal or enhanced ways), I much prefer to _feel _them to get a better sense of them.


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