# Starting IV's - warn patient what it will feel like if you hit a nerve?



## J B (May 2, 2013)

"This will hurt a little, but stop me if you feel a shock or numbness."

Would saying something like this cause too much stress for patients?

Many people (patients and providers alike) seem to be oblivious to the fact that permanent and debilitating injury can occur from starting an IV.

I've spent the last few hours reading horror stories about nerve damage in patients from IVs.  It seems as though lasting damage is fairly rare, and permanent damage is even more rare... But it does happen, and probably more often than people think.


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## TheLocalMedic (May 2, 2013)

Hmmm...  well, I am a big proponent of not sticking someone unless you're actually able to see/palpate a vein.  I think that blind sticks or fishing around for a vein will more often result in doing unintended damage.  Honestly, with practice you shouldn't ever have a problem finding veins and hitting them consistently.  And if you're having trouble with this, there's no shame in talking to your company about arranging to spend some time in an ED practicing your IV skills.  

That being said, I don't think I have ever or will ever warn a patient to tell me to stop during an IV attempt.  I absolutely inform them that I will be poking them and why I am doing it, but telling people about all the potential side effects and risks of a procedure (especially in an emergent situation where you have neither the time nor the inclination to rattle off all the "possible" deleterious effects a procedure) isn't productive.  If they don't want me to stick them, they have the right to decline.  But warning them about the potential for nerve damage (which I have yet to actually witness) seems a little over the top.  

Besides, half the time when you tell people what "might happen" they will think that it _has_ happened.


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## Carlos Danger (May 2, 2013)

Nerve injury is probably exceedingly rare with peripheral IV starts. I know it happens with radial arterial blood draws (happened to someone I know very well, in fact), but unless you are fishing around blindly near a joint, it shouldn't ever happen from a PIV attempt.

I wonder what the overall incidence is of serious complications resulting from IV starts?



TheLocalMedic said:


> That being said, I don't think I have ever or will ever warn a patient to tell me to stop during an IV attempt.  I absolutely inform them that I will be poking them and why I am doing it, but telling people about all the potential side effects and risks of a procedure (especially in an emergent situation where you have neither the time nor the inclination to rattle off all the "possible" deleterious effects a procedure) isn't productive.  If they don't want me to stick them, they have the right to decline.  But warning them about the potential for nerve damage (which I have yet to actually witness) seems a little over the top.
> 
> *Besides, half the time when you tell people what "might happen" they will think that it has happened.*



Well, I'm not really sure that the fear of this is a good reason to not obtain informed consent....

But it does bring up an interesting point. How much info are you obligated to provide your patient about a specific procedure or medication in order for their consent to be "informed"?

In a life-threatening emergency, or if the patient is unable to communicate, the standards for consent are very low ("implied consent" and all that). 

But how many IV sticks are emergent? 10%? 50%? That means a whole lot of people are being exposed to the potential hazards of an unnecessary procedure without probably being told anything about the risks of the procedure. I know I've never done it.


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## Rialaigh (May 2, 2013)

Halothane said:


> Nerve injury, which is probably exceedingly rare with peripheral IV starts. I know it happens with radial arterial blood draws (happened to someone I know very well, in fact), but unless you are fishing around blindly near a joint, it shouldn't ever happen from a PIV attempt.
> 
> I wonder what the overall incidence is of serious complications resulting from IV starts?
> 
> ...



Almost none. I know every doc that walks into a patients room and gives something for pain says "I'm going to give you something for pain". The nurse walks in and says "here's some dilaudid something for pain". They don't talk about reactions to medication, medication allergies, possible side effects, etc...

When I get on scene and ask if I can treat you I am obtaining consent for everything I am going to do until I transfer care to someone else. I reenforce this by saying "Ive got some medication to help your stomach (zofran)" etc when giving a medication. The patient can refuse treatment at any time but they have already consented to treatment so that falls on them.


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## Carlos Danger (May 2, 2013)

Halothane said:


> How much info are you obligated to provide your patient about a specific procedure or medication in order for their consent to be "informed"?





Rialaigh said:


> *Almost none. *I know every doc that walks into a patients room and gives something for pain says "I'm going to give you something for pain". The nurse walks in and says "here's some dilaudid something for pain". They don't talk about reactions to medication, medication allergies, possible side effects, etc...
> 
> *When I get on scene and ask if I can treat you I am obtaining consent for everything I am going to do until I transfer care* to someone else. I reenforce this by saying "Ive got some medication to help your stomach (zofran)" etc when giving a medication. The patient can refuse treatment at any time but they have already consented to treatment so that falls on them.




I would be very careful with that. Just because you see others do it - and I know we all do it - doesn't mean that you couldn't get jammed up by a patient claiming that they wouldn't have allowed you to do some specific thing, had they only known the potential complications.

It's probably a pretty safe bet that if someone calls 911 and lets you into their house and cooperates with your questions and exam, that that constitutes "consent to treat". But simply getting "consent" is not good enough; you have to obtain "_informed_ consent".

Because, what if the patient thinks "treat" simply means you will take their BP and ask a few questions and drive them to the hospital? Can they then not refuse an IV? What if they think "treat" means starting an IV and putting them on the monitor, but nothing else? Then you give them a med, and they have a bad reaction to it. You can bet everything you own that the fact they they did not consent to that med will be made an issue of. 

Even if you do get explicit permission to give them a medication but you don't talk at all about the risks and they have a complication, all they have to do is say the magic phrase "If I had known this could happen, I would have refused the medication". If the complication was something that you should have known about and could have reasonably foreseen as a risk (i.e., if it is a known complication), just open up your checkbook and turn in your EMT card. 

Obviously there is a lot of gray area, which is the point of my question. It's clearly not practical to take the time to describe every potential side effect or complication and have a detailed discussion of the risk:benefits of everything we do, but patients absolutely have a legal right to *informed* consent and you are putting yourself at legal risk if you make no attempt at all.


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## mycrofft (May 2, 2013)

Psychoprophylaxis: "You may experience a short pain. Let me know if it doesn't go away or changes".

Non-Psychoprophylaxis: "Here comes the pain!!"*.






(*"Carllito's Way",1993)


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## Fish (May 3, 2013)

J B said:


> "This will hurt a little, but stop me if you feel a shock or numbness."
> 
> Would saying something like this cause too much stress for patients?
> 
> ...



I would not say this, if someone said this to me I would be mortified....... "What do you mean shock of numbness??? Will it be permanent??? I have had IVs and blood draws before and never have a I heard!!!" Those are the thoughts I could imagine a patient would be having.

I just say, "Your gonna feel a sting, please don't move..... 1...2...3"


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## J B (May 3, 2013)

Fish said:


> I would not say this, if someone said this to me I would be mortified....... "What do you mean shock of numbness??? Will it be permanent??? I have had IVs and blood draws before and never have a I heard!!!" Those are the thoughts I could imagine a patient would be having.



Yeah.... I guess you just have to hope they make a comment or scream in pain if you hit something, and be responsive to what they say.  A lot of horror stories go something like, "I told the nurse my hand went numb and to please stop, but she said that's normal and kept pushing the needle in."

If you google "iv nerve damage" you get links to a bunch of lawyers' websites, so I assume lawsuits over this do happen with some regularity.


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## Rialaigh (May 3, 2013)

Halothane said:


> I would be very careful with that. Just because you see others do it - and I know we all do it - doesn't mean that you couldn't get jammed up by a patient claiming that they wouldn't have allowed you to do some specific thing, had they only known the potential complications.
> 
> It's probably a pretty safe bet that if someone calls 911 and lets you into their house and cooperates with your questions and exam, that that constitutes "consent to treat". But simply getting "consent" is not good enough; you have to obtain "_informed_ consent".
> 
> ...



There is no reasonable way to protect yourself completely in the field, however I think making some attempt to explain a medication and side effects may be worse then making no attempt at all. You give them a medication and tell them it may make their stomach hurt for a bit, they get to the hospital and have a GI bleed or a blockage, and they will swear up and down your medication did it to them, will that hold up in a court of law, no, but will it cause you a huge headache..yes...


Where I run EMS when you go out to a call and are trying to get a medical history on people you ask them questions like "Hey hun, do you got suga?" if they say yes they are diabetic, then you ask "do you got pressure?" if yes then they have high blood pressure. I can't even think about how I would start to explain medication side effects beyond "this will help ya for pain, it might make ya a bit woozy but it should help".


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## Carlos Danger (May 3, 2013)

Rialaigh said:


> Where I run EMS when you go out to a call and are trying to get a medical history on people *you ask them questions like "Hey hun, do you got suga?" if they say yes they are diabetic, then you ask "do you got pressure?" if yes then they have high blood pressure.* I can't even think about how I would start to explain medication side effects beyond "this will help ya for pain, it might make ya a bit woozy but it should help".



I know the patient population here well. It is an interesting place to practice.  



Rialaigh said:


> *There is no reasonable way to protect yourself completely in the field*, however I think making some attempt to explain a medication and side effects may be worse then making no attempt at all. You give them a medication and tell them it may make their stomach hurt for a bit, they get to the hospital and have a GI bleed or a blockage, and they will swear up and down your medication did it to them, will that hold up in a court of law, no, but will it cause you a huge headache..yes...



I understand what you are saying, and I don't disagree about how most of us actually practice. I am not all about practicing CYA medicine. I am of the philosophy that if you just treat people well and provide good patient care, then 99.99% of the time, you will be fine.

However, at the same time, you absolutely are legally obligated to obtain _informed consent_ for everything that you do to a patient.

Without documenting that, if something bad happens, all a patient has to say is, "I never would have let him do that if I knew this could happen - he should have warned me" and you can be really screwed.

I believe the legal standard is that you have to make a "reasonable" attempt, and what constitutes "reasonable" depends on the circumstances.

The only thing that is certain is that legally, "making no attempt at all" to explain things is the absolute worst thing you can do.


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## Fish (May 3, 2013)

J B said:


> Yeah.... I guess you just have to hope they make a comment or scream in pain if you hit something, and be responsive to what they say.  A lot of horror stories go something like, "I told the nurse my hand went numb and to please stop, but she said that's normal and kept pushing the needle in."
> 
> If you google "iv nerve damage" you get links to a bunch of lawyers' websites, so I assume lawsuits over this do happen with some regularity.



A vien and a nerve feel nothing alike when palpating, my advice. Do not stick a needle in someones skin unless your sure of what you are poking at. To prevent any complications that can arise.


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## Carlos Danger (May 4, 2013)

Fish said:


> A vien and a nerve feel nothing alike when palpating, my advice. Do not stick a needle in someones skin unless your sure of what you are poking at. To prevent any complications that can arise.



Can you palpate a nerve?


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## Fish (May 4, 2013)

Halothane said:


> Can you palpate a nerve?



I ment tendon, it is my understanding you cannot palpate nerves unless they are enlarged. Even then, I could not tell you if it is a neve or a tendon just by feel, personally.


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