# IV's in Paramedic School



## jaksasquatch (Jun 23, 2015)

Hello all,

   Just entering my 2nd semester of paramedic school. So far I've found the coursework to be the easiest part. Instead of being stressed over tests I'm stressed over IV's. 170 sticks in overall my % sucks. Granted most of those were just "oh I wonder if that vein could be hit with this gauge" attempts to find what could and couldn't be done. Now that I'm on the truck I know what veins are my go to. Still struggling mentally with it but over the last 45 sticks my % is approx. 75% first attempt success. I have no clue what is going on, it seems so easy but I wind up screwing it up somehow. From my standpoint I'm getting flash but I'm blowing it on insertion still. I know to still go that little bit more but I'm wondering if I'm pulling the needle back while inserting the cath. Anyone else struggle like this this late in medic school? Really tired of getting made fun of when I can't secure access first attempt.


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## EMSComeLately (Jun 23, 2015)

Some of the technique can vary slightly by type of catheter.  Both going through the vein by pushing needle to far after flash, but before advancement and pulling catheter are common coordination challenges. I do much better with insyte autoguards than jelco protectiv styles.  And some do better with advancing catheter with another hand versus the single finger push.  Just keep finding your own style and ignore the competitive haters.

Last, I've had to learn to start passing up a juicy AC that likely has a valve to find a vein less plump but more likely to allow catheter advance.


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## TomB (Jun 23, 2015)

The habits you develop right now will last your entire career (good or bad). Lay out your equipment and spike your IV bag using the proper aseptic technique. Shut down the roller clamp prior to squeezing the drip chamber. It helps prevent air bubbles in the IV line. There is no need to remove the cap when you charge the line. Lower the side rail on the gurney and take a knee alongside the patient. Place the arm in a dependent position (below the patient's heart). Apply the tourniquet in such a way that the tails are pointing superiorly (not toward your work space). Cleanse the area with alcohol. Once that is done don't palpate again without re-cleansing. Hold the skin taught with the thumb of your left hand below the target vein. Make your first "stick" count (you should strive to get a flash with the initial stick). Then give a "bump" to ensure that the bevel clears the lumen (omitting this step is a very common error). As you advance the catheter look for the secondary flash. If you always do it this way you will become highly skilled at IV therapy. Conversely, I have seen paramedics with poor technique after 5, 10, 15 years in the field.


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## mgr22 (Jun 23, 2015)

75% isn't bad. Don't overthink it -- you might just need a little fine-tuning. There's a book called "The Art of the IV Start" by Bob Rynecki that has some helpful tips to go along with the advice you're getting here.


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## jaksasquatch (Jun 23, 2015)

After reading that book mgr22 I think I'm overthinking it, rushing because of nerves, and making some pretty simple mistakes. Thanks for the reference to that book.


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## jassid (Jun 23, 2015)

Time, patience, practice, and consistency my friend…the keys to all your EMS successes! As TomB said, "the habits you develop now will last your career." I've seen great medics miss over and over, good and bad days/weeks! (hit and miss), nobody is perfect but definitely find what works and don't be afraid to take advice (even if it's from a humble medic or paragod)…find what works for you and stick to it.


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## phideux (Jun 24, 2015)

Like most folks already said, time, practice, sticks, keep your technique consistent. I feel like I've stuck a million people, I'm one of the go-to folks in the ER for "hard sticks". But remember there's some magic, or voodoo, or something involved too. I've had streaks where I could throw a 14 from across the room, blindfolded, over my shoulder, and thread it up the thumb vein of a dialysis patient first stick, and streaks the other way where I couldn't hit a vein like a rope on the side of some muscle guys arm, after a pumped out workout, with a 24 if my life depended on it.
Keep sticking, the more you do, the better you get, you build alot of confidence after awhile. Just watch out for them VooDoo streaks.


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## phideux (Jun 24, 2015)

We were working one night, really busy night too, me and one of my favorite nurses. We were getting hit pretty hard with patients, I had one of those good magic streaks, and poor little K was on a voodoo curse streak, could't find a vein if she filleted the arm open went digging for it. Then the magic patient came in and screwed me for the rest of the shift, I had a 13 stick streak going, she came in, had decent looking veins, popped up nicely, easy 20ga in the AC, as soon as I touched that vein with the tip of the cath it just blew all to hell. I couldn't hit crap the rest of the night, the VooDoo curse come and got me. At right about that same time Nurse K had a reversal of her fortunes, and she became the IV Queen the rest of the night.


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## cannonball88 (Jun 24, 2015)

Like you, I struggled with IV lines in school, so I'll try to pass on a few tips I picked up.


Yes, you're scared, and with every missed stick, that fright gets worse--been there, done that. That being said, poking tentatively rather than taking, (no pun intended), a stab at it, will only make the problem worse. The vein will move if you don't actually put the needle in. Poke like you have confidence, even if you don't.
Don't look, palpate. It helps to ensure that the vein you're targeting is indeed suitable for access, and often times, rather than poking at a small vein you can see, you'll find yourself poking at a large vein, even though you can't necessarily see it. If you want some practice on that, pick a friend and try an IV blindfolded. Yes, it actually works.
The smaller gauges aren't ALWAYS easier. In fact, getting a small and very flexible catheter to move where it should isn't always as simple.
Remember that knowledge and proficiency comes from experience and experience often comes from bad experiences. 
Hope this helps a bit.


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## Angel (Jun 24, 2015)

I'm like Phideux, I'll have really good streaks and some bad. I just don't let it bother me. I won't repeat all the other good advice.


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## SeeNoMore (Jun 25, 2015)

It's hard but you just have to relax OP. No matter how much you read or think about Iv insertion, there is nothing like practice to make you better. Sounds like you are getting a lot of opportunities and doing fine. Try to improve each time (based on all the techniques and tricks and tips) but accept you will sometimes miss. I find I don't give Ivs a second thought on most patients - just get access no problem. Others I need to look carefully to get the first stick. And then there are others who get a ride with no Iv or an IO. It happens. I was awful at IVs in medic school and was super stressed. You're already doing better than I was.


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## jaksasquatch (Jun 25, 2015)

SeeNoMore said:


> It's hard but you just have to relax OP. No matter how much you read or think about Iv insertion, there is nothing like practice to make you better. Sounds like you are getting a lot of opportunities and doing fine. Try to improve each time (based on all the techniques and tricks and tips) but accept you will sometimes miss. I find I don't give Ivs a second thought on most patients - just get access no problem. Others I need to look carefully to get the first stick. And then there are others who get a ride with no Iv or an IO. It happens. I was awful at IVs in medic school and was super stressed. You're already doing better than I was.



Thanks for the encouragement. I think you're right, just need to keep improving and let the fear/nerves go.


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## Jessi (Jun 25, 2015)

By far the most common IV mistake I see is_ *not* *adequately securing the vein prior to or during insertion*_.  The skin [and vein] must be held taut until the catheter is all the way in. From the description of the problem my guess is you are initially securing the vein, but loosening the tension once the initial flash is seen. When you try to advance further, the advancing catheter can actually push the vein right off of the end of the needle! With this extremely common mistake you will have problems like you described, as well as "rolling veins" and having to angle your needle to the side to hit the vein after you have pierced the skin [how did it get over there? I was right on top of it...]. I would focus on securing the skin/vein really well - including the skin on both sides of the vein - and see if this makes a difference. Remember, the vein will move to the area of least resistance.
[Visualize trying to insert a toothpick lengthwise into the body of a worm.... does this help? =)]


[BTW I also don't think 75% first attempt success is bad for a medic student, but I applaud your initiative to try to get better!]


This has nothing to do with IV technique, but here are a few things that I haven't seen posted yet that I find helpful when starting an IV:


1) I place the tourniquet first [on top of a sleeve if I can - a little more comfortable for pt]


2) Then I prep my fluid & equipment, making sure I can reach some 4x4's if needed.


3) Lastly I choose my site: I use A LOT of alcohol preps! I can frequently see the contour of the vein in the light reflecting off of the wet skin. If I don't see any good options on either side [or I really want a particular location for some reason] I will have the pt let the arm dangle for a minute or two, then look again. I also "tap" the veins with 2 fingers. Many times I have nothing on my first look, but between giving the vein time to fill, some tapping and plenty of alcohol I can find a viable vein - or make a difficult stick much easier.


4) I recommend placing a towel under your chosen site: if you end up with a "bleeder" you don't drip blood down the side of your cot or all over the pt's clothes/bed/carpet. Makes clean up much easier. =)

Good luck!


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## phideux (Jun 30, 2015)

Most of our sticks include blood draws, so we can't put a tourniquet on and then get our stuff together, so I just get my stuff together first, we're supposed to put the tourniquet on than we have about a minute to stick and get blood, otherwise the lab folks ***** about the hemolysis rates.

The tourniquet over the sleeve thing, I do that, I usually cinch my tourniquet pretty tight, so some extra padding is good for the patient.

Pull the skin tight before you stick helps hold the "rollers" in place. The closer to the joints, the less veins "roll". Stick "rollers" from the top, poke them quick and hard.

Skin wet with alcohol and the lighting can help you see veins, wipe it down and look at different angles in the light.

After a while you will get good at feeling veins you can't see, you'll get used to that "bounce". Remember your A&P, and you know where the veins should be, start looking there, your fingertips will get used to picking up the feeling between veins and tendons and arteries.

Alot of times, especially with "hard sticks", I let my fingers do the walking and "look" for a vein with my eyes closed.

If an IV is absolutely necessary, don't stick to the usual AC and hand sticks. I've stuck plenty of EJs, feet, legs, upper chest/shoulder stick, I've even stuck a boob vein. Don't just look in the usual spots.


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## DrParasite (Jul 2, 2015)

I don't have anything useful to contribute to this thread.....

However, I was close to 90+% on my IV starts in my hospital clinicals.... the last two shifts I have done, I can't seem to find a vein, or stick a vein on the first shot.  Not sure why, but I seem to be having problems (and it might be more psychological than anything else, who knows).  

So maybe i can pick up some new tricks by following this thread.


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## ChoctawMedic92 (Sep 11, 2015)

EMSComeLately said:


> Last, I've had to learn to start passing up a juicy AC that likely has a valve to find a vein less plump but more likely to allow catheter advance.



That was something I learned pretty fast. Our school hammed in "AC OR HIGHER" on pretty much every patient requiring an IV. I definitely stand by this for a patient that might require a drug with an extremely short half-life, but typically I'll go for the first good vein I see on my first scan of the patient's arm. I typically end up going for the forearm or the "nurse vein" on the wrist... I'm by no means the most experienced medic, but that's just the little bit of technique I've learned.


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## Deltachange (Oct 21, 2015)

Also if you carry hot packs and it isn't against your protocols, sometimes applying a hot pack(with proper insulation) will help pop some veins up. If you are worried about valves, run your finger down the vein proximal to distal, and where the vein won't flatten is your valve. You are pushing the blood the wrong way and the valves are there to prevent backflow, so where you can't produce backflow is where the valves are. Once you get your initial flash, drop your angle (move the flash chamber of the needle towards the body part you're accessing) and advance a millimeter more into the vein before you advance the catheter. Sometimes you'll get just the needle into the vein and get flash, so this pushes the catheter past the vein wall, so you don't push the needle out of the vein when you try to advance.


That's all I can think of that hasn't been covered already. Hopefully even if this doesn't help OP it will help someone else down the line.


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## Akulahawk (Oct 21, 2015)

One thing that I think wasn't quite touched on is that you MUST become very familiar with the equipment. Just the other day I had a patient whose veins were just GREAT. I secured the skin, prevented the vein from getting away from me, getting a great flash, and everything... then as I was attempting to advance the catheter into the vein, I changed positions ever so slightly on my inserting hand and the patient moved just a little bit at the same time, which probably released the skin just a little bit and the whole assembly backed out just enough that when I advanced the catheter, it pushed the vein right off the needle. I saw the cath curl under the skin... while I've never had _that_ happen before, I recognized it instantly. Part of the problem was that the catheter system we're using doesn't really allow for an easy advance of the hub with one hand, though it is possible. Other systems are a little easier to use. 

Fortunately the patient had another good vein that I'd prepped at the same time and hadn't contaminated and that one just slid in easily.

I can't disagree with some of the above posters that say smaller gauge catheters can be more difficult. Those small diameter needles can flex a LOT and if you're having to push through tough skin, they'll flex a lot more than you want. Yes, I'm currently an ER nurse and my go-to catheters are 18 and 20 gauge. I can usually get one of those in, those catheters don't flex much, they're large enough for IV contrast studies (20 ga barely but it works), have a reasonable flow rate, and don't hurt too horribly much. 

Oh, and trust your fingers, especially once you get the feel for veins. They'll tell you just how big a vein really is and where it goes.


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