# Like asking a patient their favorite color for IVs?



## TransportJockey (Mar 22, 2017)

Well you might wanna reconsider. 
http://www.delawareonline.com/story...ics-investigated-large-size-needles/99441612/
I'm glad to see that punitive ALS is being investigated 

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## NPO (Mar 22, 2017)

We had a medic who also got caught doing this. Before my time, but the story goes he started bilateral 14Gs in an elderly woman's hand to "teach her to call 911." The story also says he was investigated, but I don't know his name so I can't look it up on our state website. 

@VentMonkey, can you confirm?

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## NomadicMedic (Mar 22, 2017)

Jesus. I thought the "go big or go home" mentality had ended.

20s usually and maybe an 18 if I'm feeling like I need to flow some fluid. 16s in young traumas. That's it.

Sad that it's in Delaware.


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## VentMonkey (Mar 22, 2017)

Interesting piece, sadly I don't think this is all that unheard of.

That said, what all are you guys being taught is a "large-bore" IV? When I went through paramedic school I was taught either a 16g, or 14g respectively.

The other day I brought a standard ALS patient in to an area ED with an 18g locked off. The triage RN commented on how most everyone else that brings in patients is putting in 20's (medicals); she seemed pleased it was an 18 as this particular ED likes drawing labs from our IV's. I was taught 18 and down for medicals. If they can fit, my STEMI/ stroke alerts get 18's locked off, if not, 20's are fine.

Typically I don't ask the patient, TBCH. I can gauge it (pun intended) by looking at their vascularity. If they give the infamous "butterfly remark" I do my best to honor their request, though.

I'm a bit different about my IV's, and their placement though, as my wife often hounded me about technique (still does) all through paramedic school.


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## VentMonkey (Mar 22, 2017)

NPO said:


> We had a medic who also got caught doing this. Before my time, but the story goes he started bilateral 14Gs in an elderly woman's hand to "teach her to call 911." The story also says he was investigated, but I don't know his name so I can't look it up on our state website.
> 
> @VentMonkey, can you confirm?


PM sent.


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## chaz90 (Mar 22, 2017)

Yep. Our agency just got an email pointing out this article. Absolute shame and an embarrassment for EMS. 


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## DesertMedic66 (Mar 22, 2017)

A while ago we fired a medic who was starting 14 and 16s in little old ladies "because why not" who did not need it. He was picked up as a firefighter paramedic for our state agency. 

We have several other medics who "if I see a vein that will hold a 14G then they get a 14G". I hope they get canned soon.


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## NPO (Mar 22, 2017)

VentMonkey said:


> Interesting piece, sadly I don't think this is all that unheard of.
> 
> That said, what all are you guys being taught is a "large-bore" IV? When I went through paramedic school I was taught either a 16g, or 14g respectively.
> 
> ...


I was taught 18g is a large-bore. I'll generally use 20s in standard medicals, or 18g if I think we will need blood, fluids, or contrast. I was told they prefer 18g in the AC for contrast. 

Obviously for more sick people, a 16g, once a 14g.

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## TransportJockey (Mar 22, 2017)

We don't even carry 14s outside of for needle decompression. If they're septic or need a bunch of fluid I might go for a 16. Otherwise bilateral 18s or just a single 18 handles it nicely 

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## VFlutter (Mar 22, 2017)

I am completely against any form of punitive medicine and unnecessary treatments however in my experience large bore IVs placed in appropriately sized veins are not anymore painful than an smaller IV.


a 16g PIV will flow faster than any central line sans a Cordis and is king when large volume resuscitation is needed. Also useful for drawing labs.


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## VentMonkey (Mar 22, 2017)

TransportJockey said:


> We don't even carry 14s outside of for needle decompression. If they're septic or need a bunch of fluid I might go for a 16. Otherwise bilateral 18s or just a single 18 handles it nicely.


Right, that's what I was taught as well. Most critically ill patients get 2 IV's if permissible, but defining critically ill can be subjective.

I've had some paramedics balk at bilateral IV's for strokes and STEMI's, and think it was overkill; they had similar thoughts re: 18's if feasible in these patients. That said, I'm not doing it to be a richard, or to "show off", I'm doing it because it helps the hospitals more often than not with things such as @NPO points out. 

20 gauge IV's aren't always the easiest to draw labs from, especially if the patient is somewhat dry.


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## GMCmedic (Mar 22, 2017)

Im glad to see this article. I came up in a system that preferred 18's for medical and 16 up for trauma activations. I decided for myself very quickly that I would look at that as a suggestion and use my judgement on what size IV to use. 

I have never started an IV larger than a 16g and 20 is the most common size I use. 



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## VFlutter (Mar 22, 2017)

Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.


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## VentMonkey (Mar 22, 2017)

Chase said:


> Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.


Again, married to an RN helps understand y'alls thought processes. I don't think most medics take that into account, by no fault of their own. The hand-off I give isn't just in a report, but also what I (we've) done to expedite, and/ or ease transition of care.

More often than not they're über appreciative, and the patient is as well. Most of this is common sense, and I am sure these two DE medics were not exactly using their better judgment.


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## TransportJockey (Mar 22, 2017)

Chase said:


> Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.


In unstable, critical, or potentially unstable patients this is my train of thought. If a stable patient just needing some light IVF or maybe zofran or a simple narcotic, then I tend to stick with one 18 or 20. 

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## VentMonkey (Mar 22, 2017)

TransportJockey said:


> In unstable, critical, or potentially unstable patients this is my train of thought. If a stable patient just needing some light IVF or maybe zofran or a simple narcotic, then I tend to stick with one 18 or 20.


Right, and not to derail too much, but I almost feel like this isn't something taught in most standard paramedic programs.

I learned this with critical care training, which in turn has helped add to my critical thinking skills and buffered my train of thought, broadening my knowledge-base horizons. 

Perhaps you concur? Or perhaps it's because I went to paramedic school in California.


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## StCEMT (Mar 22, 2017)

NomadicMedic said:


> 20s usually and maybe an 18 if I'm feeling like I need to flow some fluid. 16s in young traumas. That's it.


This. 95% of the time I just go with a 20.


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## NomadicMedic (Mar 22, 2017)

I was taught "2 is one and 1 is none" in anythibg that may go pear shaped. My paramedic instructor was very big on "building a safety net". Why wait and maybe struggle with an IV when you really need it when you can get two and maybe never need them. That's also why I bro g my gear in the house,,treat in the house, start lines in the house and get 12 leads in the house.  It may be nothing, but more things are missed by not looking than not knowing.


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## chaz90 (Mar 22, 2017)

Chase said:


> I am completely against any form of punitive medicine and unnecessary treatments however in my experience large bore IVs placed in appropriately sized veins are not anymore painful than an smaller IV.



I actually really liked the way the newspaper article phrased the issue. They mentioned that "larger needles are believed to be more painful." I'm not certain if they are or aren't, but intent matters. I think we can all agree that if someone is deliberately placing an inappropriately large IV catheter when it isn't indicated in the hopes of causing more pain to the patient we have a real issue on our hands.


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## VFlutter (Mar 22, 2017)

chaz90 said:


> I actually really liked the way the newspaper article phrased the issue. They mentioned that "larger needles are believed to be more painful." I'm not certain if they are or aren't, but intent matters. I think we can all agree that if someone is deliberately placing an inappropriately large IV catheter when it isn't indicated in the hopes of causing more pain to the patient we have a real issue on our hands.



Agreed. I just seems that some people, especially some nurses, think that placing large bore IVs is akin to medieval torture when really most don't notice a difference.


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## Carlos Danger (Mar 22, 2017)

Chase said:


> I am completely against any form of punitive medicine and unnecessary treatments however in my experience large bore IVs placed in appropriately sized veins are not anymore painful than an smaller IV.
> 
> 
> a 16g PIV will flow faster than any central line sans a Cordis and is king when large volume resuscitation is needed. Also useful for drawing labs.



There are plenty of factors that go into a patients perception of how painful an IV stick is. But generally speaking, there's no way that a 14g isnt more painful than a 20g.


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## TransportJockey (Mar 22, 2017)

Remi said:


> There are plenty of factors that go into a patients perception of how painful an IV stick is. But generally speaking, there's no way that a 14g isnt more painful than a 20g.


From personal experience, I actually thought a 22g was more painful than a 16g, probably due to needle flex. 

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## E tank (Mar 22, 2017)

Anyone do a 0.5% lido wheal for their IV's? It's no big deal and doesn't hurt as much as an IV stick. I never did it in my EMS, trauma/ER days, but I should have. Sounds like a medical director call, but folks ought to have the option.


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## VentMonkey (Mar 22, 2017)

E tank said:


> Anyone do a 0.5% lido wheal for their IV's? It's no big deal and doesn't hurt as much as an IV stick. I never did it in my EMS, trauma/ER days, but I should have. Sounds like a medical director call, but folks ought to have the option.


I recall learning it as basic IV technique, but we don't carry topical lidocaine at my current service. It seems like it's more commonly shuffled in the "consider/ strongly consider" portion of IV skills learning. You're right though, it certainly seems like the humane thing to do more often than not.


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## StCEMT (Mar 22, 2017)

E tank said:


> Anyone do a 0.5% lido wheal for their IV's? It's no big deal and doesn't hurt as much as an IV stick. I never did it in my EMS, trauma/ER days, but I should have. Sounds like a medical director call, but folks ought to have the option.


Once in a pediatric hospital for a clinical, otherwise no. Never seen it anywhere else.


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## E tank (Mar 22, 2017)

Not topical local or skin refrigerant, this:


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## DesertMedic66 (Mar 22, 2017)

Never covered that in medic school haha


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## GMCmedic (Mar 22, 2017)

Ive personally felt that a 25 gauge needle was the worst feeling ever, and Ive had a medic  give me IM zofran with an 18 gauge straight needle. 

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## Akulahawk (Mar 22, 2017)

I am also of the opinion that 14-16 are large bore, 18's are medium bore, and 20-under is small bore. Most of my IV starts are 20ga, if I anticipate a need for volume or IV contrast, I'll do 18 if possible. I've only gone large on a very small number of cases and those all required  VOLUME. Chase is correct in that a 16 will give flows than almost anything smaller than a Cordis. Most folks really can't tell a difference one size up or down but if you go 2 or more, they'll certainly notice. One of my VOLUME resus patients never noticed the 14 I placed...

And no, I don't do punitive IV starts or any other procedure. Never have and never will. Not worth it.


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## E tank (Mar 22, 2017)

Threatened an abusive hostile (drunk) patient with a "brain shot" once. Worked too. It was a 60 cc syringe filled with betadine and a 17 ga epidural needle on it. 

As to the large bore conversation, if someone needs 2 iv's for volume resuscitation, one should be 16 or larger otherwise don't bother. Any thing less than a 16 ga is plastic in the way, IMHO.

There is this awesome device called a RIC (catheter). 



7 fr peripheral catheter. Place a standard 20 ga iv, run a wire up that, take it out, load up the RIC/introducer- dilator onto the wire, nick the skin with the knive, run the whole thing up the wire, take the dilator and wire out leaving the catheter insitu. Absolute sewer pipe capable of something like 13000 ml/minute. I'll have to look that up...


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## Carlos Danger (Mar 22, 2017)

E tank said:


> Threatened an abusive hostile (drunk) patient with a "brain shot" once. Worked too. It was a 60 cc syringe filled with betadine and a 17 ga epidural needle on it.
> 
> As to the large bore conversation, if someone needs 2 iv's for volume resuscitation, one should be 16 or larger otherwise don't bother. Any thing less than a 16 ga is plastic in the way, IMHO.
> 
> ...


I absolutely love the RIC.


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## captaindepth (Mar 22, 2017)

We pretty frequently use 16g and 14g IV catheters but never in a punitive manor. Any time we have an emergent return with a trauma activation the standard we try to meet is bilateral 16g or 14g but of course, get what you can and an 18g is absolutely better than nothing. Same thing with strokes and cardiac alerts, bilateral IV's is the standard but its more acceptable to have an 18g or 20g on one side. I'd say 80% of the time I use an 18g with the rest of the time being equally divided between large bore (16g or 14g) and a 20g purely for medication administration. Out of curiosity how long are most of your catheters? We use 2 inch catheters which make the IV needle look much bigger and can cause some patients to become a little nervous. I have noticed that  larger bore needles in the forearm/AC are less painful for patients than a 20g in the hand... for the most part.


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## VFlutter (Mar 22, 2017)

I wish we had RICs, they are awesome. Best I could do in the unit was grab the US and a long 16g off the Anesthesia cart and toss it in the basilic/cephalic. Worked like a charm.


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## Akulahawk (Mar 22, 2017)

Chase said:


> I wish we had RICs, they are awesome. Best I could do in the unit was grab the US and a long 16g off the Anesthesia cart and toss it in the basilic/cephalic. Worked like a charm.


I wish we had either the RIC or a LONG 16g cath where I used to work. Longest cath we had was a 3 or 3.5" 18ga cath. If we needed anything longer, we'd have to use a Cordis or similar central line.


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## Seirende (Mar 23, 2017)

Red Cross uses 16g with their donors. When I go in to donate platelets, it's mostly a pleasant experience even though I get bilateral 16s, because they're very skilled in IV placement  AND because they're very considerate and do everything that they can to make sure that I'm comfortable throughout the 1.5 hour process. The gauge that you're using doesn't matter near as much as does your skill and compassion (or lack thereof).


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## Ensihoitaja (Mar 23, 2017)

E tank said:


> Anyone do a 0.5% lido wheal for their IV's? It's no big deal and doesn't hurt as much as an IV stick. I never did it in my EMS, trauma/ER days, but I should have. Sounds like a medical director call, but folks ought to have the option.



Obviously personal, but I always felt like the lidocaine hurt way, way more than the IV stick.


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## agregularguy (Mar 23, 2017)

Seirende said:


> Red Cross uses 16g with their donors. When I go in to donate platelets, it's mostly a pleasant experience even though I get bilateral 16s, because they're very skilled in IV placement  AND because they're very considerate and do everything that they can to make sure that I'm comfortable throughout the 1.5 hour process. The gauge that you're using doesn't matter near as much as does your skill and compassion (or lack thereof).



Glad your Red Cross is good at IV placement... Mine had to poke me 3 times to get a line, and anyone whose met me knows I have literally the easiest IV access in the world, if you can't get a line on me, you shouldn't be placing lines.


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## jaeems (Apr 11, 2017)

GMCmedic said:


> Ive personally felt that a 25 gauge needle was the worst feeling ever, and Ive had a medic  give me IM zofran with an 18 gauge straight needle.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk




Hahaha, just got Zofran 2 nights ago with a 21 gauge needle. It hurt quite a bit. 

When I got Morphine at another ER a year they failed almost 6 times before they used a "vein finder", called Accuvein. Because my veins are so small and stubborn.


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## RocketMedic (Apr 23, 2017)

I am of mixed opinions on this. 

Patient abuse is wrong, and in this case it seems appropriate to discipline these medics, but who is to determine what abuse is?

I have placed IOs in conscious and semi-conscious patients on multiple occasions. Is this abusive?

I have placed 14G and 16G catheters in ill patients who needed high-volume medications. Is this abuse when an 18 or 20 _could_ have worked?

I've put 20s and 22s in kids because they needed fluids/meds- is that abuse?

I think that a lot of what we are doing depends on the rationale for it. I don't think we should tie abuse to use of a tool in the appropriate circumstances.


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## Carlos Danger (Apr 23, 2017)

RocketMedic said:


> I am of mixed opinions on this.
> 
> Patient abuse is wrong, and in this case it seems appropriate to discipline these medics, but who is to determine what abuse is?
> 
> ...


I think you are kind of missing the point here.

No one is saying that you can't use large IV's. It's when you use large IV's or other painful interventions _as a punishment_ that there is a serious ethical problem.


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## Tigger (Apr 24, 2017)

RocketMedic said:


> I am of mixed opinions on this.
> 
> Patient abuse is wrong, and in this case it seems appropriate to discipline these medics, but who is to determine what abuse is?
> 
> ...


Seems pretty cut and dry that when you try to "teach em a lesson" that there is no clinical need and therefore no question that it's abuse.


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