# Whats your "criteria" for starting iv access on a pt?



## mrhunt (Mar 12, 2020)

So fairly straightforward but looking to see both sides of the story. 

for me i feel like i sometimes lack consistency. Overall i look at my pt's and say: Do they need meds? do they need fluids? Do i think their complaint warrants IV access in case their condition deteriorates and they need meds or fluids later down the road during transport?

I know alot of medics who will say "well the hospital is gonna start one anyway so i'll just do it" and that seems kinda strange to me... 

My inconsistencies come as far as.....A seizure pt who HAD a seizure? Absolutely iv access. A chest pain pt who is now asymptomatic? Absolutely iv access in case symptoms return. 

but on cases of syncope if pt isnt exibiting any FURTHER cardiac symptoms aside from the syncope itself alot of times i wont. Or if i can do an ODT med such as oral zofran then i'll go that route since its the preferred method within our counties protocols. 

Example: had a lady who fell 24 hour ago, hit her head. She said she was fine and called 911 a full 24 hour's later "to get checked out" cause her neighbor said she should. Pt had a long list of chronic complaints, non of which were in anyway involved in prior fall or head injury. hx of etoh abuse, no seizure hx, Pupils fine. No lethargy, vitals fine, sugar fine. pt was just chilling. She had chronic nausea / vomiting on a daily basis for MONTHS due to her diverticulitis.... No iv access. doesnt seem warranted at all. 

We get her to the ER and she has a seizure the second we wheel her in. Since everything else basically ruled out it kinda appeared to be an (obvious in my mind) subdural. but even if i DID get iv access it wouldnt have changed the treatment. She was already in the er next to the bed we were placing her in while it happened so its not like i was pushing versed at that point and care was actively being transferred WHILE she seized and everyone witnessed it. Sure...iv access would have saved the nurses like 20 seconds but pt was out of the seizure by the time they had access OR meds were able to be drawn up anyways.

So.....what would u guys have done? What is your critera for iv access on your pt's?


----------



## NPO (Mar 12, 2020)

It's very case dependant. I prefer to have IV access, but I know what veins I can hit and I can't. If I'm not going to get the IV, I'm not going to poke them.

All emergency meds can be given via an alternate route if their condition changes. (I'm assuming they were well compensated/stable when I decided not to establish an IV)

Routine IV access is a convenience for me and the hospital.


----------



## mrhunt (Mar 12, 2020)

we also have a hospital that tends to scoff if a pt has an iv that they want to go to triage or will scold medics for putting in an iv. 

It doesnt change my treatment protocols whatsoever but its in the back of my mind. Ultimately its if i think my pt needs iv access while in MY care, and not in the hospitals care that matters.


----------



## Peak (Mar 12, 2020)

In the field I put IVs in critical patients or patients who require one for therapeutic intervention. 

On the ED I don't care if EMS puts an IV in a stable patient. Chances are I'm going to need blood that wasn't drawn (and sometimes it just needs to be redrawn, especially with lactate and amonia), so I'm going to put in a second line the vast majority of the time (unless I need to do an art stick for some reason).

Right or wrong most hospital require field starts to be removed in 24 hours or less regardless, so the patient has a good chance of getting stuck again if they get admitted.


----------



## DesertMedic66 (Mar 12, 2020)

Ground job: the county only wants us starting IVs on patients who are going to need medications or fluids during the prehospital setting or if it’s a critical patient.

Flight job: 
	

		
			
		

		
	






If you already have an IV we will probably be looking for a second. If you only have a 22G we will probably be looking to see if we can get something larger however most of our patient encounters are for critical/unstable patients.


----------



## NPO (Mar 12, 2020)

DesertMedic66 said:


> ...however most of our patient encounters are for critical/unstable patients.



Really? It seems like at least 50% of patients flown around here are pretty stable. We just had one come in for "palpitations". Everything else was normal.


----------



## silver (Mar 12, 2020)

mrhunt said:


> We get her to the ER and she has a seizure the second we wheel her in. Since everything else basically ruled out it kinda appeared to be an (obvious in my mind) subdural. but even if i DID get iv access it wouldnt have changed the treatment. She was already in the er next to the bed we were placing her in while it happened so its not like i was pushing versed at that point and care was actively being transferred WHILE she seized and everyone witnessed it. Sure...iv access would have saved the nurses like 20 seconds but pt was out of the seizure by the time they had access OR meds were able to be drawn up anyways.



Could have given it IM so really doesn't matter in that instance. Don't feel bad.


----------



## johnrsemt (Mar 12, 2020)

Good luck switching IV's on me;  I don't like getting stuck, and if I have a good IV in me; it stays for 72 hours.  I had that conversation with an ICU nurse:  She was bound and determined that she was going to put a new IV in me, because they didn't like IV's that the ED started.  I told her she was good them because mine was started in the mountains on the way to the hospital.  I thought she was going to faint.  I told her the only way she was going to put a new one in me was if the DON would come show it to me in writing in the hospital policy at 0200.   The IV stayed for 66 more hours.  The DON came in the next day and asked me if I was harassing her nurse and when I said yes she told me to keep up the good work.

To answer the original question though:  I put at least 1 IV in almost every patient I transport:  but our transport distances for my FT job is 45-90 miles minimum and may be an additional 60 miles and we don't transport BS patients (I have had 1 BS patient in 12 years here). 
 PT job is 105-130 miles from base and can be up to an additional 100 miles, maybe 50 of that dirt and gravel roads:  again we don't get a lot of BS patients;  a lot of critical patients.  I put 2 IV's in probably 25% of patients and try to get 2 in every one I fly;  and it might be over an hour before we can meet a helicopter.


----------



## Peak (Mar 12, 2020)

johnrsemt said:


> Good luck switching IV's on me;  I don't like getting stuck, and if I have a good IV in me; it stays for 72 hours.  I had that conversation with an ICU nurse:  She was bound and determined that she was going to put a new IV in me, because they didn't like IV's that the ED started.  I told her she was good them because mine was started in the mountains on the way to the hospital.  I thought she was going to faint.  I told her the only way she was going to put a new one in me was if the DON would come show it to me in writing in the hospital policy at 0200.   The IV stayed for 66 more hours.  The DON came in the next day and asked me if I was harassing her nurse and when I said yes she told me to keep up the good work.
> 
> To answer the original question though:  I put at least 1 IV in almost every patient I transport:  but our transport distances for my FT job is 45-90 miles minimum and may be an additional 60 miles and we don't transport BS patients (I have had 1 BS patient in 12 years here).
> PT job is 105-130 miles from base and can be up to an additional 100 miles, maybe 50 of that dirt and gravel roads:  again we don't get a lot of BS patients;  a lot of critical patients.  I put 2 IV's in probably 25% of patients and try to get 2 in every one I fly;  and it might be over an hour before we can meet a helicopter.



There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.

Where are you that a hospital has a director of nursing? DONs are a nursing home thing.


----------



## DesertMedic66 (Mar 12, 2020)

Peak said:


> There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.
> 
> Where are you that a hospital has a director of nursing? DONs are a nursing home thing.


One of the hospitals that I am pretty familiar with in SoCal (trauma, STEMI, stroke) has a DON.


----------



## Aprz (Mar 12, 2020)

It is such a low risk procedure, very likely to be done at some point of the patient care process whether by us or not, I don't get why people worry themselves over whether they should do it or not. If you believe the patient at some point will need it, whether you are going to use it or not, I say do it.


----------



## akflightmedic (Mar 12, 2020)

Peak said:


> There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.
> 
> Where are you that a hospital has a director of nursing? DONs are a nursing home thing.




Standard around here is 96 hours for IV, then start thinking about changing it IF indicated. Usually, by the time 4 days have come and gone, they are either having the IV removed and prepping for discharge or they have had a mid line placed.

As for DON, quite common...many DONs here in the area hospitals.
(State of Maine for reference)


----------



## Peak (Mar 12, 2020)

I've had IVs last for weeks on some kids, a handful have lasted over a month. There is no need to pull them early.


----------



## Peak (Mar 12, 2020)

In the places I've worked we have CNOs and ACNOs. There are directors of services (emergency, trauma, transplant, et cetera), but not of 'nursing' in the hospital. Directors are typically an operational term.


----------



## GMCmedic (Mar 12, 2020)

One of our local hospitals started a policy where they refused to use prehospital IVs, thats when I really started paying attention to what I did and did not start IVs on. 

If the patient was stable, I assed veins and felt confident that I could get an IV fairly quickly if needed, the complaint was relatively non emergent, and I foresaw no need for fluids or medication, I did not start and IV. 

Now everyone gets an IV or typically already has one. I havent attempted an IV start since October of 2018.


----------



## johnrsemt (Mar 12, 2020)

Where I used to work, when I worked private service we used to do a lot of small hospital to larger hospital for cardiac cath etc.  1 particular hospital was really bad about sending out patients with a good patent 22 or 24 g IV site.  I would almost always put a larger IV in them during the early part of the 30 mile transport:  2 reasons:  1: if the patient was going to have a cardiac procedure done there was a decent, but small chance that they would crash on me and push ACLS drugs through a 24 g IV sucks.   2:  Cath labs like at least a 20 g, if not bigger.  Surprising how many of the Cath lab docs would let my partner and I stay and watch the procedures since we helped them get a head start on the Procedure.  1 doctor would take us to lunch at least once a month for doing that.


----------



## Akulahawk (Mar 13, 2020)

Around here, our prehospital guidelines are reasonably specific about which patients will get a line and which ones won't. Basically if your patient needs to be given medication via IV or your specific protocol you're working from states that an IV must be placed, then the patient gets a line. If your patient doesn't need IV meds or you're not working from a protocol that requires IV access, you don't place the line. The medics are NOT allowed to place IV's for "precautionary" reasons. Nearly every patient that lands in an ED bed will get a line. If you end up in a chair (because you're not that sick) then you won't get one. It's a VERY rare shift that I don't put in an IV, let alone less than 2-3, as I'm one of the "go-to's" for the difficult sticks (I also do US guided sticks). 

Also, one of the "nicer" things about our IV catheters is that they do have a pretty high flow rate. They're a PITA to place sometimes, but they have a slightly higher flow rate than the previous catheters and ours are pressure rated so we can do CT Angio procedures with a 22g placed instead of a 20g. 

At least I have reasonable discretion about how many IVs to place once IV access is ordered...


----------



## Peak (Mar 13, 2020)

Akulahawk said:


> Also, one of the "nicer" things about our IV catheters is that they do have a pretty high flow rate. They're a PITA to place sometimes, but they have a slightly higher flow rate than the previous catheters and ours are pressure rated so we can do CT Angio procedures with a 22g placed instead of a 20g.



Are you using the diffusics?


----------



## Akulahawk (Mar 13, 2020)

Peak said:


> Are you using the diffusics?


Yep. Hate to place 'em but once they're in, the flow rate is pretty decently good.

Added bonus: they don't dribble blood...


----------



## Peak (Mar 13, 2020)

Akulahawk said:


> Yep. Hate to place 'em but once they're in, the flow rate is pretty decently good.
> 
> Added bonus: they don't dribble blood...



I've only used the regular nexivas, I like them for EJs and patients with HIV or hepatitis. I refuse to use them on kids though, you just can't feel the same with them.

Do you find that the diffusics still flow quicker with blood or albumin?


----------



## Akulahawk (Mar 13, 2020)

Peak said:


> I've only used the regular nexivas, I like them for EJs and patients with HIV or hepatitis. I refuse to use them on kids though, you just can't feel the same with them.
> 
> Do you find that the diffusion still flow quicker with blood or albumin?


I have used them with kids, though I don't like to. Like you, I have found that you don't have quite the same feel with the Nexiva catheters as you do with a "standard" catheter. Another issue is that our "standard" catheters were 1/4 inch longer so that actually made it a little easier. The Nexiva product pretty much requires that you puncture the skin and nearly immediately also puncture the vein to ensure good placement, especially if the vein is a little deep. All of our "standard" catheters that we stock now are 2-2.5 inch length and we use those for US placed lines. Every great once in a while I'll grab one of those and use it for a regular PIV stick. I just wish they'd purchased the slightly longer Nexiva caths... 

One interesting side benefit of these is that I can rotate the needle to do a bevel-down insertion technique if I need to. I don't do that very often, but it can help obtain placement in certain situations. 

Incidentally I have noticed slightly better flow rates with the Diffusic catheter when infusing more viscous fluids than with a standard catheter. The biggest "benefit" of the Diffusic is that the catheters are a bit more stable (apparently) during pressure infusion (like contrast CT) than standard catheters and they do have a slightly higher flow rate so you can use a 22g for a CTA. You still must use the same sites for CTA as with a standard catheter but when your patient has smaller veins, going 22 vs 20 can certainly improve the chance of successful placement without turning your patient into a pincushion. My default for most adult patients is an 18 or 20g, though a 22 will do if necessary.


----------



## Peak (Mar 13, 2020)

Akulahawk said:


> I have used them with kids, though I don't like to. Like you, I have found that you don't have quite the same feel with the Nexiva catheters as you do with a "standard" catheter. Another issue is that our "standard" catheters were 1/4 inch longer so that actually made it a little easier. The Nexiva product pretty much requires that you puncture the skin and nearly immediately also puncture the vein to ensure good placement, especially if the vein is a little deep. All of our "standard" catheters that we stock now are 2-2.5 inch length and we use those for US placed lines. Every great once in a while I'll grab one of those and use it for a regular PIV stick. I just wish they'd purchased the slightly longer Nexiva caths...
> 
> One interesting side benefit of these is that I can rotate the needle to do a bevel-down insertion technique if I need to. I don't do that very often, but it can help obtain placement in certain situations.
> 
> Incidentally I have noticed slightly better flow rates with the Diffusic catheter when infusing more viscous fluids than with a standard catheter. The biggest "benefit" of the Diffusic is that the catheters are a bit more stable (apparently) during pressure infusion (like contrast CT) than standard catheters and they do have a slightly higher flow rate so you can use a 22g for a CTA. You still must use the same sites for CTA as with a standard catheter but when your patient has smaller veins, going 22 vs 20 can certainly improve the chance of successful placement without turning your patient into a pincushion. My default for most adult patients is an 18 or 20g, though a 22 will do if necessary.



I wish they made longer nexivas period. I find myself favoring at least a 0.75 in 24 and 1.75 or longer in anything bigger. 

If they get too difficult I just get a 22, a baby wire, and a 2.5F RA kit an use that for IV access; although with ultrasound its pretty rare that I get that desperate. 

With the exception of CTAs and triple phase livers I can hand push contrast so the catheter size doesn't bother me that much, but I would love to see some flow rates with albumin or blood since I think the diffusics could potentially bring a lot to the trauma arena. Placing RICs and cordis (what is the plural of cordis? cordi? cordises?) takes too much time, if 14 or 16 diffusics existed that would be amazing.

Every once in a while the do gooders in our system like to point out that technically the regular nexivas are not pressure rated and shouldn't be used for CT, so I've been tempted to push the diffusics instead but the cost difference is pretty substantial espeically since nobody seems to be able to show a single ruptured catheter or extension in a freshly placed nexiva.


----------



## Akulahawk (Mar 13, 2020)

Peak said:


> if 14 or 16 diffusics existed that would be amazing.


I absolutely agree with this! The flow rate from such a beast would be mind-blowing.


----------



## Akulahawk (Mar 13, 2020)

Peak said:


> Every once in a while the do gooders in our system like to point out that technically the regular nexivas are not pressure rated and shouldn't be used for CT, so I've been tempted to push the diffusics instead but the cost difference is pretty substantial espeically since nobody seems to be able to show a single ruptured catheter or extension in a freshly placed nexiva.


The problem isn't that the regular Nexiva's can't be used for CT w/ contrast, it's that they _shouldn't_  be used for CTA procedures because of the pressure/flow rates required to get a good study. If you need to push for the Diffusics vs regular Nexiva products, at least push for a small supply of them for patients for whom you would need a CTA. The 20g Diffusics can flow 10ml/sec at 325 psi. That's 36L/hour. The 18g version can do 54L/hr. Stock 'em for use in cardiac/stroke/trauma rooms (in the ED or ICU) for initial IV placement. Pretty much everywhere else should be able to do OK with the regular Nexiva catheters. 

My hospital went basically to standard Nexiva catheters on the floors but the ED and ICU uses Diffusics for everything except 24g and US placed IV caths (due to length reasons).


----------



## johnrsemt (Mar 13, 2020)

The thing I don't like with the new IV angiocaths that don't dribble (or pour) blood is you can't get blood out of them to check glucose while you are sticking the IV.


----------



## Akulahawk (Mar 15, 2020)

johnrsemt said:


> The thing I don't like with the new IV angiocaths that don't dribble (or pour) blood is you can't get blood out of them to check glucose while you are sticking the IV.


That's true most of the time, but not ALL the time. The standard Nexiva and Nexiva Diffusics catheters can be basically "bloodless" but what happens is that the tubing fills up with blood and the vent cap. If I need labs, I will usually attach a clave port to the tubing and do the draw. If I need to check blood glucose right then, I'll have that set up and ready to go because once I detach a syringe from the clave port, there's usually a little venous blood right on the end of the port or I can push a little drop to the end of the syringe and test that drop. It's not that different from having your glucometer ready when you're doing the initial stick and getting the blood off the hub vs off a clave port or out of a syringe. 

Most of the anti-dribble stuff I've used over the years are simply one-use one-way valve systems. When you put a loop on the end of the catheter, it destroys the valve and you can draw any lab stuff off that loop before you flush the loop. I'm a big fan of saline locks for a number of reasons, this is but one of them.


----------



## medichopeful (Apr 12, 2020)

For my ground job, I generally only do IVs in two circumstances:
1) I'm going to use it for something (mostly meds, primarily fentanyl and zofran.  I very rarely give fluids working 911)
2) There is the potential for the patient to need an urgent or emergency treatment but does not currently need it ("anticipated clinical course")

For my flight job, I very rarely start IVs.  In the past year, I've probably started less than 5.  Same basic rules apply as above, though I'll also add in if the patient is coming in as a trauma I'll generally make sure they have good access.  I've done more IOs than I have IVs working flight.


----------



## Frank frankerson ESQ (Apr 19, 2020)

If youre on the fence, like well maybe i should, then you should.


----------



## MSDeltaFlt (Apr 19, 2020)

My protocols are pretty specific. If they're stable "condider" it.  If they're not, get it. If you can't and they need it, drill 'em.


----------



## Tunnel Cat (Apr 20, 2020)

I have a pretty loose criteria for starting an IV even if I don't plan on doing anything with them.  If I can justify it I normally will, not just for treatment but because call volume here can be a little low (usu 1-3 ALS calls per shift) and I'm still newish as a medic (less than a year) so I'm trying to hone my skill.

The other reason is just having a better relationship with the hospitals.  My service is one of those that hires everyone with a patch and a pulse then turn them loose with a week's worth of FTO time so hospital staff can have really low expectations/be really dismissive.  I've had them express surprise (and thanks) when I come in with a pt who has an IV started and I know there are medics here who miss everything or refuse to try starting them or both.  A couple days ago I brought someone in from an assisted living and the ER nurse just assumed the line was started by the facility.  Starting IVs (as long as it's not for a silly reason) is just me trying to signal I might be competent enough to listen to.


----------



## NomadicMedic (Apr 20, 2020)

I start a line if I’m considering or administering medications, fluid or if their clinical course will require access immediately on arrival, like a stroke going directly to CT. 

Starting an IV for no good reason is just silly. And it doesn’t prove you’re competent, it just proves you can place a catheter in a vein. Don’t ever make the mistake of confusing simple skills competency with anything else.


----------



## Peak (Apr 20, 2020)

Tunnel Cat said:


> I have a pretty loose criteria for starting an IV even if I don't plan on doing anything with them.  If I can justify it I normally will, not just for treatment but because call volume here can be a little low (usu 1-3 ALS calls per shift) and I'm still newish as a medic (less than a year) so I'm trying to hone my skill.
> 
> The other reason is just having a better relationship with the hospitals.  My service is one of those that hires everyone with a patch and a pulse then turn them loose with a week's worth of FTO time so hospital staff can have really low expectations/be really dismissive.  I've had them express surprise (and thanks) when I come in with a pt who has an IV started and I know there are medics here who miss everything or refuse to try starting them or both.  A couple days ago I brought someone in from an assisted living and the ER nurse just assumed the line was started by the facility.  Starting IVs (as long as it's not for a silly reason) is just me trying to signal I might be competent enough to listen to.



On the receiving side I am frustrated when a sick patient who needs access doesn’t arrive with at least an attempt or the EMS provider telling me that they couldn’t find a site. This is very rare.

Often placement by EMS does not help all that much. IVs that don’t draw back are useless for CT or other vesicant administration. I also typically draw labs with an IV, so if the line doesn’t draw or come with blood I’m going to be drawing anyway.

It is very frustrating when there are multiple blind and unsuccessful attempts made, especially on kids or patients with limited peripheral vasculature (typically done by smaller lower volume services). I have tools at my disposal that many in the field do not (weesight, ultrasound, et cetera). Shredding vasculature just makes it harder to place access on arrival, and doesn’t benefit the patient. I’d far rather a sick patient come in with an IO that I pull after placing a good IV than have no access and difficulty even finding a peripheral site due to multiple blind unsuccessful attempts.

While I may not be confident in an EMS provider who does not place access in a patient who is clearly sick and needed one, I don’t expect said EMS provider to do my job for me.


----------



## KingCountyMedic (Apr 20, 2020)

Sick: IV

Not sick: No IV


----------



## Tunnel Cat (Apr 20, 2020)

NomadicMedic said:


> Starting an IV for no good reason is just silly. And it doesn’t prove you’re competent, it just proves you can place a catheter in a vein. Don’t ever make the mistake of confusing simple skills competency with anything else.





Peak said:


> On the receiving side I am frustrated when a sick patient who needs access doesn’t arrive with at least an attempt or the EMS provider telling me that they couldn’t find a site. This is very rare.
> 
> Often placement by EMS does not help all that much. IVs that don’t draw back are useless for CT or other vesicant administration. I also typically draw labs with an IV, so if the line doesn’t draw or come with blood I’m going to be drawing anyway.
> 
> ...


I'll say I don't start them for no reason.  It's not like I'm sticking say, a sprained ankle or a simple cough or a pulled g-tube.  I definitely don't stick peds unless I know I need it.  I don't stick blind and when I've got someone who looks difficult stick I consider whether I'm likely to just mess up the vasculature for the ER.  But earlier on I definitely struggled with IVs and needed the practice.  And I've definitely been groused at for not getting an IV on patients even when there was nothing I needed it for.  There's one hospital in particular where they seem to always want me to have an IV no matter the patient.

But thank you.  I'll keep all this in mind.


----------



## RedBlanketRunner (Apr 24, 2020)

Looking back over the years. Some of you may notice the evolution of procedures you do today. An awful lot of non viables were delivered to get where we are now..

-Grab and run. Only permitted intervention was direct pressure, or by physician orders over often faulty radio coms. (This is where my name on this forum comes from. Two of our ambulances were retired hearses.)
-Limited intervention procedures.  All had to be authorized by a physcian.
-Slightly expanded procedures. Pre EMS days when physicians great fear was medics and nurses would be practicing medicine without blah blah blah.
-EMS getting established.  Standing orders for a wider variety of procedures. Code blues were still grab and run.
-EMT II's hit the scene. This was in part motivated by medics returning from the Vietnam war griping loudly about their abilities being restricted. IVs were in the standing orders under a strict list of conditions.
-An odd period when all non ambulatory patients had a line established.
-Followed by expanded standing orders, a long list of conditions where a line was established and physicians could be requested to authorize for conditions not on the list.
-And finally, full ACLS and a report sent to EMS required with every run where a procedure besides evac was performed. IVs became discretionary.
And so on. As the saying goes. a long strange trip... and still evolving.


And just saying, if a practice, procedure, position or title (like DoN) isn't that way where you are doesn't mean it doesn't exist or is BS. The emergency medical responses and training vary from location to location.  Want an IV established here? You have to have an RN riding on the ambulance. One county west, no such thing outside of hospitals. EMS? Paramedic? Several dozen countries have never heard of such things. In other countries, ambulance attendants are trained in field surgical intervention procedures inclusive of chest and abdominal surgery.


----------



## johnrsemt (Apr 24, 2020)

Almost all of my transports get IV's, but almost all of them are ALS and sick; due to the fact that they are all long distance and none are BS transports  (after 12 years I almost miss BS transports).
FT job closest hospital is 45 miles away (longer depending where we start from) up to 90 miles.  PT job closest is 110 miles to 130 miles.


----------



## Jn1232th (Apr 30, 2020)

It’s up to my discretion in my system but typically I just do a IV if I wanna start fluid or meds. If not then I won’t bother. There is two or so ERs that I will get one for even if it’s nonsense just to be nice since they like it. 
of course any trauma/stemi/ stroke needs a line. Which I have pretty much discretion where except for an EJ in a stroke or STEMI patient


----------



## StCEMT (Apr 30, 2020)

Usually I have to either be giving fluids or meds. That or STEMI/CVA/trauma. Sometimes other calls will get one from me if I feel like being helpful and am more than 5 minutes from a hospital. On rare occasion if I hit a rare slump I may throw a few easy shots in to break it. 

But as a general practice?  No courtesy lines.


----------



## AusPara (May 7, 2020)

Indications for IV? Immediate need or expected clinical course. Fairly straightforward I would have thought. 

I would add for the OP that a nurse’s criticism in isolation doesn’t equal wrong doing. They, like everyone, have their own pressures, biases and stressors and not every piece of feedback is going to be a well reasoned critique of your practice. Don’t ignore it. You should always reflect on your own practice. But don’t get to bent out of shape. 

Not sure if it was ever published but we had some quality improvement data a while back showing a very concerning number of prehospital IVs were associated with subsequent infection. No doubt we needed procedural improvements and we did that. But you’ve got to ask yourself why you would place an IV outside of the criteria I list above if it is associated with some risk to the patient. 

I recall a study from a while back indicating that a huge number of IVs placed in EDs were never used. Yes IV are low risk. But they aren’t no risk. So if you put in enough IVs for not much reason, then eventually a patient is going to come to grief. Not to mention from a patient experience point of view, they’re pretty unpleasant. 



NPO said:


> Really? It seems like at least 50% of patients flown around here are pretty stable. We just had one come in for "palpitations". Everything else was normal.



Wow....why?


----------



## NPO (May 8, 2020)

AusPara said:


> Wow....why?



That particular patient? The crew didn't want to transport and wanted to go back to station. That was the flight crews interpretation anyway.

That service is known for lazy and poor standard of care. I can't attest to much about their actual quality, but it's incidents like that, that given them a poor reputation.


----------



## AusPara (May 8, 2020)

NPO said:


> That particular patient? The crew didn't want to transport and wanted to go back to station. That was the flight crews interpretation anyway.
> 
> That service is known for lazy and poor standard of care. I can't attest to much about their actual quality, but it's incidents like that, that given them a poor reputation.



Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient? 

The risk, the expense and the opportunity cost or that resource....boggles the mind.


----------



## NPO (May 8, 2020)

AusPara said:


> Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient?
> 
> The risk, the expense and the opportunity cost or that resource....boggles the mind.


I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".

In either case, it may not be appropriate, but it happens.


----------



## AusPara (May 8, 2020)

NPO said:


> I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".
> 
> In either case, it may not be appropriate, but it happens.


My education continues.

Thanks


----------



## DesertMedic66 (May 8, 2020)

AusPara said:


> Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient?
> 
> The risk, the expense and the opportunity cost or that resource....boggles the mind.





NPO said:


> I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".
> 
> In either case, it may not be appropriate, but it happens.


This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.


----------



## AusPara (May 8, 2020)

DesertMedic66 said:


> This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.



Yeah I guess the for profit stuff makes sense. 

Oh my goodness. You have a box for that. America (I assume it's America) never fails to amaze.


----------



## Akulahawk (May 8, 2020)

Partly to get things back on topic... Something that I don't think I indicated earlier is that if I was left to my own devices to determine when/if I would place an IV in a particular patient, I'd basically use an "anticipated clinical course" approach. If I thought it more likely that the patient would need IV access for meds or fluids, then I'd place at least a saline lock. The location and size of the line would basically primarily depend upon what I anticipate the patient would need. 

On a slight tangent from this, there are a few patients that I'll grab the ultrasound right away to have in the room and a patient or two that I won't bother attempting a line without the ultrasound. I'm not exactly a fan of ours but at least it'll allow me to get the job done.


----------



## StCEMT (May 8, 2020)

DesertMedic66 said:


> This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.


Why the **** would they think that is even remotely reasonable or appropriate?


----------



## DesertMedic66 (May 8, 2020)

StCEMT said:


> Why the **** would they think that is even remotely reasonable or appropriate?


Those specific hospitals do not care. It’s all about getting the patients out. We ended up closing the bases that would respond there due to a huge number of unpaid transports.


----------



## GMCmedic (May 8, 2020)

DesertMedic66 said:


> This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.


I would add, that though we would not deny a patient transport, we have been known discourage it. Its situation dependent and a balance between doing what's right for the patient and not alienating EMS. Often times its just true that the ground crew isnt comfortable, whether its an education gap, laziness, or a gut feeling.


----------



## CanadianBagel (Jul 3, 2020)

I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC. 

I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.


----------



## Tigger (Jul 3, 2020)

SplintedTheWrongLeg said:


> I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC.
> 
> I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.


Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...

Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.


----------



## mrhunt (Jul 3, 2020)

He's obviously had some run-in's with the "dr helpers".....and havent we all?  Ive had nurses abuse me Just because they were obviously bored at 2am with no pt's. And it sucks.  and i def appreciate your view of doing whats Right for the pt....However, I typically (especially on IFT's) wont ever place a second line unless my pt appears unstable and Im seriously thinking i need additional access ENROUTE. Once they get to the hospital....Who cares if they JUST have a 22 in the ac........Access is access and sometimes thats all you can get. 

keep in mind that above statement is JUST on IFT's and my rules are different for 911's and i think Myself and other posters have covered those (traumas, Chest pain of cardiac nature, Stroke, Seizure, Hypovolemia or any need for fluids or medications)

Hell, Ive had to show up with 22's in peoples Feet and the nurses couldnt do any better and that was the access they used the whole time. Ideal? Not hardly. But for sure better than no access at all.


----------



## Akulahawk (Jul 4, 2020)

SplintedTheWrongLeg said:


> I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC.
> 
> I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.





Tigger said:


> Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...
> 
> Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.


Generally speaking, hospitals are going to pull field-start lines on admitted patient, including those going for surgery, unless the patient is going to require urgent/emergent surgery upon arrival. This is because they cannot control the procedure/policy that you follow for ensuring as clean insert of the line as they can within their own facility and if another facility started the line, it is properly documented and such that proper procedure was followed. In short, they're not going to trust your line and therefore they'll pull it ASAP. As an ED RN and previous Paramedic, I will test and verify that a field start IV is patent before I'll use it. I'm also not going to pull an existing line until I've placed a new one. That being said, by you placing a line in the AC, you've basically removed a lot of potentially good sites from consideration at the other facility. Most IV lines I place aren't in the AC. They're usually in the wrist, hand, or upper forearm, just distal to the AC space. If you've blocked all those with your AC-placed line, I'm going to have to do an USGPIV if I need to pull your line. 

Something also to consider, the receiving facility knows what vascular access the patient has. This is one of the things that is discussed during the RN-RN report. If they're OK with a 22g in the AC and I don't expect any additional need for vascular access, I'm sending the patient with the 22g in the AC. There have been times that I've been asked to place a 2nd line (and sometimes a 3rd line as 2 are already in place) before the patient leaves my facility. Otherwise I expect that they'll place an additional appropriate line if it becomes necessary. Another thing that will be discussed (and probably brought up in report to you) is whether or not that other arm is available for IV lines. I have seen some wonderful veins on a given side but can't place a line on that side because doing so is contraindicated. 

Sometimes I'll place another line in the ED because I know the patient is likely to get (or has orders for) medications that are Y-site incompatible.


----------



## CanadianBagel (Jul 4, 2020)

Akulahawk said:


> Generally speaking, hospitals are going to pull field-start lines on admitted patient, including those going for surgery, unless the patient is going to require urgent/emergent surgery upon arrival. This is because they cannot control the procedure/policy that you follow for ensuring as clean insert of the line as they can within their own facility and if another facility started the line, it is properly documented and such that proper procedure was followed. In short, they're not going to trust your line and therefore they'll pull it ASAP. As an ED RN and previous Paramedic, I will test and verify that a field start IV is patent before I'll use it. I'm also not going to pull an existing line until I've placed a new one. That being said, by you placing a line in the AC, you've basically removed a lot of potentially good sites from consideration at the other facility. Most IV lines I place aren't in the AC. They're usually in the wrist, hand, or upper forearm, just distal to the AC space. If you've blocked all those with your AC-placed line, I'm going to have to do an USGPIV if I need to pull your line.
> 
> Something also to consider, the receiving facility knows what vascular access the patient has. This is one of the things that is discussed during the RN-RN report. If they're OK with a 22g in the AC and I don't expect any additional need for vascular access, I'm sending the patient with the 22g in the AC. There have been times that I've been asked to place a 2nd line (and sometimes a 3rd line as 2 are already in place) before the patient leaves my facility. Otherwise I expect that they'll place an additional appropriate line if it becomes necessary. Another thing that will be discussed (and probably brought up in report to you) is whether or not that other arm is available for IV lines. I have seen some wonderful veins on a given side but can't place a line on that side because doing so is contraindicated.
> 
> Sometimes I'll place another line in the ED because I know the patient is likely to get (or has orders for) medications that are Y-site incompatible.



idk where you work, but there’s only one hospital I know of in my area who won’t use EMS lines. Most of my transfers have EMS lines that are from anywhere from 4-24 hours old. Nurses here use whatever is established.


----------



## CanadianBagel (Jul 4, 2020)

Tigger said:


> Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...
> 
> Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.



I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta, I do another IV because I’m thinking about what I would do if the patient crashed in route. BP was skyrocketing as well. The patient’s best interest was to have a second IV.

Idk where you are, but where I am an EMS IV is only pulled if it’s over 24 hours old. And when it comes to my attitude and being “that guy;” People like working with me, my bosses like me, and most importantly my patients like me and the care that I give them. It’s fine if you don’t agree with my way of doing things, but I’m secure in who I am, and the kind of provider I am. Cheers


----------



## Bishop2047 (Jul 4, 2020)

I start IVs based on what will most likely be needed, either en route or in the ER. I don't like waiting for a patient to sour, and veins to start disappearing. If the probability is high that they will need something or if my a few of my possible diagnosis would require it, you are getting a poke.

I am not a homer for 14/16 gauges and don't consider their placement the badge of honour that some do. Most people just need access and if your patient will only be getting meds and most likely won't need 4 Liters and blood, she will just be getting a smaller gauge (22s are often plenty). Traumas are pretty up in the air and I don't mind going big and placing 2 or 3 lines if there is a decent probability that I (or the destination) will need them.

I work flight, in facility, and on car, I don't think I change up this way of thinking regardless of where I am working that day. 

I work in Canada, and most provinces now keep a field poke as long as possible. Until it is showing signs of infection or infiltration. Peds can be the exception, but still will often stay in place for a week. Access is access, it is not rocket science. The Vein doesn't know if it was poked by a EMT or an anesthesiologist, and sterility is not so much due to the environment but the practitioner's method. That is why I don't understand this prejudice towards field pokes.


----------



## mgr22 (Jul 4, 2020)

SplintedTheWrongLeg said:


> I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.



I was with you until I read that. Would it be too radical to suggest that an MD or RN might have advice for you worth considering?


----------



## mrhunt (Jul 4, 2020)

SplintedTheWrongLeg said:


> I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta, I do another IV because I’m thinking about what I would do if the patient crashed in route. BP was skyrocketing as well. The patient’s best interest was to have a second IV.
> 
> Idk where you are, but where I am an EMS IV is only pulled if it’s over 24 hours old. And when it comes to my attitude and being “that guy;” People like working with me, my bosses like me, and most importantly my patients like me and the care that I give them. It’s fine if you don’t agree with my way of doing things, but I’m secure in who I am, and the kind of provider I am. Cheers



Again, It sounds like you probally have some ****ty nurses where your at. attitude mostly, Skill wise i have no idea. and we've ALL been there but they arent all like that. Hell, ive been that way (and still am to some degree) with the fire department who's bls and helps us out here but they arent all bad


----------



## CanadianBagel (Jul 4, 2020)

mgr22 said:


> I was with you until I read that. Would it be too radical to suggest that an MD or RN might have advice for you worth considering?


You have no idea how ****ty the hospital staff is in my area. I’ve seen a MD try to intubate a two year old with an an adult sized blade. First pediatric arrest I worked and they literally stopped chest compressions for a solid minute to check tube placement with an X ray. Couldn’t even find the right sized ET tube in the crash cart. Same hospital also refused to give any sedation to a pediatric GSW to the face until one of our critical care guys demanded that someone get propofol for the kid. It’s pretty bad when the medics have to tell the ED staff, who are supposed to be higher levels of care; how to do their jobs.

I have a bias, and I understand maybe it’s not always justified; I’ll admit that. I learned how to do IV’s from nurses exclusively, and there are a few that I like.. but in general I’m just not a fan of hospital staff. I don’t really trust them after seeing them hurt so many people.


----------



## mrhunt (Jul 4, 2020)

Lol. Do you work for D.A.S.??


----------



## CanadianBagel (Jul 4, 2020)

mrhunt said:


> Lol. Do you work for D.A.S.??


What the hell is a das


----------



## mrhunt (Jul 4, 2020)

I'll take that as a no. Sounds like the ambulance company I used to work for in Kern county and a very specific hospital.


----------



## CanadianBagel (Jul 4, 2020)

mrhunt said:


> I'll take that as a no. Sounds like the ambulance company I used to work for in Kern county and a very specific hospital.


I’m from St. Louis. We seem to have a different dynamic out here than other places do. Nurses and medics not getting along is a daily problem. 

We also don’t have nurses or physicians ride along with us, ever. Our critical care division acts like supervisors and meets us at CCT calls in fly cars. It’s also weird at nurses make more than medics other places. Out here being a medic is typically a six figured job.


----------



## mgr22 (Jul 4, 2020)

SplintedTheWrongLeg said:


> You have no idea how ****ty the hospital staff is in my area. I’ve seen a MD try to intubate a two year old with an an adult sized blade. First pediatric arrest I worked and they literally stopped chest compressions for a solid minute to check tube placement with an X ray. Couldn’t even find the right sized ET tube in the crash cart. Same hospital also refused to give any sedation to a pediatric GSW to the face until one of our critical care guys demanded that someone get propofol for the kid. It’s pretty bad when the medics have to tell the ED staff, who are supposed to be higher levels of care; how to do their jobs.
> 
> I have a bias, and I understand maybe it’s not always justified; I’ll admit that. I learned how to do IV’s from nurses exclusively, and there are a few that I like.. but in general I’m just not a fan of hospital staff. I don’t really trust them after seeing them hurt so many people.



Your profile says you're an EMT. Are you?


----------



## medichopeful (Jul 4, 2020)

SplintedTheWrongLeg said:


> I’m from St. Louis. We seem to have a different dynamic out here than other places do. Nurses and medics not getting along is a daily problem.



I’m sure that attitudes like your really help that dynamic. Referring to nurses as “doctor helpers” and basically saying that they are incompetent doesn’t really do a lot to help improve relations between specialties.

You also said in one of your earlier posts that you don’t have faith in the hospitals because of what you have seen.  Man, do I have some news for you about what I’ve seen EMS do as well.

I would drop the “holier than thou” attitude you have.

Edited for spelling


----------



## CanadianBagel (Jul 4, 2020)

mgr22 said:


> Your profile says you're an EMT. Are you?


I’m a medic now.


----------



## CanadianBagel (Jul 4, 2020)

medichopeful said:


> I’m sure that attitudes like your’s really help that dynamic. Referring to nurses as “doctor helpers” and basically saying that they are incompetent doesn’t really do a lot to help improve relations between specialties.
> 
> You also said in one of your earlier posts that you don’t have faith in the hospitals because of what you have seen.  Man, do I have some news for you about what I’ve seen EMS do as well.
> 
> I would drop the “holier than thou” attitude you have.


Sorry if it offends you, but it’s just the way I feel.


----------



## medichopeful (Jul 4, 2020)

SplintedTheWrongLeg said:


> Sorry if it offends you, but it’s just the way I feel.


I’m not offended, but I’ve been on both sides (EMS and nursing). There is a divide between the two at times, and attitudes like yours do nothing to improve that.

How long have you been a medic for?

Edited for spelling


----------



## CanadianBagel (Jul 4, 2020)

medichopeful said:


> I’m not offended, but I’ve been on both sides (EMS and nursing). There is a divide between the two at times, and attitudes like yours do nothing to improve that.
> 
> How long have you been a medic for?
> 
> Edited for spelling


I’m not going to be apart of a pissing match. It doesn’t matter how long I’ve been a medic, your opinion is not superior to mine because of how long you’ve been in the field vs my time in the field. Cheers


----------



## DesertMedic66 (Jul 4, 2020)

SplintedTheWrongLeg said:


> I’m not going to be apart of a pissing match. It doesn’t matter how long I’ve been a medic, your opinion is not superior to mine because of how long you’ve been in the field vs my time in the field. Cheers


Actually it kinda does. Newer medics tend to show more of the “in right and your wrong” or “I’m better than you” attitude especially when it comes to nursing staff. The more you interact with nursing staff the more you realize their education is much different from ours. They also have a much better understanding about the next steps in patient care than paramedics have. Typically we drop patients off at a facility and magical things happen inside the cath lab or neurological department and the patient gets better without a real understanding of what actually happens. 

I work with a nurse on every single shift and they are a great and extremely valuable resource. IMO the nurse/medic configuration makes for a very strong team.


----------



## CanadianBagel (Jul 4, 2020)

DesertMedic66 said:


> Actually it kinda does. Newer medics tend to show more of the “in right and your wrong” or “I’m better than you” attitude especially when it comes to nursing staff. The more you interact with nursing staff the more you realize their education is much different from ours. They also have a much better understanding about the next steps in patient care than paramedics have. Typically we drop patients off at a facility and magical things happen inside the cath lab or neurological department and the patient gets better without a real understanding of what actually happens.
> 
> I work with a nurse on every single shift and they are a great and extremely valuable resource. IMO the nurse/medic configuration makes for a very strong team.



That’s your job. Mine is adamant about having our district operationally autonomous. No doctors or nurses on our trucks, because we don’t need them. Our staff is trained to handle any case thrown at them. Critical Care here does not have protocols, they have guidelines. Their care is based on their research and experience, much like that of a physician.

You just told me to stop generalizing nurses as ****ty, but then you just generalized new medics as stuck up and self righteous.


----------



## medichopeful (Jul 4, 2020)

DesertMedic66 said:


> Actually it kinda does. Newer medics tend to show more of the “in right and your wrong” or “I’m better than you” attitude especially when it comes to nursing staff. The more you interact with nursing staff the more you realize their education is much different from ours. They also have a much better understanding about the next steps in patient care than paramedics have. Typically we drop patients off at a facility and magical things happen inside the cath lab or neurological department and the patient gets better without a real understanding of what actually happens.
> 
> I work with a nurse on every single shift and they are a great and extremely valuable resource. IMO the nurse/medic configuration makes for a very strong team.


Dunning-Kruger in action.


----------



## mgr22 (Jul 4, 2020)

SplintedTheWrongLeg said:


> That’s your job. Mine is adamant about having our district operationally autonomous. No doctors or nurses on our trucks, because we don’t need them. Our staff is trained to handle any case thrown at them. Critical Care here does not have protocols, they have guidelines. Their care is based on their research and experience, much like that of a physician.
> 
> You just told me to stop generalizing nurses as ****ty, but then you just generalized new medics as stuck up and self righteous.



You said you're from St. Louis, but are you working in the U.S.? I'm asking because of your statement about "no doctors or nurses on our trucks." That's the norm in this country, although nurses often accompany critical care transports. As to your staff having research and experience "much like that of a physician," are you talking about a largely paramedic staff? There's a pretty big difference in formal education between doctors and medics here.


----------



## CanadianBagel (Jul 4, 2020)

mgr22 said:


> You said you're from St. Louis, but are you working in the U.S.? I'm asking because of your statement about "no doctors or nurses on our trucks." That's the norm in this country, although nurses often accompany critical care transports. As to your staff having research and experience "much like that of a physician," are you talking about a largely paramedic staff? There's a pretty big difference in formal education between doctors and medics here.


I’m an American. Never lived anywhere else. Critical Care Paramedics aren’t trained to the level of physicians, but they are trained to be autonomous like physicians. I don’t believe our critical care medics ever contact medical control for anything. I’ve never contacted medical control, I literally just call critical care. It’s easier than way because those guys are always at our base and always available to meet us. They are single resource, and they are the highest level of medical authority in our county. They can override any fire or EMS Officer in terms of medical treatment. 
I respect the HELL out of my medical directors, but they expect us to talk to critical care before calling them.


----------



## Akulahawk (Jul 4, 2020)

SplintedTheWrongLeg said:


> I’m an American. Never lived anywhere else. Critical Care Paramedics aren’t trained to the level of physicians, but they are trained to be autonomous like physicians. I don’t believe our critical care medics ever contact medical control for anything. I’ve never contacted medical control, I literally just call critical care. It’s easier than way because those guys are always at our base and always available to meet us. They are single resource, and they are the highest level of medical authority in our county. They can override any fire or EMS Officer in terms of medical treatment.
> I respect the HELL out of my medical directors, but they expect us to talk to critical care before calling them.


News flash. You and the Critical Care Paramedics derive ALL of your ability to do things from  your Medical Directors. Your EMS System Medical Directors are the highest medical authority for EMS in your County. There's a HUGE education gap between even the CCP and a Physician. While you are given some autonomy, you are not autonomous. Although you have "guidelines" for your practice, if you significantly deviate from those guidelines, you still have to pay the piper or have a well-reasoned argument as to why you deviated from them. 

Newer Paramedics really don't know what they don't know. Same with newer Nurses and newer Physicians. I've been a Paramedic and an RN for quite a while. I'm not anywhere near a "new" RN or Paramedic. Most of us here have see a LOT more than you likely have as an advanced field provider. Nurses in particular have a knowledge of what happens after you drop off a patient. I'm absolutely comfortable with being able to take care of a patient from the time I pick them up in the field all the way through transferring care to an inpatient floor or ICU. That's HOURS, not minutes. Now can you do that with 4 or 6 patients? 

The point is simple. While you have seen things that aren't great, you also likely don't know what else has been going on within the ED. It very well could have been that the intubation equipment for peds was not available so the Doctor used the next best available thing. It could be that while sedation for an intubated patient would have been nice for the patient, perhaps the sending ED was concerned about bottoming out the patient's BP. Propofol is a decent drug but it's not without it's side effects.


----------



## CanadianBagel (Jul 4, 2020)

Akulahawk said:


> News flash. You and the Critical Care Paramedics derive ALL of your ability to do things from  your Medical Directors. Your EMS System Medical Directors are the highest medical authority for EMS in your County. There's a HUGE education gap between even the CCP and a Physician. While you are given some autonomy, you are not autonomous. Although you have "guidelines" for your practice, if you significantly deviate from those guidelines, you still have to pay the piper or have a well-reasoned argument as to why you deviated from them.
> 
> Newer Paramedics really don't know what they don't know. Same with newer Nurses and newer Physicians. I've been a Paramedic and an RN for quite a while. I'm not anywhere near a "new" RN or Paramedic. Most of us here have see a LOT more than you likely have as an advanced field provider. Nurses in particular have a knowledge of what happens after you drop off a patient. I'm absolutely comfortable with being able to take care of a patient from the time I pick them up in the field all the way through transferring care to an inpatient floor or ICU. That's HOURS, not minutes. Now can you do that with 4 or 6 patients?
> 
> The point is simple. While you have seen things that aren't great, you also likely don't know what else has been going on within the ED. It very well could have been that the intubation equipment for peds was not available so the Doctor used the next best available thing. It could be that while sedation for an intubated patient would have been nice for the patient, perhaps the sending ED was concerned about bottoming out the patient's BP. Propofol is a decent drug but it's not without it's side effects.


Propofol is short acting, and isn’t hard to manage as long as you have vasoactive drugs and airway control available. I’ve never felt uncomfortable managing a propofol drip, and I’m not critical care.


----------



## CanadianBagel (Jul 4, 2020)

Akulahawk said:


> News flash. You and the Critical Care Paramedics derive ALL of your ability to do things from  your Medical Directors. Your EMS System Medical Directors are the highest medical authority for EMS in your County. There's a HUGE education gap between even the CCP and a Physician. While you are given some autonomy, you are not autonomous. Although you have "guidelines" for your practice, if you significantly deviate from those guidelines, you still have to pay the piper or have a well-reasoned argument as to why you deviated from them.
> 
> Newer Paramedics really don't know what they don't know. Same with newer Nurses and newer Physicians. I've been a Paramedic and an RN for quite a while. I'm not anywhere near a "new" RN or Paramedic. Most of us here have see a LOT more than you likely have as an advanced field provider. Nurses in particular have a knowledge of what happens after you drop off a patient. I'm absolutely comfortable with being able to take care of a patient from the time I pick them up in the field all the way through transferring care to an inpatient floor or ICU. That's HOURS, not minutes. Now can you do that with 4 or 6 patients?
> 
> The point is simple. While you have seen things that aren't great, you also likely don't know what else has been going on within the ED. It very well could have been that the intubation equipment for peds was not available so the Doctor used the next best available thing. It could be that while sedation for an intubated patient would have been nice for the patient, perhaps the sending ED was concerned about bottoming out the patient's BP. Propofol is a decent drug but it's not without it's side effects.


At my agency, as long as you do the right thing, the district backs you. A guy at my work did a finger thoracotomy on a pt before they had a protocol for it, and since it worked they backed him and wrote a protocol for it. I work for a hardcore progressive agency.


----------



## medichopeful (Jul 4, 2020)

SplintedTheWrongLeg said:


> Propofol is short acting, and isn’t hard to manage as long as you have vasoactive drugs and airway control available. I’ve never felt uncomfortable managing a propofol drip, and I’m not critical care.



Why are you managing propofol drips if you are not critical care?

Your attitude is, quite honestly, scary. You present yourself as someone who knows way more than they actually do, and that is going to end up hurting a patient.


----------



## CanadianBagel (Jul 4, 2020)

medichopeful said:


> Why are you managing propofol drips if you are not critical care?
> 
> Your attitude is, quite honestly, scary. You present yourself as someone who knows way more than they actually do, and that is going to end up hurting a patient.


We’re allowed to manage propofol here without critical care. You do you, I’ll do me. Cheers


----------



## mgr22 (Jul 4, 2020)

SplintedTheWrongLeg said:


> I’m an American. Never lived anywhere else. Critical Care Paramedics aren’t trained to the level of physicians, but they are trained to be autonomous like physicians. I don’t believe our critical care medics ever contact medical control for anything. I’ve never contacted medical control, I literally just call critical care. It’s easier than way because those guys are always at our base and always available to meet us. They are single resource, and they are the highest level of medical authority in our county. They can override any fire or EMS Officer in terms of medical treatment.
> I respect the HELL out of my medical directors, but they expect us to talk to critical care before calling them.



The part about paramedics being "autonomous like physicians" -- it's simply not true. It may seem that way to you, or you may have been told that by another medic. You may even work in a system or for an agency that is reckless enough to preach that philosophy, but I urge you to read the healthcare laws of your state and perhaps consult with an attorney before you start hanging propofol drips or inserting chest tubes.


----------



## Bishop2047 (Jul 5, 2020)

Sounds like a lot of lawsuits waiting to happen.

Prosecutor: So when you attempted the pericardiocentesis you believed that you could perform any task that was "necessary" and that you felt "comfortable" with?

CB: Yes sir and I didnt even have to pull over, cause I am just that hardcore. Also I had just watched a Youtube video a week ago on the subject so the procedure was fresh in my mind.

Prosecutor: Well it seems clear that you are inline with the laws that govern medical professionals in this made up utopia. No further questions your honour.


----------



## Peak (Jul 5, 2020)

CanadianBagel said:


> That’s your job. Mine is adamant about having our district operationally autonomous. No doctors or nurses on our trucks, because we don’t need them. Our staff is trained to handle any case thrown at them. Critical Care here does not have protocols, they have guidelines. Their care is based on their research and experience, much like that of a physician.
> 
> You just told me to stop generalizing nurses as ****ty, but then you just generalized new medics as stuck up and self righteous.



Tell me how to manage a field delivery or critical care transport of a ductal dependent 800 gram DTGA. What is the emergency procedure if they lose communication?

How about a 1200 gram CAVC? What are goal saturation. What happens if you give high flow oxygen?


----------



## Akulahawk (Jul 5, 2020)

CanadianBagel said:


> Propofol is short acting, and isn’t hard to manage as long as you have vasoactive drugs and airway control available. I’ve never felt uncomfortable managing a propofol drip, and I’m not critical care.





medichopeful said:


> Why are you managing propofol drips if you are not critical care?
> 
> Your attitude is, quite honestly, scary. You present yourself as someone who knows way more than they actually do, and that is going to end up hurting a patient.





CanadianBagel said:


> We’re allowed to manage propofol here without critical care. You do you, I’ll do me. Cheers


Propofol is not that bad of an agent when you're not moving or unnecessarily stimulating your patient. Most of the time it is generally predictable. Most of the time. I'm comfortable with Propofol but I also know it can do some scary stuff at times. Propofol isn't a benign drug.


----------



## cruiseforever (Jul 5, 2020)

Akulahawk said:


> Propofol is not that bad of an agent when you're not moving or unnecessarily stimulating your patient. Most of the time it is generally predictable. Most of the time. I'm comfortable with Propofol but I also know it can do some scary stuff at times. Propofol isn't a benign drug.



So very true.  I am not a fan of it if we are transferring a pt. that has been on it for some time in an ICU.  It takes a while to make the proper adjustment to keep them comfortable.


----------



## Akulahawk (Jul 5, 2020)

CanadianBagel said:


> At my agency, as long as you do the right thing, the district backs you. A guy at my work did a finger thoracotomy on a pt before they had a protocol for it, and since it worked they backed him and wrote a protocol for it. I work for a hardcore progressive agency.


Sounds like they did a "since it worked we're going to write a protocol so we don't get sued for it." Do I know how to do a finger thoracostomy? Yes. In the absence of a protocol, would I do one without being authorized to perform surgery _and _a verbal order from a Base Physician to perform said procedure?_ Not a chance._ I have learned many things over the past 25-ish years of taking care of patients in several different areas of medicine. What keeps me from getting into too much trouble? I know what my limits are and I will only step outside those limits in very specific and defensible situations.


----------



## Peak (Jul 5, 2020)

cruiseforever said:


> So very true.  I am not a fan of it if we are transferring a pt. that has been on it for some time in an ICU.  It takes a while to make the proper adjustment to keep them comfortable.



I think it depends on what your sedation goals are. I think that propofol is a great drug to maintain a RASS -1 to -2 for adults in a dark, quiet ICU. That being said it requires far larger doses to maintain that level of sedation in the ED or during transport, and I typically find versed or Ativan to be a more effective sedation agent without going into what is clearly anesthetic dosing. Precedex is a great sedation option in many cases, and giving a dose of haldol or ketamine can also help bridge that transport gap.


----------



## mrhunt (Jul 5, 2020)

Akulahawk said:


> Sounds like they did a "since it worked we're going to write a protocol so we don't get sued for it." Do I know how to do a finger thoracostomy? Yes. In the absence of a protocol, would I do one without being authorized to perform surgery _and _a verbal order from a Base Physician to perform said procedure?_ Not a chance._ I have learned many things over the past 25-ish years of taking care of patients in several different areas of medicine. What keeps me from getting into too much trouble? I know what my limits are and I will only step outside those limits in very specific and defensible situations.



Exactly. I'll call for consults and base orders even when it doesn't REQUIRE a base order. I took a transfer a while ago where guy was doped up as **** on pain meds and 20 mins or less into transfer is just in excruciating pain.... Called base for 50mcg of fentanyl.

It's a standing order that I cAn make automatically, but was concerned cause he JUST had 8mg morphine and a bunch before that.

So if things went south and he od'd and I had to narcan him I could at least have put in my narrative that meds were approved by Dr so and so, and by Micn Betty boop.

Takes the pressure off of me to a good extent.


----------



## Akulahawk (Jul 5, 2020)

Peak said:


> I think it depends on what your sedation goals are. I think that propofol is a great drug to maintain a RASS -1 to -2 for adults in a dark, quiet ICU. That being said it requires far larger doses to maintain that level of sedation in the ED or during transport, and I typically find versed or Ativan to be a more effective sedation agent without going into what is clearly anesthetic dosing. Precedex is a great sedation option in many cases, and giving a dose of haldol or ketamine can also help bridge that transport gap.


That's where I was going with my propofol post. Great drug for what it's indicated for. It's the "far larger" doses part that I'm not sure are understood... partly because of what those "far larger" doses can do considering both the "expected" and "less common" side effects. I do like propofol, just not as much for transport, even if it's just down the hall.


----------



## silver (Jul 5, 2020)

Tigger said:


> Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...
> 
> Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.


We use IVs from the field. Generally we determine if its safe to induce with whatever is in place or not and then if needed place additional IVs. That being said, the most frustrating thing is seeing a 22 in the AC with distal targets that weren't attempted. The AC just isn't reliable enough for long term use.


----------



## Tigger (Jul 5, 2020)

CanadianBagel said:


> idk where you work, but there’s only one hospital I know of in my area who won’t use EMS lines. Most of my transfers have EMS lines that are from anywhere from 4-24 hours old. Nurses here use whatever is established.





silver said:


> We use IVs from the field. Generally we determine if its safe to induce with whatever is in place or not and then if needed place additional IVs. That being said, the most frustrating thing is seeing a 22 in the AC with distal targets that weren't attempted. The AC just isn't reliable enough for long term use.


What the ED does and what other units in the hospitals do are often different, at least here. Here the floors and ICUs aren't going to use your lines (or even that of the sending) unless the patient needs immediate management and most of the time these patients get diverted to the ED anyway.


----------



## Peak (Jul 6, 2020)

I think I mentioned this in a previous thread, but our IV policy is essentially that field EMS IVs will come out within 24 hours.

IVs that are started in the hospital (whether that be the ED, clinic, or inpatient areas), by outside hospitals, or HEMS/CCT are all treated the same and stay in until there is a medical indication for removal. I’ve had several IVs that have lasted over a month and a small handful that have lasted 6 weeks.

Unfortunately for a long period of time one of the local EMS agencies wouldn’t even use a tegaderm over their IVs and often the skin was just as dirty at insertion as the remainder of the extremity meaning that there was most likely a cursory at best wipe with an alcohol pad. While there are many IVs inserted in the field with good technique, the few bad apples soured it for everyone.


----------



## PotatoMedic (Jul 6, 2020)

Peak said:


> I think I mentioned this in a previous thread, but our IV policy is essentially that field EMS IVs will come out within 24 hours.
> 
> IVs that are started in the hospital (whether that be the ED, clinic, or inpatient areas), by outside hospitals, or HEMS/CCT are all treated the same and stay in until there is a medical indication for removal. I’ve had several IVs that have lasted over a month and a small handful that have lasted 6 weeks.
> 
> Unfortunately for a long period of time one of the local EMS agencies wouldn’t even use a tegaderm over their IVs and often the skin was just as dirty at insertion as the remainder of the extremity meaning that there was most likely a cursory at best wipe with an alcohol pad. While there are many IVs inserted in the field with good technique, the few bad apples soured it for everyone.


The hospital system that I worked at had the police that any central line not placed in the ICU would be replaced asap once the patient was in the ICU and stable enough for the procedure.  Pissed a lot of ER docs off.


----------



## DrParasite (Jul 6, 2020)

CanadianBagel said:


> I’m an American. Never lived anywhere else. Critical Care Paramedics aren’t trained to the level of physicians, but they are trained to be autonomous like physicians. I don’t believe our critical care medics ever contact medical control for anything.


that's cool.  I imagine their medical director gives them a lot of autonomy, that's awesome.  Are they on a CCT ambulance, or just hanging out at the station?  maybe they are in a flycar, so they are always available?





CanadianBagel said:


> I’ve never contacted medical control, I literally just call critical care.


you call critical care for what?  orders?  advice?  a discussion on what to do since you're not sure what to do?  





CanadianBagel said:


> It’s easier than way because those guys are always at our base and always available to meet us. They are single resource, and they are the highest level of medical authority in our county.


 I am pretty sure your medical director is a little higher than a critical care medic.  It sounds like your critical care paramedics are supervisors.  Please educate me on the educational differences between your critical care paramedics and your regular paramedic?  I mean, a doctor goes to med school, residency, and maybe a fellowship.... a paramedic has an associates degree in EMS... do your CC paramedics have a masters degree?  how much more educated are your CC paramedics than the regular paramedics?


CanadianBagel said:


> They can override any fire or EMS Officer in terms of medical treatment.


haha, maybe if your county, but in most places I have worked, it's the treating paramedic who is in charge... and if I'm the treating medic, and this is my patient, well, the CC paramedic better have a damn good reason for overriding my treatment path. After all, if I'm not competent enough to do my job, then why was I credentialed as a paramedic by the medical director, and allowed to work on the ambulance in the first place? 





CanadianBagel said:


> I respect the HELL out of my medical directors, but they expect us to talk to critical care before calling them.


I have never called critical care for anything. If I have a weird call, I might call a supervisor for guidance. if I'm not sure what to do, I might discuss it with my partner. if I need advice, I might ask the senior fire medic on what they think I should do. But again, I'm asking for help, I don't expect someone to tell me what I should do with my patient unless I ask them to.

If I need medical orders, or have an unusual clinical situation, that doesn't fit any of my protocols,  and I need to consult someone to give me advice, I am going to pick up the phone or radio and want to speak to someone who has MD/DO after their name.  But that's just me...


----------



## DrParasite (Jul 6, 2020)

Peak said:


> Tell me how to manage a field delivery


well, I'm just a dumb hose dragger, but I imagine mom does most of the work... as moms have been doing for the past 10,000+ years... once the baby comes out, warm, suction, dry and stimulate the little poop machine until they start crying... and don't drop the newborn... mom's tend to panic when those slippery suckers hit the ground...

How did I do?


----------



## DrParasite (Jul 6, 2020)

CanadianBagel said:


> At my agency, as long as you do the right thing, the district backs you. A guy at my work did a finger thoracotomy on a pt before they had a protocol for it, and since it worked they backed him and wrote a protocol for it. I work for a hardcore progressive agency.


Translation: you can do whatever you want, as long as it is successful.  if it's not successful, they are going to throw you to the wolves, and you are on your own.

hardcore and progressive are not the terms I would have used to describe an agency that you describe...... scary is much more like it.


----------



## ffemt8978 (Jul 6, 2020)

DrParasite said:


> Translation: you can do whatever you want, as long as it is successful.  if it's not successful, they are going to throw you to the wolves, and you are on your own.
> 
> hardcore and progressive are not the terms I would have used to describe an agency that you describe...... scary is much more like it.


I was thinking more along the lines of "reckless", "a malpractice attorney's dream" and maybe even "dangerous".


----------



## Peak (Jul 6, 2020)

DrParasite said:


> well, I'm just a dumb hose dragger, but I imagine mom does most of the work... as moms have been doing for the past 10,000+ years... once the baby comes out, warm, suction, dry and stimulate the little poop machine until they start crying... and don't drop the newborn... mom's tend to panic when those slippery suckers hit the ground...
> 
> How did I do?




Poorly, especially since you chose to selectively quote such a small portion of the question that you missed it entirely. If you think just warming, drying, and stimulating is is all you need to manage a shunt dependent 28 weeker then it all the more proves how little most clinicians understand about OB and neos.

Even if you want to address it as a simple full term birth then I would point out the historic mortality of moms and babies over those 10,000 years. It’s about as valid as saying that we don’t need modern medicine because humanity survived without it for 10,000 years.


----------



## Carlos Danger (Jul 6, 2020)

CanadianBagel said:


> I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. *When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta,* I do another IV because I’m thinking about what I would do if the patient crashed in route.


I call BS on that entire story.


----------



## DrParasite (Jul 7, 2020)

Peak said:


> Poorly, especially since you chose to selectively quote such a small portion of the question that you missed it entirely. If you think just warming, drying, and stimulating is is all you need to manage a shunt dependent 28 weeker then it all the more proves how little most clinicians understand about OB and neos.


my bad, I thought you were asking about two separate patients, esp since you said " Tell me how to manage a field delivery or critical care transport of a ductal dependent 800 gram DTGA. " Now if you had said "Tell me how to manage a field delivery of a premie who requires critical care transport of a ductal dependent 800 gram DTGA" than I would have had no clue how to handle it.  I know my limits, and that's faaaar beyond my abilities.


Peak said:


> Even if you want to address it as a simple full term birth then I would point out the historic mortality of moms and babies over those 10,000 years. It’s about as valid as saying that we don’t need modern medicine because humanity survived without it for 10,000 years.


The exact same argument (with the studies supporting it) have been made about prehospital ALS... but that's a different topic altogether.  not going there


----------



## wtferick (Jul 15, 2020)

Peak said:


> There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.
> 
> Where are you that a hospital has a director of nursing? DONs are a nursing home thing.


A lot of Hospitals tend to have multiple DONs...


----------



## Peak (Jul 15, 2020)

wtferick said:


> A lot of Hospitals tend to have multiple DONs...



In a hospital the term director is typically used in regards to the leadership of a service line, but they wouldn’t be a ‘director of nursing.’ You would typically have a director of adult critical care, director of outpatient surgical services, director of organ transplant and procurement, et cetera.


----------



## Ridryder911 (Jul 22, 2020)

Peak said:


> In a hospital the term director is typically used in regards to the leadership of a service line, but they wouldn’t be a ‘director of nursing.’ You would typically have a director of adult critical care, director of outpatient surgical services, director of organ transplant and procurement, et cetera.



I agree. It all depends on the _newest management style and jargon for today!_ We just recently have a new CEO for our statewide hospital system. We have totally overhauled the hierarchy titles, no longer directors except for those that manage multiple departments. No longer individual hospital presidents as they are now corporate vice presidents.... and so forth. DON =Chief Nursing Director/ Administrator or Vice President or President of Clinical Affairs...etc.....etc.... It's all where and what they want to call the boss these days! 

Chances are, the more titles they can distribute, the larger the role = more responsibilities = same amount of pay of one executive. 

Be safe, 

R/r911!


----------



## Old Tracker (Jul 22, 2020)

If we're outside the city limits the Pt might get an IV.  Depends on what the problem is, cardiac probably, but good vitals and nothing major, then no, we are about 3 miles max from the hospital.  Out in the county, different story, anything that might need meds gets an IV.


----------

