# Getting the hard IV's.



## Granola EMT (Feb 8, 2009)

So I've been an Advanced for about 8 months now, and I feel like I should be getting some of the harder IV's. I know it's a combo of technique, skill, and luck, but Im wondering if anyone has tips/tricks that work to help get the harder IV's . Mostly dehydrated pt's with nothing in the veins, I guess?

I have a few tricks up my sleeve that have worked, but wouldn't mind learning a few more...


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## marineman (Feb 8, 2009)

If they taught you to go in at a 45 then drop down once you got flash throw that out the window. Low and slow especially on old people (don't know why they say slow, if you go fast it hurts less.) Another trick I use is rather than pulling the skin back like we were taught I grab under their arm and pull their skin to the sides to keep it tight, I have better luck popping veins up that way and keeping them from rolling. Not sure maybe that's been proven to be a bad idea and someone else will correct me but so far it's been working with no complaints from patients. 

I'm still learning myself so I hope others can come in and toss in their 2 cents. I think there was a thread about this a while ago if you feel like searching but I'm kind of lazy tonight.


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## Aidey (Feb 9, 2009)

Have you tried a roller tourniquet?  

The other thing I suggest is getting the IV you can get, and once you get some fluid in them, get the IV you want. If that means putting a 24 in, then put a 24 in. It will take a while, but you will get some fluid in, and then you can try for a bigger one.


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## OzAmbo (Feb 9, 2009)

I had some issues not long ago with my IV's. After months of having an extrememly high success rate i started missing multiple cannula's.

Myself i often find that the whole 45 degree pop then drop approach just does not work. I prefer a much shallower approach around 10-15 degrees. The other problem i have had is that the overwhelming majority of the time i had no problem locating and puncturing a vein but i would go thorugh the other side of the damn thing. As for anchoring i dont really have a system, theree so many variations of skin types and thickness that i just use whatever seems to work best at the time.

I have cheated once with someone i was trying to place 14g in. I put a 24g in the back of their hand, pulled a tournequet on realy tight then pushed 20-30ml saline which made her cephalic an AC pop up nicely

Good luck bro!


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## Granola EMT (Feb 9, 2009)

Thanks! good feedback! Im normally very proficient, but you always want to be better I guess. Some people just don't pack good veins I guess...
Funny, after posting this last night, we went on a code and the guy had been down approx 10 min W/O CPR. No veins... I tried an AC... Nothing... So we put in an EZ-IO. Zipped that in gave a round of epi/atropine, and after 250cc of NS I got the other AC. Nothing special, but a little ironic... 

Ya the whole 45* thing IS crap! EZ-IO's are great, though. Second time I've used it on a code, and gotten an IV after administering NS. It's amazing what a little fluid can do...

Has anyone tried using a hot pack to get veins to pop up, on, say pt's that have been exposed to cold/down a little while/dehydrated, etc?

I always forget to try it, but I guess it works?


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## MSDeltaFlt (Feb 9, 2009)

The thing about IV's is that what works for one situation won't necessarily work for every situation.  Sometimes you have to LET the vein show up.  It takes time.  Also, if you can't feel it, don't stick it.


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## Sasha (Feb 9, 2009)

MSDeltaFlt said:


> Also, if you can't feel it, don't stick it.



What!? You mean don't go fishing around in someone's arm for a vein? 

Blasphemy.


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## Granola EMT (Feb 9, 2009)

Fishing is okay sometimes, I guess... I would rather feel it and not see it, then see it, and not feel it. At least you know there is something in there...

Has anyone tried the hot pack thing?


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## BossyCow (Feb 9, 2009)

Granola EMT said:


> Fishing is okay sometimes, I guess... I would rather feel it and not see it, then see it, and not feel it. At least you know there is something in there...
> 
> Has anyone tried the hot pack thing?



Even with fishing you want to know where the fish are.


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## Sasha (Feb 9, 2009)

Granola EMT said:


> Fishing is okay sometimes, I guess... I would rather feel it and not see it, then see it, and not feel it. At least you know there is something in there...
> 
> Has anyone tried the hot pack thing?



Fishing hurts. And you run the risk of doing some damage to the tissue or the patient.


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## Granola EMT (Feb 9, 2009)

Of course it hurts... Thats why it's not nice. 

There is a difference between "fishing for the vein" (okay sometimes) ( not conscious/really need it/think its there) and digging around in someone's arm/hand/whatever, with a needle hoping to find something blindly....


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## marineman (Feb 9, 2009)

Last night had a critical patient, needed an IV big time. I couldn't find anything, paramedic I was riding with couldn't see or feel anything but took a shot at the AC. After that he looked at me and said never do what I did, I knew anatomically it was there but couldn't feel it. He got it but not something I'm hoping to have to do ever.


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## medic417 (Feb 9, 2009)

Best way to get good at IV's is to close your eyes and find your site.  Learn to go by feel not sight.  Practice that way.


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## BLSBoy (Feb 9, 2009)

medic417 said:


> Best way to get good at IV's is to close your eyes and find your site.  Learn to go by feel not sight.  Practice that way.



DING DING DING!!

Close your eyes, and feel. It might freak the pts out but use your other senses besides sight.


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## medic417 (Feb 9, 2009)

BLSBoy said:


> DING DING DING!!
> 
> Close your eyes, and feel. It might freak the pts out but use your other senses besides sight.



And if you lower your head like your looking intently they will not even be able to see that your eyes are closed.


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## MSDeltaFlt (Feb 9, 2009)

Sasha said:


> What!? You mean don't go fishing around in someone's arm for a vein?
> 
> Blasphemy.



As I'm sure you're joking, no.  One should know their anatomy well enough to already know where the veins are.  Plus, one should also be able to feel even some of the deep ones because they tend to not get used for IV's very often. 



Granola EMT said:


> Fishing is okay sometimes, I guess... I would rather feel it and not see it, then see it, and not feel it. At least you know there is something in there...
> 
> Has anyone tried the hot pack thing?



"Fishing for veins" tells me that you might not have been trained as well as you probably should have been.  It takes assessment.  It takes patience.  It takes knowledge of anatomy.  It takes feeling of your pt's anatomy.  It takes critical thinking of the situation.  In short, it takes a skilled clinician.


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## fma08 (Feb 9, 2009)

MSDeltaFlt said:


> "Fishing for veins" tells me that you might not have been trained as well as you probably should have been.  It takes assessment.  It takes patience.  It takes knowledge of anatomy.  It takes feeling of your pt's anatomy.  It takes critical thinking of the situation.  In short, it takes a skilled clinician.



Sooo..... don't poke and hope?


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## rmellish (Feb 9, 2009)

For the tough ones I usually have them hold their arm as far below the heart as possible to encourage filling. Also quite a bit of massaging with an alcohol prep seems to help them pop up as you tend to force the valves closed in a given vein. Give it plenty of time. 

Don't be afraid to start the IV from the floor of the truck, rather than the bench.


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## Sasha (Feb 9, 2009)

> As I'm sure you're joking,



I was joking :]



> Don't be afraid to start the IV from the floor of the truck, rather than the bench.



I prefer to start them while kneeling on the floor between the stretcher and the bench. Maybe it's just me, but it feels more steady.


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## rmellish (Feb 9, 2009)

Sasha said:


> I prefer to start them while kneeling on the floor between the stretcher and the bench. Maybe it's just me, but it feels more steady.



It seems to, always trashes the knees on my pants though...


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## marineman (Feb 9, 2009)

I too like to kneel beside the cot and will rest their arm on my knee or the bench seat to help steady. Only problem with that is I have a tendency to do a little blood letting every now and then and if their arm is on my knee I have to change before the next call.


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## Devilz311 (Feb 10, 2009)

marineman said:


> I too like to kneel beside the cot and will rest their arm on my knee or the bench seat to help steady. Only problem with that is I have a tendency to do a little blood letting every now and then and if their arm is on my knee I have to change before the next call.



Placing a 4x4 under the catheter before disconnecting the sharp and attaching the extension helps with that, if you can't occlude the vein.


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## Epi-do (Feb 10, 2009)

marineman said:


> I too like to kneel beside the cot and will rest their arm on my knee or the bench seat to help steady. Only problem with that is I have a tendency to do a little blood letting every now and then and if their arm is on my knee I have to change before the next call.



And that is why I always try to remember to put a towell over my knee first.  The more IVs I start, the less blood letting there is, but at first, I could be pretty bad at times.


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## Sasha (Feb 10, 2009)

Oooh. Look what I found!

http://www.vascular.co.il/index1.html

Do these work? Has anyone used them?


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## Ridryder911 (Feb 10, 2009)

The problem should not be in knowing if your in the vein or not (as that device lets you know). It won't be on the market long. Just aspirate or lower the IV bag, blood return should be seen. 

Here is an old hint. Apply your tourniquet (constricting band) then "milk" the veins downward. This can be done by wrapping your hands or placing another constriction band a little looser and rolling it downward. It causes the blood to fill up the veins. 

So many do not allow gravity to work as well. Allow the arm to dangle down while you prepare your equipment. Also heat packs to cold or those with poor circulation. 

In regards to allow the arm to sit your lap, one should always have a towel under the arm for several reasons (mainly sanitary) also if they bleed it go onto the towel as well. 

R/r 911


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## rmellish (Feb 10, 2009)

Yeah, you don't forget the towel after that first time that you really needed it.


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## MSDeltaFlt (Feb 10, 2009)

Ridryder911 said:


> The problem should not be in knowing if your in the vein or not (as that device lets you know). It won't be on the market long. Just aspirate or lower the IV bag, blood return should be seen.
> 
> Here is an old hint. Apply your tourniquet (constricting band) then "milk" the veins downward. This can be done by wrapping your hands or placing another constriction band a little looser and rolling it downward. It causes the blood to fill up the veins.
> 
> ...



That is exactly what I meant by being patient and allowing the vein to fill.


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## reaper (Feb 10, 2009)

Ridryder911 said:


> The problem should not be in knowing if your in the vein or not (as that device lets you know). It won't be on the market long. Just aspirate or lower the IV bag, blood return should be seen.
> 
> *Here is an old hint. Apply your tourniquet (constricting band) then "milk" the veins downward. This can be done by wrapping your hands or placing another constriction band a little looser and rolling it downward. It causes the blood to fill up the veins. *
> So many do not allow gravity to work as well. Allow the arm to dangle down while you prepare your equipment. Also heat packs to cold or those with poor circulation.
> ...



This product works very well. I cary one for hard to find veins. The only problem is it does not fit large arms. But, you can use it on the forearm and get a hand vein.
http://www.narescue.com/BOA-Constricting-Band-P79C197.aspx


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## TransportJockey (Feb 10, 2009)

reaper said:


> This product works very well. I cary one for hard to find veins. The only problem is it does not fit large arms. But, you can use it on the forearm and get a hand vein.
> http://www.narescue.com/BOA-Constricting-Band-P79C197.aspx



I think I might have to go get one. That is kinda cool. What is the exterior made of? Would Cavi-wipes hurt it?


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## reaper (Feb 10, 2009)

jtpaintball70 said:


> I think I might have to go get one. That is kinda cool. What is the exterior made of? Would Cavi-wipes hurt it?



It is a vinyl type covering. I clean mine with Cavi-wipes after every pt. I buy a new one every couple months.


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## ruffems (Feb 11, 2009)

I only stick a patient twice and then I have someone else in my ER do it.  I very rarely will go fishing.   I've been fished in before and it's not fun.  

I find that if you cannot see the vein but feel it is much more reliable than seeing vein but not feeling it.  

As for elderly,  I find that if you use a 22 or 24 ga if they don't need fluid replacement then that is the size I'll use.   

spider veins are another story,  24 gauge is the way to go.   The smaller the spider vein the harder the stick.  

practice practice practice and more practice.


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## emtfarva (Feb 11, 2009)

or only find the Pts with fire hoses for veins. Like me, they can draw me without a tourniquet.


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## emtfarva (Feb 11, 2009)

emtfarva said:


> or only find the Pts with fire hoses for veins. Like me, they can draw me without a tourniquet.



Not about geting IV's but what to do after you get it, if you do:

http://www.jems.com/news_and_articles/articles/jems/3402/Bubbles.html


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## awhiting (Feb 12, 2009)

*Yeah...need a little help too*

I'm finishing up my clinicals in the ER and am trying to "master " IV insertions before I'm done. Sometimes it goes great....... but the last couple pts I had I blew the vein. I'm at a 15-20 degree angle. Once you see the "flash" what does everybody else do? I'm just trying to find different techniques so I can find what works best for me......and my pts!

thanks!


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## TransportJockey (Feb 12, 2009)

awhiting said:


> I'm finishing up my clinicals in the ER and am trying to "master " IV insertions before I'm done. Sometimes it goes great....... but the last couple pts I had I blew the vein. I'm at a 15-20 degree angle. Once you see the "flash" what does everybody else do? I'm just trying to find different techniques so I can find what works best for me......and my pts!
> 
> thanks!



I've had a few problems in my clinicals with getting the flash, but when I advance the catheter I blow the vein. One of hte nurses showed me to advance the entire needle into the vein once you get flash, only a quarter inch or so, but then advance the cath. Seems to work great. You do have to level off once you see flash though


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## AJ Hidell (Feb 20, 2009)

A couple of years back, all the best IV tips and techniques were put together in a guide called, "Uncovering Difficult IV's", which is available for free download at:

http://www.ems-safety.com/free.htm

It's good stuff.  That one pearl of wisdom that you need to greatly increase your success may well be in there!


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## ILemt (Feb 20, 2009)

Almost all protocol within 100 miles of me states that after two attempts AC
 the medic shall immediately switch to the I-O drill/gun. 

And if they can't get it after all that.... they probably need an in-service. <_<


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## marineman (Feb 20, 2009)

ILemt said:


> Almost all protocol within 100 miles of me states that after two attempts AC
> the medic shall immediately switch to the I-O drill/gun.
> 
> And if they can't get it after all that.... they probably need an in-service. <_<



Ours says each medic tries twice then we transport without. No EZ-IO here yet so we don't have that option. The service just south of me does an EZ-IO after 2 failed perp. IV attempts and they go straight to the EZ-IO on all PNB's.


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## Sasha (Feb 20, 2009)

Protocols for both fire services I do rides with is two IVs and then an IO. Some medics I've talked to says they'll take a look and if the patient is critical not waste time with trying to establish IVs if they haven't got anything and go straight to IO.

I've recently got to use the EZIO drill. It's awesome!


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## sir.shocksalot (Feb 20, 2009)

I really like the IO myself. I think its just one of those things every service should have, having access is very important, I couldn't imagine transporting anybody to the hospital without access that needed it.


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## Sasha (Feb 20, 2009)

sir.shocksalot said:


> I really like the IO myself. I think its just one of those things every service should have, having access is very important, I couldn't imagine transporting anybody to the hospital without access that needed it.



Just because you don't have IV/IO access doesn't mean you can't give drugs. There are drugs that can be given IM, Subq, transdermal, sublingual, nebulized, and if your patient is intubated, there's another route for some specific drugs, too. Not the ideal choice of drug administration but it's possible!


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## sir.shocksalot (Feb 20, 2009)

Sasha said:


> Just because you don't have IV/IO access doesn't mean you can't give drugs. There are drugs that can be given IM, Subq, transdermal, sublingual, nebulized, and if your patient is intubated, there's another route for some specific drugs, too. Not the ideal choice of drug administration but it's possible!


But I can't give fluid IM, SQ, TD, SL, IN, nor can I dump a bag of saline down a tube :sad: Sorry I'm being a smarta$$. For most drugs the circulatory system is the best way to go, and I just like having the ability to drill a hole in a bone and have access just like that. But the grand majority of patients don't really need an IV anyway, just a taxi.


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## AJ Hidell (Feb 20, 2009)

ILemt said:


> Almost all protocol within 100 miles of me states that after two attempts AC
> the medic shall immediately switch to the I-O drill/gun.


Man, I can't imagine having to function in a system where a medical practitioner were constrained to painting by the numbers or working out of a cookbook like that.  What a sad comment on the state of affairs in EMS.



sir.shocksalot said:


> But the grand majority of patients don't really need an IV anyway, just a taxi.


I have always found it ironic that so many "Emergency" Medical Service systems tailor their systems to the needs of the so-called "grand majorty", with little concern for the needs of those with true emergencies.  Sort of defeats the purpose.


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## ILemt (Feb 21, 2009)

AJ,

There was nothing cookbook about the directive I mentioned, it merely is meant to enforce common sense.

In my Region, a good many (new) Paramedics and even RN's (in and out of the ER) had a tendency to attempt IV's the usual way until the patient looked like the loser in a knife fight.

This directive merely ensures that access is achieved. Two attempts with an 18 or 20 and then go for the gun. It serves the patients needs.

And after all that is what we are here for.


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## AJ Hidell (Feb 21, 2009)

ILemt said:


> There was nothing cookbook about the directive I mentioned, it merely is meant to enforce common sense.


Anytime you have to enforce common sense, you are cooking by the book.  Common sense tells me that the person who wrote the "protocols" has not the slightest clue what is wrong with my patient, or what the condition of his veins are, yet he is attempting to write a flow chart for his or her care.  I can envision multiple scenarios where this guideline would be medically inappropriate, can't you?  Automatically drilling into bone just because you're having difficulty with an IV is insane.  There are so many other ways to achieve IV access.  A great deal of the time, simply stopping the truck and focusing takes care of the problem.  But now, if two paramedics are absolutely convinced that this patient has nada for veins, and lack any confidence in the situation, then why wait until two futile, time wasting attempts are taken before going for the sure thing?  See what I mean?  There is no common sense behind this protocol.  It's just an arbitrary number that may or may not be relevant to, or good for my patient.

This is why my statement specifically said that it was a sad comment on the state of affairs in EMS.  There is absolutely no reason that true healthcare professionals should have to have "common sense" written in a flow chart for them.  Anyone cut loose with a patch should have this decision making process down pat without having to whip out a field guide.  Unfortunately, "common sense" is not so common in this field, and neither is professional education.  Consequently, we are stuck with the madness you cite in Illinoise.


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## CurbDoc70 (Mar 12, 2009)

I've heard a little nitro spray will pop up a vein, but the few times I tried, I got little effect.

Also, using a saw and cutting off the opposing arm works. All of the blood comparments over to the other arm and BINGO, veins a poppin'.


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## benkfd (Mar 12, 2009)

CurbDoc70 said:


> I've heard a little nitro spray will pop up a vein, but the few times I tried, I got little effect.
> 
> Also, using a saw and cutting off the opposing arm works. All of the blood comparments over to the other arm and BINGO, veins a poppin'.



That's just wrong!!! (but funny)


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## AJ Hidell (Mar 12, 2009)

CurbDoc70 said:


> I've heard a little nitro spray will pop up a vein, but the few times I tried, I got little effect.


Is there anything written in your MD approved protocols, or in the nitro manufacturers literature that endorses, recommends, or orders this practice?  Please tell me you are not just randomly experimenting on your patients with dangerous drugs because of a rumor you heard somewhere.  That would be off the scale unethical and illegal.


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## Sasha (Mar 13, 2009)

I've actually heard of the "nitro trick" from quite a few people. 

I don't really get how it works... Dilates the veins, yes, but doesn't increase blood volume in those veins you just dilated, just widened the container, I would think they'd lay flat.

Gravity works real well, just hang their arm off the side of the stretcher for a few seconds and let the veins "fill up" tourniquet and pop in an angiocath.


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## CurbDoc70 (Mar 13, 2009)

AJ Hidell said:


> Is there anything written in your MD approved protocols, or in the nitro manufacturers literature that endorses, recommends, or orders this practice?  Please tell me you are not just randomly experimenting on your patients with dangerous drugs because of a rumor you heard somewhere.  That would be off the scale unethical and illegal.




Actually, I just told you. A few patients. My medical director, and a highly respected ER physician is the one who showed me. Suggesting that is is unethical or illegal is like saying slapping the top of the skin to raise a vein is assault and patient abuse.


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## reaper (Mar 13, 2009)

Yes, It could be!

Funny, I never have to "slap" a vein, to make it stand up.


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## maxwell (Mar 16, 2009)

Lots of tourniquets, nitropaste <_<, heating packs,  hanging the arms and legs off the stretchers, use EJs (<3!)


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