Question about IV starts

Ambulance_Driver said:
Use a steeper angle when inserting, just to pierce the skin, and pull greater skin traction. If you *****foot around with it, yes, it will probably hurt more and tear the skin. If you make a decisive stick, however, it works pretty well. The trick is learning how to be decisive and delicate at the same time.

I didn't come up with the technique. It was taught to me by a grizzled old peds nurse in a PALS class years ago, and used to be a commonly taught trick.

I would object to the notion that needles are expressly designed to be inserted bevel-up, however. They may work well that way, but that's not necessarily a function of design.
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For some reason I seem to get a lot of peds, and I thank God that I had a great pediatric rotation in medic school as well as having a host of partners who have extensive pediatric experience. The bevel-down technique works well if you practice it, and not just for peds! I find that it works well for the elderly as well as patients with very dark skin. You get a flash a hair sooner than you would otherwise which can be helpful. Granted, it's one of those things that you have to practice a little bit, but once you are comfortable with the technique it is a good tool to have in your belt.

The last time I did it was on an 8 YOF with serious burns over 30% of her body and I was able to pop in two 20 gauges in a heartbeat. I really do like, and recommend, this technique.
 
Interesting that I found this post, I have read the article Kelly wrote about starting the IV bevel down and had practiced it a few times. The other night we had a terrible case, elderly lady, severe osteoporosis, had leaned down to grab something and felt a pop and snap both above and below the knee. She was in terrible pain, and we were a very bumpy 35 mins from the hospital. I start searching for a vein, we can only use 1 arm because of a dialysis port on the other arm. So I start looking at the "good" arm and she has a large scar that covers the AC from a previous port. Of course tiny, rolling veins.

My partner tried with a 22g, got flash, and it blew. I had called a neighboring agency who carries fentanyl (we only carry morphine) so I decided to "save" any veins for them. As I was warming her arm I noticed a tiny little vein "pop" up, so I thought what the hell. I grabbed a 24g, and went bevel down. It worked! I had the line started. She said that IV hurt less than any that she can remember. So maybe it was luck, but I won't hesitate to use bevel down again should the scene call for it!
 
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