# Trouble with Ivs



## SeeNoMore (Nov 22, 2012)

I'm a new paramedic working for a transport company that does a lot of critical care transport. I have had command for 3 months. We also do infrequent emergency runs from nursing homes. Overall I feel I am doing a decent job with the critic care runs and am keeping in the books in an effort to become as educated as I can be. However my iv skills are very weak. I have read everything I can on different techniques and am trying to improve but my progress seems slow at best. The odd thing is that in school and orientation I did not miss many. Now while most pts will get an iv it is common to need two attempts and the last month has been awful with several pts arriving at the ed with no access. Generally if the pt is not in dire need of access I stop at two attempts. I am trying to stay positive and honestly report my failures but as my success rate hovers around 50 percent I cant help but feel like the worst medic ever. Ive spoken to a supervisor who felt my technique was ok but its not iv arms or pts with decent veins I have trouble with. I was hoping others could share their thoughts of experience. I am also starting some 911 time so maybe that will give me more regular exposure. Thanks.


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## Shishkabob (Nov 22, 2012)

Just keep going.


Hell, been doing it for close to 3 years now, and I had a stretch of WAY too long rather recently where I couldn't hit a darn thing, no matter how great and easy the vein was.


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## Thricenotrice (Nov 22, 2012)

Are you going in right where you see it and where you want to be? Or are you inserting a little before and "fishing" for it


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## SeeNoMore (Nov 22, 2012)

I typically get a flash but have difficulty advancing the cath.  I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.


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## SeeNoMore (Nov 22, 2012)

And thanks linuss good to know.


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## Tigger (Nov 22, 2012)

SeeNoMore said:


> I typically get a flash but have difficulty advancing the cath.  I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.



I also had difficulty with lowering the needle and was told to drop the cath even lower than the book recommended "10-15 degrees" to more like 5, this helped a lot.


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## NomadicMedic (Nov 22, 2012)

If you can, get some more ER time. Most medical directors would rather have you be proactive in improving your skills. The only way to get good at IVs is to do a lot of them.


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## pghboy2011 (Nov 22, 2012)

Hi There! 

I can say from an EMS Standpoint,and working in hospital...bigger is NOT always better. 20-22 is almost always appropriate, and the AC isn't your only option!! For some reason, medics I know are HELL-BENT on an 18g. If the PT isn't a trauma, ST-E, or arrest, you can drop to a 20, or 22.

My best advice for you on the ones who are more difficult to stick, don't be afraid to use gravity as your friend...put a tourniquet, and just let the arm hang down for a 30 seconds, if you can't feel, or palpate an appropriate vein, put on another tourniquet distal the other. When in doubt, start with a 22, if the vein can support a 20, go for that (with the exception of arrests, those are definitely bigger, the better), but for pre-hospital, and in-hospital, a 20 is almost always appropriate, and 22's are also appropriate. If they need to go in with a bigger needle in hospital, that's fine, but for the ambulance ride, if you're just worried about maintenance fluids, and maybe some pain meds, a 22 will do the job, and when you get to the hospital, and they go to draw blood, that 22 will work just fine also. 

Also, take a tourniquet, and tape it to a desk, or something similar, take an IV cath, with a needle, and just practice. Someone before me mentioned the 5 degrees, I like that number...if you tape the tourniquet, and keep a part of it pulled tight, you'll be able to practice. Grab it with your 2nd and 3rd fingers, tilt it just enough to pierce the skin (tourniquet in the case of practicing)...remember...you only need to typically insert the needle until you get a flash...once you get the blood return, start advancing the cath, otherwise, you can risk piercing, and blowing the vein. 

You're skills will develop. You just have to miss a few times, until you can palpate effectively...use your eyes less, and your fingers more...also...don't be fooled by the garden hoses, they can be tricky with valves!!!

Good luck to you!


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## RocketMedic (Nov 22, 2012)

Even in trauma, you really don't need to be using anything larger than 18g IVs. We really don't want to be adding saline to blood that we want to clot, and a 20G will support what we want quite reasonably. 

I've only started a handful of 16g IVs and never a 14g in my career. No reason to.


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## pghboy2011 (Nov 23, 2012)

Rocketmedic40 said:


> Even in trauma, you really don't need to be using anything larger than 18g IVs. We really don't want to be adding saline to blood that we want to clot, and a 20G will support what we want quite reasonably.
> 
> I've only started a handful of 16g IVs and never a 14g in my career. No reason to.


Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way,  than I am trying to clot an internal bleed. 

16's and 14's are almost always unreasonable.


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## VFlutter (Nov 23, 2012)

pghboy2011 said:


> Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way,  than I am trying to clot an internal bleed.
> 
> 16's and 14's are almost always unreasonable.



Just keep them at a MAP of 60-70. No need try to get them normotensive.


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## NYMedic828 (Nov 23, 2012)

SeeNoMore said:


> I typically get a flash but have difficulty advancing the cath.  I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.



Little tip.

When you insert the catheter, brace your fingers to the skin of the patient and use your index finger to advance the catheter into the vein, firmly holding onto the barrel of the rear half of the angiocath.

As silly as it is, for a good few IVs whenever I tried to push them forward with my index finger I would instead pull the needle backwards, removing it from the vein that was successfully punctured.


Also as stated, very rarely is anything bigger than 18 necessary and the chance of failure is substantially higher for a needle as large as a 16/14g. I put a 20 in 80% of patients. I use an 18 for trauma, fluid resus and if the patient happens to have pipelines I know for a fact I won't miss.


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## Akulahawk (Nov 23, 2012)

My normal go to IV size is 18g. I have rarely placed in IV that was larger than that, those very few times that I have, the patient truly needed fluid. I feel no shame in going for a 20g IV, I just prefer what ever size fits the vein appropriately. Personally, I think in 18 g IV catheter is a good compromise size. You get the good flow rate of a larger bore IV and the ease of placement of a smaller gauge. I'm certainly not hell-bent on sticking with that particular size however. A 20 g IV will do just fine if that is all I can place.


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## usalsfyre (Nov 23, 2012)

pghboy2011 said:


> 16's and 14's are almost always unreasonable.



Have you participated in very many resuscitations? Generally the bigger/more accesses available the better.


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## usalsfyre (Nov 23, 2012)

SeeNoMore said:


> I'm a new paramedic working for a transport company that does a lot of critical care transport.


No offense, but what are you doing on these runs? CCT is a seperate sub-discipline that requires if not mastery than at least a strong base in paramedic level care. What are you considering to be CCT?


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## Aidey (Nov 23, 2012)

pghboy2011 said:


> Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way,  than I am trying to clot an internal bleed.
> 
> 16's and 14's are almost always unreasonable.



If you can't clot the bleed, for the love of the FSM don't dilute their clotting factors into kool-aid! Permissive hypotension is a good thing. Dumping a few liters of saline in them is going to do more to prevent a clot than it will help their BP. 

16s and 14s are perfectly reasonable if the pt actually needs fluid resuscitation (think sepsis) or you anticipate the pt will need blood products and/or surgery.


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## ExpatMedic0 (Nov 23, 2012)

if its a code just go straight to EZ-IO


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## VFlutter (Nov 23, 2012)

schulz said:


> if its a code just go straight to EZ-IO



It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.


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## usalsfyre (Nov 23, 2012)

One of which would be a peri-arrest patient your trying to keep from coding....

What are you basing your opinion of not needing to use IO access on?


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## Aidey (Nov 23, 2012)

ChaseZ33 said:


> It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.



Right. Because we arrive on scene before most of our cardiac arrest patients get around to coding.


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## VFlutter (Nov 23, 2012)

usalsfyre said:


> One of which would be a peri-arrest patient your trying to keep from coding....
> 
> What are you basing your opinion of not needing to use IO access on?





Aidey said:


> Right. Because we arrive on scene before most of our cardiac arrest patients get around to coding.



That comment was phrased poorly, I was trying to make the point that you should not rely on IO access due to poor IV proficiency. Yes, if they are peri-arrest and have no viable IV access then go for the IO. But being able to secure IV access, even with difficult anatomy, is a key skill. In my personal experience few patients truly have no viable veins.


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## SeeNoMore (Nov 23, 2012)

usalsfyre said:


> No offense, but what are you doing on these runs? CCT is a seperate sub-discipline that requires if not mastery than at least a strong base in paramedic level care. What are you considering to be CCT?




No offense taken. I don't mean to pretend I am some expert on critical care. Its als transport with vent pts and pts on drips. Its actually the only place I applied that called me back. We do backup for a more formal critical care and 911 hospital based service. So often pts are very ill and sometimes going long distances. I understand critical care is a specific field and ibreally enjoy it. I study a lot and have piles of books on cardiology rt critical care etc. But I see why you could object to me doing the job. I just hops 911 time will help me out. 

Thanks everyone else for all the iv suggestions.


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## usalsfyre (Nov 23, 2012)

ChaseZ33 said:


> In my personal experience few patients truly have no viable veins.



Which, no offense, is incredibly limited. There's also a difference between "no viable veins" and "no veins that will support what I need in the time it will take to access them". Finally, your used to working with backup, often not the case out-of-hospital.

Realistically an IO is less invasive than a central line. Yet I rarely see an issue made by nursing over centrals. What it really comes down to is comfort zone.


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## TransportJockey (Nov 23, 2012)

I've spent two years as an EMT-I and now a medic for coming up on a year... I still have times I can't stick for crap. It happens. On the elderly, some times you might want to try not using a tq at all. I've gotten decent at not using one on elderly patients, especially those on Warfarin or with very fragile skin, and gotten good results.

As for big lines... in the past month I've started... 6, I think, 14g lines. 5 of those on real honest to goodness septic shock patients who I've given at least 2l of fluid to during transport. One of which wound up with a second line (20g) in his wrist so I could run dope after I ran in my 3L of NS.


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## TransportJockey (Nov 23, 2012)

SeeNoMore said:


> No offense taken. I don't mean to pretend I am some expert on critical care. Its als transport with vent pts and pts on drips. Its actually the only place I applied that called me back. We do backup for a more formal critical care and 911 hospital based service. So often pts are very ill and sometimes going long distances. I understand critical care is a specific field and ibreally enjoy it. I study a lot and have piles of books on cardiology rt critical care etc. But I see why you could object to me doing the job. I just hops 911 time will help me out.
> 
> Thanks everyone else for all the iv suggestions.


Hey one class I recommend if you can swing the cost is the Creighton Univserity distance learning CCP class. I'm doing it now because at my transfer service we run patients similar to yours, and as a new medic I wanted the extra education.


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## the_negro_puppy (Nov 23, 2012)

Back to the OP-

Practice makes perfect. It took me just over a year of starting IVs to get really decent at them.

Vein selection. Spend extra time looking for suitable veins don't just compromise on the first you see.

Hand veins are easy to see but often hurt more and are more fragile. I go the forearm if possible. Still allows use of wrists hands and elbows.

Traction is under-estimated. always pulls the skin taught to allow proper penetration and prevent veins from rolling.

Tourniquets are not always necessary- today my student had 2 attempts on a 95 y.o with very visible veins. Both vein 'blew out" immediately. The pt's BP was 168/90 and with a tourniquet on the veinous pressure was high. I removed it completely and cannulated with ease.

- Dangle the limb, use gravity to engorge veins. The warmer the limb the better.

- I always insert the needle at the shallowest angle possible. Make sure when you get flash you advance the needle little bit more before you slide the catheter forward. The tip of the needle may be in but the tip of the cath may not be.

- If you are getting flash and can't advance you are most likely going through the other side of the vein. Go more gently. Other reasons are that you may be up against a valve or the wall of the vein. Try adjusting the direction of the cath or using saline to 'float' it in through a valve.


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## ExpatMedic0 (Nov 23, 2012)

ChaseZ33 said:


> It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.


not to "play the protocol call card" but going straight to IO in the case of cardiac arrest is written into many protocols. 

If your the only ALS provider (and lets just assume your not one of the best at your agency when it comes to IV's), do you think taking extra time and possibly multiple attempts of placing an IV line on an obese dead person will out way the benefit? The person is already dead...

Can you show me some peer reviewed evidence or anything that would suggest that going straight to IO with a product like EZ-IO is less beneficial in cardiac arrest or ROC?

in terms of the OP. He/she is struggling with IV access, I think mentioning IO for a possible code situation is quite relevant to the topic


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## SeeNoMore (Nov 23, 2012)

Certainly I would use an io if the need was there. I have placed two during my clinical ride time. So far the majority of pts who I wish to gain access on get an iv. I just want to reduce attempts made. I really appreciate all the tips.


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## rwik123 (Nov 23, 2012)

Can someone explain the "floating technique". My preceptor was trying to explain it to me as I was sticking a patient the other day and I just couldn't get it. Also the technique of using the flush to open valves to make advancing the cath easier.


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## NYMedic828 (Nov 23, 2012)

rwik123 said:


> Can someone explain the "floating technique". My preceptor was trying to explain it to me as I was sticking a patient the other day and I just couldn't get it. Also the technique of using the flush to open valves to make advancing the cath easier.



Unlike arteries, veins have "valves." These valves are for the purpose of preventing the backflow of blood. They open only in one direction and they require pressure in that direction to force them open. 

Blood does not flow through veins as simply as it does in arteries. Arteries receive direct pressure to move blood from the pumping action of the heart. By the time blood reaches post capillary venous circulation the pressure is mostly diminished and requires the action of skeletal and respiratory muscles to keep the blood moving. The valves essentially prevent the blood from moving backwards towards arterial circulation and heading in the direction of the heart.

The valves appear as little bumps on the veins. Unless it is your only available vein, it is best to avoid a presumed valve as it is like trying to push a firehose through a locked door. The only way you are going to get it through is with force, which causes damage and could blow out the vein. 

What people are saying when they refer to "floating" is as follows:

When you insert your angiocath and get flash and all that good stuff, you go to advance your catheter and it seems to get stuck halfway. You presume you are "in" but you just can't advance the catheter, odds are you hit a valve. So at this point, you attach a flush to your catheter and attempt to flush the vein while advancing the cath in at the same time essentially "floating" it in and trying to force the valve open with the pressure of the flush. I would advise removing the VCB prior to attempting to float the catheter as well.


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## Shishkabob (Nov 24, 2012)

ChaseZ33 said:


> It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.



And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO.  As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.  


Drill 'em when you can prevent it, drill 'em when you can't.  



As an aside, I brought in a hypotensive GI/Vaginal bleed to a level 1 trauma center not too long ago, and I was BARELY able to get a 22g in a hand vein.  Some of the nurses did a friendly scoffing when they saw it... and proceeded to miss 4 sonogram guided IVs, 2 EJs, a femoral cut down, a foot cut down, and finally had to have a trauma surgeon do a central.  The doc laughed saying "He did that bouncing down the road and you can't do it with her sitting here for 40 minutes?"


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## NYMedic828 (Nov 24, 2012)

Linuss said:


> And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO.  As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.
> 
> 
> Drill 'em when you prevent it, drill 'em when you can't.
> ...



If working an arrest I take a quick look at both arms and legs, look at the neck, if I see nothing I don't putz around with making them a pin cushion I go straight for the tibial EZ-IO. I wish we had humoral IO as studies have been showing it as equal efficacy to IV access. Hopefully we will have it at some point but we don't currently have the 145mm needles even if I wanted to do it.

Have to hear words from time to time as to why no IV attempt was documented and I went straight to using a $114 needle.


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## Shishkabob (Nov 24, 2012)

NYMedic828 said:


> If working an arrest I take a quick look at both arms and legs, look at the neck, if I see nothing I don't putz around with making them a pin cushion I go straight for the tibial EZ-IO. I wish we had humoral IO as studies have been showing it as equal efficacy to IV access. Hopefully we will have it at some point but we don't currently have the 145mm needles even if I wanted to do it.
> 
> Have to hear words from time to time as to why no IV attempt was documented and I went straight to using a $114 needle.



Yeah my medical director is not a fan of the IO and wants us to do the 90 second / 2 try thing "if there's time".


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## NYMedic828 (Nov 24, 2012)

Linuss said:


> Yeah my medical director is not a fan of the IO and wants us to do the 90 second / 2 try thing "if there's time".



Medical director doesn't care here.

Its the bosses who act like it comes out of their pocket.


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## NomadicMedic (Nov 24, 2012)

I use an IO on every arrest. Nobody says anything.


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## RocketMedic (Nov 24, 2012)

Linuss said:


> And if I have a peri-arrest patient, they're getting what I can get in the quickest, which typically is an IO.  As a corollary, it's far more important to obtain the IO then take the time searching for an IV after they arrest.
> 
> 
> Drill 'em when you can prevent it, drill 'em when you can't.
> ...



I'd have EZ-IOed.


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## RocketMedic (Nov 24, 2012)

n7lxi said:


> I use an IO on every arrest. Nobody says anything.



Pretty much the same here. We can go humoral or tibial. I personally look for an amazing AC then go IO.


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## Sublime (Nov 24, 2012)

n7lxi said:


> I use an IO on every arrest. Nobody says anything.



Does anyone look for an EJ before going IO in an arrest?


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## Sublime (Nov 24, 2012)

n7lxi said:


> I use an IO on every arrest. Nobody says anything.



Anyone try for an EJ before going IO?


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## Sublime (Nov 24, 2012)

Double post sorry ... iPad acting up


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## NomadicMedic (Nov 24, 2012)

Funny, I just told my partner I was gonna look for an EJ on my next code. It's been a while since I started one.


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## Jon (Nov 24, 2012)

Sublime said:


> Does anyone look for an EJ before going IO in an arrest?



Sounds dumb- I usually forget. I've never done one.


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## RocketMedic (Nov 25, 2012)

Sublime said:


> Anyone try for an EJ before going IO?



It's honestly never crossed my mind. I like to drop a C-collar on after we intubate to appease the Protocol Gods.


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## usalsfyre (Nov 25, 2012)

Rocketmedic40 said:


> It's honestly never crossed my mind. I like to drop a C-collar on after we intubate to appease the Protocol Gods.



Just as an aside...on a totally anecdotal level I'm not sold on the utility of c-collars for this purpose.


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## NYMedic828 (Nov 25, 2012)

Never have I used a C-collar for maintaining airway. Tape the tube and don't kick the head around...


I also have never personally started an EJ. My partners have. I just find it easier to grab the IO if I don't have a peripheral vein.


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## ffemt8978 (Nov 25, 2012)

n7lxi said:


> Funny, I just told my partner I was gonna look for an EJ on my next code. It's been a while since I started one.



Our medical director prefers us not to use the EJ if an IO is available, but it's not forbidden outright.  Just strongly discouraged.


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## RocketMedic (Nov 25, 2012)

usalsfyre said:


> Just as an aside...on a totally anecdotal level I'm not sold on the utility of c-collars for this purpose.




Neither am I, but it is what it is. Personally, I've always thought that the best answer to maintaining a stable position of an intubated patient is to tape it in, recheck it after every move, and monitor capnography thoughout. Collars and backboards put a lot of unneeded manipulation of that head, neck and airway into place and breed complacency.


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## usalsfyre (Nov 25, 2012)

I'm really surprised by the number of people who have never started an EJ. When I was on the truck I usually started at least one a week. If I need good access and the arms look iffy, I go to the neck.


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## Handsome Robb (Nov 25, 2012)

usalsfyre said:


> I'm really surprised by the number of people who have never started an EJ. When I was on the truck I usually started at least one a week. If I need good access and the arms look iffy, I go to the neck.



I'm the youngest medic at my company and people look at me like I have 3 heads when I bring in patients with EJs courtesy of yours truly.

"Why didn't you just do an IO?" 

While an EJ is definitely invasive an IO surpasses it, no reason to put a hole in someone's tibia when you can easily drop a peripheral line in their EJ and yes, an EJ is a peripheral line. Plus, they tend to flow better, in my experience, even if the IO was properly placed and flushed. 

Still generally go straight to the IO in arrests though.


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## shfd739 (Nov 25, 2012)

NYMedic828 said:


> Never have I used a C-collar for maintaining airway. Tape the tube and don't kick the head around...
> 
> 
> I also have never personally started an EJ. My partners have. I just find it easier to grab the IO if I don't have a peripheral vein.



Same here..

Reminds me I havnt started an EJ in years. Ive either had good luck with the arms or it was a code which for us is EZIO for access.


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## usalsfyre (Nov 25, 2012)

shfd739 said:


> Same here..



It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....


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## shfd739 (Nov 25, 2012)

usalsfyre said:


> It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....



I havnt thought about it before but you're right. 

None of my vented patients have collars unless the hospital left it in place/or applied it because imaging showed an injury. 
And we've never displaced one moving someone without it.


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## RocketMedic (Nov 25, 2012)

I think the collar instills false confidence.


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## VFlutter (Nov 25, 2012)

usalsfyre said:


> It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....



Are you guys using commercial ET tube holders or tape? 

The ICUs around here use the hollister anchor fast and they seem to work great. I assume they would be good for transport as well.


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## NYMedic828 (Nov 25, 2012)

ChaseZ33 said:


> Are you guys using commercial ET tube holders or tape?
> 
> The ICUs around here use the hollister anchor fast and they seem to work great. I assume they would be good for transport as well.



Volly establishment has the clamping tube holder with the velcro, FDNY uses Hy-Tape.


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## Sublime (Nov 25, 2012)

usalsfyre said:


> It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....



I worked in a level 1 trauma center ER and all we used to secure tubes (in non c-spine precaution patients) was string. Can't think of the name of the string/tie we used for some reason but it looks like shoe lace kind of. We would move people from the bed to the CT machine then back to the bed and up to the ICU bed... never needed a c-collar to keep the tube secure.


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## Aidey (Nov 25, 2012)

usalsfyre said:


> It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....



Here that gospel was started by the ED docs after a couple of tubes were displaced. There were a couple of incidents in which the crew swore the tube was in, but the hospital found it was bad. The c-collar rule was implemented along with a couple other rules in an attempt to prevent fighting between us and the hospital about who displaced the tube.


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## Shishkabob (Nov 25, 2012)

Meh, it can't hurt, and that's probably the only thing in medicine that is true in regards to no evidence.


I pop one on when I remember... and when I'm not doing every single damn other thing.


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## firecoins (Nov 25, 2012)

On my last cct of an intubated pt, I put a c collar on to protect to tube. We hit some rough roads under construction around the receiving facility and wanted extra protection.


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## Thricenotrice (Nov 25, 2012)

Why are the EJs discouraged? Possibility of an embolus? Only been trough internship with no job yet but I started one almost every shift on people with terrible vasculature


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## NYMedic828 (Nov 25, 2012)

Thricenotrice said:


> Why are the EJs discouraged? Possibility of an embolus? Only been trough internship with no job yet but I started one almost every shift on people with terrible vasculature



I wouldn't say anyone discourages them here but we really only use them on a patient in extremis or in arrest. On a patient in arrest, doesn't really matter just get the access in as timely a manner possible (which it's almost always faster to use an IO) but for a living patient you do run risks by using an EJ. The main factor in my eyes if just the dangers of making a mistake in that region where you can easily spike an artery instead of a vein. I advise against EJs while moving but Im not a cowboy like some people.

Some providers here work single provider and the cop (CPR trained only) will drive the ambulance so they always try to get an EJ so they can run the entire arrest from the head. (Meds/airway)



Back to the ET tube securement, the only time I have had a properly inserted tube displace is when an EMT or firefighter forcibly pulled it out of place. Never has patient movement messed up my tube. Don't we all use capnography? It's pretty obvious when the tube is out of place if your waveform goes from 40mmHg to 0...


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## Shishkabob (Nov 25, 2012)

EJs aren't frowned upon here, but it's always entertaining to see a nurses face when you walk in with one.  (Even the local L1 trauma doesn't allow their nurses to do them anymore).


Although it IS considered a peripheral access point just like an AC or hand, it conjures up more serious thoughts.  If I've run out of the usual suspects, something is needed, but haven't justified an IO, I'll do an EJ.


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## TransportJockey (Nov 25, 2012)

Linuss said:


> EJs aren't frowned upon here, but it's always entertaining to see a nurses face when you walk in with one.  (Even the local L1 trauma doesn't allow their nurses to do them anymore).
> 
> 
> Although it IS considered a peripheral access point just like an AC or hand, it conjures up more serious thoughts.  If I've run out of the usual suspects, something is needed, but haven't justified an IO, I'll do an EJ.



The hospitals here consider them 'central access' so the RNs, even at the state L1 TC, are always freaked when I roll in with someone with one


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## VFlutter (Nov 25, 2012)

TransportJockey said:


> The hospitals here consider them 'central access' so the RNs, even at the state L1 TC, are always freaked when I roll in with someone with one



I hate that. According to the INS and AVA an EJ is a peripheral line due to the fact that it does not break the intrathoracic cavity at point of entry and the tip does not enter the SVC. If we have any drips that require central lines we can not use EJs.(unless it is a PICC).  I think IJs are considered acceptable.


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## Thricenotrice (Nov 25, 2012)

On the topic of EJ's... I never ended up liking them. Much more difficult than an arm or foot, roll like crazy. But sometimes the only option from what I could see (didn't have IO's)


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## TransportJockey (Nov 25, 2012)

ChaseZ33 said:


> I hate that. According to the INS and AVA an EJ is a peripheral line due to the fact that it does not break the intrathoracic cavity at point of entry and the tip does not enter the SVC. If we have any drips that require central lines we can not use EJs.(unless it is a PICC).  I think IJs are considered acceptable.



I know. They just call it that I think because they don't want their nurses to start an EJ in the ER or on the floor. And their nurses are allowed to start 'all peripheral intravenous lines'.


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## jwk (Nov 25, 2012)

usalsfyre said:


> It's funny, I hear a lot of "911" medics state the c-collar method as gospel, but most CCT medics/nurses (the people who move intubated patients all the time) don't do this yet don't seem to displace tubes all that often....



Those of us who put in ETT's every day tape them in.  That includes cases where the patient is in a lateral or prone position for many hours.  The C-collar idea, frankly, is one of the more pointless things I've heard on this board.



Sublime said:


> I worked in a level 1 trauma center ER and all we used to secure tubes (in non c-spine precaution patients) was string. Can't think of the name of the string/tie we used for some reason but it looks like shoe lace kind of. We would move people from the bed to the CT machine then back to the bed and up to the ICU bed... never needed a c-collar to keep the tube secure.



You're probably thinking of umbilical tape.  It's made by the suture manufacturers, so it comes in the same type of sterile package that regular suture material comes in.  The problem with tying in a tube is that in order to actually secure the tube, you have to pull the tape tight, which actually compresses the lumen of the tube - not really desirable.  And if you don't tie it tightly around the tube, it's worthless because it will slip.

The commercial tube holders (as pictured in a previous post) are fine, and that's what our respiratory therapists change to as soon as our ventilated post-op patients hit the ICU.  More than once, they've pulled out the tube when untaping it and putting the fancy device on.


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## Shishkabob (Nov 25, 2012)

TransportJockey said:


> The hospitals here consider them 'central access' so the RNs, even at the state L1 TC, are always freaked when I roll in with someone with one



I love doing things that freak nurses out who think it's physician level only... EJs, conscious sedation, RSI with 300mcg of Fent (Yup, nurse freaked out about that level of Fent... on a patient I gave Roc and Etomidate to... while I was bagging them...)


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## VFlutter (Nov 25, 2012)

TransportJockey said:


> I know. They just call it that I think because they don't want their nurses to start an EJ in the ER or on the floor. And their nurses are allowed to start 'all peripheral intravenous lines'.



We are allowed to start them but no one ever does. The PA will usually do it. If we have a new kindney failure patient who may need dialysis they sometimes go for a EJ until they decide were they are going to out the AVF.


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