Ultrasound IV in the field

[FiremanMike]

My state recently approved this for the paramedic scope of practice. I'm quite good as an ED nurse at ultrasound IV and my new dept has a long transport time. I'm mildly interested in trialing some devices but wanted to get thoughts/opinions from the group on good brands or overall experience.

My personal feelings - it took me a long time and a lot of practice to become efficient with these. I can crank one out in 3-4 mins now from start to finish, but as I said, it took me awhile to get to that point. I definitely won't justify waiting 10 minutes extra on scene (how long it took me early on) and I'm not convinced how well this will work bouncing down the road. I've also become quite picky with the brand of machine - I only use the sonosite, I can't easily find the tip of my needle with the other brands.

Thoughts/opinions/experience welcome..

 

[Carlos Danger]

PIV's are probably the easiest application of US to learn but as you say, it still takes quite a bit of practice to get to where you can do it quickly and efficiently. I can definitely see agencies struggling with that as well as seeing it delay transport times.

 

[Akulahawk]

I'm also very, very good at doing USGPIV's. While I can take 20-30 minutes to do one, most of that time is spent looking for an appropriate site. Once I find a site and all the tubing for a saline lock is ready, the actual time from start to finish is maybe 3-4 minutes. If I'm doing one urgently, that's maybe a 5 minute procedure from start to finish. I do agree that this is a procedure that should be available to field Paramedics but it shouldn't be something that is relied upon as a crutch for people that are not good at doing normal IV starts and shouldn't delay scene times, and shouldn't be done anywhere but on-scene, as doing this while en-route will be nearly impossible due to all the motion artifact thanks to all the road imperfections.

I wouldn't suggest allowing anyone to begin doing USGPIV training until they're decently good at standard IV starts. On top of that, you will also need to have longer length IV catheters available to reliably reach deeper veins and not have them extravasate.

My own personal favorite is doing these with captive guidewire units... makes starts very reliably easy as you can literally feel if you're in a vessel.

 

[FiremanMike]

30 minutes?! I meant 3-4 minutes including finding the site, I have my process down pat. I always start pretty much dead center of the anterior forearm, nearly everyone has a juicy one there about 1-1.5cm deep that I can toss in an 18-long without any issue. When that one isn't there, I'll scan the entire anterior forearm for something, my last choice is usually one of the antecubital ones that are on either side of that artery. There's been some cases where I can't find anything, but they're few and far between.

Had one the other day that was so vaso-constricted from dopamine that I couldn't find anything, which sucked because all we had as a tibial IO (fun fact, dopamine DEFINITELY works through an IO). Ended up with a subclavian line up in ICU.

 

[Summit]

In hospital, on non-critical patients, you spend time looking for an appropriate US IV. Something not in the AC, not in one of the already-blown veins, the patient may already have several lines, one that the patient will tolerate while maintaining mobility on the limb, and a bore approrpiate for contrast.

In the field, get an 18 or 20 in the crux of the arm. Bam. That should not involve much time on most patients.

 

[Tigger]

I feel like it has limited utility. Generally, I can find a PIV, it might be a 22 in a weird vein but it usually will do for my purposes. Is delaying transport to get a larger gauge of access useful? I don’t know. Seems unlikely? If it’s not a critical need the hospital can have at it, even with a longer transport time.

If the patient is in desperate need of large bore access, the IO works just fine.

 

[Akulahawk]

30 minutes?! I meant 3-4 minutes including finding the site, I have my process down pat. I always start pretty much dead center of the anterior forearm, nearly everyone has a juicy one there about 1-1.5cm deep that I can toss in an 18-long without any issue. When that one isn't there, I'll scan the entire anterior forearm for something, my last choice is usually one of the antecubital ones that are on either side of that artery. There's been some cases where I can't find anything, but they're few and far between.

Had one the other day that was so vaso-constricted from dopamine that I couldn't find anything, which sucked because all we had as a tibial IO (fun fact, dopamine DEFINITELY works through an IO). Ended up with a subclavian line up in ICU.

When I'm called, most of the usual sites have been already chewed through and/or they're vasoconstricted from either dehydration or use of vasopressors. I can go MUCH faster than that, 3-5 minutes as you do, when necessary. I happen to like the anterior forearms but I also use the cephalic vein and basilic veins not to ignore brachial veins... I try to stay away from actually having the catheter crossing a joint line. Keeps the pumps happy.

I have used the greater saphenous vein too, on one occasion.

 

[E tank]

A patient with illness requiring inopressor that preclude routine PIV access in the ER needs a central line. If the u/s is coming out in that situation, somebody ought to be prepping the neck.

 

[FiremanMike]

A patient with illness requiring inopressor that preclude routine PIV access in the ER needs a central line. If the u/s is coming out in that situation, somebody ought to be prepping the neck.

We had 2 codes and a dissecting aortic aneurysm, doc unfortunately didn’t have time and ICU will not come down to do stuff in the ED..

 

[DrParasite]

When I did my clinical time in the ER, we had one patient (I want to say complaint was chest pain, but it's been a while) who the ER staff could not get an IV on. guy was a little heavy and had edema in all 4 ext. so they called the Ultrasound IV person (full time RN who was assigned to the UIV team) to assist. I want to say it took over an hour for the person to get there. would an hour response time be appropriate for prehospital?

back in the day, paramedics would often make patient pin cushions trying to get an IV, esp if they were sick. I remember one who tried R ACx2, L ACx2 , R hand, and 10 minutes later on this actively seizing patient, R EJ was successful. Now it's two attempts and if no go, you're getting an IO in your leg, esp if you're that sick (cardiac arrests start off with an IO).

Also, how frequently would providers use PIV? we know from intubation numbers that skills that aren't using get worse over time; would this be the same with PIV? don't get me wrong, I would support things that benefit the patient, and help to expand out skill set, but since paramedics often get the IV on the first attempt 85-97% of the time (here is the source for that statistic), how frequently will they be practicing their PIV skills on a truly sick patient?

Since it takes practice to be initially proficient, and at 3am on a sick patient, how well will providers be at using the ultrasound device that they haven't touched in 6 months?

 

[FiremanMike]

When I did my clinical time in the ER, we had one patient (I want to say complaint was chest pain, but it's been a while) who the ER staff could not get an IV on. guy was a little heavy and had edema in all 4 ext. so they called the Ultrasound IV person (full time RN who was assigned to the UIV team) to assist. I want to say it took over an hour for the person to get there. would an hour response time be appropriate for prehospital?

back in the day, paramedics would often make patient pin cushions trying to get an IV, esp if they were sick. I remember one who tried R ACx2, L ACx2 , R hand, and 10 minutes later on this actively seizing patient, R EJ was successful. Now it's two attempts and if no go, you're getting an IO in your leg, esp if you're that sick (cardiac arrests start off with an IO).

Also, how frequently would providers use PIV? we know from intubation numbers that skills that aren't using get worse over time; would this be the same with PIV? don't get me wrong, I would support things that benefit the patient, and help to expand out skill set, but since paramedics often get the IV on the first attempt 85-97% of the time (here is the source for that statistic), how frequently will they be practicing their PIV skills on a truly sick patient?

Since it takes practice to be initially proficient, and at 3am on a sick patient, how well will providers be at using the ultrasound device that they haven't touched in 6 months?

People discuss skill degradation as a universal and it just isn’t. For some people, shooting a gun requires constant training, whereas I haven’t fired a round in nearly a year and can pick up my gun and nail my target (I’ve gone this long between practice before). Same with intubation, I just don’t find it to be a difficult skill, so when it’s time to go - I’ll slide that tube right in.

So it’s really more on the person than the prefixed. I’d say ultrasound guided iv is about 95% hand-eye coordination and the ability to make minute and accurate adjustments. Some people have it, some don’t.

As an add on to my statement, I’d contend that initial mastery on a given before you can forego skill degradation..

 

[E tank]

Same with intubation, I just don’t find it to be a difficult skill, so when it’s time to go - I’ll slide that tube right in.



As an add on to my statement, I’d contend that initial mastery on a given before you can forego skill degradation..

Dang...I take 2 weeks off and I can't find my a** with both hands my first day back....it depends on the level you're operating at. If the level you leave off at is 'ok', then there isn't much skill to degrade. If you operate at a pretty sophisticated level, the degradation curve can be pretty steep. It's definitely a thing.

 

[FiremanMike]

Dang...I take 2 weeks off and I can't find my a** with both hands my first day back....it depends on the level you're operating at. If the level you leave off at is 'ok', then there isn't much skill to degrade. If you operate at a pretty sophisticated level, the degradation curve can be pretty steep. It's definitely a thing.

I know it’s a thing and I know plenty of people experience it, no shame in that whatsoever, but it’s not universal and not something everyone go through..

I’m not saying I’m a god or bragging, I am just fairly good at retaining psychomotor skills..

 

[Akulahawk]

A patient with illness requiring inopressor that preclude routine PIV access in the ER needs a central line. If the u/s is coming out in that situation, somebody ought to be prepping the neck.

Not a fan of using a peripheral line for pressors or inotropes... but sometimes their use is necessary to buy time to get a central line in place. Edematous patients can also be an indication for a peripheral US line.

I’d say ultrasound guided iv is about 95% hand-eye coordination and the ability to make minute and accurate adjustments. Some people have it, some don’t.

I generally say that it's a lot like playing a video game. If you have good skills for manipulating things out of your line of sight (like using a controller and buttons on said controller) while watching the screen and adjusting appropriately, you can be an OK PIV starter but excellent at USGPIV. If you can't really "get" the video game, you won't be good at doing a USGPIV.

 

[Capital]

The good ultrasound machines are so fragile and expensive. I don't think the probe/crystal would survive a week in the back of our ambulance.

 

[FiremanMike]

I generally say that it's a lot like playing a video game. If you have good skills for manipulating things out of your line of sight (like using a controller and buttons on said controller) while watching the screen and adjusting appropriately, you can be an OK PIV starter but excellent at USGPIV. If you can't really "get" the video game, you won't be good at doing a USGPIV.

I 100% agree with this comparison, it is exactly the same skillset.

Side note, anyone else feel that the tip on your 20ga is significantly harder to find at first compared to the 18?

We had a sick baby one day that no one could get a line on, I tried doing ultrasound with a 24ga, never did find that stupid needle.

 

[NomadicMedic]

The good ultrasound machines are so fragile and expensive. I don't think the probe/crystal would survive a week in the back of our ambulance.

The butterfly is designed for this environment. I dont think that’s a reason to not use it.

 

[Akulahawk]

I 100% agree with this comparison, it is exactly the same skillset.

Side note, anyone else feel that the tip on your 20ga is significantly harder to find at first compared to the 18?

We had a sick baby one day that no one could get a line on, I tried doing ultrasound with a 24ga, never did find that stupid needle.

Yes. The 20g tip can be very hard to find compared to the 18g unless you manage to stick the vein during your initial puncture attempt... when that happens, you get a nice sudden bright spot in the center of the vein. Of course when you're being observed and this happens, you look like a miracle worker.

I normally don't use a cath smaller than a 22 when using the US because the 24's are just so hard to see...