Keeping skills up while working per diem?

We have gotten way off topic, let's just agree the line you CAN get is better then the one you CAN'T, and move along.
 
COmedic17 said:
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".
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If it's all you can get, then sure. Sometimes a 22 sized hand vein is what the patient has, and that's the end. No sense and trying to force something larger (phrasing).
 
CANMAN said:
We have gotten way off topic, let's just agree the line you CAN get is better then the one you CAN'T, and move along.
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No, because the point of the digression was the line that's APPROPRIATELY SIZED is better than the line you can CRAM IN.

That should be the take home.
 
Tigger said:
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.
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Evidence please? And I'm not sure where I laughed or called anyone here an idiot. If you cant participate in a healthy debate then why keep returning to the thread?
 
Remi said:
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.



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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And how are you aware of this? Do your system do follow up on all patient encounters? Group discussions on improvement? Or do you just drop them off at the hospital and make assumptions about their status after that?
 
CANMAN said:
Insists on 14 gauges for above mentioned conditions, has <50% success rate with said 14 gauge attempts ;) sounds about right....
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And how are you, or anyone else on here for that matter, aware of anyones IV success rate?
 
NYBLS said:
And how are you aware of this? Do your system do follow up on all patient encounters? Group discussions on improvement? Or do you just drop them off at the hospital and make assumptions about their status after that?
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You are the one who has to prove your position, not me. The onus is always on the intervention to prove itself, not the other way around. So your claim that "small IV's kill people" means absolutely nothing unless you can validate it with evidence.

But because you asked, yes, actually - for about the last 4 years that I flew, my program received feedback on every patient that we flew to our home trauma center, and we could look at their chart online anytime. The feedback was always passed on to the crew who delivered the patient, and anything that needed to be done differently was shared with the entire staff. Never once did I ever hear from the trauma service (or any other service) that a patient died because their prehospital IV was too small.

Also because I read and I'm aware of current trends in resuscitation. The days of septic patients getting 8 liters slammed in an hour are over. MI and CVA patients are typically kept dry. These days pretty much no one gets large volumes of fluid quickly. Even massive trauma patients get only limited resuscitation with blood products and are kept hypotensive until bleeding is stopped.

Just as an example, let's do the math on a hypothetical burn patient. Just to make it interesting, let's say he's a really big guy - 120kg. And let's say he suffered 80% BSA burns, and that he didn't have an IV started until 1 hour after he suffered the burn. Let's also elect to resuscitate with the high-end, 4 ml/kg/BSA formula.

120 X 4 x 80 = 38,400 ml of LR in the first 24 hours, with half of that (19.2 liters) over the next 7 hours. Wow, that is a crap-ton of fluid. We'll easily need bilateral 14's to make that goal, right?

Well, let's see....19.2 liters over 7 hours works out to 2742 ml per hour. You can actually get 60ml/min from a 20g, though.....which is 3600 ml per hour, well above the 2700 per hour that we need to keep our guy from getting too dry.

And that's if you free-flow that 20g; if you put it under pressure, you can get up to 5ml/sec, which is 18,000 ml per hour, which is almost enough to give this guy his entire 24-hour prescription in just 60 minutes.

In fact, you could very nearly meet his requirements with a free-flowing 22g, which delivers 2100 ml/hr. Put that baby under pressure, and you can get 3 ml/sec (10,800 ml/hr), which again, easily meets his needs. ​

So tell me again how large PIV's are so important?
 
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NYBLS said:
Evidence please? And I'm not sure where I laughed or called anyone here an idiot. If you cant participate in a healthy debate then why keep returning to the thread?
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Part of a "debate" is recognizing that you must provide evidence in backing up your claim, which is something you have yet to do. As has been said, the intervention must be proved to be beneficial before it is accepted.

The risk of phlebitis is increased when a large-gauge catheter is used, possibly because of the physical trauma caused by the insertion of a large-bore catheter into a relatively short, narrow vein. - See more at: http://www.nursingcenter.com/lnc/static?pageid=1374284#sthash.mtEVIgm1.dpuf
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From: Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access
Journal of Infusion Nursing
http://www.nursingcenter.com/lnc/static?pageid=1374284#sthash.mtEVIgm1.dpuf

  • Depending on location, larger catheter sizes can create increased mechanical irritation to vein wall
  • Vessel should be large enough to accommodate catheter and provide adequate hemodilution
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From:BD Clinical Brochure (You know, the people that actually design IV catheters)
https://www.bd.com/infusion/products/ivcatheters/clinical_expertise/pdfs/clinical_brochure1.pdf

Patients requiring venous access for the administration of IV medications, who will not require rapid fluid/blood administrations, may benefit from the use of a smaller catheter. Smaller catheters (i.e. 22 gauge) allow for greater hemodilution of medications and reduce the risk of phlebitis.
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From: Venous Access Devices
University of California Chico School of Nursing
https://www.csuchico.edu/nurs/current/accessDevices.shtml

Few of your examples require a rapid infusion of fluid or blood (CVA? really?). And even if they did, something other than a 14 in the back of the hand of an elderly female (the scenario at hand), would be appropriate.

But again, the onus is on you to prove that your choice of intervention is beneficial to the patient. So how about your evidence?
 
Remi said:
Also because I read and I'm aware of current trends in resuscitation. The days of septic patients getting 8 liters slammed in an hour are over. MI and CVA patients are typically kept dry. These days pretty much no one gets large volumes of fluid quickly. Even massive trauma patients get only limited resuscitation with blood products and are kept hypotensive until bleeding is stopped.
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There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.

Which is not common outside the military.
 
Brandon O said:
There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.

Which is not common outside the military.
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And they usually get a central line.
 
FireWA1 said:
And they usually get a central line.
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Sure (ideally something like a Cordis), but that's not usually an option in the field and not always a viable option in the initial ED resuscitation.
 
Brandon O said:
There are still occasional bleeders who need truly massive transfusion over minutes/hours. Not common unless you see a lot of trauma.

Which is not common outside the military.
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Sure. And a frequent contibuting factor in coagulopathy of trauma is over-resuscitation with crystalloids.

A Cordis or RIC can be placed in the OR, if they are needed. EMS should focus on establishing reliable access and not worry about the massive transfusion that may become necessary later.
 
For the most part I agree. But in principle I feel that one of our primary goals in the field -- and this is increasingly true with more critical patients -- is to facilitate the transfer of care so they can get what they need more quickly. Since part of "what they need" for a minutes-matter hemorrhagic trauma patient is blood products, it would theoretically be better if you could show up with big, numerous, bomb-proof peripheral access.

That doesn't mean it's mandatory, and it absolutely doesn't mean nonsense like staying on scene to play with EJs or skipping the 18 you can get for the 16 you can't. But all things being equal, the platonic ideal for these patients would involve walking in the door, maybe picking up some blood, and heading upstairs to where some knives are waiting.

Just to draw a parallel, airway management would fall under a similar category. If it's not absolutely necessary and it means delaying transport you're probably wrong to do it. But if it can happen without detriment, if it's already done it will expedite the process.

Again, this is rarely real life. But that applies to most of the true emergencies we study.
 
My point wasn't that large IV's shouldn't be placed in the field. I was just saying that it will likely never impact outcomes, so shouldn't be a priority at all.
 
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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There is the concept of permissive hypotension in trauma that I think as a community we don't take enough time to delve into. Is pumping them full of saline actually going to increase that patient's survivability? Evidence suggests it may not. I've seen plenty of docs close the lines after bringing a serious trauma patient in.

Why would a CVA require high volume resuscitation? It's not as if you can drown an embolism in saline. I would prefer a twin-cath in that scenario to a large bore iv. It does help the nursing staff to have two ivs for any patient that may require tpa but they don't have to be 14s.
 
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