# How long until you were comfortable starting an IV?



## MMiz (Jan 8, 2017)

I live in North Carolina, the land of cheap community college, and am looking at Lenoir Community College's online EMT-Intermediate program.

It's only four months, 6 in class sessions, and $180.  I'd be doing it merely for the experience.

Can a provider really learn to consistently start an IV in 6 in-class sessions and 96 hours of clinical time?


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## VentMonkey (Jan 8, 2017)

Yes, I think that's more than enough training. It probably took a couple of months---if that---of me being on my own as a paramedic until I was fairly confident. Now, it's typically as routine as taking a blood pressure.

I will say, when I was still a basic my old EMT school used to offer up an "ER tech" course as well. It included basic EKG interpretation, and a phlebotomy tutorial followed by clinicals at a local area hospital following around a phlebo tech for IV sticks. I think that class may have also helped my confidence with IV starts ahead of time.

With all of that, it's a pretty standard skill that comes to most providers in a fairly short amount of time.


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## Jim37F (Jan 8, 2017)

I remember the Army teaching us to start IVs on each other in a 2 week CLS course back in the day, and the IV module was all of a day or 2. This was like 8 years ago now, and they've since removed IVs from CLS because they found guys when faced with a real casualty for the first time would panic and fall in on the monkey skills they were taught and go for the IV before other more important interventions (mostly airway as bleeding control was throw a tourniquet on and done). At least that's what we were told when we redid CLS 2 years ago and no IVs included. So yeah I'd say it's possible to learn IV starts in a short amount of time, but as far as overall competency goes? Whole 'nother story..


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## EpiEMS (Jan 8, 2017)

Looks interesting...
Additional question if anybody is aware: I am under the impression (based on the NC Scope of Practice document, see page 3) that ETI is part of AEMT/EMT-I scope of practice in NC - they can't really expect people to learn how to perform ETI with only six in class sessions, can they?


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## NomadicMedic (Jan 8, 2017)

Sure. You can put a tube in Fred the head after a couple of tries. Competence in performing ETI on people is a whole different thing.


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## StCEMT (Jan 8, 2017)

Absolutely. I think my first 15 were rough, then it clicked. Only got better from there.


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## VentMonkey (Jan 8, 2017)

StCEMT said:


> Absolutely. I think my first 15 were rough, then it clicked. Only got better from there.


Until you meet "Dia-Betty" with skin like a rhinoceros, no legs, a fistula in one arm, no neck, and maaaaybe a knuckle vein.


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## NomadicMedic (Jan 8, 2017)

StCEMT said:


> Absolutely. I think my first 15 were rough, then it clicked. Only got better from there.



Most of the studies say that only after 70 or so intubation are operators baseline competent. (80% success without any outside assistance)


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## StCEMT (Jan 8, 2017)

VentMonkey said:


> Until you meet "Dia-Betty" with skin like a rhinoceros, no legs, a fistula in one arm, no neck, and maaaaybe a knuckle vein.


Those took a lot more, I had to learn the finesse and tips on people like this. Like not blowing sensitive veins. But the basic AC, not missing 3/4 attempts? Yea that only took about 15 before it began leveling out. I definitely hit random slumps, but for the most part I could hit most. From there I learned alternative sites, little tips to control it, how to work with limited/short veins.



DEmedic said:


> Most of the studies say that only after 70 or so intubation are operators baseline competent. (80% success without any outside assistance)


That I believe, but I intubated significantly less than I start IV's.


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## Carlos Danger (Jan 8, 2017)

MMiz said:


> Can a provider really learn to consistently start an IV in 6 in-class sessions and 96 hours of clinical time?



No way. Not in "real world" patients, anyway. 

But I don't think being able to "consistently" start IVs is really the point of the course.


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## PotatoMedic (Jan 8, 2017)

Yeah but in any other aemt class you won't get any more education or clinical time.


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## hometownmedic5 (Jan 8, 2017)

On the rubber arm, maybe 5. 

On real human flesh, many many more. 

During clinical, I logged 150 or so; and I stopped counting less than halfway through my ED rotation. I probably started at least 300.

I had the concept down fairly quickly, say less than 20. Learning the nuances took some time. The elderly, diabetics, drug users, black people etc. all have different characteristics. 

I was certainly comfortable with it before finishing clinicals.


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## VentMonkey (Jan 8, 2017)

hometownmedic5 said:


> On the rubber arm, maybe 5.
> 
> On real human flesh, many many more.
> 
> ...


What?! Pre tell...


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## hometownmedic5 (Jan 9, 2017)

You don't notice a difference?


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## VentMonkey (Jan 9, 2017)

hometownmedic5 said:


> You don't notice a difference?


Honestly? No. Aside from the other diseases that I may take into account as a "difficult stick", their race has little to do with finding a decent vein in a presumably healthy individual.


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## hometownmedic5 (Jan 9, 2017)

I have noticed they frequently have tougher skin. Not universally and not insurmountable, but I have noticed it. 

There's also the color disparity to consider. It's tougher to see dark veins through dark skin compared to light skin.


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## akflightmedic (Jan 9, 2017)

A smiley only because I have no words.


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## EpiEMS (Jan 9, 2017)

DEmedic said:


> Sure. You can put a tube in Fred the head after a couple of tries. Competence in performing ETI on people is a whole different thing.



Right, I just wouldn't want to be expected to perform ETI on people just because I can intubate Fred...
The idea that people are just thrown to the wolves to intubate is a bit frightening. (Now I'm picturing some poor medic student walking around the woods with a laryngoscope and a steak...)


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## ExpatMedic0 (Jan 9, 2017)

It took me a while after school, probably 1 year on the job before I had a pretty solid success rate.


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## NomadicMedic (Jan 9, 2017)

And the smallest thing can ruin your confidence. We recently switched catheters at my service and I am having little success with them. :/


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## hometownmedic5 (Jan 9, 2017)

DEmedic said:


> And the smallest thing can ruin your confidence. We recently switched catheters at my service and I am having little success with them. :/



The shanks will get you every time. I went through maybe three months last year where I don't think I successfully started a line. No change in equipment or anything, I just missed a couple in a row and developed a complex about it.


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## StCEMT (Jan 9, 2017)

DEmedic said:


> And the smallest thing can ruin your confidence. We recently switched catheters at my service and I am having little success with them. :/


Ugh, this I struggled with in school. Hospitals had some awesome ones, the truck had the ones I have hated the most. So glad work doesn't stock them.


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## NomadicMedic (Jan 9, 2017)

We went to a style that does not seem to want to advance at all. I get a good flash and then I just can't advance the catheter off the needle. I blew two that way yesterday. I guess it's just going to be a matter of practice.


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## TrueNorthMedic (Jan 9, 2017)

It took me probably 30 iv starts before I had the basic technique down pat, and close to a year before I felt really confident. Like others, there are times when I feel like I can't miss and also times when I miss a bunch in a row. Interesting how your level of confidence can make a difference.


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## VentMonkey (Jan 9, 2017)

DEmedic said:


> We went to a style that does not seem to want to advance at all. I get a good flash and then I just can't advance the catheter off the needle. I blew two that way yesterday. I guess it's just going to be a matter of practice.


DE, can you post a pic of the catheters next shift on? 

We switched brands for about a month, and apparently the majority of our crews were having issues and getting blood specs being spewed about with the needle retraction. I'm curious if it's the same brand.

They resolved the issue, and went back to the old angiocaths.


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## NomadicMedic (Jan 9, 2017)

Sure. I'm not in again til Wednesday night.  These have a little clip in the hub that slides out and covers the needle when it's removed. It's not like the push button/spring loaded or slide lock caths I'm used to. And I was already told, "Nope. This is what we're using now. Not switching."


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## hometownmedic5 (Jan 9, 2017)

What seems to derail me is missing a "gimme" line. One of those nice, fat, well anchored, Hellen Keller could put a 10g in this vein 14 shots of jaeger deep iv's. Everybody misses occasionally, but when I whiff the 50mph fastball, my confidence in my skills evaporates like rubbing alcohol.


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## E tank (Jan 9, 2017)

DEmedic said:


> Sure. I'm not in again til Wednesday night.  These have a little clip in the hub that slides out and covers the needle when it's removed. It's not like the push button/spring loaded or slide lock caths I'm used to. And I was already told, "Nope. This is what we're using now. Not switching."



If they're the ones I'm thinking they are, they are absolutely awful, IMO/E...were popular years ago with the clip board warriors when needle sticks became potentially lethal events and this was a feeble attempt at making the needle safer. Can't believe they're still around. VERY gritty feel as you slide the catheter off of the needle. It feels like the metal is shearing on the catheter. Awful, like I said. 

You need to advance the needle/catheter unit into the vessel several mm's further than other brands before advancing the catheter. 
Good luck with those...


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## Tigger (Jan 9, 2017)

DEmedic said:


> Sure. I'm not in again til Wednesday night.  These have a little clip in the hub that slides out and covers the needle when it's removed. It's not like the push button/spring loaded or slide lock caths I'm used to. And I was already told, "Nope. This is what we're using now. Not switching."


If they are made my Braun, those are my favorite!

Which just goes to show how the smallest things can make a difference. I'm ok with the spring loaded ones, the Jellco ones that retract all the way back into the barrel on the other hand, just awful.


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## StCEMT (Jan 9, 2017)

Tigger said:


> If they are made my Braun, those are my favorite!
> 
> Which just goes to show how the smallest things can make a difference. I'm ok with the spring loaded ones, the Jellco ones that retract all the way back into the barrel on the other hand, just awful.


Those are the ones I was talking about, couldn't remember the name. Words cannot describe the level of hatred I have for those.


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## VFlutter (Jan 9, 2017)

Sounds like the "Braun Introcan" IVs. They are the type that come in PICC and Central line kits as finder needles. They are great for US assisted IVs.


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## luke_31 (Jan 9, 2017)

Chase said:


> Sounds like the "Braun Introcan" IVs. They are the type that come in PICC and Central line kits as finder needles. They are great for US assisted IVs.


These are the ones we use too, they work great for us.


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## VentMonkey (Jan 9, 2017)

I will add, I still take pride in my IV start etiquette and skills. By no means will I turn patients into the proverbial "pin cushion", but my SoCal cohorts can probably attest to a certain rather large department that notoriously abides by a "one and done" attempt technique regardless of the criticality of the patient.


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## NomadicMedic (Jan 9, 2017)

Right. And I love the Jelcos that slide back and l


Chase said:


> Sounds like the "Braun Introcan" IVs. They are the type that come in PICC and Central line kits as finder needles. They are great for US assisted IVs.




Those the the ones. Big on the suck factor. I can't get em to advance worth a lick!


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## PotatoMedic (Jan 9, 2017)

We use the jelco that cover the needle as you advance the Cath.  Love those.  Hate most auto carbs.


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## VentMonkey (Jan 9, 2017)

So the IV catheters we had briefly switched to are pictured here on the left, our original (and ones we almost instantaneously put back in service) are on the right. 

I found a bizarro catheter lying around our station and felt compelled to share.


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## Handsome Robb (Jan 9, 2017)

Chase said:


> Sounds like the "Braun Introcan" IVs. They are the type that come in PICC and Central line kits as finder needles. They are great for US assisted IVs.



I love these things. So easy to use. I can't stand the ones at my new job. I'm finally figuring them out but I still strongly dislike them. 


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## Tigger (Jan 10, 2017)

We briefly switched to the Jelco ones at my AMR place and successes rate plummeted while accidental needle sticks when up...


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## akflightmedic (Jan 10, 2017)

IOs....they all get the EZIO....if they are sick enough to need an IV, then they are sick enough to get IO. Have not missed a bone yet!


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## StCEMT (Jan 10, 2017)

akflightmedic said:


> IOs....they all get the EZIO....if they are sick enough to need an IV, then they are sick enough to get IO. Have not missed a bone yet!


What about the pukers? Drill baby drill?


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## akflightmedic (Jan 10, 2017)

Drill them allllll  !!!!!!!


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## Aprz (Jan 10, 2017)

I felt like I quickly got really comfortable when I started working on my own as a medic. I worked on a very busy unit, or I felt it was busy, and started a lot more IVs on all types of calls. I was not good with IVs at all during my internship. Not good at all.


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## PotatoMedic (Jan 10, 2017)

I'm kind of curious how I will get used to the different IVs in Colorado since all my partner's are IV techs and my guess are usually the ones starting an IV.


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## NomadicMedic (Jan 10, 2017)

Funny that you say that. I've been playing fill in for the last couple of weeks and the guy that was a partner du jour last week said he hasn't started an IV in ages, because the paramedic does them all.

Wut? Get back there and start me a line son!

He did all my I level skills the other day and said it was the most he'd done in the back of the rig in a year. I said, "what does your partner let you tech?" He said "BLS".

Ugh. Why mandate that medics have to have an I partner and then not let them do anything? No wonder people get pissed and quit.


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## PotatoMedic (Jan 10, 2017)

I'm looking forward to the extra help honestly.  It will just be an interesting dynamic that I now have to think about.  I'm so used to basic medic that IV or aemt will be a big change.


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## Handsome Robb (Jan 10, 2017)

FireWA1 said:


> I'm looking forward to the extra help honestly.  It will just be an interesting dynamic that I now have to think about.  I'm so used to basic medic that IV or aemt will be a big change.



I've never worked with a basic, but having an intermediate partner is nice because you don't have to do everything. 

What's funny to me is now working in a dual medic system I generally do everything myself on the vast majority of calls. Might ask my partner to draw up meds or something but unless it's a high acuity call the lead medic does everything while the partner charts. 


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## VentMonkey (Jan 10, 2017)

A close friend of mine who's now one of our supervisors worked with me on a dual medic unit when he was still fairly new.

I swore he was like a super sneaky "position-himself-right-by-the-head-to-get-the-tube" ninja. Every arrest it never failed. 

The relevance to my tale regarding this thread...I was always the IV medic.


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## NomadicMedic (Jan 10, 2017)

VentMonkey said:


> A close friend of mine who's now one of our supervisors worked with me on a dual medic unit when he was still fairly new.
> 
> I swore he was like a super sneaky "position-himself-right-by-the-head-to-get-the-tube" ninja. Every arrest it never failed.
> 
> The relevance to my tale regarding this thread...I was always the IV medic.



This was a common occurrence at SCEMS when the admin staff would crash your call to try and steal an intubation. We called them flash dancers.


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## VentMonkey (Jan 10, 2017)

DEmedic said:


> This was a common occurrence at SCEMS when the admin staff would crash your call to try and steal an intubation. We called them flash dancers.


Oh, we had one those supervisors as well. I cannot confirm nor deny that I have done that in the height of my supervisory days myself.

Honestly, I used to like showing up, activating said trauma, strip the line, help package, and see that it was as an expedient and efficient call as one could hope, but I digress...


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## DrParasite (Jan 10, 2017)

Back to the original questions, I know of several people who completed the Lenor program, and 3 or 4 of them are now paramedics.  And they all said they program was questionable at best, and the paramedic program there was horrible.

BTW, getting your Intermediate in NC is pretty much as waste of time IMO.  Many counties don't recognize it, many won't pay you for more it., and unless your agency operates at the Intermediate level, you can't do anything with it, and have to handle all the continuing education on your own.


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## DrParasite (Jan 10, 2017)

DrParasite said:


> Back to the original questions, I know of several people who completed the Lenor program, and 3 or 4 of them are now paramedics.  And they all said they program was questionable at best, and the paramedic program there was horrible.


just to clarify what I said before: Lenoir's program was questionable at best, and none of them attended their online hybrid paramedic program; they all attended the paramedic program located in the county where they worked full time, which was not Lenoir.

I do know one person who did attend the Lenoir paramedic program, and he didn't speak very highly about it.


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## Aprz (Jan 11, 2017)

We don't have intermediates here; Only EMTs and paramedics. I try to turf my call to my EMT partner whenever appropriate. Unfortunately, I feel like it is too easy for a call to have to go ALS here. My EMT partners can go many days or even a week or two without running a call.


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## CWATT (Jan 11, 2017)

Aprz said:


> We don't have intermediates here; Only EMTs and paramedics. I try to turf my call to my EMT partner whenever appropriate. Unfortunately, I feel like it is too easy for a call to have to go ALS here. My EMT partners can go many days or even a week or two without running a call.



I feel like there's a huge misunderstanding of what it means to 'run a call'.  When I did my EMT program, one of my preceptors was a Paramedic.  He was a quiet guy to begin with, but he would stand back and let the EMTs do almost everything.  He recognized the most benefitial role both in the group-dynamic and patient care was to contribute his experience.  Rather than feel the need to perform every skill and intervention himself, he would stand-back and guide the call offering input or direction when he felt necessary.  

Just so I don't derail this thread even more, I'll offer some feedback to the OP:

I missed my first few IVs as result of poor instruction.  They will likely teach you to approach at a 45' and once you've pierced the skin, lower that angle to around 20'.  In all honesty, that's crap.  It's way too steep an angle and all it's doing is preparing you to stab someone (or yourself) unintentionally when your unit hits a bump in the road.  What changed the game for me was when my instructor told me to lay the IV flat on the patient's skin (Needle/catheter elevated in the air and the flash chamber against the body) and anchor it there with your finger tips.  First prep the skin (obviously), but laying the needle flat will allow you to eye-up your vein again and do so safely when bouncing down the road.  When ready, tip the needle down to make contact with the skin and pivot up to a low angle and advance.  It's WAY shallower than the textbooks say and it will change depending on adipose tissue and how superficial or deep the vein you intend to cannulate is, but it made all the difference for me.  Also keep in mind, for pediatrics you're going to be entering at a similar low-angle.


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## VentMonkey (Jan 11, 2017)

@CWATT I agree with a shallow approach as well. Finesse seems to go much further with most vascular access procedures.

I also never got why they taught the 45 degree angle and watched a lot of my fellow classmates struggle with that particular technique.


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## StCEMT (Jan 11, 2017)

CWATT said:


> I feel like there's a huge misunderstanding of what it means to 'run a call'.  When I did my EMT program, one of my preceptors was a Paramedic.  He was a quiet guy to begin with, but he would stand back and let the EMTs do almost everything.  He recognized the most benefitial role both in the group-dynamic and patient care was to contribute his experience.  Rather than feel the need to perform every skill and intervention himself, he would stand-back and guide the call offering input or direction when he felt necessary.


One of my favorite preceptors was like this. With the exception of the reallllly sick/injured people I got with him, he just sat back in the chair and let me do my thing. I've somehow dodged like 3 cardiac arrests lately, but my goal once I actually have to run one where I work is to essentially stay hands off unless I absolutely need to. I work with good partners and we have worked with the FD's to get on the same page for how we run them, all I gotta do is make sure all the details are being accounted for and let them do their parts. Think that's better than trying to crowd everyone.


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## Tigger (Jan 11, 2017)

FireWA1 said:


> I'm kind of curious how I will get used to the different IVs in Colorado since all my partner's are IV techs and my guess are usually the ones starting an IV.


It can be pretty hit or miss, it's only a 24 hour class.


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## gotbeerz001 (Jan 12, 2017)

You will remember the first call where you got the IV bumping down the road C3. 

Mine was a stroke activation. 


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