# IV Sticks - AEMT noob tips and tricks?



## Altered Mental Status (Oct 24, 2011)

I'm hit-or-miss. 

So far, I've only practiced with 20g in a non-moving ER setting for clinicals.
I'm about 50-50. I don't know how the eff I'm gonna get good at this in the back of a moving truck.

I look to you, oh wise veterans to tell me where my *ss is and where my elbow. :unsure:

PLEEZ HALP.


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## Shishkabob (Oct 24, 2011)

Practice.  I know it's cliche, but that's really all it is.  Some days you won't hit the best veins ever, and other days you'll hit veins no one else can.

Don't be afraid to poke away, and jump in on all the ones you can.


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## Cup of Joe (Oct 24, 2011)

http://emtlife.com/showthread.php?t=25740


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## Akulahawk (Oct 24, 2011)

Seriously, it just takes practice. Otherwise, just get a little zen and become the needle.


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## foxfire (Oct 24, 2011)

When you look at the arm, picture in your mind where the Vein is and then go for it. I have totally sucked for a month during my training. could not hit the broadside of a barn. but after some medics watching me start a few, they where able to figure out what I wasdoing wrong. 
like linuss said keep at, ya have your good days and bad ones.


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## MSDeltaFlt (Oct 24, 2011)

Altered Mental Status said:


> I'm hit-or-miss.
> 
> So far, I've only practiced with 20g in a non-moving ER setting for clinicals.
> I'm about 50-50. I don't know how the eff I'm gonna get good at this in the back of a moving truck.
> ...



If you can't feel it, don't stick it.


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## Altered Mental Status (Oct 24, 2011)

Thanks, guys. I feel like having Paramedics standing over me is _exactly_ what I need. Nurses at the hospital can't really _instruct_ me. They say things like "It's just in and then advance the cath, see?" 

Every time I try doing it by the book (45º then drop it to 15º), someone goes "Wait, you don't want to go so deep, she's got flat veins," or something like that.

It's getting so that I'm starting to feel like it's sort of random and unique each time...like there _are_ no real rules.

I hope I get better at this.


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## Altered Mental Status (Oct 24, 2011)

MSDeltaFlt said:


> If you can't feel it, don't stick it.



What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?


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## Shishkabob (Oct 24, 2011)

Honestly, shoo off anyone that tries to tell you their specific way.  It's medicine, it's an art.  If it works, works for you, and is safe, do it.


You'll learn what works for you, what doesnt, and what works for certain patients.




You're GOING to miss IVs.  Don't let it bug you... even if it makes a little kid scream bloody murder.


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## tylerp1 (Oct 24, 2011)

When I began my clinicals, my first few starts were in the ACs. It gave me a good idea as to what I was feeling for when I palpated hands, forearms, etc, as well as technique.  Worked well when you _do_ encounter those dehydrated 80 year olds.

Just remember that when you get to clinicals, you [should] have the proper equipment, good lighting, knowledgeable preceptors, etc etc.  They are there for help; 'somebody to fall back on', if you will. They aren't trying to set you up for failure. Many times, other medics, nurses, and physicians would show me alternative ways to do what I had just performed successfully.

I simply wanted to learn how to do as much as I could in as many different ways as I could encounter.  It allowed me to find my style and it'd be nice to know another technique for those times you're in an unfavorable situation.


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## mikie (Oct 24, 2011)

*slow down...*

*Take your time!*  No need to hurry and forget minute things or 'penetrate' too fast and end up missing/going though the vein.  Ask for help.


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## MSDeltaFlt (Oct 24, 2011)

Altered Mental Status said:


> What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?



The veins are there.  Start feeling for them. Learn to feel for them. Every pt contact you make start feeling for veins even if you're not even going to stick them. Feel for them anyway.  They're there.


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## Akulahawk (Oct 24, 2011)

MSDeltaFlt said:


> The veins are there.  Start feeling for them. *Learn to feel for them*. Every pt contact you make start feeling for veins even if you're not even going to stick them. Feel for them anyway.  They're there.


This will most definitely help... especially when you're trying to get a line in a patient that you can't SEE a vein, but you need that line put in...

Also get to know the general anatomic locations of the veins. While there's always some variability, veins will be in the same _general _area from person to person.


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## fast65 (Oct 24, 2011)

It sounds like pretty much everything has been said already, but let me reiterate that you WILL miss IV's, don't let that discourage you, because we all miss them. 

What my preceptor once told me was once you get flash, let the flash chamber fill completely, if it doesn't, advance a little more. The key is to find a technique that works for you, and the only way to do that is to practice, practice some more, and then practice some more after that. Take your time, be patient, and practice as much as possible.


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## Handsome Robb (Oct 24, 2011)

Don't forget to pop the tourniquet before pulling the needle outta the cath  Unless you like holding absurdly hard tamponade on your patients.


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## fast65 (Oct 24, 2011)

NVRob said:


> Don't forget to pop the tourniquet before pulling the needle outta the cath  Unless you like holding absurdly hard tamponade on your patients.



Oh yeah, I almost forgot about that one


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## Handsome Robb (Oct 24, 2011)

fast65 said:


> Oh yeah, I almost forgot about that one



I also know someone who *****ed and moaned and ended up starting another line in the opposite arm during a lab day in class cause their drip wouldn't flow, to only realize after starting the second drip the tourniquet was still on the original arm.

It wasn't me ... I swear! ...  ... ok ... it was me :rofl:


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## Chief Complaint (Oct 24, 2011)

^^^^this, be mindful of your TQ.

Be sure to have all of your supplies ready.  Teg out of the package, tape torn, gauze handy, etc.


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## Fish (Oct 25, 2011)

Personal pref.

I always start lower than a 45 degree angle because most peoples viens are very close to the surface, I always keep the skin taught. Once I get a flash, I insert the needle just a bit more than thread the cath. This works good for me, I am successful over 95% of the time if I had to guess.

Another tip, that alcohol prep is your friend. When you are doing your cleaning of the IV site prior to putting an IV in push down abit harder than you might think you should this helps irritate the vien causing it to stand up more and it causes less sensitivity in the area so you can insert your IV slower and increase your chance for success all the while causing less pain.

Try it on yourself, have someone start an IV normal way. Then the way I described you will find it hurts less and is easier.


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## Altered Mental Status (Oct 25, 2011)

Fish said:


> Personal pref.
> 
> I always start lower than a 45 degree angle because most peoples viens are very close to the surface, I always keep the skin taught. Once I get a flash, I insert the needle just a bit more than thread the cath. This works good for me, I am successful over 95% of the time if I had to guess.
> 
> ...



This is brilliant. Thank you.


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## the_negro_puppy (Oct 25, 2011)

I am in the same boat. I have performed less than 50 IV attempts and have good days and bad.

Its much harder to start IVs in the field than in supine patient on a hospital bed.


The other week I had my first go on a pt in cardiac arrest I got in the vein successfully but just as I was about to advance the pt's arm moved a bit due to compressions and the needles went straight through 

Its all about confidence. Having people standing over you and watching all the time can put the pressure on. The best preceptors are the ones that once they know you have the technique down, go get the stretcher/do other things and let you do it on your own!


try to learn the common anatomical positions where veins are found, especially helpful in children, obese pts etc







Just remember, not everyone needs a large bore cannula in the AC. Different gauges and positions should be used for different reasons. Why put a 16 or 18 gauge in the AC just to give analgesia in an uncomplicated pt?

a 20 gauge (even 22) if need be in the hand, wrist or forearm will suffice! I also find dangling the limb (using gravity) and lightly smacking/tapping veins (releases histamines) works wonders to bring out veins.

If you start distally and blow the vein, you can always move proximal. 


Thanks for the tips


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## alphatrauma (Oct 27, 2011)

the_negro_puppy said:


> If you start distally and blow the vein, you can always move proximal.



*This!*


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## BeachmedicJB (Oct 31, 2011)

Altered Mental Status said:


> What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?[/QUOTE
> 
> 
> You can place her feet up and hope that helps, use a flashlight against her skin  (this is my personal favorite) or you can place an IO if you REALLY need access. If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway; however the hypotension can be a complication. On the other hand,if she has a pressure of like 90/50 and weighs like 85lbs then she may not be truly hypotensive as the books will teach you. Always treat your patient, (i.e. capillary refill, skin color/conditon/temperature of the extremities) and learn to apply what you learned in class with real world experience.


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## Shishkabob (Oct 31, 2011)

We can't treat dehydration?


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## NomadicMedic (Oct 31, 2011)

BeachmedicJB said:


> If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway.



Really? Cuz I treat that all the time.  

(I hate to clue you in, but those big bags of fluid you have on your truck? Ya know, the one's that say "Normal saline" on 'em? Yeah... that's what they're for...)


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## usalsfyre (Oct 31, 2011)

Dangit, I guess I WASN'T really treating the last patient I gave a bolus too...


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## TomB (Oct 31, 2011)

Put down the rail on the gurney and take a knee along side the patient. Place your tourniquet and learn to apply it so that the ends point up toward the patient's head (not your work area). Hold the arm below the level of the patient's heart so the veins become distended. Hold the skin taut. If you do these things you will be well on your way. Don't be afraid to stick the patient. I almost always attempt to obtain a flash with the initial stick. Then give it a little bump to make sure the bevel clears the lumen and look for the secondary flash up the catheter as you advance that lets you know you're in. If you miss (which you will from time to time) keep your cool and don't let the patient see you sweat. It's a rare patient indeed who as ever died for want of a prehospital IV. It's not a big deal so treat it that way and your patient will forgive you. On those rare occasions where you're not sure whether or not you're running fluid into the patient's vein or into the patient's flabby arm you can occlude the vein several inches above the hub of the catheter. If the IV stops flowing you're in the vein. Good luck!


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## 18G (Oct 31, 2011)

TomB said:


> Put down the rail on the gurney and take a knee along side the patient. Place your tourniquet and learn to apply it so that the ends point up toward the patient's head (not your work area). Hold the arm below the level of the patient's heart so the veins become distended. Hold the skin taut. If you do these things you will be well on your way. Don't be afraid to stick the patient. I almost always attempt to obtain a flash with the initial stick. Then give it a little bump to make sure the bevel clears the lumen and look for the secondary flash up the catheter as you advance that lets you know you're in. If you miss (which you will from time to time) keep your cool and don't let the patient see you sweat. It's a rare patient indeed who as ever died for want of a prehospital IV. It's not a big deal so treat it that way and your patient will forgive you. On those rare occasions where you're not sure whether or not you're running fluid into the patient's vein or into the patient's flabby arm you can occlude the vein several inches above the hub of the catheter. If the IV stops flowing you're in the vein. Good luck!



+1 Some good tips indeed.


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## 18G (Oct 31, 2011)

BeachmedicJB said:


> What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?[/QUOTE
> 
> 
> You can place her feet up and hope that helps, use a flashlight against her skin  (this is my personal favorite) or you can place an IO if you REALLY need access. If it's just dehydration then you can take her in without an IV and let the ER do it since we can't really treat that anyway; however the hypotension can be a complication. On the other hand,if she has a pressure of like 90/50 and weighs like 85lbs then she may not be truly hypotensive as the books will teach you. Always treat your patient, (i.e. capillary refill, skin color/conditon/temperature of the extremities) and learn to apply what you learned in class with real world experience.



I just had an 88 y/o from a nursing home the other day with profound dehydration. Pt. refused to eat for four days, poor skin turgor, membranes dry as a dessert,  hypotensive at 77/50, change of mental status.

A line with a bolus of NSS improved pressure to 115/70's and had the patient having a conversation with me enroute to the hospital. DEHYDRATION IS VERY EASILY TREATED IN THE FIELD.


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## firetender (Oct 31, 2011)

It's not half as bad now, while you're learning as it will be when, 2 years down the line and you believe yourself proficient that you get a "run" of calls where you can't start an IV to save your life (or theirs, I guess!)

It happens that way sometimes...

...and never neglect the value of sticking your partner (with consent, of course!).


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## Akulahawk (Oct 31, 2011)

18G said:


> I just had an 88 y/o from a nursing home the other day with profound dehydration. Pt. refused to eat for four days, poor skin turgor, membranes dry as a dessert,  hypotensive at 77/50, change of mental status.
> 
> A line with a bolus of NSS improved pressure to 115/70's and had the patient having a conversation with me enroute to the hospital. DEHYDRATION IS VERY EASILY TREATED IN THE FIELD.


I had one fairly similar to this one about 10 years ago, only she started off with a BP at about 180/102-ish and by the time I was called to check on her 3 days later, she'd gone to 128/84-ish. A little fluid (about 600 mL) and she was conscious, alert, talking to me. I fully expect that the ED ran more tests and likely switched fluid to something more like D5 1/2NS, however, I was long gone by then...


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## BeachmedicJB (Oct 31, 2011)

n7lxi said:


> Really? Cuz I treat that all the time.
> 
> (I hate to clue you in, but those big bags of fluid you have on your truck? Ya know, the one's that say "Normal saline" on 'em? Yeah... that's what they're for...)



We treat hypotension with fluid bolus'. Dehydration is treated over the long term with fluid administration based on labs in the hospital. We can reverse hypotension most of the time but we are not fixing dehydration unless you're giving fluids that are not merely volume increasers such as NaCl and you have a set of labs telling you what the patient's needs are such as K+ etc.


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## Handsome Robb (Oct 31, 2011)

Last time I checked we are treating hypotension which often is secondary to dehydration...so therefore treating the hypotension with fluid boluses we are also treating the dehydration.

I'm pretty sure Na is an electrolyte replaced during infusions of 0.9% NS. Also I'm pretty sure H2O is replaced in that whole solution as well


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## BeachmedicJB (Oct 31, 2011)

NVRob said:


> Last time I checked we are treating hypotension which often is secondary to dehydration...so therefore treating the hypotension with fluid boluses we are also treating the dehydration.
> 
> I'm pretty sure Na is an electrolyte replaced during infusions of 0.9% NS. Also I'm pretty sure H2O is replaced in that whole solution as well



I ll agree with start the treatment of dehydration; however we do not completely replace it. That is all that I meant when I said that. There is truly very little we can do other than treat the symptoms. Would you agree?


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## usalsfyre (Oct 31, 2011)

I personally treat dehydration in the absence of hypotension. You don't need chemistries to treat dehydration. Give a liter, see if they look and feel better.

Treatment of electrolyte disturbance is a whole 'nother kettle of fish.


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## Handsome Robb (Oct 31, 2011)

I do agree.

Most if not all of the things we do are treating the symptoms and starting the ball rolling on treatments not actually definitive treatments.


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## BlakeFabian (Nov 11, 2011)

I like to inflate a BP cuff to the Pt's mean BP and let their arm dangle while I prep my equipment. When I'm ready to stick, those veins are usually huge and obvious.

Or I'll run a flashlight under my Pts hand and search for one.

If worse comes to worse, and you're just not able to get one. Just tell the ER that... 'Unable to initiate IV therapy'

Until you develop confidence in your skills, you WILL miss some IVs. Don't let it get you down. Just keep trying. Always start as distal as you can and work your way up.


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## Ardmoreff (Nov 14, 2011)

I was told by a Paramedic t if you couldn't Laplace a vein you could spray Ntg on it


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## Handsome Robb (Nov 14, 2011)

If you need a line that badly drill an IO or look for an EJ...


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## Akulahawk (Nov 14, 2011)

Ardmoreff said:


> I was told by a Paramedic t if you couldn't Laplace a vein you could spray Ntg on it


I wouldn't, even if I had NTG spray on hand... and if you would, what if your service doesn't carry NTG spray?


NVRob said:


> If you need a line that badly drill an IO or look for an EJ...


Agreed.


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## usalsfyre (Nov 14, 2011)

I have, earlier in my career, tried that trick. It doesn't work.


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## Fish (Nov 14, 2011)

BeachmedicJB said:


> I ll agree with start the treatment of dehydration; however we do not completely replace it. That is all that I meant when I said that. There is truly very little we can do other than treat the symptoms. Would you agree?



I would, Dehydration is diagnosed with Lab values. So in essence, we are guessing, and in the meantime treating hypotension.


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## systemet (Nov 15, 2011)

* Giving a patient a dose of NTG (which is what spraying NTG on the skin does -- anyone remember the dosing on a nitropatch?) to facilitate IV access, doesn't seem like a good idea.

* The flashlight / trans-illumination technique can work, but be very careful with how hot your flashlight can get.  A lot of people try and do this on little kids.  If you give them a second degree burn with a Stinger flashlight trying to get a line, you will be asked why you didn't go for an IO.


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## Nervegas (Nov 16, 2011)

Ardmoreff said:


> I was told by a Paramedic t if you couldn't Laplace a vein you could spray Ntg on it



Idk about using nitro, but using an alcohol swab and rubbing vigorously can cause them to become agitated and stick out more pronounced. I have been known to just run my fingers across the skin lightly and wait until I feel a trough that is springy to the touch and that has no pulse. 

For every medic you meet, there will be another way to start an IV, find what works for you, practice as much as possible and eventually you just get comfortable with them, and know that you won't always be able to hit it, even the giant A/C that could take two 14ga's.


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## Ardmoreff (Nov 16, 2011)

Yea it was a pretty seasoned Paramedic that told me that trick. Haven't used it myself and don't plan to. I was just curious of what you guys thought.


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## Fish (Nov 16, 2011)

systemet said:


> * Giving a patient a dose of NTG (which is what spraying NTG on the skin does -- anyone remember the dosing on a nitropatch?) to facilitate IV access, doesn't seem like a good idea.QUOTE]
> 
> This makes me wanna slap someones mama


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## Imacho (Nov 16, 2011)

Altered Mental Status said:


> I'm hit-or-miss.
> 
> So far, I've only practiced with 20g in a non-moving ER setting for clinicals.
> I'm about 50-50. I don't know how the eff I'm gonna get good at this in the back of a moving truck.
> ...



Try one on yourself.


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## systemet (Nov 17, 2011)

Ardmoreff said:


> Yea it was a pretty seasoned Paramedic that told me that trick. Haven't used it myself and don't plan to. I was just curious of what you guys thought.



For what it's worth, I was told the same thing myself when I was training.  But I still think it's a terrible idea.


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## airbornemedic11 (May 25, 2012)

*Dehydrated 80 yr old*



Altered Mental Status said:


> What do you do when you have a hypotensive, dehydrated, skinny 80-year-old lady?


 
Welcome to the suck. 1st, I would find the biggest, bluest vein you can find on her, hopefully forearm or AC. 2nd, I would use a 20 or 22 g. 3rd, I would use my favorite beer bottle grip on her arm, using your thumb to pull down on the vein and straighten it out. Be carefull, that paper thin, flabby skin is not going to move in tandem with the vein. Also, since she's dehydrated, make it a quick, smooth motion. If you go slow, you will blow that vein. Hooah.


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## dawgsfan11 (May 25, 2012)

systemet said:


> For what it's worth, I was told the same thing myself when I was training.  But I still think it's a terrible idea.



x2!


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## kindofafireguy (May 25, 2012)

Imacho said:


> Try one on yourself.



+1. Or on classmates. My wife said I looked like a hardcore heroin addict with my  track marks. But I took every stick I could get, and did a few on myself.

Still do from time to time to stay sharp.


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## the_negro_puppy (May 26, 2012)

Yep the only way to get better is to do as many as you can on real people. Training arms are next to useless. We weren't permitted to do them on each other during our training so basically we did a few on fake arms then had to 'practice' on live patients.


I feel sorry for patients getting stuck lots of times but I guess everyone has to learn somehow.


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## jroyster06 (May 28, 2012)

I can see the OP was taught with a Nacy book. Don't start at a 45. Penetrate the skin shallow, you can always work a little deeper.

Alcohol preps can help you see the vein a little better. Also those hard stick pts i like to use a BP cuff for a tourniquet instead of the band. Inflate to diastolic pressure and watch the veins pop up.... IT WORKS. My pts that say oh you can't get a line i was stuck 7 times before they got an IV last time in the ER usually get the BP cuff! It works 90% of the time or maybe I'm just lucky. Its also more comfortable for the pt. 

And those pts that you need a line on and don't really want to drill, use the bp cuff as well as a heat pack. Heat packs seem to help the vein rise up a little more.

Older medics told me when i was new that the iodine prep in your start kit makes it easier to see the vein. Its never worked for me but it may for you! 

Im also a fan of going just proximal to the a/c. All to often those pts that need fluid get stuck in the a/c. Problem is the pt can usually pinch the cath off just by moving their arm around. Go above the joint and you isolate that problem. And one more bit of advice, your ob pts that are in labor, avoid the A/C. The pts pinch it off when they are laying on their back pushing. Go for the forearm or above the a/c and your will be an L&D nurse's hero!


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## NYMedic828 (May 28, 2012)

Not sure whats already been said as I am not in the mood to read 6 pages but,

IV's in the ER are MUCH easier for the simple fact that the patient is elevated and situated in an optimal position for you to work and have a nice work space. This is also an optimal way to learn, obviously.


Quite honestly, it isn't that neccesary to do an IV while moving. Sure we all do it. Personally I don't really even try while moving unless its a real nice vein. The streets of NYC are so bumpy its just asking for failure.

Also, if it was that detrimental for me to establish an IV, I'd rather pull over for the 10 seconds it takes to physically cannulate the vein than try 5 times while moving and not succeed.

Working with needles while moving also has its obvious safety issues.


As far as tips for performing the IV/finding veins I think they were all covered.

For hands I personally like to aim for bifurcations, makes it pretty hard to miss if you go right at the angle of the Y.


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## VFlutter (Jun 5, 2012)

Anyone else ever use one of these? http://http://www.accuvein.com/

We have them on a few floors of the hospital, they can be very helpful in patients with dark skin. Not sure if they are used prehospital.


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## Christopher (Jun 5, 2012)

jroyster06 said:


> Also those hard stick pts i like to use a BP cuff for a tourniquet instead of the band...



From experience I would not do this if the truck is moving 

If you get any sort of blood on your gloves or the screw which deflates the BP cuff you're gonna have a hard time deflating it...


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## jroyster06 (Jun 11, 2012)

Christopher said:


> From experience I would not do this if the truck is moving
> 
> If you get any sort of blood on your gloves or the screw which deflates the BP cuff you're gonna have a hard time deflating it...





You are correct, I have only done this moving once or twice, with those oh crap drive fast pts. If they are a hard iv stick then i usually do it on scene.


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## CTBryan11 (Jul 4, 2012)

Personally, I had more problems with the AC's than more peripheral veins, I know that's kind of weird.  A medic told me to take a tourniquet home and put it on, then close my eyes and feel for my own veins, just to get an idea of how they feel and bounce.  After doing that I didn't have problems with AC's either.  STILL to this day I struggle with tamponading AC's and not freaking my pt. out by covering them with blood, but it's getting better.  Just practice, practice, practice, and accept criticism from your preceptor, most of them want to help you learn and aren't just being rude!!!


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