# Butterfly or No?



## EmtTravis (May 6, 2012)

So I was just wondering who prefers using butterfly caths vs strait caths.  I know if you need to go large bore for trauma say either 16 or 14 you can't do butterflies.  So what is your preference and why do you prefer the one over the other?


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## MSDeltaFlt (May 6, 2012)

My philosophy is "if it'll fit it, stuck it".  The larger bore the cath means they (manufacturer) have more metal to make the cath sharper.  Sharper is better.  Also the larger bore caths have thicker cathlon walls making them more stable.  And that's in addition to the increased laminar flow of the larger bore.

If they need it then they need it. So if it'll fit it, stick it.


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## Epi-do (May 6, 2012)

We don't even carry butterflies, so it isn't an issue for me.


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## RustyShackleford (May 6, 2012)

We only carry straight caths, last time I used a butterfly was in the army but to be honest I don't notice a difference they are both tubes with holes in them.


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## mycrofft (May 6, 2012)

Before I stopped hitting veins, I liked butterfly because of my big fingers. Also, they were on the BD sets that did not leak blood all over , you pulled the needle out of the cannula with a stylette which passed through a needle injection port. Problem was, too small a caliber for bigtime stuff.


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## Akulahawk (May 6, 2012)

MSDeltaFlt said:


> My philosophy is "if it'll fit it, stuck it".  The larger bore the cath means they (manufacturer) have more metal to make the cath sharper.  Sharper is better.  Also the larger bore caths have thicker cathlon walls making them more stable.  And that's in addition to the increased laminar flow of the larger bore.
> 
> If they need it then they need it. So if it'll fit it, stick it.


This is one reason why I normally reach for an 18ga cath first. It's going to be quite sharp and it'll deliver a good amount of volume if necessary. Of course, if the patient's veins will only take a 20ga... that's what I'll use.


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## socalmedic (May 6, 2012)

I have only used butterflys for blood draws, everything thats going to stay in the patient is an angiocath. as for my go to size, 20 seams to be my favorite followed closely by an 18g. there is no point in me starting a 14 ever, the macro sets we have dont flow more than a 16g can handle.


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## Akulahawk (May 6, 2012)

socalmedic said:


> I have only used butterflys for blood draws, everything thats going to stay in the patient is an angiocath. as for my go to size, 20 seams to be my favorite followed closely by an 18g. there is no point in me starting a 14 ever, the macro sets we have dont flow more than a 16g can handle.


If my patient needs a 16ga, chances are pretty good that they need a 14ga. I've only had occasion to place a big bore line a few times, but most of the time, I "stick" with an 18... or a 20. I've noticed that the hospital IV RN's around here seem to like using 20 or 22 ga. I like the 18 just because it's kind of a jack-of-all-trades size in that you can get good flow, you can saline lock them, you can do lab draws pretty easily w/o hemolyzing the sample... and you can push D50 through it without too much difficulty.


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## MSDeltaFlt (May 6, 2012)

socalmedic said:


> I have only used butterflys for blood draws, everything thats going to stay in the patient is an angiocath. as for my go to size, 20 seams to be my favorite followed closely by an 18g. there is no point in me starting a 14 ever, the macro sets we have dont flow more than a 16g can handle.



Have You timed the 14's vs 16's vs 18's etc?

My pt will get the largest size they need that I can fit according to my assessments.  You never say never and you never say always. Or else you're just limiting yourself; not to mention your pt.


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## usalsfyre (May 6, 2012)

Catheter length also plays a role in flow rate. If you ever wondered what a particular size will flow, it's printed on most pacakges.

If your referring to "winged" caths, I have no preference. If you referring to needle infusion sets, I'm not real keen of leaving a metal needle in the patient, particularly when they're often no smaller than a Teflon cath.


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## NYMedic828 (May 6, 2012)

Only use straight caths at work.

Have butterfly blood drawing needles on the volly bus. Don't prefer them.


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## socalmedic (May 6, 2012)

MSDeltaFlt said:


> Have You timed the 14's vs 16's vs 18's etc?
> 
> My pt will get the largest size they need that I can fit according to my assessments.  You never say never and you never say always. Or else you're just limiting yourself; not to mention your pt.



yes I have timed it, I have also talked with the baxter rep. the set we use flows 250ml/min our 16g cath (jelco protective plus) flows 230ml/min. if you have blood tubing I guess a 14g is appropriate for you. I was simply saying I have no need to ever start a 14g. however we don't use Y tubing, our hospitals don't even use special blood tubing.


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## NYMedic828 (May 6, 2012)

A doctor or few have told me that unless you have access to transfusions in the very near future, the infusion rate of a 14/16g catheter can quickly turn into a mistake.

If a patient has lost 1/4 of their blood volume to a traumatic injury, a 14/16g isn't easily obtained for starters if vascular collapse occurs and in theory if we establish a pair of 14g IVs, we could infuse 500ccs a minute. How quickly do you think that would turn your blood into kool-aid?

If a tank of red liquid is leaking and we put clear liquid and pressure into it, we only force out the red liquid faster and make what remains diluted.

I work around a few of the busiest trauma centers in NYC and they rarely go bigger than 18g in the trauma room.


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## Sasha (May 6, 2012)

We don't carry butterflys.. I've never seen them for anything other than blood draws on in the hospital.


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## Shishkabob (May 6, 2012)

I like butterflies for the fact that I seem to NEVER miss a stick with them... but have only ever used them for draws in the hospital.  In the field, it's a normal IV, and usually a 20g.

I've been pretty crappy with IVs the past few weeks, but last week I actually hit every single one.  Darn inconsistency.


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## EmtTravis (May 7, 2012)

Yea I've never missed with a butterfly and being a paramedic student I need the confidence lol.  The fire dept where I do my ride time carries both strait and butterflies.  I'm sure once my confidence gets up I start using straits more and more but as for now if the medics I ride with don't stop me when I reach for a butterfly i'll continue using them.  And yes my go to sizes are either a 18 or 20.  Most generally a 18 in case they need a CT.


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## MSDeltaFlt (May 7, 2012)

socalmedic said:


> yes I have timed it, I have also talked with the baxter rep. the set we use flows 250ml/min our 16g cath (jelco protective plus) flows 230ml/min. if you have blood tubing I guess a 14g is appropriate for you. I was simply saying I have no need to ever start a 14g. however we don't use Y tubing, our hospitals don't even use special blood tubing.





NYMedic828 said:


> A doctor or few have told me that unless you have access to transfusions in the very near future, the infusion rate of a 14/16g catheter can quickly turn into a mistake.
> 
> If a patient has lost 1/4 of their blood volume to a traumatic injury, a 14/16g isn't easily obtained for starters if vascular collapse occurs and in theory if we establish a pair of 14g IVs, we could infuse 500ccs a minute. How quickly do you think that would turn your blood into kool-aid?
> 
> ...



Oh, I a big fan of permissive hypotension in the prehospital setting. I also believe in having large bore access, even if it is an INT, get that access.  Because unless your receiving facility has capabilities of trauma lines, your hypovolemic trauma pt will need the laminar flow of your short 14's.  

Get the access while you can when you can if you.  Because waiting until the pt needs it (even on the way to surgery) is too late.

I'll start a 14G INT if I think my nonhypotensive pt is going to surgery and will/may need a lot of blood.  Doesn't hurt me at all to stick them.


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## Aidey (May 7, 2012)

I've been told by the trauma center they prefer 14/16s if the pt is going to surgery and will need blood. 18s are ok, and they can give blood through a 20 if they have no other choice, but they don't like it.

We don't carry butterflies and I'm ok with that. What size I start depends on a few things. If it is an AC I almost always use an 18g because they are harder to bend than a 20g. Anywhere else it depends mostly on the pts veins and if they are getting fluid or if it is just a lock.


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## Hockey (May 8, 2012)

Linuss said:


> I like butterflies for the fact that I seem to NEVER miss a stick with them... but have only ever used them for draws in the hospital.  In the field, it's a normal IV, and usually a 20g.
> 
> I've been pretty crappy with IVs the past few weeks, but last week I actually hit every single one.  Darn inconsistency.



I hear ya...I just lost my IV skills I think...


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## mycrofft (May 8, 2012)

Carpal tunnel and c4-c5 compression robbed me of my stick talents. Limit those video games kiddies!

Not to advertise, but here's the brochure about the BD bloodless IV sets, and they make them up to 18g.

http://www.bd.com/infusion/pdfs/D14441.pdf


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## NYMedic828 (May 8, 2012)

mycrofft said:


> Carpal tunnel and c4-c5 compression robbed me of my stick talents. Limit those video games kiddies!
> 
> Not to advertise, but here's the brochure about the BD bloodless IV sets, and they make them up to 18g.
> 
> http://www.bd.com/infusion/pdfs/D14441.pdf



Diablo 3 is coming out one week from today. /life is over.


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## MSDeltaFlt (May 8, 2012)

NYMedic828 said:


> Diablo 3 is coming out one week from today. /life is over.



I'm a Rainbow Six and COD man, myself.


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## Akulahawk (May 8, 2012)

mycrofft said:


> Carpal tunnel and c4-c5 compression robbed me of my stick talents. Limit those video games kiddies!
> 
> Not to advertise, but here's the brochure about the BD bloodless IV sets, and they make them up to 18g.
> 
> http://www.bd.com/infusion/pdfs/D14441.pdf


Those are the winged sets that I'm thinking of... I like them, but I prefer a regular angiocath. I like the Insyte Autoguard and the Jelco Protectiv caths. Of the two, I like the Jelco because it's really easy to get a blood sample to feed the glucometer (if glucometer is OK with venous blood).

Like others here, I'm also a fan of permissive hypotension. To me, it just makes sense... and while I'd still put in a larger bore IV (or two) it's basically because one port in a storm is good, two is better, and it's far better to reach a safe harbor before the storm hits. In other words, I believe in getting access while it's still easily possible, and if the patient is going to surgery, all the better. If not, the facility still has the choice to stick with what they've got or they can start new IV's before removing the old ones.


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## Akulahawk (May 8, 2012)

NYMedic828 said:


> Diablo 3 is coming out one week from today. /life is over.





MSDeltaFlt said:


> I'm a Rainbow Six and COD man, myself.



I'm just glad I never got into those games much... I'm far more a fan of X-Plane. Not exactly a game with lots of action though. -_-


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## MSDeltaFlt (May 8, 2012)

Akulahawk said:


> I'm just glad I never got into those games much... I'm far more a fan of X-Plane. Not exactly a game with lots of action though. -_-



Fits perfectly with my ADHD.  Though sometimes it does Get old always getting cut from behind by some 9yo mouth breathing, chewing bubble gum, and crying when Mama makes them stop to do homework.


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## Akulahawk (May 8, 2012)

ADHD? Those folks have a longer attention span that I do. Heck, even a gnat sometimes has a longer attention span.  I'm mostly glad I didn't get into those games because my wallet would be perpetually empty... or at least worse than it is now.:blink:


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## mycrofft (May 8, 2012)

I forgot the other EMTLIFE Black Hole: video games


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## jwk (May 8, 2012)

NYMedic828 said:


> A doctor or few have told me that unless you have access to transfusions in the very near future, the infusion rate of a 14/16g catheter can quickly turn into a mistake.
> 
> If a patient has lost 1/4 of their blood volume to a traumatic injury, a 14/16g isn't easily obtained for starters if vascular collapse occurs and in theory if we establish a pair of 14g IVs, we could infuse 500ccs a minute. How quickly do you think that would turn your blood into kool-aid?
> 
> ...



I understand this physician's rationale behind dumping in too much fluid simply because it's possible with a larger bore catheter - BUT - if you still have access to rope like veins prior to cardiovascular collapse in a big trauma patient, I, your OR friend, will GREATLY appreciate that big access.  You have to think past the first 15 minutes of a trauma case - that patient will in all likelihood end up in an OR.  Early vascular access is a HUGE help, and can save some precious time.

No offense to your NYC trauma buddies, but I can promise you that if that trauma patient comes to my OR with a couple of 18's because the damn ER doc thought that was big enough, we will have a chat post-op - and I will be putting in an 8FR introducer in the IJ so I will have plenty of access.  And having to take the time to put in bigger access when it could have been done earlier is really gonna irritate me.  

Butterfly needles are for drawing blood - nothing more, ever - end of discussion.


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## Dwindlin (May 8, 2012)

jwk said:


> I understand this physician's rationale behind dumping in too much fluid simply because it's possible with a larger bore catheter - BUT - if you still have access to rope like veins prior to cardiovascular collapse in a big trauma patient, I, your OR friend, will GREATLY appreciate that big access.  You have to think past the first 15 minutes of a trauma case - that patient will in all likelihood end up in an OR.  Early vascular access is a HUGE help, and can save some precious time.
> 
> No offense to your NYC trauma buddies, but I can promise you that if that trauma patient comes to my OR with a couple of 18's because the damn ER doc thought that was big enough, we will have a chat post-op - and I will be putting in an 8FR introducer in the IJ so I will have plenty of access.  And having to take the time to put in bigger access when it could have been done earlier is really gonna irritate me.
> 
> Butterfly needles are for drawing blood - nothing more, ever - end of discussion.



There needs to be a thumbs up icon. . .


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## Shishkabob (May 8, 2012)

MSDeltaFlt said:


> I'm a Rainbow Six and COD man, myself.



Original R6 with Red Storm Entertainment?  Yes.  Ubisoft?  No.  They ruined the Tom Clancy franchise by catering to ADHD kids and going away from actual tactics.


Same with COD... too much catering to the ADHD generation.  It's a fun game and I play it from time to time, but far from the 'greatness' that people proclaim, especially since each iteration is essentially the same as the last.


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## Remeber343 (May 8, 2012)

All I have to say is battlefield 3


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## mycrofft (May 9, 2012)

Field 14's ok if you can do it first try and don't crank it up to 11. And if it is appropriate.
We have had so many inappropriate IV starts and failed ones that our local EMSA has a specific prohibition against starting IV's "just in case". That way the anesthesiologist can still find an unused site when it is REALLY needed.


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## Akulahawk (May 9, 2012)

mycrofft said:


> Field 14's ok if you can do it first try and don't crank it up to 11. And if it is appropriate.
> We have had so many inappropriate IV starts and failed ones that our local EMSA has a specific prohibition against starting IV's "just in case". That way the anesthesiologist can still find an unused site when it is REALLY needed.


That prohibition against "just in case" IV starts was in place about 10 years ago... If I needed to start a line, I could always articulate a reason for doing so... however, if the patient didn't need a line, they didn't get one. Not everyone got a line.

And I'm not a "go big or go home" kind of medic when it comes to IVs. If I have to go big, I will. Otherwise, they'd get a small/medium bore as needed/indicated.


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## jwk (May 9, 2012)

mycrofft said:


> Field 14's ok if you can do it first try and don't crank it up to 11. And if it is appropriate.
> We have had so many inappropriate IV starts and failed ones that our local EMSA has a specific prohibition against starting IV's "just in case". That way the anesthesiologist can still find an unused site when it is REALLY needed.



I think you missed my point.  A major trauma case assumes an IV - it's hardly inappropriate.  It is not a "just in case" IV.  It's putting in a big IV while you still are able to do so - 5 minutes from now when they've bled out another liter, you're not going to see those big rope veins.  A major trauma case is going to get fluid, colloid, and blood products.  More viscous substances like blood flow far better through a 14 than with an 18 or 20.  If you're trying to stick in a 20, you might as well just load and go anyway so I have more time to stick that 9FR cordis in their IJ.


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## Aidey (May 9, 2012)

Akulahawk said:


> And I'm not a "go big or go home" kind of medic when it comes to IVs. If I have to go big, I will. Otherwise, they'd get a small/medium bore as needed/indicated.



I put a 16g in a 75yo with a temp of 103.2 and GCS of 10 the other day. It feels so wrong, even though it was the right thing to do. The fluid brought her GCS up to a 14.


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## Handsome Robb (May 10, 2012)

My "go to" size is an 18g, but ill take what i can get. The hospital is always appreciative if we get it high and it draws, especially if they are going to CT. I'm guilty of starting up near the AC, or in it, if there's a good vein. I try to keep it distal though so they can still bend their arm. I don't care who you are. AC IVs aren't comfortable. 

I've started one 14, I haven't really had the trauma calls to warrant it. If its a critical patient I'll usually start with a 16 though.


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## Akulahawk (May 10, 2012)

Aidey said:


> I put a 16g in a 75yo with a temp of 103.2 and GCS of 10 the other day. It feels so wrong, even though it was the right thing to do. The fluid brought her GCS up to a 14.


Believe me, I know _exactly_ how you feel. I've had to do a very similar thing... once upon a time, way back when.


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## mycrofft (May 10, 2012)

Akula I was working Methodist ER (before the Grey Sisters took it over) and we had to bite our tongues sometimes when we saw the IV's coming in. House policy was to DC every field IV, but sometimes they left no unpunctured veins for the OR to use. (We could always weasel something).


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## Sasha (May 10, 2012)

NVRob said:


> My "go to" size is an 18g, but ill take what i can get. The hospital is always appreciative if we get it high and it draws, especially if they are going to CT. I'm guilty of starting up near the AC, or in it, if there's a good vein. I try to keep it distal though so they can still bend their arm. I don't care who you are. AC IVs aren't comfortable.
> 
> I've started one 14, I haven't really had the trauma calls to warrant it. If its a critical patient I'll usually start with a 16 though.



CT won't put contrast in anything less than an 20 and will not take hand IVs. 

Learned that while we stood in a hallway with a patient with crap veins, transport nurse with one arm, me with the other, trying to get a line for grumpy CT lady, despite a patent 20 in the hand.


Edited to fix a mistake.


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## Tigger (May 10, 2012)

The hospital where I did my clinical time used almost exclusively 20s, so that's what I used too. I wanted to try an 18 or 16 (gasp) when I got some rope veins but was quickly told that was "overkill," and that a 20 could be used for "pretty much anything." When I get home I need to go back and do more clinical time with a preceptor that's a bit more open minded I think.


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## Akulahawk (May 10, 2012)

mycrofft said:


> Akula I was working Methodist ER (before the Grey Sisters took it over) and we had to bite our tongues sometimes when we saw the IV's coming in. House policy was to DC every field IV, but sometimes they left no unpunctured veins for the OR to use. (We could always weasel something).


Given the mentality of the II's back then, I'm not surprised. You'd have had a really hard time distinguishing one of mine from one of "yours"... In any event, I always left a vein (or a bunch) for the ED to use. Policy is still to DC every field IV within 24 hours, as far as I know.


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## Shishkabob (May 10, 2012)

Akulahawk said:


> Policy is still to DC every field IV within 24 hours, as far as I know.



And that's just a stupid, money grubbing policy not based on anything BUT to make money.


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## mycrofft (May 10, 2012)

...and maybe infection control studies? Or just covering fanny despite (lack of?) any scientific proof of infection rates for field starts?


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## Smash (May 10, 2012)

Levine, R. et al Comparison of Clinically Significant Infection Rates Among Pre-hospital- Versus In-hospital-initiated IV Lines (1994) Annals of Emergency Medicine 25,4 p502-506

In 3185 IV starts, 4 significant infections found in the in-hospital cohort, versus 1 in the pre-hospital cohort.  No significant difference.  

IVs get changed out every 24-72 hours anyway, so all they are doing is making another port of entry by pulling one out straight away.  
I have had some glorious facepalm moments when some clever person pulls my IV out before establishing another, and then spends half an hour trying to get another one before having to get someone in with an ultrasound to do a jugular.


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## Shishkabob (May 10, 2012)

mycrofft said:


> ...and maybe infection control studies? Or just covering fanny despite (lack of?) any scientific proof of infection rates for field starts?



I've looked at a bunch of studies, and the vast majority show no difference in infection rates between EMS and hospital initiated IVs, and infact, the few that do show a difference tend to show more infections from hospital-initiated IVs, but they're all within the allowed margin of error.



Again, based PURELY on money.  Nothing more.


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## mycrofft (May 10, 2012)

Then they are just covering their butts and charging for another IV start.


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