# Question about IV starts



## Cindigo (Nov 25, 2012)

I just read this article about peds IV starts with the bevel side down, 

http://www.ems1.com/ems-training/articles/804343-The-bevel-down-technique/

and it made me wonder, why bevel side up in the first place?


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## NYMedic828 (Nov 25, 2012)

Some people claim that by going bevel down you don't run as much risk of piercing the opposite side of the vessel but the needle is meant to be inserte bevel up because any hole is easier to make with a smaller sharper object. That's the way it is designed to be inserted and I personally have never had a problem with it...


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## NomadicMedic (Nov 25, 2012)

Because bevel up allows the sharp point to pierce the skin first.


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## Anjel (Nov 25, 2012)

I had a classmate start an IV on me bevel down and it hurt really bad, and left a big hole.


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## Shishkabob (Nov 25, 2012)

n7lxi said:


> Because bevel up allows the sharp point to pierce the skin first.



You cans till technically start "point first" even when bevel down.  Just takes some, err, interesting angling.


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## NYMedic828 (Nov 25, 2012)

As for the article, I don't particularly care to continue reading when the author titles himself an ambulance driver...


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## TransportJockey (Nov 25, 2012)

I haven't read the link but I'm assuming its written by Kelly Grayson... He's one hell of a medic, and a pretty strong advocate for our profession advancing.


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## Anjel (Nov 25, 2012)

Kelly Grayson is a very smart experienced medic. Who lectures at all of the EXPOs, and is pretty well respected.


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## Cindigo (Nov 25, 2012)

Thanks guys. Makes sense.


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## Shishkabob (Nov 25, 2012)

NYMedic828 said:


> As for the article, I don't particularly care to continue reading when the author titles himself an ambulance driver...



Kelly Grayson has been around for a very long time and is a respected EMS figure / blogger.  He chose Ambulance Driver as a joke, not as a true to self title.


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## Aidey (Nov 25, 2012)

He even posts here once in a while. He seems to have a detector for whenever we talk about him.


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## MagicTyler (Nov 26, 2012)

Bevel down hurts, the needle rips through your skin instead of piercing it. Please dont cause harm to your patients because you're not confident with ivs. If ivs are hard for you, then practice, practice, practice!  If you get good at feeling for veins, and take your time, even tiny pediatric ivs are possiable.


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## Ambulance_Driver (Nov 26, 2012)

Aidey said:


> He even posts here once in a while. He seems to have a detector for whenever we talk about him.



It's called "Google Alerts," an indispensable tool for narcissistic EMS speakers and writers. 

The title "Ambulance Driver" is satirical, yes.

As for the bevel-down technique, there's a learning curve to using it, but I've found it to work well for me after I got the trick. Using shielded catheters that way does require some serious finagling, though.

At the least, it's a useful trick to pull out of the bag on those rare occasions.

Use a steeper angle when inserting, just to pierce the skin, and pull greater skin traction. If you *****foot around with it, yes, it will probably hurt more and tear the skin. If you make a decisive stick, however, it works pretty well. The trick is learning how to be decisive and delicate at the same time.

I didn't come up with the technique. It was taught to me by a grizzled old peds nurse in a PALS class years ago, and used to be a commonly taught trick.

I would object to the notion that needles are expressly designed to be inserted bevel-up, however. They may work well that way, but that's not necessarily a function of design.

A lot of things we do have their roots in tradition, and have no legitimate application any more. For instance, we were all taught never to withdraw the needle from the cath and then re-advance it, right? 

The stated reason for not doing that was the danger of catheter shear and resulting embolus. Y'all try that some time: TRY to shear off a piece of catheter that way. It may bugger up the cath, and cause a little more trauma when you D/C the IV, but it is damned near IMPOSSIBLE to shear off a piece of the catheter.

To do it, you have to poke the stylet through the side of the catheter, hold it against the cutting bevel of the needle, and then rotate it 360 degrees to shear off anything. And supposedly, we're supposed to be at risk of doing this ACCIDENTALLY, while INSIDE a vein? Not gonna happen.

That caveat was a holdover from the days of THROUGH-the-needle catheters, and do not apply to modern over-the-needle catheters. Yet it still gets taught as gospel every day.

Why?  Because your instructors were taught that way, that's why. As were their instructors, and their instructors... and no one ever bothered to question why.

ALWAYS question, especially when the rationale doesn't make sense, whether it comes from your medical director, your EMT instructor, me or some other dude with a laptop and Powerpoint presentation.

That's how we discard the dogma in our profession.


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## Anjel (Nov 26, 2012)

See... Told ya he is a pretty smart fella.


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## Aidey (Nov 26, 2012)

Ambulance_Driver said:


> It's called "Google Alerts," an indispensable tool for narcissistic EMS speakers and writers.



So you're like Beetlejuice...except you help new EMTs rather than  dead people.

Edit: In the interest of keeping this thread on topic, I have never used the bevel down technique. I would consider trying it, but I start so few IVs on peds as it is, I'm not sure it is a good idea to start experimenting too much.


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## Ambulance_Driver (Nov 26, 2012)

Aidey said:


> So you're like Beetlejuice...except you help new EMTs rather than  dead people.
> 
> Edit: In the interest of keeping this thread on topic, I have never used the bevel down technique. I would consider trying it, but I start so few IVs on peds as it is, I'm not sure it is a good idea to start experimenting too much.



Honestly, I wouldn't. If you do, practice it on a manikin arm or people with good veins.

I have gotten to the point in my career where I have realized that, when it comes to peds patients, they either need vascular access RIGHT NOW, or it can safely be deferred until ED arrival, and I'm far beyond caring what some ED nurse thinks about me for not attempting an IV in the field. 

And if the patient needs a vascular access RIGHT NOW, I'm going with an IO.


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## Shishkabob (Dec 7, 2012)

Drill, baby, drill.


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## JPINFV (Dec 7, 2012)

NYMedic828 said:


> As for the article, I don't particularly care to continue reading when the author titles himself an ambulance driver...


http://ambulancedriverfiles.com/2010/03/24/r-e-s-p-e-c-t/


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## Clare (Dec 7, 2012)

I am a little weary of putting a drip into paeds especially asthmatic children.  

While we still carry 2% lignocaine for IV cannulation in practice nobody uses this, I have never used and only heard of it being used once in a 6 yof where it was such a pain in the *** the AO said would never use it again. 

I have always been taught to start an IV with the bevel up, bevel down is an interesting idea.  

Distraction and such is a  good technique and one I find works fairly well; but luckily most of our common paediatric drugs come in forms other than parenteral such as intranasal fentanyl and midazolam, oral ketamine, nebulised salbutamol etc.


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## VFlutter (Dec 9, 2012)

Quote...

"Every post, without fail, there’s an avalanche of “ZOMG! I went to school  for [insert length of curriculum here] to learn how to do questionably beneficial stuff without really knowing why, and I didn’t give up a rewarding career in the fast food service industry just to be called an AMBULANCE DRIVER!"

:rofl::rofl::rofl:


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## TheLocalMedic (Dec 11, 2012)

Ambulance_Driver said:


> Use a steeper angle when inserting, just to pierce the skin, and pull greater skin traction. If you *****foot around with it, yes, it will probably hurt more and tear the skin. If you make a decisive stick, however, it works pretty well. The trick is learning how to be decisive and delicate at the same time.
> 
> I didn't come up with the technique. It was taught to me by a grizzled old peds nurse in a PALS class years ago, and used to be a commonly taught trick.
> 
> I would object to the notion that needles are expressly designed to be inserted bevel-up, however. They may work well that way, but that's not necessarily a function of design.



For some reason I seem to get a lot of peds, and I thank God that I had a great pediatric rotation in medic school as well as having a host of partners who have extensive pediatric experience.  The bevel-down technique works well if you practice it, and not just for peds!  I find that it works well for the elderly as well as patients with very dark skin.  You get a flash a hair sooner than you would otherwise which can be helpful.  Granted, it's one of those things that you have to practice a little bit, but once you are comfortable with the technique it is a good tool to have in your belt.  

The last time I did it was on an 8 YOF with serious burns over 30% of her body and I was able to pop in two 20 gauges in a heartbeat.  I really do like, and recommend, this technique.


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## epipusher (Dec 20, 2012)

NYMedic828 said:


> As for the article, I don't particularly care to continue reading when the author titles himself an ambulance driver...



Is that because he never drives it?


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## med109 (Dec 28, 2012)

Interesting that I found this post, I have read the article Kelly wrote about starting the IV bevel down and had practiced it a few times. The other night we had a terrible case, elderly lady, severe osteoporosis, had leaned down to grab something and felt a pop and snap both above and below the knee. She was in terrible pain, and we were a very bumpy 35 mins from the hospital. I start searching for a vein, we can only use 1 arm because of a dialysis port on the other arm. So I start looking at the "good" arm and she has a large scar that covers the AC from a previous port. Of course tiny, rolling veins.

My partner tried with a 22g, got flash, and it blew. I had called a neighboring agency who carries fentanyl (we only carry morphine) so I decided to "save" any veins for them. As I was warming her arm I noticed a tiny little vein "pop" up, so I thought what the hell. I grabbed a 24g, and went bevel down. It worked! I had the line started. She said that IV hurt less than any that she can remember. So maybe it was luck, but I won't hesitate to use bevel down again should the scene call for it!


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