Like asking a patient their favorite color for IVs?

TransportJockey

TransportJockey

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We had a medic who also got caught doing this. Before my time, but the story goes he started bilateral 14Gs in an elderly woman's hand to "teach her to call 911." The story also says he was investigated, but I don't know his name so I can't look it up on our state website.

@VentMonkey, can you confirm?

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Jesus. I thought the "go big or go home" mentality had ended.

20s usually and maybe an 18 if I'm feeling like I need to flow some fluid. 16s in young traumas. That's it.

Sad that it's in Delaware.
 
Interesting piece, sadly I don't think this is all that unheard of.

That said, what all are you guys being taught is a "large-bore" IV? When I went through paramedic school I was taught either a 16g, or 14g respectively.

The other day I brought a standard ALS patient in to an area ED with an 18g locked off. The triage RN commented on how most everyone else that brings in patients is putting in 20's (medicals); she seemed pleased it was an 18 as this particular ED likes drawing labs from our IV's. I was taught 18 and down for medicals. If they can fit, my STEMI/ stroke alerts get 18's locked off, if not, 20's are fine.

Typically I don't ask the patient, TBCH. I can gauge it (pun intended) by looking at their vascularity. If they give the infamous "butterfly remark" I do my best to honor their request, though.

I'm a bit different about my IV's, and their placement though, as my wife often hounded me about technique (still does) all through paramedic school.
 
NPO said:
We had a medic who also got caught doing this. Before my time, but the story goes he started bilateral 14Gs in an elderly woman's hand to "teach her to call 911." The story also says he was investigated, but I don't know his name so I can't look it up on our state website.

@VentMonkey, can you confirm?
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PM sent.
 
Yep. Our agency just got an email pointing out this article. Absolute shame and an embarrassment for EMS.


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A while ago we fired a medic who was starting 14 and 16s in little old ladies "because why not" who did not need it. He was picked up as a firefighter paramedic for our state agency.

We have several other medics who "if I see a vein that will hold a 14G then they get a 14G". I hope they get canned soon.
 
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VentMonkey said:
Interesting piece, sadly I don't think this is all that unheard of.

That said, what all are you guys being taught is a "large-bore" IV? When I went through paramedic school I was taught either a 16g, or 14g respectively.

The other day I brought a standard ALS patient in to an area ED with an 18g locked off. The triage RN commented on how most everyone else that brings in patients is putting in 20's (medicals); she seemed pleased it was an 18 as this particular ED likes drawing labs from our IV's. I was taught 18 and down for medicals. If they can fit, my STEMI/ stroke alerts get 18's locked off, if not, 20's are fine.

Typically I don't ask the patient, TBCH. I can gauge it (pun intended) by looking at their vascularity. If they give the infamous "butterfly remark" I do my best to honor their request, though.

I'm a bit different about my IV's, and their placement though, as my wife often hounded me about technique (still does) all through paramedic school.
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I was taught 18g is a large-bore. I'll generally use 20s in standard medicals, or 18g if I think we will need blood, fluids, or contrast. I was told they prefer 18g in the AC for contrast.

Obviously for more sick people, a 16g, once a 14g.

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We don't even carry 14s outside of for needle decompression. If they're septic or need a bunch of fluid I might go for a 16. Otherwise bilateral 18s or just a single 18 handles it nicely

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I am completely against any form of punitive medicine and unnecessary treatments however in my experience large bore IVs placed in appropriately sized veins are not anymore painful than an smaller IV.


a 16g PIV will flow faster than any central line sans a Cordis and is king when large volume resuscitation is needed. Also useful for drawing labs.
 
TransportJockey said:
We don't even carry 14s outside of for needle decompression. If they're septic or need a bunch of fluid I might go for a 16. Otherwise bilateral 18s or just a single 18 handles it nicely.
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Right, that's what I was taught as well. Most critically ill patients get 2 IV's if permissible, but defining critically ill can be subjective.

I've had some paramedics balk at bilateral IV's for strokes and STEMI's, and think it was overkill; they had similar thoughts re: 18's if feasible in these patients. That said, I'm not doing it to be a richard, or to "show off", I'm doing it because it helps the hospitals more often than not with things such as @NPO points out.

20 gauge IV's aren't always the easiest to draw labs from, especially if the patient is somewhat dry.
 
Im glad to see this article. I came up in a system that preferred 18's for medical and 16 up for trauma activations. I decided for myself very quickly that I would look at that as a suggestion and use my judgement on what size IV to use.

I have never started an IV larger than a 16g and 20 is the most common size I use.



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Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.
 
Chase said:
Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.
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Again, married to an RN helps understand y'alls thought processes. I don't think most medics take that into account, by no fault of their own. The hand-off I give isn't just in a report, but also what I (we've) done to expedite, and/ or ease transition of care.

More often than not they're über appreciative, and the patient is as well. Most of this is common sense, and I am sure these two DE medics were not exactly using their better judgment.
 
Chase said:
Two is one and one is none in the transport environment. I always try to get two IVs if able and preferably bilateral.
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In unstable, critical, or potentially unstable patients this is my train of thought. If a stable patient just needing some light IVF or maybe zofran or a simple narcotic, then I tend to stick with one 18 or 20.

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TransportJockey said:
In unstable, critical, or potentially unstable patients this is my train of thought. If a stable patient just needing some light IVF or maybe zofran or a simple narcotic, then I tend to stick with one 18 or 20.
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Right, and not to derail too much, but I almost feel like this isn't something taught in most standard paramedic programs.

I learned this with critical care training, which in turn has helped add to my critical thinking skills and buffered my train of thought, broadening my knowledge-base horizons.

Perhaps you concur? Or perhaps it's because I went to paramedic school in California:p.
 
I was taught "2 is one and 1 is none" in anythibg that may go pear shaped. My paramedic instructor was very big on "building a safety net". Why wait and maybe struggle with an IV when you really need it when you can get two and maybe never need them. That's also why I bro g my gear in the house,,treat in the house, start lines in the house and get 12 leads in the house. It may be nothing, but more things are missed by not looking than not knowing.
 
Chase said:
I am completely against any form of punitive medicine and unnecessary treatments however in my experience large bore IVs placed in appropriately sized veins are not anymore painful than an smaller IV.
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I actually really liked the way the newspaper article phrased the issue. They mentioned that "larger needles are believed to be more painful." I'm not certain if they are or aren't, but intent matters. I think we can all agree that if someone is deliberately placing an inappropriately large IV catheter when it isn't indicated in the hopes of causing more pain to the patient we have a real issue on our hands.
 
chaz90 said:
I actually really liked the way the newspaper article phrased the issue. They mentioned that "larger needles are believed to be more painful." I'm not certain if they are or aren't, but intent matters. I think we can all agree that if someone is deliberately placing an inappropriately large IV catheter when it isn't indicated in the hopes of causing more pain to the patient we have a real issue on our hands.
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Agreed. I just seems that some people, especially some nurses, think that placing large bore IVs is akin to medieval torture when really most don't notice a difference.
 
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