Keeping skills up while working per diem?

NYBLS said:
And if your mom is truly ill?
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There are a few other options. An EJ. An IO.
An apropriate sized catheter.

My mom is 77 and has dementia. I treat all my patients, especially the frail little old ladies, just like I treat my mom. If I saw a medic attempting to place a 14 in the hand of a little old lady, you can bet there'd be a discussion.

While malfeasance may be a stretch, the care would certainly be grossly inapropriate.
 
People rarely need anything larger than a 20. Honestly unless they're needed a fast fluid bolus, blood or contrast dye a 22g would be fine.

I get a lot of flack for using 20s as my standard IV cath rather than an 18.
 
My go to is a 20 as well. I put a 16 in a trauma* last week and it seemed HUGE.





*20 year old male with ropes, and it went in his AC.
 
Remi said:
A 14g has roughly twice the outer diameter that a 20g does. Claiming to be able to put a 14g anywhere you can put a 20g is just ridiculous. You may as well have claimed to be able to poop diamonds.
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Again, where did I say anywhere?
 
Tigger said:
Then post them for all to critique. No need to be coy.

You have made several absurd statement that you have yet to backup. Now would be a good time to do so.
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Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.
 
COmedic17 said:
I would be pissed that you dropped a 14g when it's unnecessary.

The hospital can even push blood through a 18g or 16g. There's no reason for a 14g.

Get a line because you need it. Not because "it would look cool" if you rolled in with a 14g.
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I'm not sure where I said "it would look cool." People around this forum seem huge on providing quotations around things that were never said, even with the quote option right next to each post.
 
DEmedic said:
There are a few other options. An EJ. An IO.
An apropriate sized catheter.

My mom is 77 and has dementia. I treat all my patients, especially the frail little old ladies, just like I treat my mom. If I saw a medic attempting to place a 14 in the hand of a little old lady, you can bet there'd be a discussion.

While malfeasance may be a stretch, the care would certainly be grossly inapropriate.
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A 14 will offer better flow rates. Im surprised you would rather me drill a needle into your moms leg or arm then place an IV. And if I place an EJ it will be a 14.
 
NYBLS said:
I'm not sure where I said "it would look cool." People around this forum seem huge on providing quotations around things that were never said, even with the quote option right next to each post.
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The only reason you would want to drop a 14g in a little old lady is to try to validate yourself in someway. There's no situation a 14g would be necessary.
 
NYBLS said:
Again, where did I say anywhere?
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I never said that you said that. I was making a point about the absurdity of your claim.

If you are just going to deflect rather than defend your claim, then just drop it.

NYBLS said:
Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.
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Really?

No one ever died because they had a 20g placed instead of a 14g. Certainly not a CVA or MI patient. Even sepsis is now treated with much lower volumes than used to be recommended.

It's a very rare case these days where it's necessary to slam in large volumes of fluid very quickly.
 
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double post
 
NYBLS said:
A 14 will offer better flow rates. Im surprised you would rather me drill a needle into your moms leg or arm then place an IV. And if I place an EJ it will be a 14.
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I said "place a 14 in the hand of a frail little old lady"

A patient needing fluid resuscitation needs a patent IV, not a medic with a "go big or go home" mentality.

For someone who likes to ***** about quotations, you sure do a good job of misquoting.
 
NYBLS said:
Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.
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Did not say anything about reducing pain. Meanwhile, there are known complications with larger catheters, especially in the back of the hand.

That's ok though. You've clearly made up your mind and would rather discount evidence in the name of "doing what is right." Ok then. While I know it's fun to laugh at all of us idiots who aren't as "aggressive" as you, take heed.
 
NYBLS said:
Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.
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Insists on 14 gauges for above mentioned conditions, has <50% success rate with said 14 gauge attempts ;) sounds about right....
 
NYBLS said:
Sepsis/septic shock, MI, CVA, trauma with significant or potentially significant chance of hemodynamic instability. These patients may or will need large volumes of blood or fluid and you putting in a small needle to avoid increased pain can lead to their death.
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Sepsis- you can run more then enough fluid in an 18g or 16g ( if really needed). If your so concerned over flooding them with fluid, why not bilateral 18gs? Most hospitals would prefer bilateral 18gs over one garden hose(14g).

MI- I have never heard of a 14g being recommended in a MI. I routinely place bilateral 18g IVs for cardiac alerts and that has always been more then enough.

CVA- thrombolytic drugs can be ran through smaller gauge needles then a 14. There's absolutely no indication a 14g is needed in a CVA.

Trauma- if they are that hemodynamically unstable, bilateral 18gs or 16g are going to be much more appropriate then one 14g. Have you ever ran two 18gs wide open? Works pretty well. Also good luck dropping a 14g on a trauma patient in hypovolemic shock. Unless they have some massive EJ. But even then, a 16g is going to be more realistic. Remember permissive hypotension- saline doesn't have hemoglobin. No one needs 3 liters ran through a 14g.

And again, blood can be ran through 18gs and up. You don't need to drop a garden hose in someone to get good results. Do bilateral lines if you need more access. Also, bilateral lines gives you a "backup" route if one becomes compromised.


Think. Your driving argument here is "what if they need lots of fluid" but there's ways to ensure they can get what they need without providing necessary interventions.
 
I can't help but add since my original post got changed into iv size debate.... That you can and I have seen blood given via a 24g!!
 
Knightinwhitesatin said:
I can't help but add since my original post got changed into iv size debate.... That you can and I have seen blood given via a 24g!!
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24g are almost always reserved for pediatrics. (Unless it's literally all you can get. However, I have yet to be in a situation where I couldn't at least get a 20g somewhere (in an adult). My go to is an 18 for adults, 20 for pediatrics, and 24 for an infants)

Blood CAN be ran though a 24g, but very very slowly. This might be adequate for a 10 pound baby, but the rate at which blood can be administered through a 24g for an adult is inadequate and inappropriate. This is why it's recommended to have at least an 18g to run blood for adults.

If your giving blood to an adult in a traumatic situation, they are going to need that blood administered FAR quicker then a 24g will permit. Same with fluid,or medication administration. 24g's are just to slow to suffice. They are also more prone to kinks and clotting off.

That is also why PHTLS calls for "large bore" IV access. You can't run fluids in fast enough with a 24g for an adult (or even most older children).
 
@COmedic17. Trying not to stoke the fires of this off topic issue too much, but there's nothing wrong with medication or fluid administration through a 22G in an adult. I've had plenty of patients where a 22G was the only size I was able to place, whether that was my own failing, time based, or patient based. I've given most medications through some small IVs (including one where we RSIed through a 22G because it was flowing better than our IO), and I've run 500 mL of fluid through a 22 even during my transport time of ~40 minutes.

In any case, I think I agree with the spirit of what you're saying even if I implement it slightly differently. Blood does change things slightly of course, and I can't say I have much experience administering blood products of any sort.
 
chaz90 said:
@COmedic17. Trying not to stoke the fires of this off topic issue too much, but there's nothing wrong with medication or fluid administration through a 22G in an adult. I've had plenty of patients where a 22G was the only size I was able to place, whether that was my own failing, time based, or patient based. I've given most medications through some small IVs (including one where we RSIed through a 22G because it was flowing better than our IO), and I've run 500 mL of fluid through a 22 even during my transport time of ~40 minutes.

In any case, I think I agree with the spirit of what you're saying even if I implement it slightly differently. Blood does change things slightly of course, and I can't say I have much experience administering blood products of any sort.
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In a critical patient though?
( I'm basing my commentaries off of treatment for critical patients since that was the original topic)

Just in my experience I encounter difficulties doing rapid fluid bolus's in unstable, hypotensive patients with small gauge IVs. Or drugs (like adenosine) that have such a short half life and need to be "slammed".
 
20g is the standard go to for our medics for the vast majority of patients. 18g if they're going to the Trauma Center and 22g for grandma/grandpa. I think the only time I've seen one of our medics use a 16g is for a bariatric trauma, and the 24g for infants/toddlers. Never seen a 14g get used, heck most of us wonder why we stock so many on the ambulance (10 of each size).
 
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