# Tips for starting IV's



## newmedic33 (Nov 22, 2013)

How's it goin everyone, had some concerns, Im currently taking an Advanced EMT course and were nearing the end, Haven't started clinicals yet though. Seems like the book work and everything else isn't a problem I'm doing really well at it, I've scored above 90's on everything but it seems I'm having problems doing the skills, specifically IV's I'm able to hit our practice arm almost everytime but its nothing like a real person. I've only been able to hit one IV successfully out of 8 tries and it was in the AC which is easy, seems I have a really hard time getting them on the hand or forearm, and I can only occasionally get the AC. I just am startin to lose hope and need some tips or help, I've asked our instructors and they say practice makes perfect.

I've been applying the tourniquet properly and selecting decent straight veins, I make puncture at 45, get a flash. then level out and go to insert and when I go to advance the catheter that's when I lose it, either the vein blows or it like slides away and I just infiltrate. I don't know where im having problems the first few I was nervous and a little shaky now I've calmed my nerves and still cant get them, just gets a little depressing especially cuz I'm also taking the paramedic through percom, seems a medic who can't start IV's isn't of much good...

any tip guys? thanks.


----------



## SeeNoMore (Nov 22, 2013)

The cold hard truth is that you do have to practice to become better at skills and that everyone comes to the table with different levels of inate ability. It's also stressful to practice a skill that causes pain and anxiety to the patient in question. 

Don't despair though! Some people are excellent at IVs out of the gate, but many take time to develop at them. As you note, there are changes in technique you can consider, or make sure you are using, but either way you are going to need to practice. Personally my angle of insertion is usually less than 45 degrees , you may conser attempting a more shallow approach. Picking a good site is really important. It's worth the time to look. But eventually you have to pick your best bet and make the attempt. Also consider the size you really need. Leaving Macho hero crap aside, there is not shame in obtaining a patent 20 or 22 gauge site if that is appropriate or all that you can get. It's better than a 14 gauge bleeding hole. 

My advice, try and do as many IVs as you can. Try not to be defeated by a missed attempt. It might help  your anxiety to not endlessly stick the same person if urgent access is not required. Some people are very anxious or get upset with your failure. It's not your fault, it's just scary for many people. Let them know they are in control and that obviously you will stop trying if they wish. Don't blame people patients for "bad veins" etc, it's just agitating. But the more you attempt the better you will get. And I at least felt that I got pretty proficient at IVs without really noticing it. I worked in a busy ED, and rode 911 and critical care. My confidence grew as did my percentage of first time success. 

But even with that, I have days or calls where I just plain suck. You just have to calm down, consider whether you can make some changes to your approach, and if needed consider IO placement or and EJ etc. 

Best of luck.

PS: And I will take a new Paramedic that has excelled in their program academically but has some room to grow on IV insertion over a paramedic who is excellent at IVs but is not interested in "the book stuff" any day.


----------



## polisciaggie (Nov 22, 2013)

Try reducing the angle of insertion. I know the book/skill sheets say to go in at 45 degrees but I've always found it to be too steep.

When I first started doing IVs I would do the 45 degree thing and end up going straight through the vein. After I reduced the angle to around 10-15 degrees my success rate went up to and still is around 90%.


----------



## Akulahawk (Nov 22, 2013)

You can do the skin puncture itself at 45 degrees, but as soon as you've got the bevel through the skin, immediately shallow that angle to maybe 15 degrees. You want to be nearly parallel with the skin and aim for the middle of the lumen. I normally don't start the line immediately "above" the vein, I puncture to the side and then enter the vein from the side. This way, if the vein rolls, it can only roll "into" the catheter. At my best, I was pretty much also in the 90% range for first-time sticks and nearly 100% if I had to do 2 attempts. I shall be forever haunted by that one kid that had veins that looked really good but were beyond fragile... 

If I'm going to start the line by doing the skin puncture right over the vein, 45 degrees is just way too steep. I'll use an approach angle that's maybe half that and once I've buried the bevel, I'm going to go really shallow and aim for the middle of the lumen. Once I get flash, I'm going to maybe advance another couple mm and advance the catheter from there. 

This is just one of those things that you have to do a lot to get good at doing them and part of learning to do them well is missing a few (unintentionally, of course as we all want to get the stick perfect every time) and learning from those.


----------



## teedubbyaw (Nov 22, 2013)

I agree with the above posts. 45 is incredibly high. Depending on the site, 15-20 ends up being more realistic at times. 

Don't get too bummed on it. IVs can be hard to learn, especially when each patient is different. A very intuitive preceptor can be of great assistance.


----------



## Handsome Robb (Nov 22, 2013)

Agreed with all points. I can't do the side stick like Akula was talking about.

I have no idea what my percentage of first attempt success is. I'd guess in the mid to low 80s.

You might not like it but you're instructor is correct, practice makes perfect. I always try and have new students/employees start on the easy veins because being successful helps with confidence and in turn confidence helps with success. I know for a fact that I tend to miss more when I make a comment or think to myself about missing but when I just set it up and do it it isn't a problem. 

Not all ACFs are easy. Not all big veins are easy. Big veins roll a lot. Good traction on the skin and vein is important. 45* is definitely too steep unless it's a deep vein, there is not set angle, every stick is different.

*****These manual restraint techniques have the potential to really hurt someone if you do them incorrectly and/or with too much force. Practice in your downtime with your fellow students, family, friends or partner before you try it on a patient. Please don't crank super hard on someone's wrist or elbow and break it. I'm not responsible if you do.*****

A trick for hands my medic preceptor taught me is to sit on the bench or CPR seat with your foot on the rail then ask them to lightly grip your pointer and ring finger on your non dominant hand "like a gun" is how I generally describe it. Then use my leg as a fulcrum to flex their wrist so the plantar aspect of their hand is facing me and use my thumb of my off hand that they're holding on to to pull traction on the skin between the first and second knuckle which, in turn, pulls traction on the skin and veins on the top of the hand. Gets good traction and using your leg as a fulcrum makes it near impossible for them to flinch much if at all when you stick them. 

Another trick that works well fore forearm IVs on patients that are altered or seizing or something of the sort is (assuming sitting in the CPR chair for this, you can reverse it for the bench) with your left foot on the floor out their arm on your left leg just distal to the elbow. You can then use your left leg to put their wrist/hand under your right leg and put your foot on the frame of the gurney and you've trapped their arm and have both hands free. Be careful though if they're grabby...I've had an altered grandma or two try to get frisky so if you're gonna use it you better have quick reflexes. *Also, if someone is seizing exorcism style don't try this because you're going to break their arm.*

*****These manual restraint techniques have the potential to really hurt someone if you do them incorrectly and/or with too much force. Practice in your downtime with your fellow students, family, friends or partner before you try it on a patient. Please don't crank super hard on someone's wrist or elbow and break it. I'm not responsible if you do.*****


----------



## the_negro_puppy (Nov 27, 2013)

Honestly, you just need to do several hundred, but other tips-

Gravity - make sure limb is lowered to encourage venous pooling
Warm = vasodilated
Tapping veins (not slapping hard) can help bring them up.
Learn to go by feel
Traction, traction, traction, secure the vein and loose skin.
Not all pt's require tourniquets. Elderly with high BPs often blow veins easily.
Forearms are the best spot for limb movement and functionality
Ask the patient where they usually get blood draws from if possible.
I usually go as shallow as possible, rarely ever 45 degrees.
Often the tip of the needle is slightly longer than the catheter, hence you will get some flash with needle in the vein but catheter might not be. Make sure to advance a little more after flash.


----------



## Carlos Danger (Nov 27, 2013)

the_negro_puppy said:


> Honestly, you just need to do several hundred



Exactly.

There have been some good tips given here, but what it comes down to is that IV's are not an easy skill to learn. They become so routine and mundane that we completely forget how much time it takes for us to get good at them.


----------



## Jawdavis (Nov 27, 2013)

Puppy said something that I've been yelled at for so many times but not all patients need tourniquets. I have gotten more successful starts without a tourniquet than with. 

In RN school the only IV starts that I got to attempt were on patients that were 90+ years old and the biggest thing that I found that helped me was to grab the arm distal to where you are going to puncture (dont do a death grip though), pull the skin taught (this helps drastically from keeping the vein roll) and then like all of the above posters said, angle plays a huge part. I've found out sometimes you might have to pull some ninja moves to get those angles. 

Biggest thing though is if you miss just brush it off and try again. Everyone knows how many we all have missed!


----------



## PotatoMedic (Nov 27, 2013)

Take a phlebotomy class.  Lots of sticks if they do an internship along with it.


----------



## unleashedfury (Nov 27, 2013)

I am not a big fan of the 45* angle and when I was first doing IV's my success rate was in the tanks like less than 50% 

When I start a IV I look for a few seconds. for the straightest vein possible, and select my site. 

My biggest problem with the 45* angle was that I would punch right through the vein I could save it by backing off and advancing at less of an angle while the catheter was still in the vein but its unnecessary pain for the patient. 

My other big problem was I would fail to keep the skin taught, 

Select the appropriate site. 
Select the appropriate size catheter 
if you feel that 45* is too steep drop it back to like 30* 
Once you flash the chamber drop to 10* and advance with the needle more. advance your catheter sheath and remove your needle. *placing in the appropriate sharps receptacle. NREMT exams will NO GO you and it is unsafe to have sharps lying around*


----------



## Quin (Nov 27, 2013)

1) Get your instr to sign a note for you, or carry credentials*

2) Practice on yourself and at least 1 buddy (ideally get 5-10 of you).  A lot. Work your way up the veins. Then do it again. And again. 

* Welcome to track marks. 

I was taking a 6 week phlebotomy seminar during my AAS (4 hours a day twice a week of practicing on ourselves and classmates), and the instructor signed cards for all of us that didn't have healthcare provider creds as yet. "Huh?" changed into "Ahhhhhh I see.." when I got pulled over for a tail light out. If ANYTHING is going to mean interacting with LEOs, it's goong to happen while you're covered in track marks! 

3) Find out who the best local guy is/ guys are (Javier! in my case) and bribe them for an hour of 1:1 and shadow them for a shift. Hint: the best phlebotomists (or IV Gods, regardless of actual specialty or tech) in hospital are almost always sent to peds outpatient (to keep cranky parents/kids cycling through as fast as possible). Javier did 200+ sticks a day. I'm nowhere near as good as him. Completely outclassed.  But Im a 1000x better than I was after having him help me out. 

2+3) After youre competant in an ideal encironment:  Try to get your "study" group out in the field. Work in the back seat of a moving car, in the cold (a walk-in freezer if you're somewhere sunny & warm), in the rain, after running 3miles, in a sauna, with a strobe light in a dark closet. With your mother in law insulting you at the top of her lungs... Et cetera. 

HTH


----------



## hogwiley (Nov 28, 2013)

I'm curious where you are attempting these IV starts, as 1 out of 8 is pretty bad(not trying to be mean, just being honest). Are these IV starts done on an ambulance? Is someone watching you and giving you pointers or are they just cutting you loose on poor unsuspecting patients unsupervised?

I started out doing IVs in an ER and had RNs that were generally easy going and helpful, and had lots of lab practice before I subjected real patients to my attempts, not to mention my Paramedic school actually required Nursing level A&P so we had a little bit of a clue what lies beneath the skin were sticking a needle through, which probably aint the case for an AEMT class. As a result starting IVs so far has been the easiest part of Medic school(the paperwork we have to do after every IV start is another story).

My advice is to watch some RNs or Paramedics start some IVs in a well lit controlled environment and hopefully talk you through the process as they do it, and to get some easy sticks under your belt before you go trying on 80 year old chemo patients and life long diabetics.


----------



## ChewyEMS (Nov 28, 2013)

I am a paramedic here in Florida.  I speak from experience, having missed one IV in the last year and that patient actually had to have the PICC nurse place the line. Here is my method. Anchoring the vein is key, stick SHALLOW, 15-20 degree angle, and keep in mind, veins u feel are better than the ones u see.


----------



## NomadicMedic (Nov 28, 2013)

ChewyEMS said:


> I am a paramedic here in Florida.  I speak from experience, having missed one IV in the last year and that patient actually had to have the PICC nurse place the line. Here is my method. Anchoring the vein is key, stick SHALLOW, 15-20 degree angle, and keep in mind, veins u feel are better than the ones u see.



Really. You've missed only ONE IV in the past year. You must not stick a lot of people. I'm sorry friend, but I'm calling BS on this one.


----------



## Kidquick (Nov 29, 2013)

polisciaggie said:


> Try reducing the angle of insertion. I know the book/skill sheets say to go in at 45 degrees but I've always found it to be too steep.
> 
> When I first started doing IVs I would do the 45 degree thing and end up going straight through the vein. After I reduced the angle to around 10-15 degrees my success rate went up to and still is around 90%.



Yes, this. I also struggled with IV's when I was new, and after studying the technique of co-workers with skills my success rate shot up to 90%+. Even going in flush with skin can guarantee a flash if you're aim is correct, especially if your ride is a little bumpy. And when it comes to advancing the catheter, do it with the pointer finger of the hand holding the IV rather than your opposing hand. It takes a little practice, but it allows you maintain traction on the vein and has the added bonus of not making you look like a rookie.

Edit: Also, the majority of the pain involved with IV sticks is due to residual alcohol on the skin. Take a second to let it dry and shouldn't hurt so much.


----------



## ChewyEMS (Nov 29, 2013)

Doesn't matter if you want to call BS or not I'm just telling you from experience what I have realized I stick 4-5 people every shift sometimes more


----------



## Carlos Danger (Nov 29, 2013)

Kidquick said:


> Edit: Also, the majority of the pain involved with IV sticks is due to residual alcohol on the skin. Take a second to let it dry and shouldn't hurt so much.



I don't know about this. I've never noticed a difference in folk's reaction to the stick whether I let it dry or not, or whether I use alcohol, chlorhexidine, or betadine.




ChewyEMS said:


> Doesn't matter if you want to call BS or not I'm just telling you from experience what I have realized I stick 4-5 people every shift sometimes more



48 work weeks x 3 shifts/week = approximately 144 shifts.

144 shifts x 4 IV start attempts per shift = 576 IV starts....on the low side.

If you can hit all but 1 out of over 600 IV attempts than you are better than the best IV starters I've ever known, by probably a factor of 10. I doubt the IV team nurses at my hospital are that good....even using ultrasound.


----------



## Handsome Robb (Nov 29, 2013)

So because I use my left hand to advance the cath does that mean I'm a rookie? It's more controlled and causes the tip of the catheter to move less causing less of a chance to blow the line... Just my personal preference though. 

I consider myself pretty damn good at obtaining IV access and only missing one line in a year is pretty far fetched. I could see not being able to obtain access on only one patient, maybe, but only missing one line I call bogus.

We average 10 runs in a 12 and, unfortunately, the majority get lines due to protocol constraints so you do the math.


----------



## ChewyEMS (Nov 29, 2013)

You know what? I have loved this forum for all the wealth of information and the advice. Not to be questioned on my skill or lack thereof.  I'm not going to sit by and keep reading this garbage. I could care less how many patients you have and the "you do the math" bs. Move on. Just because you aren't as good at IV's leave me alone.


----------



## Handsome Robb (Nov 29, 2013)

It's been stated before but I want to reiterate it. There is no hard and fast rule about the angle you start at. Every stick is different, some veins are superficial and require a small angle while others are DEEP and require a steep angle.

In elderly patients I've heard of people starting the line bevel down and having more success, I tried it, couldn't figure it out and went back to what works for me.

Take bits and pieces of all the advice you get, try different ways and choose what you like and don't like to come up with your own style. 



ChewyEMS said:


> You know what? I have loved this forum for all the wealth of information and the advice. Not to be questioned on my skill or lack thereof.  I'm not going to sit by and keep reading this garbage. I could care less how many patients you have and the "you do the math" bs. Move on. Just because you aren't as good at IV's leave me alone.



We called you on a BS claim. When you get all defensive and throw a fit it doesn't help. 

Look at the numbers, if you really only missed one out of 832 sticks (4/day x 4 days/wk x 52 wks/yr) then you're the best person I've ever heard of starting IVs. That means you have a 99.88% success rating. I call BS. 

Personal attacks aren't appreciated here. No one belittled you just said we don't believe your claim, there's no reason to point fingers. 

I can pull my stats from my agency when it comes to skill successes/failures. I'd bet your QA/CQI would be able to provide something like that to substantiate your claims.


----------



## teedubbyaw (Nov 29, 2013)

He's so pro. I'm so jelly. Maybe he should write a book.


----------



## STXmedic (Nov 29, 2013)

teedubbyaw said:


> He's so pro. I'm so jelly. Maybe he should write a book.



"Exaggerating Abilities for Dummies"

or

"Hyperbole: My Life as a Paramedic"


----------



## chaz90 (Nov 29, 2013)

I'll be honest. I'm not the world's greatest at IV starts. I'm probably hovering around ~85% on first attempt success, and I would bet my percentage drops for additional attempts on the same patient as they typically have more difficult vasculature from the beginning. I obtain access on probably 95% of my patients when deemed necessary however, and the EZ-IO remains my friend for the critical patients without immediately obtainable venous access. I'll continue to strive for the above mentioned 99.88% success rate though  I suppose it's good to have a goal. Perhaps I'll start one IV this Jan. 1st and then avoid them for the rest of the year. 100% success rate for 2014!


----------



## NomadicMedic (Nov 29, 2013)

Agreed. There are days when I can't miss and other days when I blow a line that looks like a "no miss". It's simply experience, as I realized over the last couple of years, the more I start, the fewer I miss. And the less I think about it, the better I do. I just looked at my stats (yeah, we track all that stuff) I'm good, but I ain't no 99.98% good.


----------



## Akulahawk (Nov 29, 2013)

When I first started out, I was probably somewhere in the 70% range for first time stick success, and about 90% by 3rd attempt. Once I got the feel for it, I probably ended up in the low 90% for first, and about 98% second attempt overall. With two exceptions, I have a 100% success rate as of the last line I started, by a 3rd attempt. The first was a young male in DKA with extremely fragile veins (needed a central line, nobody got a PIV on him) and the other was an IVDU that I could only manage one attempt before a flight crew got their line started.

The point is that until I _did _get the feel for starting IV lines, I never had a 100% success rate. Because of those two calls, I will never have a 100% success rate. I had to start quite a few before I approached proficient... Nowdays, I'm probably rusty enough that while I could start the line, I might inadvertently cause a bit more iatrogenic blood loss than I would otherwise have.


----------



## VFlutter (Nov 29, 2013)

ChewyEMS said:


> Just because you aren't as good at IV's leave me alone.



Haters gonna hate. I would hit 99% if I threw 22s in everyone. Go big or go home, Brah. 16g or nothing. 

But seriously, I doubt I am that good even with ultrasound. I guess I could never be a paramedic.


----------



## Handsome Robb (Nov 29, 2013)

Chase said:


> Haters gonna hate. I would hit 99% if I threw 22s in everyone. Go big or go home, Brah. 16g or nothing.
> 
> But seriously, I doubt I am that good even with ultrasound. I guess I could never be a paramedic.



I'm trying to decide if you're giving me :censored::censored::censored::censored: or him :censored::censored::censored::censored:. :lol:

Everyone here is all about 18s. I drop 20s all day long. I have been told that lab draws off 18s don't end up hemolyzed as often as smaller gauges but that's just hearsay.


----------



## MasterIntubator (Dec 1, 2013)

So after years of studying and technique analyzing... I have grown to like the blood pressure cuff method....  learned in the 80's... rebirthed it in the late 90s when my success rate for critical patients and the elderly was not great.

Gotta take a BP anyway for med admin.... so why not save a step.  Once you get the BP.... your target range for good vein stand up is between the systolic and diastolic.  Elderly I will adjust to lower BP - more near the diastolic or less... this will help with the sudden 'blown' vein. 

The perks for me:
- Adjustable pressure to get the best venous back pressure ---> nice plump vein
- Surface area to cover the upper arm....
- Time saving for VS taking
- Pt enjoys not having skin pinched

The Down falls:
- BP cuff leak ( user error on maintenance )
- Not proficient in manual BPs ( NIBP takes the back step for me )
- Need tactful positioning to keep the hoses out of the way

Play around... see how it works.

Also.... lighting has a great role... a dimmer light will cast shadows and tend to make the un-seeable seeable.

Someone mentioned 'feel'. mmMMMmm... yes, get in touch with your fingers. Feel the anatomical area and close your eyes or look away, let your fingers do some talking.... it does help. 

Choose your IV cath size based off need, and not the size of your ego. Nothing wrong with a 22 if all you need is a something to give a med with and not fluid replacement. I figure we all do excellent assessments.

Hemolyzing serum is almost all the fault of technique, sample handling and excessive force/vacuum, not the size of the needle. Beautiful serum harvesting come from 24g/25g needles all day long.  I agree with the hearsay on size.  Yeah... its a factor, but not as common as technique

Be safe and make every experience a learning factor.


----------



## Summit (Dec 1, 2013)

95% first stick success. Wow.

I feel inadequate at 75%. I guess most of my patiens are several of the following: very sick, vasculopaths, diabetic, over 60, obese, etc.


----------



## NomadicMedic (Dec 1, 2013)

I was brainwashed with the "go big or go home" mantra in medic school. Now, it's a 20 or 22 in most cases. Trauma still gets a big cath, but most trauma I seem to stumble across is young guys with ropes. 

I think our advice is all the same. Shallow angle, wait a moment after the flash before advancing and practice, practice, practice. The only way to get better is to do lots.


----------



## Percomonline (Dec 3, 2013)

*2 Quick IV Tips from PERCOMONLINE*

Hi, my name is Jane Dinsmore, and I have starting IV's for 30 years and have been teaching people to start IV's for 20 years. Here are my 2 big tips....

1.  Patience and a little time is your best friend. Don't rush. While you shouldn't leave the tourniquet on so long that the arm gets mottled and acids start to be retained down in the tissues in any significant quantity, try putting the tourniquet on and letting the arm drop and hang below the level of the heart for a moment before trying to find your vein. Let it fill up.  I put the tourniquet on, let the arm hang down, and then tear my tape or get my IV dressing out and ready, check my catheter and loosen the cap, and ensure my IV tubing is filled with fluid.  Then and only then do I bring the arm up to take a look.  And in most cases, you can find a good vein quickly that way and maybe NOT the AC. 

2.  Insert the needle into the vein and when you get the flash, stop for just an instant and then gently push the needle forward again just a fraction - just enough to ensure you are in the lumen of the vein and not just in the vein layers of the wall.  This is a common reason IV's "blow".  Sometimes we forget to push the end of the needle a little bit farther to make sure you are in the lumen.

Hope these help, good luck!

Jane E. Dinsmore, Program Director
PERCOMOnline


----------

