# Fishing for IVs



## DesertMedic66 (May 23, 2015)

So a recent call made me start to think about IV starts. 

How many of you "fish" for an IV? For those who have not heard that term before it means you don't see or feel a vein so you insert a cath and just hope you get a vein. 

Does it change fore you depending on the patients age or condition?

The story behind this question was a pretty standard 16 month old febrile seizure. The fire medic could not find a vein after only checking the left AC so he went fishing and caught nothing. 

For myself I was taught never to fish for a vein during medic internship and I still don't. If I don't feel or see a vein I will move on and check other areas. I may then decide not to do an IV or depending on patient condition I'll just go to IO.


----------



## Chewy20 (May 23, 2015)

Agree, sounds like a waste of time to me. If you absolutely need an IV but can not find anything, just go IO. Pt at that point needs fluids or meds, no need to try and fish for something you probably wont catch.


----------



## Flying (May 23, 2015)

Why would one do anything based on a gamble? We can do better than that.


----------



## DesertMedic66 (May 23, 2015)

Flying said:


> Why would one do anything based on a gamble? We can do better than that.


Welcome to EMS in SoCal...


----------



## jwk (May 23, 2015)

Your medic ought to learn some more pediatric techniques - saphenous veins are pretty easy in little kiddos.


----------



## DesertMedic66 (May 23, 2015)

jwk said:


> Your medic ought to learn some more pediatric techniques - saphenous veins are pretty easy in little kiddos.


Wasn't my medic. I'm the medic on the ambulance haha. After he missed I looked and got a 24G in her right AC. 

I will usually check the ACs first and then go straight to the saphenous.


----------



## Angel (May 23, 2015)

Sometimes I'll "fish"...usually I get it, other times I don't. Not getting doesn't mean I'm going to go directly to an io though. EJ is always an option.


----------



## Tigger (May 23, 2015)

When I say fishing it usually means that I have a vein in mind but I am struggling to get it. 

If you're just rooting around with blind squirrel finding a nut philosophy, maybe don't.


----------



## DesertMedic66 (May 24, 2015)

Angel said:


> Sometimes I'll "fish"...usually I get it, other times I don't. Not getting doesn't mean I'm going to go directly to an io though. EJ is always an option.


I won't go directly to IO. I'll check all the other sites, then move up to EJ, then IO if absolutely needed.


----------



## STXmedic (May 24, 2015)

On occasion with someone who needs an IV, I've started one where a vein _should_ be. I'm probably about 50% successful on those. These are usually on rather obese patients. Like others have said, I'm not at all opposed to an EJ. I won't claim to be stellar at pediatric IVs, though... They get drills if they're that bad off.


----------



## Akulahawk (May 24, 2015)

If I'm having to fish for a vein, it means that I can feel (or even see) a vein that's right _there_ and I didn't hit it during the initial stick. For me, it usually means that the patient's veins roll around more than I expected them to. I'm about 50% on those. I only spend a minute or two with those before I move on to a different site.


----------



## COmedic17 (May 24, 2015)

The only time I "fish" for a vein I can't feel/see is if I see scars over it...so I know something is under there. Usually in obese patients or patients who recently gained a lot of weight.


----------



## Carlos Danger (May 24, 2015)

I don't believe in doing it at all. Making a few careful movements to try to enter a vein that you know is there, but just can't see or feel? Sure. Blindly stabbing into the tissue over and  over in the hopes that you'll get lucky? No way. I'd smack the crap out of someone I saw doing that to my 16 month old. 

You either NEED access, or you don't. If you NEED it, stop screwing around and place an IO. If you don't really NEED it, then just stop, and drive to the hospital. 

Multiple IV attempts are painful, can potentially result in serious complications, and probably 90% of prehospital IV's are just for show.


----------



## dalmain (May 24, 2015)

I don't fish for veins..I have to see it or feel it to attempt it.


----------



## Knightinwhitesatin (May 24, 2015)

That call doesn't even need an iv.


----------



## DesertMedic66 (May 24, 2015)

Knightinwhitesatin said:


> That call doesn't even need an iv.


I normally agree, however the hospital we were going to be transporting to and the doctor that was on duty like us to get a line on febrile seizures if possible.


----------



## cannonball88 (Jun 11, 2015)

A couple of useful things to remember here:

There is a difference between "fishing" and using your experience and instinct to attempt accessing a vein. For example, in placing a central line, physicians do not palpate or visualize anything other than the anatomical landmarks. Why? Because they have sufficient knowledge of anatomy to know that if they poke "here" there will subsequently be a vein "there." The same is true for peripheral veins.
Consider whether you really NEED the IV or if you're simply doing it because you "should." Those who got to this thread first covered this well, I won't beat a dead horse.
Move up the "ladder" sooner rather than later. If they do indeed need that access and a peripheral is going to be difficult, consider moving straight to an external jugular or even IO line. With new equipment such as the EZ-IO drill, they are being considered less and less "invasive" and more akin to your peripheral line.
Hope this helps a little!


----------



## Jason (Jun 12, 2015)

Remi said:


> I don't believe in doing it at all. Making a few careful movements to try to enter a vein that you know is there, but just can't see or feel? Sure. Blindly stabbing into the tissue over and  over in the hopes that you'll get lucky? No way. I'd smack the crap out of someone I saw doing that to my 16 month old.
> 
> You either NEED access, or you don't. If you NEED it, stop screwing around and place an IO. If you don't really NEED it, then just stop, and drive to the hospital.
> 
> Multiple IV attempts are painful, can potentially result in serious complications, and probably 90% of prehospital IV's are just for show.



I agree with Remi.
Normally ... I try to find two places that I'm pretty sure or ok with.  Pick one I think I can get in one attempt.  No fishing or blind sticking.  If the access is NEEDED and a peripheral is not happening, then time to move on and up ... EJ or IO.


----------



## EMSComeLately (Jun 12, 2015)

I'm so glad this thread got started.  I've been doing pretty well with IV starts (in clinicals) but have been too nervous about going for what I've heard is called an "anatomical stick."


----------



## Gurby (Jun 12, 2015)

http://www.cnci.co.uk/site/library/casestudies/Nerve_damage_from_cannula.html
http://goldberghirshlaw.com/nerve-damage-from-iv/


----------



## akflightmedic (Jun 13, 2015)

Just a question....

Does your respective system place IO last "in the ladder"? Is an EJ still preferred prior to an IO? Even on pediatric?
Do you have to attempt an EJ before moving onto IO?


----------



## NomadicMedic (Jun 13, 2015)

akflightmedic said:


> Just a question....
> 
> Does your respective system place IO last "in the ladder"? Is an EJ still preferred prior to an IO? Even on pediatric?
> Do you have to attempt an EJ before moving onto IO?




Not for me.  An EJ is just another peripheral IV site.


----------



## chaz90 (Jun 13, 2015)

akflightmedic said:


> Just a question....
> 
> Does your respective system place IO last "in the ladder"? Is an EJ still preferred prior to an IO? Even on pediatric?
> Do you have to attempt an EJ before moving onto IO?


No to all of the above. We place EJs, but we use IOs far more frequently. There's no rigidly defined "ladder" in place either. Some patients end up getting an IO placed after a missed attempt or two, and some get it right off the bat. 

On a semi-related note, I've never even attempted an EJ on a pediatric patient. Is that an overly common access point?


----------



## RocketMedic (Jun 13, 2015)

There is a significant difference between an educated anatomical stick and blindly harpooning a limb.


----------



## DesertMedic66 (Jun 13, 2015)

akflightmedic said:


> Just a question....
> 
> Does your respective system place IO last "in the ladder"? Is an EJ still preferred prior to an IO? Even on pediatric?
> Do you have to attempt an EJ before moving onto IO?


IVs are the preferred route for vascular access. They want us to try for an IV twice before we go to an IO but we have the option of just going for an IO. EJs are just considered a normal IV for us.


----------



## akflightmedic (Jun 13, 2015)

Thanks for the swift replies...I was trying to make a point based on the various replies in this thread. It seemed "EJ" had an elevated status and one which would delay an IO attempt when in many circumstance an IO might even be first line. Just seeing what is going on out there.


----------



## NomadicMedic (Jun 13, 2015)

There are LOTS of new providers that wouldn't even consider an EJ in a conscious person, because "a needle in the neck! ZOMG!!11!!!" And in a CTD patient, an IO is just so damn quick


----------



## Tigger (Jun 13, 2015)

I find a tibial IOs to just be more practical for the super sick, obtunded patient. Odds are that this patient also requires airway management, so it's just easier to drill one real quick while staying out of the airway person's way. 

Our EMTs start IVs and IOs so if it's a medic/basic truck odds are the paramedic is at the head working the airway thing while the EMT takes care of access.


----------



## NomadicMedic (Jun 13, 2015)

I agree with the tibial IO. It was my favorite method to work a code. One medic on the airway, the other at the legs, with the Lucas, monitor and drugs. 

However, were now only allowed to drill a Humeral head IO. :/


----------



## Carlos Danger (Jun 13, 2015)

DEmedic said:


> were now only allowed to drill a Humeral head IO. :/



Do you know what is their rationale for that?


----------



## NomadicMedic (Jun 14, 2015)

Because someone took a drug to central circulation study as gospel and now "if we're going to save lives, we need to only drill the Humeral head." Piffle.

http://emtlife.com/threads/humeral-head-vs-tibial-io.38091/

Also, if you read the above, I'm now working for a different agency, in a different state.


----------



## Carlos Danger (Jun 14, 2015)

DEmedic said:


> Because someone took a drug to central circulation study as gospel and now "if we're going to save lives, we need to only drill the Humeral head." Piffle.
> 
> http://emtlife.com/threads/humeral-head-vs-tibial-io.38091/
> 
> Also, if you read the above, I'm now working for a different agency, in a different state.



Yeah, I thought I vaguely remembered this thing coming up a while back, but I wasn't sure.

I guess I can see a protocol listing the humeral head as the "preferred" site where a critical drug is indicated ASAP, but to disallow alternative sites altogether seems really dumb. It ignores all the other factors that go into a resuscitation that can affect the time-to-central-circulation way more than the site of IO access. I know I'm preaching to the choir, though.


----------

