# Keeping skills up while working per diem?



## Knightinwhitesatin (Apr 17, 2015)

I'm new here. I'm a busy mom of two little kids and a medic. I took a few years off with my kids and am now getting back into it again working a 911 system as a per diem medic. Being per diem works great for my family schedule but I feel like my skills were more top notch when I worked full time. Anyone else ever feel like this? I use to rock at IVs and now I feel like I'm just okay cuz I don't do them very much being per diem. Any others just work as a medic per diem and not a full time job too? Being a mom is my full time job!


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## Ewok Jerky (Apr 17, 2015)

Nature of the beast. 

I suppose there are two ways to go with this, you could stick everyone you see for the practice, or use smaller needles on those who truly need an IV.  Well I guess there is a 3rd option you could just IO everyone.  But I am pretty sure most of our patients can wait until the IV nurse gets to them in the ED.


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## NomadicMedic (Apr 17, 2015)

I work per diem, usually a 16 or 24 on the weekends, and we're not super busy. We have a skills day every quarter that I attend. Other than that, I haven't found my skills have degraded that much. I had a decent trauma and an arrest the other day, it's like riding a bike.  I find it harder to remember where stuff is on the truck. After 4 years of doing it in the same place, with the same gear, it's a bit of a shock to show up at a new service, with different stuff and only work once a week. We don't have RSI here, which is a bit of blessing. I don't think I'd be comfortable performing that procedure every other year or so.


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## NYBLS (Apr 17, 2015)

Ewok Jerky said:


> Nature of the beast.
> 
> I suppose there are two ways to go with this, you could stick everyone you see for the practice, or use smaller needles on those who truly need an IV.  Well I guess there is a 3rd option you could just IO everyone.  But I am pretty sure most of our patients can wait until the IV nurse gets to them in the ED.



Most veins that can fit a 20 can fit a 14 (grab an ultrasound to prove it). Most IVs are about confidence in your skills. How long have you been per diem? How many calls do you run a week on average?


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## Knightinwhitesatin (Apr 17, 2015)

It's rural so it's really hit or miss on calls. Sometimes 0 sometimes 8. I've been per diem a few months now but did take some time prior to starting back again to do some IVs in the ER just to get my practice up and it really helped. But man I haven't intubated in years I have practiced on the dummy. We don't have RSI either. Unfortunately the hospitals won't let medics ett anymore some liability issue. As they use to let us.


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## COmedic17 (Apr 18, 2015)

NYBLS said:


> *Most veins that can fit a 20 can fit a 14 *(grab an ultrasound to prove it). Most IVs are about confidence in your skills. How long have you been per diem? How many calls do you run a week on average?



BS. 
The only reason I'm ever dropping a 20g is if I can't get an 18. If I can't get an 18, I'm surely not going to get a 14...


Have you ever looked at the difference in sizes of an 20 and a 14? It's substantial.


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## Carlos Danger (Apr 18, 2015)

NYBLS said:


> Most veins that can fit a 20 can fit a 14 (grab an ultrasound to prove it).



Huh?


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## NomadicMedic (Apr 18, 2015)

NYBLS said:


> Most veins that can fit a 20 can fit a 14 (grab an ultrasound to prove it)



If you tried to put a 14 in my mom's hand, we'd be having a discussion.


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## EMSComeLately (Apr 18, 2015)

What about getting a per diem job at an ER as well?  That should certainly help increase IV iterations.


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## Carlos Danger (Apr 18, 2015)

NYBLS said:


> Most veins that can fit a 20 can fit a 14 (grab an ultrasound to prove it). Most IVs are about confidence in your skills. How long have you been per diem? How many calls do you run a week on average?



There is a big difference between using US to place a larger line than you would be able to place blindly, and saying "you can fit any size catheter anywhere". That's plain untrue.


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## Ewok Jerky (Apr 18, 2015)

NYBLS said:


> Most veins that can fit a 20 can fit a 14 (grab an ultrasound to prove it). Most IVs are about confidence in your skills.



Fitting is not the same as being easily placed.

And also, the whole point is a lack of confidence.


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## NYBLS (Apr 18, 2015)

DEmedic said:


> If you tried to put a 14 in my mom's hand, we'd be having a discussion.



And if your mom is truly ill?


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## NYBLS (Apr 18, 2015)

COmedic17 said:


> BS.
> The only reason I'm ever dropping a 20g is if I can't get an 18. If I can't get an 18, I'm surely not going to get a 14...
> 
> 
> Have you ever looked at the difference in sizes of an 20 and a 14? It's substantial.



I'm not saying utilize US to guide insertion, I'm saying use it to measure the size of many of the veins sometime.


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## NYBLS (Apr 18, 2015)

Remi said:


> There is a big difference between using US to place a larger line than you would be able to place blindly, and saying "you can fit any size catheter anywhere". That's plain untrue.



I'm not certain where I said "you can fit any size catheter anywhere.".....


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## Tigger (Apr 18, 2015)

NYBLS said:


> And if your mom is truly ill?


We would still be having a discussion as that is a completely inappropriate intervention. 

A 14 is hardly ever necessary, and certainly not in the back of the hand.


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## NYBLS (Apr 18, 2015)

Tigger said:


> We would still be having a discussion as that is a completely inappropriate intervention.
> 
> A 14 is hardly ever necessary, and certainly not in the back of the hand.



I can think of several.


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## Carlos Danger (Apr 18, 2015)

NYBLS said:


> I'm not certain where I said "you can fit any size catheter anywhere.".....


A 14g has roughly twice the outer diameter that a 20g does. Claiming to be able to put a 14g anywhere you can put a 20g is just ridiculous. You may as well have claimed to be able to poop diamonds.


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## PotatoMedic (Apr 18, 2015)

When do you need to flow more then 220ml of NS per minute?  (That is the published flow rate for a BD 16g iv catch.)


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## COmedic17 (Apr 18, 2015)

NYBLS said:


> And if your mom is truly ill?




I would be pissed that you dropped a 14g  when it's unnecessary.

The hospital can even push blood through a 18g or 16g. There's no reason for a 14g.

Get a line because you need it. Not because "it would look cool" if you rolled in with a 14g.


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## Tigger (Apr 18, 2015)

NYBLS said:


> I can think of several.


Then post them for all to critique. No need to be coy. 

You have made several absurd statement that you have yet to backup. Now would be a good time to do so.


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## NomadicMedic (Apr 18, 2015)

NYBLS said:


> And if your mom is truly ill?



There are a few other options. An EJ. An IO. 
An apropriate sized catheter. 

My mom is 77 and has dementia. I treat all my patients, especially the frail little old ladies, just like I treat my mom. If I saw a medic attempting to place a 14 in the hand of a little old lady, you can bet there'd be a discussion. 

While malfeasance may be a stretch, the care would certainly be grossly inapropriate.


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## Handsome Robb (Apr 18, 2015)

People rarely need anything larger than a 20. Honestly unless they're needed a fast fluid bolus, blood or contrast dye a 22g would be fine.

I get a lot of flack for using 20s as my standard IV cath rather than an 18.


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## NomadicMedic (Apr 18, 2015)

My go to is a 20 as well. I put a 16 in a trauma* last week and it seemed HUGE.





*20 year old male with ropes, and it went in his AC.


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## NYBLS (Apr 20, 2015)

Remi said:


> A 14g has roughly twice the outer diameter that a 20g does. Claiming to be able to put a 14g anywhere you can put a 20g is just ridiculous. You may as well have claimed to be able to poop diamonds.



Again, where did I say anywhere?


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## NYBLS (Apr 20, 2015)

Tigger said:


> Then post them for all to critique. No need to be coy.
> 
> You have made several absurd statement that you have yet to backup. Now would be a good time to do so.



Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.


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## NYBLS (Apr 20, 2015)

COmedic17 said:


> I would be pissed that you dropped a 14g  when it's unnecessary.
> 
> The hospital can even push blood through a 18g or 16g. There's no reason for a 14g.
> 
> Get a line because you need it. Not because "it would look cool" if you rolled in with a 14g.



I'm not sure where I said "it would look cool." People around this forum seem huge on providing quotations around things that were never said, even with the quote option right next to each post.


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## NYBLS (Apr 20, 2015)

DEmedic said:


> There are a few other options. An EJ. An IO.
> An apropriate sized catheter.
> 
> My mom is 77 and has dementia. I treat all my patients, especially the frail little old ladies, just like I treat my mom. If I saw a medic attempting to place a 14 in the hand of a little old lady, you can bet there'd be a discussion.
> ...



A 14 will offer better flow rates. Im surprised you would rather me drill a needle into your moms leg or arm then place an IV. And if I place an EJ it will be a 14.


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## COmedic17 (Apr 20, 2015)

NYBLS said:


> I'm not sure where I said "it would look cool." People around this forum seem huge on providing quotations around things that were never said, even with the quote option right next to each post.


The only reason you would want to drop a 14g in a little old lady is to try to validate yourself in someway. There's no situation a 14g would be necessary.


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## Carlos Danger (Apr 20, 2015)

NYBLS said:


> Again, where did I say anywhere?



I never said that you said that. I was making a point about the absurdity of your claim.

If you are just going to deflect rather than defend your claim, then just drop it.



NYBLS said:


> Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and *you putting in a small needle to avoid increased pain can lead to their death.*



Really? 

No one ever died because they had a 20g placed instead of a 14g. Certainly not a CVA or MI patient. Even sepsis is now treated with much lower volumes than used to be recommended. 

It's a very rare case these days where it's necessary to slam in large volumes of fluid very quickly.


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## Carlos Danger (Apr 20, 2015)

double post


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## NomadicMedic (Apr 20, 2015)

NYBLS said:


> A 14 will offer better flow rates. Im surprised you would rather me drill a needle into your moms leg or arm then place an IV. And if I place an EJ it will be a 14.



I said "place a 14 in the hand of a frail little old lady" 

A patient needing fluid resuscitation needs a patent IV, not a medic with a "go big or go home" mentality. 

For someone who likes to ***** about quotations, you sure do a good job of misquoting.


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## Tigger (Apr 21, 2015)

NYBLS said:


> Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.


Did not say anything about reducing pain. Meanwhile, there are known complications with larger catheters, especially in the back of the hand.

That's ok though. You've clearly made up your mind and would rather discount evidence in the name of "doing what is right." Ok then. While I know it's fun to laugh at all of us idiots who aren't as "aggressive" as you, take heed.


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## epipusher (Apr 21, 2015)

I hope you are just being a troll in regards to your 14g posts.


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## CANMAN (Apr 21, 2015)

NYBLS said:


> Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.



Insists on 14 gauges for above mentioned conditions, has <50% success rate with said 14 gauge attempts  sounds about right....


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## COmedic17 (Apr 21, 2015)

NYBLS said:


> Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.



Sepsis- you can run more then enough fluid in an 18g or 16g ( if really needed). If your so concerned over flooding them with fluid, why not bilateral 18gs? Most hospitals would prefer bilateral 18gs over one garden hose(14g).

MI- I have never heard of a 14g being recommended in a MI. I routinely place bilateral 18g IVs  for cardiac alerts and that has always been more then enough.

CVA- thrombolytic drugs can be ran through smaller gauge needles then a 14. There's absolutely no indication a 14g is needed in a CVA.

Trauma- if they are that hemodynamically unstable, bilateral 18gs or 16g are going to be much more appropriate then one 14g. Have you ever ran two 18gs wide open? Works pretty well. Also good luck dropping a 14g on a trauma patient in hypovolemic shock. Unless they have some massive EJ. But even then, a 16g is going to be more realistic. Remember permissive hypotension- saline doesn't have hemoglobin. No one needs 3 liters ran through a 14g.

And again, blood can be ran through 18gs and up. You don't need to drop a garden hose in someone to get good results. Do bilateral lines if you need more access. Also, bilateral lines gives you a "backup" route if one becomes compromised.


Think. Your driving argument here is "what if they need lots of fluid" but there's ways to ensure they can get what they need without providing necessary interventions.


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## Knightinwhitesatin (Apr 21, 2015)

I can't help but add since my original post got changed into iv size debate.... That you can and I have seen blood given via a 24g!!


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## COmedic17 (Apr 21, 2015)

Knightinwhitesatin said:


> I can't help but add since my original post got changed into iv size debate.... That you can and I have seen blood given via a 24g!!


24g are almost always reserved for pediatrics. (Unless it's literally all you can get. However, I have yet to be in a situation where I couldn't at least get a 20g somewhere (in an adult). My go to is an 18 for adults, 20 for pediatrics, and 24 for an infants)

Blood CAN be ran though a 24g, but very very slowly. This might be adequate for a 10 pound baby, but the rate at which blood can be administered through a 24g for an adult is inadequate and inappropriate. This is why it's recommended to have at least an 18g to run blood for adults.

If your giving blood to an adult in a traumatic situation, they are going to need that blood administered FAR quicker then a 24g will permit. Same with fluid,or medication administration. 24g's are just to slow to suffice. They are also more prone to kinks and clotting off.

That is also why PHTLS calls for "large bore" IV access. You can't run fluids in fast enough with a 24g for an adult (or even most older children).


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## chaz90 (Apr 21, 2015)

@COmedic17. Trying not to stoke the fires of this off topic issue too much, but there's nothing wrong with medication or fluid administration through a 22G in an adult. I've had plenty of patients where a 22G was the only size I was able to place, whether that was my own failing, time based, or patient based. I've given most medications through some small IVs (including one where we RSIed through a 22G because it was flowing better than our IO), and I've run 500 mL of fluid through a 22 even during my transport time of ~40 minutes. 

In any case, I think I agree with the spirit of what you're saying even if I implement it slightly differently. Blood does change things slightly of course, and I can't say I have much experience administering blood products of any sort.


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## COmedic17 (Apr 21, 2015)

chaz90 said:


> @COmedic17. Trying not to stoke the fires of this off topic issue too much, *but there's nothing wrong with medication or fluid administration through a 22G in an adult.* I've had plenty of patients where a 22G was the only size I was able to place, whether that was my own failing, time based, or patient based. I've given most medications through some small IVs (including one where we RSIed through a 22G because it was flowing better than our IO), and I've run 500 mL of fluid through a 22 even during my transport time of ~40 minutes.
> 
> In any case, I think I agree with the spirit of what you're saying even if I implement it slightly differently. Blood does change things slightly of course, and I can't say I have much experience administering blood products of any sort.




In a critical patient though?
( I'm basing my commentaries off of treatment for critical patients since that was the original topic) 

 Just in my experience I encounter difficulties doing rapid fluid bolus's in unstable, hypotensive patients with small gauge IVs. Or drugs (like adenosine) that have such a short half life and need to be "slammed".


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## Jim37F (Apr 21, 2015)

20g is the standard go to for our medics for the vast majority of patients. 18g if they're going to the Trauma Center and 22g for grandma/grandpa. I think the only time I've seen one of our medics use a 16g is for a bariatric trauma, and the 24g for infants/toddlers. Never seen a 14g get used, heck most of us wonder why we stock so many on the ambulance (10 of each size).


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## CANMAN (Apr 22, 2015)

We have gotten way off topic, let's just agree the line you CAN get is better then the one you CAN'T, and move along.


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## Tigger (Apr 22, 2015)

COmedic17 said:


> In a critical patient though?
> ( I'm basing my commentaries off of treatment for critical patients since that was the original topic)
> 
> Just in my experience I encounter difficulties doing rapid fluid bolus's in unstable, hypotensive patients with small gauge IVs. Or drugs (like adenosine) that have such a short half life and need to be "slammed".


If it's all you can get, then sure. Sometimes a 22 sized hand vein is what the patient has, and that's the end. No sense and trying to force something larger (phrasing).


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## NomadicMedic (Apr 22, 2015)

CANMAN said:


> We have gotten way off topic, let's just agree the line you CAN get is better then the one you CAN'T, and move along.



No, because the point of the digression was the line that's APPROPRIATELY SIZED is better than the line you can CRAM IN. 

That should be the take home.


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## NYBLS (Apr 23, 2015)

Tigger said:


> Did not say anything about reducing pain. Meanwhile, there are known complications with larger catheters, especially in the back of the hand.
> 
> That's ok though. You've clearly made up your mind and would rather discount evidence in the name of "doing what is right." Ok then. While I know it's fun to laugh at all of us idiots who aren't as "aggressive" as you, take heed.



Evidence please? And I'm not sure where I laughed or called anyone here an idiot. If you cant participate in a healthy debate then why keep returning to the thread?


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## NYBLS (Apr 23, 2015)

epipusher said:


> I hope you are just being a troll in regards to your 14g posts.



No.


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## NYBLS (Apr 23, 2015)

Remi said:


> I never said that you said that. I was making a point about the absurdity of your claim.
> 
> If you are just going to deflect rather than defend your claim, then just drop it.
> 
> ...



And how are you aware of this? Do your system do follow up on all patient encounters? Group discussions on improvement? Or do you just drop them off at the hospital and make assumptions about their status after that?


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## NYBLS (Apr 23, 2015)

CANMAN said:


> Insists on 14 gauges for above mentioned conditions, has <50% success rate with said 14 gauge attempts  sounds about right....



And how are you, or anyone else on here for that matter, aware of anyones IV success rate?


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## Carlos Danger (Apr 23, 2015)

NYBLS said:


> And how are you aware of this? Do your system do follow up on all patient encounters? Group discussions on improvement? Or do you just drop them off at the hospital and make assumptions about their status after that?



You are the one who has to prove your position, not me. The onus is always on the intervention to prove itself, not the other way around. So your claim that "small IV's kill people" means absolutely nothing unless _you_ can validate it with evidence.

But because you asked, yes, actually - for about the last 4 years that I flew, my program received feedback on every patient that we flew to our home trauma center, and we could look at their chart online anytime. The feedback was always passed on to the crew who delivered the patient, and anything that needed to be done differently was shared with the entire staff. Never once did I ever hear from the trauma service (or any other service) that a patient died because their prehospital IV was too small. 

Also because I read and I'm aware of current trends in resuscitation. The days of septic patients getting 8 liters slammed in an hour are over. MI and CVA patients are typically kept dry. These days pretty much no one gets large volumes of fluid quickly. Even massive trauma patients get only limited resuscitation with blood products and are kept hypotensive until bleeding is stopped.   

Just as an example, let's do the math on a hypothetical burn patient. Just to make it interesting, let's say he's a really big guy - 120kg. And let's say he suffered 80% BSA burns, and that he didn't have an IV started until 1 hour after he suffered the burn. Let's also elect to resuscitate with the high-end, 4 ml/kg/BSA formula.

120 X 4 x 80 = 38,400 ml of LR in the first 24 hours, with half of that (19.2 liters) over the next 7 hours. Wow, that is a crap-ton of fluid. We'll easily need bilateral 14's to make that goal, right?

Well, let's see....19.2 liters over 7 hours works out to 2742 ml per hour. You can actually get 60ml/min from a 20g, though.....which is 3600 ml per hour, well above the 2700 per hour that we need to keep our guy from getting too dry.

And that's if you free-flow that 20g; if you put it under pressure, you can get up to 5ml/sec, which is 18,000 ml per hour, which is almost enough to give this guy his entire 24-hour prescription in just 60 minutes.  

In fact, you could very nearly meet his requirements with a free-flowing 22g, which delivers 2100 ml/hr. Put that baby under pressure, and you can get 3 ml/sec (10,800 ml/hr), which again, easily meets his needs. ​
So tell me again how large PIV's are so important?


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## Tigger (Apr 23, 2015)

NYBLS said:


> Evidence please? And I'm not sure where I laughed or called anyone here an idiot. If you cant participate in a healthy debate then why keep returning to the thread?


 Part of a "debate" is recognizing that you must provide evidence in backing up your claim, which is something you have yet to do. As has been said, the intervention must be proved to be beneficial before it is accepted.



> The risk of phlebitis is increased when a large-gauge catheter is used, possibly because of the physical trauma caused by the insertion of a large-bore catheter into a relatively short, narrow vein. - See more at: http://www.nursingcenter.com/lnc/static?pageid=1374284#sthash.mtEVIgm1.dpuf


From:  *Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access*
Journal of Infusion Nursing
http://www.nursingcenter.com/lnc/static?pageid=1374284#sthash.mtEVIgm1.dpuf



> Depending on location, larger catheter sizes can create increased mechanical irritation to vein wall
> 
> Vessel should be large enough to accommodate catheter and provide adequate hemodilution




From:*BD Clinical Brochure *(You know, the people that actually design IV catheters)
https://www.bd.com/infusion/products/ivcatheters/clinical_expertise/pdfs/clinical_brochure1.pdf



> Patients requiring venous access for the administration of IV medications, who will not require rapid fluid/blood administrations, may benefit from the use of a smaller catheter. Smaller catheters (i.e. 22 gauge) allow for greater hemodilution of medications and reduce the risk of phlebitis.


From: Venous Access Devices
University of California Chico School of Nursing
https://www.csuchico.edu/nurs/current/accessDevices.shtml

Few of your examples require a rapid infusion of fluid or blood (CVA? really?). And even if they did, something other than a 14 in the back of the hand of an elderly female (the scenario at hand), would be appropriate.

But again, the onus is on you to prove that your choice of intervention is beneficial to the patient. So how about your evidence?


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## CANMAN (Apr 23, 2015)

DEmedic said:


> No, because the point of the digression was the line that's APPROPRIATELY SIZED is better than the line you can CRAM IN.
> 
> That should be the take home.


 Touche'


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## Brandon O (Apr 23, 2015)

Remi said:


> Also because I read and I'm aware of current trends in resuscitation. The days of septic patients getting 8 liters slammed in an hour are over. MI and CVA patients are typically kept dry. These days pretty much no one gets large volumes of fluid quickly. Even massive trauma patients get only limited resuscitation with blood products and are kept hypotensive until bleeding is stopped.



There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.

Which is not common outside the military.


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## PotatoMedic (Apr 24, 2015)

Brandon O said:


> There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.
> 
> Which is not common outside the military.


And they usually get a central line.


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## Brandon O (Apr 24, 2015)

FireWA1 said:


> And they usually get a central line.



Sure (ideally something like a Cordis), but that's not usually an option in the field and not always a viable option in the initial ED resuscitation.


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## Carlos Danger (Apr 24, 2015)

Brandon O said:


> There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.
> 
> Which is not common outside the military.


Sure. And a frequent contibuting factor in coagulopathy of trauma is over-resuscitation with crystalloids.

A Cordis or RIC can be placed in the OR, if they are needed. EMS should focus on establishing reliable access and not worry about the massive transfusion that may become necessary later.


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## Brandon O (Apr 24, 2015)

For the most part I agree. But in principle I feel that one of our primary goals in the field -- and this is increasingly true with more critical patients -- is to facilitate the transfer of care so they can get what they need more quickly. Since part of "what they need" for a minutes-matter hemorrhagic trauma patient is blood products, it would theoretically be better if you could show up with big, numerous, bomb-proof peripheral access.

That doesn't mean it's mandatory, and it absolutely doesn't mean nonsense like staying on scene to play with EJs or skipping the 18 you can get for the 16 you can't. But all things being equal, the platonic ideal for these patients would involve walking in the door, maybe picking up some blood, and heading upstairs to where some knives are waiting.

Just to draw a parallel, airway management would fall under a similar category. If it's not absolutely necessary and it means delaying transport you're probably wrong to do it. But if it can happen without detriment, if it's already done it will expedite the process.

Again, this is rarely real life. But that applies to most of the true emergencies we study.


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## Carlos Danger (Apr 24, 2015)

My point wasn't that large IV's shouldn't be placed in the field. I was just saying that it will likely never impact outcomes, so shouldn't be a priority at all.


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## Accelerator (May 13, 2015)

NYBLS said:


> Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.



There is the concept of permissive hypotension in trauma that I think as a community we don't take enough time to delve into. Is pumping them full of saline actually going to increase that patient's survivability? Evidence suggests it may not. I've seen plenty of docs close the lines after bringing a serious trauma patient in.

Why would a CVA require high volume resuscitation? It's not as if you can drown an embolism in saline. I would prefer a twin-cath in that scenario to a large bore iv. It does help the nursing staff to have two ivs for any patient that may require tpa but they don't have to be 14s.


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