medicRob
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This would be a great prehospital research topic.
Accessing Delicate Veins
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This would be a great prehospital research topic.
alphatrauma
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I work in a pediatric ER, and bevel down is something I have yet to see or hear of anyone performing. To give a little perspective, it is not an adult hospital with a pediatric ER section. It is a stand alone pediatric hospital with it's own ER, ICU, PICU, NICU, OR, Critical Care Transport... and much more. On a daily basis the place is crawling with pediatric ER attendings, residents, orthopods, intensivists, neonatologists, radiologists and any other pediatric specialty that you could think of. Bevel down IV insertion is not anywhere in our standards of practice.
Who knows, maybe it's a regional thing? I will make it a point to inquire with my ED medical director to get her views on the matter, and will report back.
MasterIntubator
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In the 80's a few flight medics and thier medical director taught me about the bevel trick, but it was with a cut down ( and we used to do many of those... but have dropped out of favor these days ).... but honestly, in the field it really has not made any difference for me.... although, if in a pickle and I need to try a different approach I would try it again. I just seemed to have the same success either way.
I prefer to use a BP cuff for all my IV sticks... I can get the BP, then leave it there for the restricting device. Lets say the BP was 146/92. Over 146 mmHg was too restricting, under 92 mmHg was not enough venous back pressure. Sooooo, depending on what I see and feel... I adjust it accordingly. If that vein is rock hard at 130 mmHg, I tone down the pressure until that vein is "semi-squishy".
BP cuffs also work well for shocky folks as well.
I prefer to use a BP cuff for all my IV sticks... I can get the BP, then leave it there for the restricting device. Lets say the BP was 146/92. Over 146 mmHg was too restricting, under 92 mmHg was not enough venous back pressure. Sooooo, depending on what I see and feel... I adjust it accordingly. If that vein is rock hard at 130 mmHg, I tone down the pressure until that vein is "semi-squishy".
BP cuffs also work well for shocky folks as well.
Smash
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Double post sorry
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Smash
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I'm fortunate enough to not live in fear of litigation. However, regardless of the efficacy or otherwise if the technique, if you are facing a jury I would suspect that something more significant than holding a cannula upside down has occurred. Maybe some perspective is in order.
MylesC
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Once again this is why they call it "Practicing Medicine"? Somethings there just isnt a for-sure way of doing things. Great information guys I checked out all those articles and they were very cool/enlightening.
I personally was never shown the bevel down. In fact it was frowned at maybe because [the teachers] wanted to get better basics down?
Anyway. Awesome. This forum just got a thumbs up
:beerchug:
I personally was never shown the bevel down. In fact it was frowned at maybe because [the teachers] wanted to get better basics down?
Anyway. Awesome. This forum just got a thumbs up
:beerchug:
alphatrauma
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A laudable testament to say the least.
One does not have to succumb to fear in order to acknowledge it. Litigation is real, whether we choose to recognize it or not.
I would be wary of potentially trivializing the improper use of an angiocath. Most would not consider extravasation, necrosis, phlebitis, thrombosis, or extended hospital stays, that can be attributed to deliberate misuse of said device, insignificant. Yes, all of these can occur with the proper use... but why add additional unnecessary risk to the patient, or your career? If you find yourself having trouble with IV starts on peds (or any other age group), try enrolling in an approved course or the like. Why start experimenting [on patients] with techniques that you have no formal education or training in?
Wesley Snipes
Performing a daring maneuver in any situation in which a daring maneuver is completely and utterly unnecessary. - Urban Dictionary
Perspective is an illusion... one that can be twisted and distorted to create one's own reality. I'll take facts over perspective most days of the week.
Shishkabob
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Any evidence that flipping the bevel 180* has any more of a chance of complications than if you kept it normal?
8jimi8
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Alpha isn't trying to prove it is wrong. He has the design of the device as approved by the manufacturers on his side. I have to admit that at first reading of this thread, I was excited about the fact that I would have a new tool in the box... despite my excitement, I've realized that Alpha's "perspective" is quite correct.
I don't think what we're discussing here constitutes misuse of angiocaths. Consider the following quote from the 2002 PALS Provider Manual: "During catheter insertion in patients with trauma, shock, or cardiopulmonary arrest, some providers prefer to aim the bevel of the needle down. Aiming the bevel down may facilitate entrance into constricted veins." I'm not a lawyer, but I would think that this sort of statement from a recognized authority on prehospital care (the AHA) would tend to defuse an argument that a bevel-down IV attempt was negligent.
I think our topic is much more about style than protocol.
medicRob
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Also, Kelly himself said he learned this technique from an experienced neonatal intensivist in a PALS class in the article I just sent him a message asking if he would like to perhaps come weigh in on the issue. I am interested in hearing his opinion, even if it is in favor of alphantrauma's views. After all, we are all learning new things every day.
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Ambulance_Driver
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Also, Kelly himself said he learned this technique from an experienced neonatal intensivist in a PALS class in the article I just sent him a message asking if he would like to perhaps come weigh in on the issue. I am interested in hearing his opinion, even if it is in favor of alphantrauma's views. After all, we are all learning new things every day.
I'm on the road now, in a highway rest stop in Texas and running late for my shift, but I'll try to weigh in with my thoughts later this evening. Both sides make some good points.
medicRob
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Looking forward to it, thanks.
Ambulance_Driver
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Is it really an off-label use?
Those of you who read my EMS1 columns know that every other month I try to post a clinical tip not commonly found in textbooks or current clinical practice. Sometimes, like in auscultatory percussion or in assessing tactile vocal fremitus, are well-received, while others (*cough* palpating BP using a the pleth waveform *cough, cough*) saw me spanked pretty hard in comments.
I appreciate the discussion nonetheless, even when you point out how I didn't carefully think through some of those tips.
Regarding the bevel-down IV technique, I find it works well with tiny little veins, on peds or geriatric patients. Piercing the skin is no harder, although a little more skin traction is sometimes necessary on elderly patients with slack skin.
I noted in my column that studies do not show an increased success rate with bevel-down insertion. However, the unquantifiable variable in such studies is always the skill level of the providers in the study. Teach someone a new technique, and until they gain mastery of it, they'll feel uncomfortable and have limited success when compared to their old way of doing things.
Take the Gausche pediatric intubation study in L.A. years back: many of the medics in that study didn't feel comfortable doing pediatric intubation compared to BVM, and it's no wonder they felt that way - peds intubation was a new skill for them.
Still, that doesn't mean learning an additional trick is a waste of effort even if your old tricks have served you well. Tiger Woods totally reworked his golf swing when he was already the best golfer in the world. He saw a way to be better, and he took it, and saw a dip in his game until he mastered the new swing. When he did, he was better than ever.
Regarding the bevel-down technique as being off-label use, consider what other things we have done in EMS that are off-label uses - intranasal midazolam, rectal diazepam (at least until Diastat was introduced), endotracheal drug administration, sublingual Procardia, SQ terbutaline as a tocolytic agent... the list goes on. Heck, last time I checked, the package insert for amiodarone has no mention of IV bolus administration, or a 300 mg dose...
... yet we still use it, do we not?
So much of what we do is purely dogma. There's a simple reason you were taught the bevel-up technique in class: because that's the way your *instructors* learned it.
Doesn't necessarily mean it's the *right* way, though.
Case in point: Why were we all taught never to retract the needle from the catheter and re-insert it? Risk of catheter shear, right?
Have you ever TRIED to shear a catheter that way? It takes a 90 degree bend in the cath, and a very delicate 360 degree rotation of the needle, all while *inside* someone's vein.
In other words, not likely. You may bugger up a cath, but it is highly unlikely that you will ever shear off a piece. That particular admonition is a holdover from the days of through-the needle catheters. Doesn't apply to modern equipment.
Ultimately, I think the bevel-down technique is one of those tricks you keep in your bag and use infrequently, but still effective once you've gotten the hang of it.
Kind of like traction splints - rarely needed, but mighty handy when they are.
Those of you who read my EMS1 columns know that every other month I try to post a clinical tip not commonly found in textbooks or current clinical practice. Sometimes, like in auscultatory percussion or in assessing tactile vocal fremitus, are well-received, while others (*cough* palpating BP using a the pleth waveform *cough, cough*) saw me spanked pretty hard in comments.
I appreciate the discussion nonetheless, even when you point out how I didn't carefully think through some of those tips.
Regarding the bevel-down IV technique, I find it works well with tiny little veins, on peds or geriatric patients. Piercing the skin is no harder, although a little more skin traction is sometimes necessary on elderly patients with slack skin.
I noted in my column that studies do not show an increased success rate with bevel-down insertion. However, the unquantifiable variable in such studies is always the skill level of the providers in the study. Teach someone a new technique, and until they gain mastery of it, they'll feel uncomfortable and have limited success when compared to their old way of doing things.
Take the Gausche pediatric intubation study in L.A. years back: many of the medics in that study didn't feel comfortable doing pediatric intubation compared to BVM, and it's no wonder they felt that way - peds intubation was a new skill for them.
Still, that doesn't mean learning an additional trick is a waste of effort even if your old tricks have served you well. Tiger Woods totally reworked his golf swing when he was already the best golfer in the world. He saw a way to be better, and he took it, and saw a dip in his game until he mastered the new swing. When he did, he was better than ever.
Regarding the bevel-down technique as being off-label use, consider what other things we have done in EMS that are off-label uses - intranasal midazolam, rectal diazepam (at least until Diastat was introduced), endotracheal drug administration, sublingual Procardia, SQ terbutaline as a tocolytic agent... the list goes on. Heck, last time I checked, the package insert for amiodarone has no mention of IV bolus administration, or a 300 mg dose...
... yet we still use it, do we not?
So much of what we do is purely dogma. There's a simple reason you were taught the bevel-up technique in class: because that's the way your *instructors* learned it.
Doesn't necessarily mean it's the *right* way, though.
Case in point: Why were we all taught never to retract the needle from the catheter and re-insert it? Risk of catheter shear, right?
Have you ever TRIED to shear a catheter that way? It takes a 90 degree bend in the cath, and a very delicate 360 degree rotation of the needle, all while *inside* someone's vein.
In other words, not likely. You may bugger up a cath, but it is highly unlikely that you will ever shear off a piece. That particular admonition is a holdover from the days of through-the needle catheters. Doesn't apply to modern equipment.
Ultimately, I think the bevel-down technique is one of those tricks you keep in your bag and use infrequently, but still effective once you've gotten the hang of it.
Kind of like traction splints - rarely needed, but mighty handy when they are.
MylesC
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Just to throw it out there... I had a long discussion with my mom whos been a nurse for the last 30 years.
She was perplexed by the bevel down method.
I heard from , maybe medic rob that this was an "old school medic" technique?
I showed her that article with the guy talking praise about it (EMT bevel down something something had the 2 pencil drawings with the cath and the vein)
And what region are you guys in as well.
Im here in Cali.
I just want to say again I find this awesome. Im not bagging at all.
Thanks guys
She was perplexed by the bevel down method.
I heard from , maybe medic rob that this was an "old school medic" technique?
I showed her that article with the guy talking praise about it (EMT bevel down something something had the 2 pencil drawings with the cath and the vein)
And what region are you guys in as well.
Im here in Cali.
I just want to say again I find this awesome. Im not bagging at all.
Thanks guys
medicRob
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Myles, the reason I called it an "Old school medic" trick is because it seems to be one of those tips you get from seasoned veterans rather than being presented with in a textbook, a trick of the trade if you will. I probably chose the wrong wording in that, I certainly didn't mean that all the old school medics endorse it or that it is something that was taught in a textbook then but not now. What did your mom have to say about it after she read the article? Did she see how it could be beneficial or did she think it wasn't worth the effort? I am very interested to know, especially since she has been a nurse for 30 years.
As far as the article you speak of, Ambulance_Driver is Kelly Grayson, the writer of that article.
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abckidsmom
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Having been an EMS educator, I can agree that the main reason the bevel up technique is taught in class is because that's the way the instructor learned it.
Very interesting discussion, plenty of things to research here.
And I'll throw in another vote for this not being an off-label use.
Very interesting discussion, plenty of things to research here.
And I'll throw in another vote for this not being an off-label use.
socalmedic
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last i checked there was no "directions for use" for the catheter. i checked the box, the wrapper, the safety cath itself, hell i even read the whole pamphlet that comes in the box printed in 20 different languages. Nowhere did it say there was a specific way to use it and that is the only approved way. I spoke with a few more medics and they all said that they have tried it before, some had no idea about the bevel and had apparently never thought about the orientation, they just knew that the "button on the thingy" goes up. so i am sticking with my bevel down technique, if it comes up in a court of law "I cant recall how i performed the intravenous canalization" remember they have to responsibility of incriminating you. further more i have to agree with whoever said if you are in court defending yourself you probably have bigger things to worry about than which way the bevel was facing.
Melclin
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None of the guns I've owned have ever come with instructions either. Doesn't mean there isn't a right and a wrong way of using them. And legal/ethical implications for their incorrect use.
Not commenting on the bevel down technique. Just questioning the "it didn't say so on the label" logic.