Trouble with Ivs

SeeNoMore

SeeNoMore

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I'm a new paramedic working for a transport company that does a lot of critical care transport. I have had command for 3 months. We also do infrequent emergency runs from nursing homes. Overall I feel I am doing a decent job with the critic care runs and am keeping in the books in an effort to become as educated as I can be. However my iv skills are very weak. I have read everything I can on different techniques and am trying to improve but my progress seems slow at best. The odd thing is that in school and orientation I did not miss many. Now while most pts will get an iv it is common to need two attempts and the last month has been awful with several pts arriving at the ed with no access. Generally if the pt is not in dire need of access I stop at two attempts. I am trying to stay positive and honestly report my failures but as my success rate hovers around 50 percent I cant help but feel like the worst medic ever. Ive spoken to a supervisor who felt my technique was ok but its not iv arms or pts with decent veins I have trouble with. I was hoping others could share their thoughts of experience. I am also starting some 911 time so maybe that will give me more regular exposure. Thanks.
 
Just keep going.


Hell, been doing it for close to 3 years now, and I had a stretch of WAY too long rather recently where I couldn't hit a darn thing, no matter how great and easy the vein was.
 
Are you going in right where you see it and where you want to be? Or are you inserting a little before and "fishing" for it
 
I typically get a flash but have difficulty advancing the cath. I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.
 
SeeNoMore said:
I typically get a flash but have difficulty advancing the cath. I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.
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I also had difficulty with lowering the needle and was told to drop the cath even lower than the book recommended "10-15 degrees" to more like 5, this helped a lot.
 
If you can, get some more ER time. Most medical directors would rather have you be proactive in improving your skills. The only way to get good at IVs is to do a lot of them.
 
Hi There!

I can say from an EMS Standpoint,and working in hospital...bigger is NOT always better. 20-22 is almost always appropriate, and the AC isn't your only option!! For some reason, medics I know are HELL-BENT on an 18g. If the PT isn't a trauma, ST-E, or arrest, you can drop to a 20, or 22.

My best advice for you on the ones who are more difficult to stick, don't be afraid to use gravity as your friend...put a tourniquet, and just let the arm hang down for a 30 seconds, if you can't feel, or palpate an appropriate vein, put on another tourniquet distal the other. When in doubt, start with a 22, if the vein can support a 20, go for that (with the exception of arrests, those are definitely bigger, the better), but for pre-hospital, and in-hospital, a 20 is almost always appropriate, and 22's are also appropriate. If they need to go in with a bigger needle in hospital, that's fine, but for the ambulance ride, if you're just worried about maintenance fluids, and maybe some pain meds, a 22 will do the job, and when you get to the hospital, and they go to draw blood, that 22 will work just fine also.

Also, take a tourniquet, and tape it to a desk, or something similar, take an IV cath, with a needle, and just practice. Someone before me mentioned the 5 degrees, I like that number...if you tape the tourniquet, and keep a part of it pulled tight, you'll be able to practice. Grab it with your 2nd and 3rd fingers, tilt it just enough to pierce the skin (tourniquet in the case of practicing)...remember...you only need to typically insert the needle until you get a flash...once you get the blood return, start advancing the cath, otherwise, you can risk piercing, and blowing the vein.

You're skills will develop. You just have to miss a few times, until you can palpate effectively...use your eyes less, and your fingers more...also...don't be fooled by the garden hoses, they can be tricky with valves!!!

Good luck to you! :)
 
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Even in trauma, you really don't need to be using anything larger than 18g IVs. We really don't want to be adding saline to blood that we want to clot, and a 20G will support what we want quite reasonably.

I've only started a handful of 16g IVs and never a 14g in my career. No reason to.
 
Rocketmedic40 said:
Even in trauma, you really don't need to be using anything larger than 18g IVs. We really don't want to be adding saline to blood that we want to clot, and a 20G will support what we want quite reasonably.

I've only started a handful of 16g IVs and never a 14g in my career. No reason to.
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Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way, than I am trying to clot an internal bleed.

16's and 14's are almost always unreasonable.
 
pghboy2011 said:
Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way, than I am trying to clot an internal bleed.

16's and 14's are almost always unreasonable.
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Just keep them at a MAP of 60-70. No need try to get them normotensive.
 
SeeNoMore said:
I typically get a flash but have difficulty advancing the cath. I have been trying to lower the needle and advance slightly before attempting to advance. I am also trying to be more careful about site selection and considering smaller cath sizes. If I can palpate a vein I'm usually good. Its folks with very little to work with that mess me up. I have been reviewing vascular anatomy and may buy a veinlite.
Click to expand...

Little tip.

When you insert the catheter, brace your fingers to the skin of the patient and use your index finger to advance the catheter into the vein, firmly holding onto the barrel of the rear half of the angiocath.

As silly as it is, for a good few IVs whenever I tried to push them forward with my index finger I would instead pull the needle backwards, removing it from the vein that was successfully punctured.


Also as stated, very rarely is anything bigger than 18 necessary and the chance of failure is substantially higher for a needle as large as a 16/14g. I put a 20 in 80% of patients. I use an 18 for trauma, fluid resus and if the patient happens to have pipelines I know for a fact I won't miss.
 
My normal go to IV size is 18g. I have rarely placed in IV that was larger than that, those very few times that I have, the patient truly needed fluid. I feel no shame in going for a 20g IV, I just prefer what ever size fits the vein appropriately. Personally, I think in 18 g IV catheter is a good compromise size. You get the good flow rate of a larger bore IV and the ease of placement of a smaller gauge. I'm certainly not hell-bent on sticking with that particular size however. A 20 g IV will do just fine if that is all I can place.
 
SeeNoMore said:
I'm a new paramedic working for a transport company that does a lot of critical care transport.
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No offense, but what are you doing on these runs? CCT is a seperate sub-discipline that requires if not mastery than at least a strong base in paramedic level care. What are you considering to be CCT?
 
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pghboy2011 said:
Well, you'll notice I never encouraged anyone to exceed an 18, and you can't always clot a bleed...if there's abd pain, and distention, I'm more worried about keeping saline running, and prevent hypovolemic shock that way, than I am trying to clot an internal bleed.

16's and 14's are almost always unreasonable.
Click to expand...

If you can't clot the bleed, for the love of the FSM don't dilute their clotting factors into kool-aid! Permissive hypotension is a good thing. Dumping a few liters of saline in them is going to do more to prevent a clot than it will help their BP.

16s and 14s are perfectly reasonable if the pt actually needs fluid resuscitation (think sepsis) or you anticipate the pt will need blood products and/or surgery.
 
if its a code just go straight to EZ-IO
 
schulz said:
if its a code just go straight to EZ-IO
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It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.
 
One of which would be a peri-arrest patient your trying to keep from coding....

What are you basing your opinion of not needing to use IO access on?
 
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ChaseZ33 said:
It's far more important to be able to obtain IV access to potentially prevent the code than to rely on the option of IO after they arrest. There a very few situations in which you truly need to go for IO.
Click to expand...

Right. Because we arrive on scene before most of our cardiac arrest patients get around to coding. :rolleyes:
 
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