# saline-lok opinion



## cookiexd40 (Mar 24, 2010)

so at my service everyone that gets an iv gets hooked up to a 10drop and 500cc of either LR or NS. my question is...how good or bad of an idea would it be to attemp to get the equipment to do saline locks in the back of the truck for pts that get an iv? we dont run medics here just emt-b and emt-i...so iv tx in prehospital is limited to narcan,D50, and fluid bolus. i feel that pts not neccessarily requiring any of these but could use iv access for further tx in the ER could use a saline lock. but i dont have any opinions other than my own and i havent even asked anyone about it. just curious i guess....any input would be great!!!


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## mississippimedic (Mar 24, 2010)

I think it is a good idea as long as your company does not have an issue with it.  At my former service the local hospitals supplied us with saline locks and blood tubes for us to go ahead and draw blood for their lab.  Not every medic choose to do this but the ones who did were apprieciated by the ER staff.  My current service does not allow locks or blood draws.


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## medicdan (Mar 24, 2010)

This is an interesting issue... and it's worth talking to your ER and service about... Some ERs like field sticks, others do not, and see them as dangerous (re: Infection Control). Because of fairly recent Medicare rules assigning blame for "Never Events" to the hospitals, more hospitals are skeptical of lines started by non-hospital staff, and in less then aseptic environments. 
Some hospitals accept prehospital blood draws, many do not, partially because of lab accountability, labeling, timing, etc.


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## cookiexd40 (Mar 24, 2010)

we have blood tubes on the trucks but dont have the blood draw option in our protocol, my old service did it for Co poisonings, but not here...we are city based fire and ems so i figure as long as our protocol doc is cool with it then i dont see an issue....


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## firecoins (Mar 24, 2010)

we do locks, Hospitals must do their own lab work.  I like the locks alot.


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## 8jimi8 (Mar 24, 2010)

at my hospital an EMS IV has a 24 hour life.  It would be a waste of medical supplies here.  But, nice idea


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## cookiexd40 (Mar 24, 2010)

i think if we had different drip sets and our protocol would be a little different then i wouldnt even have thought about it but, being im a new EMTI, i was just considering some things and i think that the loks would be beneficial to the pts in a situation where a 10 drop and a 500cc bag of lr or ns is jsut not really needed...but then i guess if its not needed then just not do an iv...idk it was just a thought


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## TransportJockey (Mar 24, 2010)

When I work the ED if the patient is being admitted, we pull the field stick right away. And since we have to draw labs anyways, we pull the field sticks when we do the lab draws and put a lock in at the new site.


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## cookiexd40 (Mar 24, 2010)

exactly...the ED hear replaces our 500cc bag and tubing with new tubing and a 1000cc bag


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## reaper (Mar 24, 2010)

May do this because of billing reasons, which is wrong. Medicare and insurances pay a lot more for a bag hanging, then for a lock. Some services require a bag on every IV, just so they get more reimbursement. I questioned this practice at a system years ago. They flat out admitted that they are reimbursed $15 for a lock and $75 for a bag hanging. So that was why they required a bag on every IV.

This is considered fraud, if the pt did not need it.

Any pt that does not need fluids, meds or has bad veins, should only need a lock placed.


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## TransportJockey (Mar 24, 2010)

reaper said:


> May do this because of billing reasons, which is wrong. Medicare and insurances pay a lot more for a bag hanging, then for a lock. Some services require a bag on every IV, just so they get more reimbursement. I questioned this practice at a system years ago. They flat out admitted that they are reimbursed $15 for a lock and $75 for a bag hanging. So that was why they required a bag on every IV.
> 
> This is considered fraud, if the pt did not need it.
> 
> Any pt that does not need fluids, meds or has bad veins, should only need a lock placed.



But there are lots of services who don't carry locks just for this reason. You can get away with the IV hanging 'just in case' a lot better if you are unable to place a lock due to not having it on the truck


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## cookiexd40 (Mar 24, 2010)

that brings up a completly different topic and a probably very aggressive and horribly burning answer from people on such topic lol...


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## Veneficus (Mar 24, 2010)

*Just my thoughts*

just a couple of quick things in the US hospitals.

Medicare no longer pays for hospitalization or extra treatment for preventable illness or injury. Some hospitals have reacted to this by immediately pulling field IVs. In one place I worked at they always pulled ED lines when the pt was admitted as a best practice even before this change. Likewise most PICUs I have seen will insert an IO with sterile technique and then pull an ED or EMS one if they do not go right to central line.

I think under the current auspices, doing procedures "just in case" will have to be reduced considerably. 

I do like precision and accuracy and I think many providers sometimes get carried away with the "what if's."

If you are using basics or Is to insert IVs, if the patient doesn't need immediate therapy you can provide, they are probably stable enough to make it to the hospital without the IV at all.


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## 18G (Mar 24, 2010)

We use saline-loc's more than anything. If the patient does not need fluid than why hang a bag, waste the fluid, and have one more thing to get tangled up during patient transfer? 

A loc will ensure venous access in case a patient needs a med or if they later do need fluid ran its as simple as plugging the tubing into the loc. 

I do not agree with hospital's pulling EMS IV's on an emperical basis. I would like to see research that say's EMS IV's are more prone to infection than those started in the hospital. If anyone knows of any research in this area I would love to read it.


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## lightsandsirens5 (Mar 24, 2010)

18G said:


> We use saline-loc's more than anything. If the patient does not need fluid than why hang a bag, waste the fluid, and have one more thing to get tangled up during patient transfer?
> 
> A loc will ensure venous access in case a patient needs a med or if they later do need fluid ran its as simple as plugging the tubing into the loc.
> 
> I do not agree with hospital's pulling EMS IV's on an emperical basis. I would like to see research that say's EMS IV's are more prone to infection than those started in the hospital. If anyone knows of any research in this area I would love to read it.



Well.......even if EMS IVs are more prone to infection, does leaving it in there increase that risk any? I mean the cath is already in place so any "unwanted stuff" is already in and washed into the person's system, right? If I am wrong, let me know. But it just seems logical to me.

And to answer the OP, we do saline locks all the time at my service. The ER here loves it if the pt comes in with a line already in place even if no fluids were run during transport.


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## MrBrown (Mar 24, 2010)

IV fluid is not magic, it provides no clinically therapeutic properties unless specifically indicated and to hang a bag of fluid everytime you gain venous access is a waste of time and pointless.


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## el Murpharino (Mar 24, 2010)

lightsandsirens5 said:


> I mean the cath is already in place so any "unwanted stuff" is already in and washed into the person's system, right? If I am wrong, let me know. But it just seems logical to me.



The "nasties" might be in their system, but the problems may not manifest until later.  You may only see localized pain in your prehospital patient care, but if left untreated, the phlebitis can cause edema to the site, blood vessel wall deterioration, extravasation of what is being infused - which could cause tissue necrosis....it's not just about the initial phlebitis, but what can result from it.


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## cookiexd40 (Mar 24, 2010)

well said el murph


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## Shishkabob (Mar 24, 2010)

I love having access to locks myself.  As stated, not every patient needs fluid, and I'd rather have the option of lock vs bag then being forced to do one or the other.


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## Tincanfireman (Mar 24, 2010)

I use more locs than I do bags of fluid; the ED nurses appreciate having IV access in place upon EMS arrival, but I won't do an unnecessary stick, either. If I have a pretty good idea the person is heading for Triage (i.e. "chairs"), then I won't waste the resources.


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## mycrofft (Mar 25, 2010)

*Another angle or two.*

1. Someone said don't run fluids if not needed. Bravo. My local EMS standard specifically prohibits starting an IV unless indications for IV treatment are met, NEVER for "just in case". If you do so, you are faced with the worst punishment they can offer, "Death by Mumbo".<_<

I think a saline lock would be better if you were teetering on the need to go parenteral but fluid balance was an issue, like a burn victim or seizure pt with CHF.  

2. When I worked ER, along with removing all field dressings and splints, we would D/C all field IV starts UNLESS we could not find another vein....usually due to the antecubes looking like they were attacked with a sewing machine. If a venous oriented problem arises, and that field start is still in place, someone would pay.

Really side bar: my vet charges $125 to use a saline lock for euthanasia. Pretty good for $0.50 worth of hardware. Wonder if HE would accept a field start?


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## The-Reaper (Mar 25, 2010)

I know when I worked as EMT-I any pre-hospital got a lock for three reason. 
1. keeps your skills up
2. They will need it at the hospital
3. You pt could take a turn for the worse


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## mycrofft (Mar 25, 2010)

*So in my county theoretically you would lose your permit.*

My (soon to be former) cohorts will flail and thrash and finally start a butterfly 22 ga as the paramedics are under 100 ft away.h34r:


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## boingo (Mar 25, 2010)

The saline lock is useful for extrication purposes.  How many lines have been pulled while carrying a patient down several flights of stairs?  You can always hang a bag later if needed.  Also, the hospital use our lines, but change out the bag and tubing, a lock makes that a whole lot easier than trying to disconect the IV tubing at the hub of the angio.


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## MrBrown (Mar 25, 2010)

The-Reaper said:


> I know when I worked as EMT-I any pre-hospital got a lock for three reason.
> 1. keeps your skills up



That's why we have an IV arm at the station.  



The-Reaper said:


> 2. They will need it at the hospital



Not true



The-Reaper said:


> 3. You pt could take a turn for the worse



If they are crook then yeah but I'm not gonna go cannulating every single patient I come across? Whats the point? Waste of resources, unnecessary procedure and causes the patient pain they do not need.


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## reaper (Mar 25, 2010)

Exactly right Mr. Brown, Those were the 3 worst reasons I have ever heard.


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## wyoskibum (Mar 25, 2010)

*Love Em!*



cookiexd40 said:


> so at my service everyone that gets an iv gets hooked up to a 10drop and 500cc of either LR or NS. my question is...how good or bad of an idea would it be to attemp to get the equipment to do saline locks in the back of the truck for pts that get an iv? we dont run medics here just emt-b and emt-i...so iv tx in prehospital is limited to narcan,D50, and fluid bolus. i feel that pts not neccessarily requiring any of these but could use iv access for further tx in the ER could use a saline lock. but i dont have any opinions other than my own and i havent even asked anyone about it. just curious i guess....any input would be great!!!



I've been lucky and have always had saline locks available.  Even if I'm going to be administering fluids, I always use the locks for the initial IV start.  I find it much easier to secure the IV once established, especially if I'm doing the IV enroute.  I know the hospitals that do use field IV's appreciate it as it make it easier to switch out IV's and tubing.  (Pump tubing, blood tubing).


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## cookiexd40 (Mar 25, 2010)

heck im proud of myself for coming up with a good informative thread for a change lol ...all very good responses guys and gals...keep'em coming


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## mycrofft (Mar 25, 2010)

*The "three-worst-reasons" thing...*

Rural squads used to get on the radio in eastern Nebraska to find a receiving hospital which would allow them to start IV's enroute. The distance to any hosp was basically the same when you lived in Emerald or Ashland and were driving to Lincoln.

Maybe bad reasons, but in an earlier age they were part of the prehospital EMS culture.


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## Veneficus (Mar 25, 2010)

*Some more logic from microbiology*



lightsandsirens5 said:


> Well.......even if EMS IVs are more prone to infection, does leaving it in there increase that risk any? I mean the cath is already in place so any "unwanted stuff" is already in and washed into the person's system, right? If I am wrong, let me know. But it just seems logical to me.



Certain microorganisms can form biofilms, particularly on indwelling catheters of various types, which protect them against the bodies natural defenses as well as medical therapy. 

In field conditions, particularly with improperly cleaned/stored equipment and improper short cuts in procedure, there is an increase  in the chances of introducing extra amounts of microorgansims. Consider as well, that the back of an ambulance is actually a medical facility and maybe colonized with more resilient organisms. The synthetic catheter provides and excellent medium for growth. Removing the contaminated medium, removes any potential biofilm that would form over hours to days, reducing the risk of pathogenesis. 

http://www.emsresponder.com/web/online/EMS-Education-and-Training/MRSA-Colonization-in-Ambulances/5$5711

Roline CE, Crumpecker C, Dunn TM: “Can methicillin-resistant staphylococcus aureus be found in an ambulance fleet?”  Prehospital Emergency Care . 11(2):241-244, 2007. 

The real danger is not in the introducing of small amounts of microorganisms, but in introducing them on a nonshedding medium that can be colonized in a way that renders host defense ineffective.

Restarting these IV lines in a cleaner (if not sterile) way, and changing them often is the best way to reduce biofilm colonization.

a few extra needle sticks to reduce the chances of developing a resistant sepsis seems like a very reasonable trade to me.


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## 18G (Mar 25, 2010)

I've started many lines in the ED and the aspetic technique is the same. Unless EMS is starting a line in the middle of a farm field just spread with manure or starting one in a ditch, I really don't think there is any difference from starting a line in a hospital versus someones living room. 

Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.


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## TransportJockey (Mar 25, 2010)

18G said:


> I've started many lines in the ED and the aspetic technique is the same. Unless EMS is starting a line in the middle of a farm field just spread with manure or starting one in a ditch, I really don't think there is any difference from starting a line in a hospital versus someones living room.
> 
> Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.



The primary reason that field sticks get pulled is that it's not a controlled enviroment when sticking. Combined that with the fact that some EMS providers have made a bad name for field IVs and the staff didn't see it started and can't see that it was done properly. Besides, if you have to stick for labs, why not just start a line you can be sure of while you're in the ED.


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## lightsandsirens5 (Mar 26, 2010)

el Murpharino said:


> The "nasties" might be in their system, but the problems may not manifest until later.  You may only see localized pain in your prehospital patient care, but if left untreated, the phlebitis can cause edema to the site, blood vessel wall deterioration, extravasation of what is being infused - which could cause tissue necrosis....it's not just about the initial phlebitis, but what can result from it.



OK. I think I get it. Thanks.


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## Veneficus (Mar 26, 2010)

18G said:


> Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.



86 living naturally on your skin.

Quantity is only part of the infectious equation. With a few exceptions the organisms crawling around a home are generally opportunistic infections. What may be surviving in a hospital or an ambulance has been specially selected for its pathogenicity. Those organsisms are very resiliant to start with and do not compete for resources with other organisms. (because the weaker ones are dead)  It is the same as in the hospital.

I remember reading somewhere (but I forgot where or I would post it) that the healthcare location found to have the most microorganisms was dialysis clinics. 

by the numbers if you start 1000 lines and only 1% gets an infection, that is still 10 people. 

I am not suggesting that hospital providers are better or worse at preventing infection, but considering the hospital will be eating the cost of treating patients, it is reasonable to think they want control over who is starting the line and taking every precaution they can to minimize the risk.

Can we honestly say or be sure that every field provider is taking every precaution when performing procedures? Can we say the place the trucks are kept in is relatively clean? Can a hospital fire a consistently negligent field provider who constantly costs them money?

Can this be said for a majority of agencies?

It is all about prudent precaution.


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## EMTinNEPA (Mar 26, 2010)

I am very fond of locks, as are most medics at my service.  Some medics will actually start a lock and, if the patient needs fluid, will connected the drip set to the lock via an alligator clip.


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## 8jimi8 (Mar 26, 2010)

Well i thought i didn't have much to offer to this conversation, but it just dawned on me, the differences in practice between lines I have started in the field and lines I have started in the hospital.

In the field, we are taught to cleanse the area vigorously with 2 alcohol wipes.  You know... the little 1inch squares...


In the hospital we use chlorhexidine scrubber pads.  I mean how much cleaning and friction can you actually get with a tiny little 1 inch square of alcohol impregnated gauze.


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## 18G (Mar 26, 2010)

In the hospital I started lines the most, we used the little glass ampule of alcohol that you crush which allows the alcohol to saturate the gauze at the end of it.... that was because that is what came in the IV start kit. Phlebotomy used the chlorhexidine sometimes. Usually the chlorhexidine was used when they were obtaining blood cultures. For routine venipunture they used alcohol wipes. 

The alcohol disinfects by its drying effect. The wiping motion obviously will physically remove some of the nasties but ultimately its the drying effect that kills the pathogens (least this is what I was taught).  

We get out IV start kits from the hospital so we use the glass ampules of alcohol to disinfect. 

Again, I would really, really love to see some real statistics on this issue. We may all be surprised by the research. Nonetheless, it would be very interesting!


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## 8jimi8 (Mar 26, 2010)

18G said:


> The alcohol disinfects by its drying effect. The wiping motion obviously will physically remove some of the nasties but ultimately its the drying effect that kills the pathogens (least this is what I was taught).



This is WRONG.  Alcohol only kills _until_ it evaporates and that is when it _stops_ killing.  

This is why you have 70% isopropyl alcohol because any higher percentage evaporates too quickly to kill anything.

forgot to add... and it depends on which IV start kits you get because ours come with the chlorhexidine scrubber pads.


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## mycrofft (Mar 26, 2010)

*Alcohol "dries cells out" by chemical processes.*

Alcohol attacks the cell walls and any lipids involved, chemically draws out the water; 70% with water solutions seem to be most effective. You can see the cells wither. More importantly from the aspect of cleansing a site, the friction and the solvent properties disrupt the substrate (film of sweat, oil, dirt, spooge, and biofilm) on the skin so if it is wiped off (say, with a nice sterile gauze pad) most of the little beasties and plantses are removed with it. "Wither goes the substrate, goeth the microflora and fauna". I've used straight Clorox in a pinch (scratched by pus-innoculated cat claws) and the wound healed with no scar.

SO....to the post...much of what we do is tradition and empiric practice immortalized in protocols. It still is impossible to sterilize skin without destroying it, but some approaches leave the site cleaner than others. In house risk managers want everything to be accountable to the hospital. This is almost ludicrous seeing as how the simplest way for germs to get in/on a patient is off of US, the scrubs we wear from home, the shoes we wear from the car into the hospital, the hands which we "wash" with a squish of scented hand lotion with a bit oif alcohol. 

If you take the time (like, tomorrow), and CLOSELY inspect many sterile supplies in your ambulance, you are going to find a percentage which are no longer air tight due to tiny friction spots created by being driven around all the time, thermal breakdown of pkg adhesives, and etc. You might even find, as we used to in the old Chevy van units in USAF, that actual road dust and exhaust particulates make their way into storage compartments.

Once again, also, there is no medical rationale for universal IV starts. Practicing your skills on someone is a tort. Not to be rude, but that sort of willfull malfeasance is unprofessional, childish, and actionable.

OK, so I DID mean to be rude. <_<


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## cookiexd40 (Mar 27, 2010)

i agree on how bad "practicing" your skills is not a good idea. and the cell wall, alchohol attacking. blah blah blah...lol no dis respect but i had to read it 5 times jsut to understand it..lol im just a new intermediate and the knowledge base is quite minimal at this point but iteresting to say the least


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## 8jimi8 (Mar 27, 2010)

cookiexd40 said:


> i agree on how bad "practicing" your skills is not a good idea. and the cell wall, alchohol attacking. blah blah blah...lol no dis respect but i had to read it 5 times jsut to understand it..lol im just a new intermediate and the knowledge base is quite minimal at this point but iteresting to say the least



Quoted for posterity's sake.  I can't believe you admitted that.  Now I officially understand and defer to Ventmedic's adamant advocacy for higher education for paramedics.  

I feel extremely humbled.

Vent, i have arrogantly chastised you for triumphing education with a passion and fervor that is unsurpassed.  I exetremely apologize for my previous comments and I vow to follow in your footsteps.


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## Veneficus (Mar 27, 2010)

Before you get carried away 

Sometimes I find, as I am sure other teachers do as well, when explaining concepts to the less initiated sometimes we take some liberties with simplifying the topic. 

It sounds like the case here as there is a reaction time involved with the alcohol, it is why we measure the velocity of reactions. Another memory aid persists where the original knowledge was lost. (if ever known)

(When explaining immunology to paramedic students, I have found covering the concept of MHC isn't part of the curriculum and doesn't exactly win applause from the people listening, so I try not to take it to that level)

How do you fault skills based providers from not knowing something other than what they are taught? If we really were serious about educating EMS providers, they would have to take chemistry and biology before EMT class. Good luck with that. (but if you succeed add biochem to the list too, especially for nurses)


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## cookiexd40 (Mar 27, 2010)

8jimi8 said:


> Quoted for posterity's sake.  I can't believe you admitted that.  Now I officially understand and defer to Ventmedic's adamant advocacy for higher education for paramedics.
> 
> I feel extremely humbled.
> 
> Vent, i have arrogantly chastised you for triumphing education with a passion and fervor that is unsurpassed.  I exetremely apologize for my previous comments and I vow to follow in your footsteps.




well ok to spare myself as much as i can....the way alchohol attacks the "nasties" has never been taught to me nor have i taken the oppritunity to learn it on my own. im still new enough in my career that i wish to work on skills and a basic knowledge level of wtf im supposed to do and how to treat pts. when i get a few years under my belt i would love to open my knowledge base up to the details and the science of our careers.


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## mycrofft (Mar 27, 2010)

*We're swerved afield, but one more step...*

cookiexd40, I get it. Not to worry. It's good to get a response to my rambles.

I took a "statistics for health professionals" course and it has stood me i good stead. I think there ought to similarly be classes in public health, microbiology, etc. geared towards the busy working/family EMT. And in the bioethics of decision making (risk versus benefit versus profit of blanket IV starts, for instance).

As useful a tool as a saline lock is, if you start one on me without need and try to charge me for it, you're going to be in small claims court and also find a copy of a letter of complaint to as many agencies and newspapers as my retired fingers can shoot 'em.


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## 8jimi8 (Mar 27, 2010)

cookiexd40 said:


> well ok to spare myself as much as i can....the way alchohol attacks the "nasties" has never been taught to me nor have i taken the oppritunity to learn it on my own. im still new enough in my career that i wish to work on skills and a basic knowledge level of wtf im supposed to do and how to treat pts. when i get a few years under my belt i would love to open my knowledge base up to the details and the science of our careers.



Cookie, please accept my apology to you as well, I intended no disrespect towards you.  Let me explain it this way.  If you DON'T have the education to back up your "skills," you really have no place practicing them.  You see what you have done is learned a potentially life threatening procedure, incompletely and backwards.  Education should come before implementation.  I was blinded by this because I was halfway though nursing school when I started my ems training.  So I came to this field with a baseline of education and basically took for granted that people had done the requisite education beforehand, as I did.  You see I had 4 semesters of education before anyone trusted me with a sharp and someone else's health in my hands.


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## audreyj (Apr 6, 2010)

I agree that you have to know why you're doing it before you're doing it.  And that starts with why you use alcohol, iodine, or clorihexidine, before doing any form of venipuncture.  Just saying, "I rub with alcohol because that's how I always do it", isn't good enough, you need to know the reasoning behind why you do it.

As for the saline lock vs bag debate, we have a choice to do either.  Certain standing orders require a 200cc bolus, in our suspected cardiac if the BP is high enough to give Nitro we're told to withhold a 2nd dose if there is no IV access.  I'm not going to start a drip on a hypertensive pt with a diastolic of 120 or higher, I'm going to lock it in case I need to push a drug.  Not every ALS patient requires an EKG, same goes for IVs.  I'm not going to use someone as a pincushion if I can tell they have poor veins.  

Our hospitals like when we start IVs in the appropriate situation.  They don't take too kindly to someone coming with an IV that could go to triage.  Also, depending on the facility, some EMS lines only have a 12-24 hour window before their changed.  If I were transporting to a facility that pulled out EVERY EMS IV, I wouldn't waste my time putting one in unless they absolutely positively needed it.


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## irish_handgrenade (Apr 7, 2010)

My partner and I both prefer to use locks, because our protocols call for an iv if possible for all ALS calls prior to dropping them off at the er. This being said not every pt. needs fluid or drugs, and I'm sure the pt would rather be charged for the lock and the flush rather than a bag of fluid, tubing, iv maintenance and all that other :censored::censored::censored::censored: that comes with it. Also if we deliver to a different hospital they might use different tubing and then they would have to dc at the hub and risk losing the iv or infecting the site. Bottom line locks are never a bad idea.


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## zzyzx (Apr 17, 2010)

I recently read a study that compared IV starts in the field vs. healthcare settings. The conclusion was that field starts did not result in a greater number of IV-site infections. 

I just spend a while looking for the article, but I couldn't find it. I'll keep searching...


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## cookiexd40 (Apr 17, 2010)

plz do id like to read it


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## zzyzx (Apr 18, 2010)

Field-Started vs. Hospital-Started IVs

The risk of complications may be no greater in IVs inserted outside the hospital.

Researchers have reported conflicting results in
trying to determine if peripheral IVs started
“in the field” by emergency services personnel
(EMTs and paramedics) result in a higher incidence
of complications than those started by hospital
staff.
The Centers for Disease Control and Prevention
(CDC) offers extensive guidelines for the use of
any intravascular device, including peripheral IV
lines (http://www.cdc.gov/ncidod/hip/
iv/iv.htm).1 Based on current research into
intravascular device–related complications such as
phlebitis and infection, these recommendations
are used by health care facilities in writing their
own policies. The CDC advises that all fieldstarted
IVs (sometimes called prehospital IV starts)
be discontinued and new IVs placed after hospitalization.
But the CDC has acknowledged that
there’s no evidence that field-started IVs carry a
greater risk of infection2; furthermore, most
researchers have assumed that such IV starts occur
without aseptic technique. But this assumption is
flawed.
The Intravenous Nursing Standards of Practice
regarding peripheral IV lines give more weight to
what clinicians observe.3 These state that if there
are no signs of complication in the patient or of IV
contamination, the IV shouldn’t be discontinued,
regardless of who started the line and where.
They also state that signs of IV contamination,
phlebitis, or infection warrant immediate discontinuation
of the line.
The latest research supports these recommendations.
One study of peripheral IV–related phlebitis
examined 305 IV sites in 188 adult patients at a
Midwestern hospital.4 There were 10 occurrences
of phlebitis, but none was associated with the five
field-started IVs.
Researchers at a level I trauma center in Ohio
found no compelling data for the mandate that all
field-started IVs be discontinued and restarted at
hospital admission.5 The researchers developed an
algorithm to help nurses decide if a field-started IV
should be discontinued or could be left in place
for up to 72 hours (as IVs started in the hospital
were). Findings of two older studies conflict, yet
neither found high enough complication rates with
field-started IVs to warrant hospital mandates that
would change all such lines on hospitalization.
Lawrence and Lauro found that the risk of complications
increased when IVs were started in the field
by emergency personnel.6 But the study was small
and flawed—one EMT’s use of nonaseptic technique
was deemed responsible for most of the
complications. And a retrospective study by Levine
and colleagues established a lower infection rate
in field-started IVs than in hospital-started IVs.7
Hospitals should allow nurses to assess all IV
lines—both field started and hospital initiated—to
determine whether an IV is compromised. And
nurses should consider the circumstances under
which a line was started. For example, if EMTs
inserted a line while extracting a patient from a
wrecked vehicle, aseptic technique was probably
not used; in such cases, the IV should be discontinued
and restarted. In general, though, in the
absence of contamination or complications, an IV
change—an often painful procedure—isn’t necessary
for all field-started IVs. A more judicious policy
toward field-started IVs will save time and
reduce costs.—Rosalyn Gendreau-Webb, BSN,
RN, an ED staff nurse at Mercy Hospital,
Portland, ME
REFERENCES
1. O’Grady NP, et al. Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control
and Prevention. MMWR Recomm Rep 2002;51(RR-10):1-29.
2. Pearson ML. CDC guideline for prevention of intravascular
device-related infections: Part 1. Intravascular device-related
infections: an overview. Part 2. Recommendations for prevention
of intravascular device-related infections. Infect
Control Hosp Epidemiol 1996;17(7):438-73.
3. Infusion nursing standards of practice. Journal of Intravenous
Nursing 2000;23(6S):S56-S69.
4. White SA. Peripheral intravenous therapy-related phlebitis
rates in an adult population. J Intraven Nurs 2001;24(1):
19-24.
5. Shreve WS, Knotts FB. Quality improvement with prehospital-
placed intravenous catheters in trauma patients. J Emerg
Nurs 1999;25(4):285-9.
6. Lawrence DW, Lauro AJ. Complications from IV therapy:
results from field-started and emergency department-started
IVs compared. Ann Emerg Med 1988;17(4):314-7.
7. Levine R, et al. Comparison of clinically significant infection
rates among prehospital- versus in-hospital-initiated IV lines.
Ann Emerg Med 1995;25(4):502-6.


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## MGary (May 7, 2010)

Lock vs Line is our judgement call here. A Line can always be screwed onto the lock later. On drunk/non-cooperative/dependent patients I try to throw on a lock first since as a CNA I know how much of a pain it is to try and change someone from street clothes to a gown when they have a line in. Being able to take the line off and go with just the lock during the change of clothing makes the nurses far happier with you. I also throw locks on anyone that might go to surgery or need a contrast CT or MRI later but who doesn't need a bolus.


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## RDUNNE (May 7, 2010)

We have locks at my service, but due to the transport times (no hospital in our area, min. 30 minute transport) most of the medics go ahead and start fluids. We also have blood draw kits but they are almost exclusively used for drawing blood at the local jail.


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## PotashRLS (Jun 23, 2010)

This is an excellent thread.  It really shows how the same procedure or intervention can be so differently viewed or used in various areas of the country.


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## 1badassEMT-I (Jun 24, 2010)

18G said:


> We use saline-loc's more than anything. If the patient does not need fluid than why hang a bag, waste the fluid, and have one more thing to get tangled up during patient transfer?
> 
> A loc will ensure venous access in case a patient needs a med or if they later do need fluid ran its as simple as plugging the tubing into the loc.
> 
> I do not agree with hospital's pulling EMS IV's on an emperical basis. I would like to see research that say's EMS IV's are more prone to infection than those started in the hospital. If anyone knows of any research in this area I would love to read it.



Finally another WV person here I have found!


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## Lone Star (Jul 4, 2010)

The-Reaper said:


> I know when I worked as EMT-I any pre-hospital got a lock for three reason.
> 1. keeps your skills up
> 2. They will need it at the hospital
> 3. You pt could take a turn for the worse





This has got to be the worst 'justification' for poking a patient I've ever heard!

These are people, not training aids!  To simply do something 'to keep your skills up' amounts to nothing more than abusing your patient.  This is NOT why we do what we do!

I can understand starting an IV if the patient NEEDS one, but to simply do it to 'keep the skills up' is akin to intubating a patient 'just because'....


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## reaper (Jul 4, 2010)

You mean you dont intubate most of your Pt's, just to keep freash on it?

Maybe that's why my Pt's don't like me!!!!!!!!!


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