# When and When not to start IVs/saline Locks.



## xrsm002 (Jun 12, 2012)

I was wondering I had two abdominal pain calls on the truck we started an IV on the first one but the 2nd one we didn't start one.  I am a paramedic student and my preceptor told me the 2nd patient didn't need one.  I am assuming because it was a <6 min transport time to the ER.   The first one was about  15 min transport.  Or it could be cuz the first one was bent over, and the 2nd one wasn't.  Any suggestions on when and when not to start lines? or at least a saline lock?


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## Epi-do (Jun 12, 2012)

I start IV's if I need to give IV meds, fluids, or have a patient that has the potential to head south and need either of those things while on our way to the ED.  When I do start an IV, I almost always do a lock.  I only hang a bag if fluids are needed.

I work with a handful of medics that will start an IV on a pt simply because "the hospital is going to do it when we get there, anyway."  It's not something I do, but that comes down to personal preference, I guess.

If you are looking for specific signs/symptoms that will cause me to start an IV, it really varies widely from patient to patient, depending upon their complaint.


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## NYMedic828 (Jun 12, 2012)

Epi-do said:


> I start IV's if I need to give IV meds, fluids, or have a patient that has the potential to head south and need either of those things while on our way to the ED.  When I do start an IV, I almost always do a lock.  I only hang a bag if fluids are needed.
> 
> I work with a handful of medics that will start an IV on a pt simply because "the hospital is going to do it when we get there, anyway."  It's not something I do, but that comes down to personal preference, I guess.



+1

There are tons of people who will start an IV on everyone they can and use the "what if scenario" in their defense. 

If the patient could potentially head south or is already down under then they get an IV.

Next time, ask the preceptor for a clear reason why.


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## STXmedic (Jun 12, 2012)

That is highly subjective, and you will hear many different opinions. 

As far as your patient today that did not get one, maybe your preceptor:

-didn't think he could hit a vein without turning the patient into a pin cushion 

-felt it was too short of a transport time

-did not want to increase the patients chance for infection

-felt the patient's pain was not severe enough to warrant one

-wanted you to step in

-forgot

-was lazy

-flipped a coin

It's impossible to say.

For me, if I have a patient with abdominal pain, they are likely getting some meds for that pain, and therefor a line. It is all dependent on patient condition and needs. There is no discernible line on when to give an IV or some Tx and when to withhold it. You have to look at your patient, assess him/her, and use your own clinical judgement. Medicine is not black and white; it is all different shades of grey.

And +1 to epi's comment.


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## Shishkabob (Jun 12, 2012)

If they currently need fluid / medications, will need fluid / medications, or could potentially need fluid / medications, they get an IV from me.



Broad and vague?  Yes, but welcome to medicine where it's as much science as it is art.


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## the_negro_puppy (Jun 12, 2012)

- The actual or foreseeable need to administer intravenous drugs.

We don't have saline locks, we either start and IV with a bung, or hang fluids TVKO.

Having said that, it is difficult to know if a patient's condition is going to change during transport. If something happens it you alone in the back. The more prepared you are, the easier it will be if there's a problem. Having an IV started can be part of this. It's not like  at a hospital when you can call a medical emergency/code blue and have 4 doctors and 3 nurses at your side starting IV's, doing CPR and preparing defibrillators.


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## Melclin (Jun 13, 2012)

In addition to the actual or foreseeable need:

-I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc. 

-I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. *Why do people have a problem with this idea?*


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## abckidsmom (Jun 13, 2012)

Melclin said:


> In addition to the actual or foreseeable need:
> 
> -I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc.
> 
> -I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. *Why do people have a problem with this idea?*



What is a bung?

I have nothing to add to these excellent lists of thoughts except that if I put someone on the monitor because I suspect I might see something there that's interesting or relevant, that usually wins them an IV too. 

It's a vague rule, but it's my rule, and I like it.


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## TransportJockey (Jun 13, 2012)

I start them if I feel the patient will need fluids or meds, or does need fluid or meds. If I can justify it, I'll do it. But we don't carry locks, so I have to hang a full bag when I start a line.


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## Smash (Jun 13, 2012)

abckidsmom said:


> What is a bung?



A bung is a saline lock.


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## the_negro_puppy (Jun 13, 2012)

Melclin said:


> In addition to the actual or foreseeable need:
> 
> -I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc.
> 
> -I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. *Why do people have a problem with this idea?*



What do you guys use down in Vic if you are not using bungs?



abckidsmom said:


> What is a bung?
> 
> A plastic port that crews onto the end of the catheter, can be used to attaching tubing or inject drugs through


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## abckidsmom (Jun 13, 2012)

Never heard it called that.  We call that a "luer lock plug."  

Extremely effective, that one.  No one has a good word for it around here.

A saline lock, to me, is that same thing except with 3 inches of tubing between the hub of the catheter and the luer lock plug.


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## Akulahawk (Jun 13, 2012)

If I'm going to put in a lock, it's going to be done like abckidsmom's going do to it - a 3" extension with a luer-lock plug on the end. I can understand why some people might want to put the luer-lock plug right at the end of the cath, but...  I just don't want to potentially pull the cath out because I'm attempting to attach the tubing to the cath... while in a moving truck. Both have their uses.


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## the_negro_puppy (Jun 13, 2012)

these are IV bungs












If we attach IV tubing to them we secure the tubing to the patients limb with tape


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## Melclin (Jun 13, 2012)

We have 3 options. 

1) Reflux valve or "a bung".





2) Three way tap





3) Three way extension





I prefer the three way extension for the reasons mentioned. 

I've also heard there are some types of blood work that shouldn't be drawn through the reflux valve but its only hear-say. Never really looked into it because I don't use them.


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## the_negro_puppy (Jun 13, 2012)

QLD, the poverty state. We get bungs only. Some ICPs carry around 3 way extension taps + tubing, but they probably plundered them from hospital.

We've only just recently changed to the bungs used by most of the hospitals. Before that we were using the non-leur lock ones that you had to penetrate with blunt/plastic tip. Every cannulated patient brought in had to have their bung changed. Madness


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## Handsome Robb (Jun 13, 2012)

Melclin said:


> -I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. *Why do people have a problem with this idea?*



Emphasis on the bolded part. I always hear people say "the hospital is going to need one" is a bad reason. I have yet to hear why. Infection rates in prehospital vs in hospital is a defunct argument. It's been shown there is a negligible difference. 

Another argument I've heard is "nurses are better". Bull:censored::censored::censored::censored:, we start more lines than they do so inherently we will better. At least at the hospitals here the paramedic techs start lines much more often than nurses do. Call it anecdotal but personally I'll take a line from a medic/EMT over a nurse any day. 

This is a "team sport". We are all working towards the same end goal. I have one patient, rarely two, even more rarely three in the box while ER nurses have 3-5 plus helping other nurses with critical patients. If I can make their job easier by starting a line I'm absolutely going to do it. With that said I feel pretty confident in my ability to establish a good line without taking more than one or two attempts. After two ill let it be unless I need that line for something right now.


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## xrsm002 (Jun 13, 2012)

Let me add this my I was reaching for the IV to at least start a lock and my preceptor said this patient didnt' need one.


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## Akulahawk (Jun 13, 2012)

xrsm002 said:


> Let me add this my I was reaching for the IV to at least start a lock and my preceptor said this patient didnt' need one.


Give it time, and you'll just start picking up on which patients will need one and which ones don't. The majority of patients require only BLS level care. Those typically won't need a line or a lock right away. If my patient is in need of some sort of intervention above that, then they're likely to get a line or a lock, but not always. What it boils down to is whether or not I can articulate a specific need for starting a line on the patient... and it's not because I need the practice or "just in case" or "precautionary," at least in those instances where protocol doesn't direct that a line be placed.


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## JakeEMTP (Jun 13, 2012)

NVRob said:


> Emphasis on the bolded part. I always hear people say "the hospital is going to need one" is a bad reason. I have yet to hear why. Infection rates in prehospital vs in hospital is a defunct argument. It's been shown there is a negligible difference.
> 
> Another argument I've heard is "nurses are better". Bull:censored::censored::censored::censored:, we start more lines than they do so inherently we will better. At least at the hospitals here the paramedic techs start lines much more often than nurses do. Call it anecdotal but personally I'll take a line from a medic/EMT over a nurse any day.



That's some broad statements and probably not true everywhere. I would say there are alot of places where the number of IV starts for the Paramedic is the same as the number of intubations which might be 1 or less per month.  I know alot of ER and OP nurses that can do 20 IV starts a day easily.  If you are doing more than that as a Paramedic then you are probably putting a line in anybody and everybody.  Alot of ERs don't have ER Techs so the nurses do their own lines.

The infection rate is also hard to prove since hospitals have a policy of changing out any lines started in the field or even emergently in the hospital within 24 hours.  The one study that always get kicked around as showing neglible was done by a couple of RNs get their Masters and the numbers on it actually is not that impressive but most just read the summary and not look at the rest.  If hospitals are having a hard time with infections, what makes you think it is any better in the back of a truck or on the street. Most Paramedics still just use an alcohol swipe and rarely let that dry before sticking. I personally wouldn't want a field IV to stay in me or my family any longer than it takes to get another one done. Just because you have a problem with the us against them bull:censored::censored::censored::censored:, nurses still have the infection control stuff drilled into them. Alot of Paramedics can't get cleaning a truck right just for taking out their own garbage for their shift. They don't call some of the ambulances Roach Coaches for nothing. What about the medic who has worn his gloves up front touching everything for every patient call and then starts IVs? Nurses do that :censored::censored::censored::censored: and they are busted by their IC managers.


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## KellyBracket (Jun 16, 2012)

There's actually some interesting research into IV placement rates by EMS, and how it affects the patient. Of course, there doesn't appear to be a good evidence-based answer to "When should I start an IV?" but there are some important results to consider. 

For instance, one recent study found that patients transported by ALS who got an IV were less likely to die (after controlling for age, illness severity, etc...) than those who didn't get an IV. Another study found that IVs placed by EMS are used less often than IVs placed by RNs in the ED. On the other hand, maybe we need to put more IVs into kids.

For more explanation, check out *The IV placed by EMS: Too much, yet not enough. *


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## Handsome Robb (Jun 18, 2012)

JakeEMTP said:


> That's some broad statements and probably not true everywhere. I would say there are alot of places where the number of IV starts for the Paramedic is the same as the number of intubations which might be 1 or less per month.  I know alot of ER and OP nurses that can do 20 IV starts a day easily.  If you are doing more than that as a Paramedic then you are probably putting a line in anybody and everybody.  Alot of ERs don't have ER Techs so the nurses do their own lines.
> 
> The infection rate is also hard to prove since hospitals have a policy of changing out any lines started in the field or even emergently in the hospital within 24 hours.  The one study that always get kicked around as showing neglible was done by a couple of RNs get their Masters and the numbers on it actually is not that impressive but most just read the summary and not look at the rest.  If hospitals are having a hard time with infections, what makes you think it is any better in the back of a truck or on the street. Most Paramedics still just use an alcohol swipe and rarely let that dry before sticking. I personally wouldn't want a field IV to stay in me or my family any longer than it takes to get another one done. Just because you have a problem with the us against them bull:censored::censored::censored::censored:, nurses still have the infection control stuff drilled into them. Alot of Paramedics can't get cleaning a truck right just for taking out their own garbage for their shift. They don't call some of the ambulances Roach Coaches for nothing. What about the medic who has worn his gloves up front touching everything for every patient call and then starts IVs? Nurses do that :censored::censored::censored::censored: and they are busted by their IC managers.



I should have been more specific. In a rural service yes you may only get a few starts a month. Where I work and in the many other busy urban services you might be getting as many as 10-15 attempts/starts in a 12 hour shift and that doesn't mean everyone is getting a line either...

That's going to depend on the hospital as far as changing IV catheters. We have a good relationship with all of our hospitals so they tend to follow the 72-96 hour change guideline as recommended by the CDC* but your mileage my vary and as you said some systems pull EMS lines as soon as reasonably possible. 

We use 2% chlorhexidine wipes for skin prep, not alcohol but again that's going to vary depending on the service you work for. 

I've got no problems with nurses, quite the opposite actually. I have a lot of respect for nurses, more specifically ER or ICU nurses and what they do. Again, we have excellent working relationships with them so that helps quite a bit as well. Sure I don't like a few but you aren't going to get along with everyone, right? 

* http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm


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## Handsome Robb (Jun 18, 2012)

KellyBracket said:


> For more explanation, check out *The IV placed by EMS: Too much, yet not enough. *



Thanks for that. Pretty interesting actually.


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## OIFXGunner (Jun 27, 2012)

My only problem with the "hospital's gonna do it anyways" argument is that the hospital is also likely going to do blood draw when they start their lines and we don't have that capability in my agency.  I had always thought that they could just pull blood off the line once they got the patient in, but my local hospital doesn't care much for doing that.  So my rule of thumb is if they need IV meds/fluids or they have potential to crash, they get it.  If not, I'll let the hospital take care of it so we're not sticking the patient any more than really necessary.  Just my opinion


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## ZootownMedic (Jun 29, 2012)

We had this argument in my Paramedic class and I was one of the only ones (along with most of the instructors) that said I wouldn't do a line on a pt 'just because'. My current preceptor wants lines on a lot of pts that I don't think need them. The way I look at it is that even though we do IV's all day everyday doesn't mean that its right. the ambulance is far from sterile and is an uncontrolled environment. Why risk infection/embolus or whatever if you don't have too? Of course I don't ever want to be that guy that needs a line NOW and didn't have one but that means I didn't do a proper assessment or this is the 1:1,000,000 pt that just went down the drain out of nowhere. I am a new medic(intern) and am finding my own way but I will probably end up in the middle ground and only start IV's on patients that have the POTENTIAL to head south. Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.


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## STXmedic (Jun 29, 2012)

SmokeMedic said:


> Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.



/grabs popcorn


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## ZootownMedic (Jun 29, 2012)

PoeticInjustice said:


> /grabs popcorn



lol....I always treat pain. Doesn't mean I grab a line for every pt c/o some form a pain bc I am worried they are gonna circle the drain. Thats what I meant.


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## Melclin (Jun 30, 2012)

SmokeMedic said:


> We had this argument in my Paramedic class and I was one of the only ones (along with most of the instructors) that said I wouldn't do a line on a pt 'just because'. My current preceptor wants lines on a lot of pts that I don't think need them. The way I look at it is that even though we do IV's all day everyday doesn't mean that its right. the ambulance is far from sterile and is an uncontrolled environment. Why risk infection/embolus or whatever if you don't have too? Of course I don't ever want to be that guy that needs a line NOW and didn't have one but that means I didn't do a proper assessment or this is the 1:1,000,000 pt that just went down the drain out of nowhere. I am a new medic(intern) and am finding my own way but I will probably end up in the middle ground and only start IV's on patients that have the POTENTIAL to head south. Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.









Okay I'll bite. 

How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.


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## OIFXGunner (Jun 30, 2012)

Melclin said:


> Okay I'll bite.
> 
> How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.



Hahaha the picture made me literally burst out laughing.

On a serious note, however, I think we should all be able to agree that there is such a thing as unnecessary ALS. Just because you can doesn't mean you should. 

The whole aseptic environment thing... yes we should use aseptic technique. That's a given. However, most of our ambulances are nowhere near as clean as we would like to pretend they are. On the other hand, the same thing can be said about the hospitals. You know those little metal stand stands that they have in the patient rooms? Think back to the last time those were cleaned that you've seen. Or the ekg or pulse ox wires. There's plenty of potential for contamination in both environments. The trick is in reducing it.

I think this argument could be run in circles for days... I feel pretty safe in saying that as long as you can justify why you did or didn't start a line on a given patient to your omd you should be in the clear.


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## Tigger (Jun 30, 2012)

Melclin said:


> Okay I'll bite.
> 
> How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.



The aseptic technique is the real preventer of infection, not that's any excuse for not having a clean ambulance. Yes the ambulance is not a sterile environment, but neither is pretty much any other area. Don't rub the catheter on your leg or the patient's arm on the bench seat and we should be fine.


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## usalsfyre (Jun 30, 2012)

The same urban outdoorsman that puked in your truck later copped a squat in the corner of the ER room. If I'm not mistaken nothing has ever shown prehospital lines to have a higher infection rate. 

The funny thing is I started as many or more "useless" lines working in the ED. Strangely enough they got used. Don't want a line to be wasted? Put a lock in it and don't hook it straight to fluid.


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## Shishkabob (Jun 30, 2012)

Fact is, there hasn't been any real study to prove that field IVs are any more 'dangerous' than hospital IVs, and in fact, I have seen more say hospital IVs are more prone to infection.

Just like the IV nurses association came out with some silly statement stating that patients shouldn't be shaved because shaving causes "micro tears" that can cause infection.   You know... more than the giant needle breaking the skin, or any other time the person shaves in the morning... or any other countless times that can cause 'micro tears'.  




The one and only reason why pre-hospital IVs are DCd and re-done in the hospital is reimbursement.  Money, pure and simple.


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## VFlutter (Jun 30, 2012)

Melclin said:


> We have 3 options.
> 
> 1) Reflux valve or "a bung".
> 
> ...




I never used a stopcock or manifold until I was in the ICU. They are very useful when access is limited. Just make sure everything your running is compatible.


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## Jeremy89 (Jul 3, 2012)

I used to be an ER tech that was able to start IVs.  The "fast-track" pt's who came in for the sore throat and cold/flu s/sx usually didn't get on.  However, our MDs were generally pro-IV, meaning if they think the pt *might*, at some point need one, then they'll order it.  They would rather have the pt stuck once with an IV versus once for phlebotomy, then having an IV placed if they needed to infuse IV K+, for example.  The only pt's we just stuck for blood were psych pt's.

But this whole argument has another aspect I haven't seen anyone bring up yet- lets take, for example, that abd pain pt.  Well maybe they don't need prehospital pain control or fluids (Doctors around here hate when pain meds are given since it diminishes their assessment), but when you get to the ED I can almost guarantee that pt will need a CT with contrast.  Its all about critical thinking- "what *might* this pt need in the future?"

That being said, I agree with whoever posted about drawing blood from lines.  If pt's have a prehospital IV, they'll likely be poked for blood from the ED staff anyway- we were taught never to draw out of lines unless it was at the time we started them.  I think the risk for hemolysis almost doubles for blood pulled from pre-existing IVs.

Just my 2c

Edit: for the sake of this conversation, IV start=saline lock


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## usalsfyre (Jul 3, 2012)

Jeremy89 said:


> (Doctors around here hate when pain meds are given since it diminishes their assessment)


This piece of excrement myth is still around? Were they trained by Halstead himself? 

http://www.nhmrc.gov.au/_files_nhmrc/file/nics/programs/Pain medication for acute abdominal pain [PDF%20120KB].pdf


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## Shishkabob (Jul 4, 2012)

Jeremy89 said:


> (Doctors around here hate when pain meds are given since it diminishes their assessment)



Then remind that doctor that at some point in his medical school, he was most likely taught about narcotic antagonist and about his ability to give one (such as Narcan) if he so pleases, when he takes control of the patient.  Until then, it's your patient.


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## the_negro_puppy (Jul 4, 2012)

Yeah I agree the whole 'no/not too much analgesia' for abdo pain patients is rubbish. Pain relief is one thing we can do,with measurable result well in the pre-hospital environment.


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## Melclin (Jul 4, 2012)

Jeremy89 said:


> Well maybe they don't need prehospital pain control or fluids (Doctors around here hate when pain meds are given since it diminishes their assessment)


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## NYMedic828 (Jul 4, 2012)

Most reputable doctors will tell you that with the introduction of new technologies like ultrasound,MRI, X-ray that diminishing pain is hardly a problem in the assessment.

If anything a patient will truly severe pain will be less distracted and able to provider a clearer verbal presentation of their condition.


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## JakeEMTP (Jul 4, 2012)

NYMedic828 said:


> Most reputable doctors will tell you that with the introduction of new technologies like ultrasound,MRI, X-ray that diminishing pain is hardly a problem in the assessment.
> 
> If anything a patient will truly severe pain will be less distracted and able to provider a clearer verbal presentation of their condition.




I guess that is one way to justify everyone getting an X-Ray, CT Scan or some other expensive assessment to make an ER visit cost over $2000 excluding all the specialists' fees to interpret the additional exams which are billed separately. 

As for being able to clearly verbalize their pain would depend on the pain, the cause and what you gave them. Different meds react differently on different people which depends on age. other existing illness and current medications.


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## usalsfyre (Jul 4, 2012)

JakeEMTP said:


> I guess that is one way to justify everyone getting an X-Ray, CT Scan or some other expensive assessment to make an ER visit cost over $2000 excluding all the specialists' fees to interpret the additional exams which are billed separately.
> 
> As for being able to clearly verbalize their pain would depend on the pain, the cause and what you gave them. Different meds react differently on different people which depends on age. other existing illness and current medications.



Multiple reviews have shown no outcome difference based on physical exam. The patients are likely going to get imaging regardless of opioids due to defensive medicine. Analgesia in this case is not terribly complicated.


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## Jeremy89 (Jul 12, 2012)

Okay, maybe its not because of the MD's assessment.  I guess I'm not 100% sure to be honest, but I would have to guess its between this and the short transport time in the Phoenix metro area. I haven't seen prehospital narcs given more than 3 times in the 4+ yrs I've been in this field.  I'll ask around to see if I can get a better answer for you. But it goes with the original discussion- unless they need a line for prehospital use, or can foresee the use of medical imaging in the ED, most Fire-Medics around here won't throw one in "just for fun".


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## NomadicMedic (Jul 12, 2012)

Jeremy89 said:


> ... I haven't seen prehospital narcs given more than 3 times in the 4+ yrs I've been in this field.  "...



Wait a second. You've only seen narcs given THREE times in 4+ years? Is this only for abd pain or in toto? I see you're not a medic, so do you normally attend ALS patients with a medic? Maybe you've missed the administration....

I find that I use pain meds at least one or twice a tour, and the majority of those uses fall into one of three areas; Abdominal pain. Back pain. Traumatic injury (ie: femoral head fx or isolated fx/dislocation)


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## Jeremy89 (Jul 12, 2012)

n7lxi said:


> Wait a second. You've only seen narcs given THREE times in 4+ years? Is this only for abd pain or in toto? I see you're not a medic, so do you normally attend ALS patients with a medic? Maybe you've missed the administration...



I work in the ED as a tech so I hear every report given to the RN/MD.  Can't say I've ever heard "I gave him 2 of morphine for the pain on the way over"...

Usually its "We've given 0.8 of Narcan with no response". Lol

I do some volunteer work at a Collegiate Squad and we had a head injury once at a standby event.  Got xported by private ambo as an ALS trauma.  When the crew returned I askedif he gave him anything for pain and he said no because of the head injury.


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## KellyBracket (Jul 12, 2012)

Jeremy89 said:


> ...  Can't say I've ever heard "I gave him 2 of morphine for the pain on the way over"...



Well, I hope not. Unless they weigh 20 kg.


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## Jeremy89 (Jul 12, 2012)

KellyBracket said:


> Well, I hope not. Unless they weigh 20 kg.



Exactly- even if they do give anything its something minute like that.

Had a resident on the floor the other day that didn't wanna give a pt Tylenol for pain for whatever reason.  So he ordered 1 of morphine with 4 of Zofran    Then he wimped out and didn't end up giving the guy anything for pain.  Absolutely ridiculous...


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## NomadicMedic (Jul 12, 2012)

Not ripping on you, but I hope I never get hurt in your neck of the woods. 

I have no problem giving 100mcg of Fentanyl to someone who's in pain... Especially if we're driving on a bumpy road. 

I had a recent call where a logger had a huge branch fall on his shoulder. He denied pain meds for the entire 2 mike carry out... Once I got him in the truck and talked him into some fent, he was a happy camper. He said, "damn, I shouldn't have kept saying no..."

If you've got the drugs and your patient is in pain, USE THE DRUGS.


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## Milla3P (Jul 12, 2012)

n7lxi said:


> If you've got the drugs and your patient is in pain, USE THE DRUGS.



This!
Especially if you have Fent, double Especially if you can give it Up the nose. 

Though during a recent state truck inspection I was informed by the inspector that pain meds were optional and all the trucks in my fair Capitol city were without...

Back to topic: I start locks regularly and give fluid about 1% of the time. I generally take bloods 99% of the time or more. Chest pain gets a line and bloods, abdo pain gets the same, as well as AMS, diabetics and all unknown unconsciousnesses. Though that's not the whole list. If we feel it's warranted well even bring in a green tube on ice for a VBG or a grey top for a lactic. 

Always before analgesics or benzos incase they want a Tox screen. 
Were also pretty lucky, we use these fancy "BD Nexiva" catheter systems an they're pretty much set up to draw bloods instantly. 





Who are we to determine who has real pain and who's pretending for meds? The fun thing about pain is that there's no real test for it and everyone's threshold is different. 

Heck, if we DO think they're faking the pain, what's terribly wrong with finding out if the Abdo hurts more or the 18g?

Like it was said earlier, we should be looking further down the line, clinically, for our Pts. If we think this pt might need that line for SOME reason in the next 2 to 96 hours (depending on your hospital's inclination to change the line) why withhold it?

If vascular access is mentioned in prehospital standing orders and The scenario fits the orders, why would you withhold it? (The "Follow your local protocols" argument)

Lastly, Practice Makes Perfect. Coming up with reasons to not start a line generally means that you could come up with reasons why you could of. The more you do, the better you will be for when someone really is circling the drain and you need to kick it into high gear. 

P. S. I am for IV access.


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## VFlutter (Jul 12, 2012)

Does any place actually use local anesthetic for IV insertion? I saw it a few times during my OB clinical. 


Although not entirely relevant, there is nothing more frustrating than responding to a RRT or Code for a patient without a patent IV. Yes, most can get one established fairly quickly or if the need arises, an IO but things can go south fairly quickly and sometimes on "stable" patients that is not expected. 


Personally, even the small potential for a future need justifies IVs in most situations


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## Tigger (Jul 12, 2012)

ChaseZ33 said:


> Does any place actually use local anesthetic for IV insertion? I saw it a few times during my OB clinical.
> 
> 
> Although not entirely relevant, there is nothing more frustrating than responding to a RRT or Code for a patient without a patent IV. Yes, most can get one established fairly quickly or if the need arises, an IO but things can go south fairly quickly and sometimes on "stable" patients that is not expected.
> ...



Wen I had my last line started on me at a tiny ED in Vermont, the nurse used some sort of "numbing swab" (her words), I think it was lidocaine but I can't be entirely sure.


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## NomadicMedic (Jul 12, 2012)

If a patient complaints and whines that the IV is "gonna hurt"... I usually offer some of this, PO, first. (especially if it's a big biker dude or someone covered in tats and piercings.)


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## VFlutter (Jul 12, 2012)

n7lxi said:


> If a patient complaints and whines that the IV is "gonna hurt"... I usually offer some of this, PO, first. (especially if it's a big biker dude or someone covered in tats and piercings.)



Oh :censored::censored::censored::censored:! You mean those are not suppositories? I've been giving them wrong....


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## EMTNJA (Jul 13, 2012)

In my system all ALS protocols call for establishing IV access. But it boils down to do they need one, and if they don't does the medic feel like he needs one for that particular patient. So bottom line ALS gets IV, and BLS no IV. Also very few medics in our system will do a saline lock, must hang a full liter whether or not pt needs fluids.


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## EMTNJA (Jul 13, 2012)

n7lxi said:


> Not ripping on you, but I hope I never get hurt in your neck of the woods.
> 
> I have no problem giving 100mcg of Fentanyl to someone who's in pain... Especially if we're driving on a bumpy road.
> 
> ...



Amen!


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## OIFXGunner (Jul 13, 2012)

EMTNJA said:


> In my system all ALS protocols call for establishing IV access. But it boils down to do they need one, and if they don't does the medic feel like he needs one for that particular patient. So bottom line ALS gets IV, and BLS no IV. Also very few medics in our system will do a saline lock, must hang a full liter whether or not pt needs fluids.



That seems like a waste of supplies to me... so you're telling me that the CHF patient with his lungs full of fluid is going to have a bag of the very thing that is causing his problem hung anyways?


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## NomadicMedic (Jul 13, 2012)

For what it's worth... my paramedic instructor, Mike Smith, was adamant about what he called "building a safety net". 

If you think you may need IV access, get it early. Don't get behind the eight ball. If you feel that patient may need multiple lines, START multiple lines. You may not ever hang a bag of fluid, but at least get the access before things start going down hill...

And really, the only way you get and stay good at any skill is by practicing. That's why I start a lock and draw blood on almost* everyone. They may not need fluid or meds right now... but I'm ready, just in case.

*there are exceptions to this rule.


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## EMTNJA (Jul 13, 2012)

Yep. The Resp. Distress algorithim line for CHF/Pulmonary Edema/Rales goes: Inital Medical Care>Establish IV Access(whcih as above to most medics means a bag)>Nitro>Lasix

Gross over simplification but there it is.


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## STXmedic (Jul 13, 2012)

I don't think he's arguing about the IV. Just seems a bit ridiculous to hang a liter on everybody when they're typically only TKO anyway. Fairly wasteful and pointless versus a lock or even a 500cc bag


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## EMTNJA (Jul 13, 2012)

PoeticInjustice said:


> I don't think he's arguing about the IV. Just seems a bit ridiculous to hang a liter on everybody when they're typically only TKO anyway. Fairly wasteful and pointless versus a lock or even a 500cc bag


I know. Just trying to point out that the protocols only mention access, and to most *cough* fire *cough* medics thats a full blown liter. (ALS-Fire based system)...


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## usalsfyre (Jul 13, 2012)

OIFXGunner said:


> That seems like a waste of supplies to me... so you're telling me that the CHF patient with his lungs full of fluid is going to have a bag of the very thing that is causing his problem hung anyways?



Look up the current thinking on the patho of CHF to see why fluid may actually be indicated in HF.


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## OIFXGunner (Jul 14, 2012)

EMTNJA said:


> I know. Just trying to point out that the protocols only mention access, and to most *cough* fire *cough* medics thats a full blown liter. (ALS-Fire based system)...



I can't say that I see where it matters whether medics work in a fire based system or in an EMS only system. Some of the best medics I've worked with are in fire departments and some of the worst have been from EMS only squads. Don't discriminate.







usalsfyre said:


> Look up the current thinking on the patho of CHF to see why fluid may actually be indicated in HF.



I did, and wasn't able to find anything to support fluid therapy in CHF patients. Perhaps you could post a link or two supporting that?


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## medicconnor (Aug 2, 2012)

Often times in EMS a IV in general is to establish access incase something becomes worse, Generally if you are going ALS a PT you will start a IV unless your being lazy (witch we are all guilty of)....

On the subject of ABD pain, we are required to preform 12-leads on them to rule out MI because sometimes, its referred pain.


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## NomadicMedic (Aug 2, 2012)

And by the way, there's no real cost difference between a 500ml bag and a 1000ml bag of NS.


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