what do you do on an IFT from small hospital to large

[johnrsemt]

situations that I used to run into all the time (1-3 a week).

Going from small hospital ICU to Trauma one for Cardiac Cath 20 mile transport: ICU staff tells you that the patient has a good, patent 24 g IV in the back of the hand.
patient is CA+O*3 (4).

I always started at least one more IV if not 2; cath lab needs 2 IV's at least 20 g if not larger. I always told the patient what is going on, and why; never had one complain. was asked by management more than once about it, but medical director backed me up on it; mainly cause the cath teams always thanked him for having good crews on the street doing the transports.

Question: who else does it?

 

[zmedic]

The downside is that you are putting more holes in the patient which may be an issue when they get anticoagulated. I think it's fine if you see something good to hit, but should be avoided if you think you might miss. Especially since you have to either delay transport to start the IV (a big no no for cath patients) or you are doing it in route which while I'm sure you are good at, certainly isn't easier than doing it in a well lit hospital.

Now if your argument is "I don't feel comfortable transporting a potentially unstable patient 20 miles with a 24 gauge IV in case the deteriorate" that is a much more defensible position than arguing about what the cath lab does or doesn't need.

 

[terrible one]

I've never had a pt from the ICU come out with only a 24ga. I think that is kind of pathetic unless they truely had no IV access.
The pt's I have taken from ICU to cath usually all have atleast one 18ga in place, and all I do enroute is flush it to confirm patency.

 

[Akulahawk]

I'd most likely take option #5... call the receiving unit, give them an update while en-route, and ask what they'd prefer, if I don't already know... I'd consider starting a larger bore saline lock as a back-up for the 24ga that's in place. However, a 24ga that is in place is far better than no IV access at all...

I suppose it kind of comes down to "knowing your audience". Some facilities I've done transports into and out of have been happy about it... others would just rather do it themselves.

 

[LondonMedic]

I would suggest that doing an IV where one isn't immediately needed is just an infection risk, a waste of kit and unpleasant for the punter.

But, as Zmedic says, if you can justfy it in terms of wanting bigger or seconary access than you should do it or insist on it being done but that should come before you move the punter.

 

[VentMedic]

If we need access, we don't leave the sending hospital until we do have it established. If you feel that a 24 G is inadequate, you may have to find out why that was the only IV started. You do not want to be attempting to start an impossible IV enroute especially if the other hospital is prepared to place a central line immediately upon the patient's arrival. It would also be very rare for an ICU not to have already placed a central line in a patient that is a difficult stick or to have adequate IV access. The ED might be a different situation but you can also address this prior to departure. These transports should be controlled and you shouldn't have to be doing a "field stick" in the back of your truck. Your agency can also send out a memo of what you would like to see for IV access before transport. It is not uncommon for the better CCTs, Flight and Specialty teams to send out their recommendations as well as doing ongoing education for the smaller hospitals.

 

[Jersey]

Coming from a critical care transport background, I would be VERY cautious about this.

If the patient only has a 24g in an active MI or unstable angina, there is a good reason. The patient probably is an EXTREMELY difficult stick if they were only able to fish in a 24. We can all say what we want about some of the smaller hospitals we serve, but the nurses and staff can start IV's!

My concern was what if you went for a line, and BLEW one of the bigger veins that the patient may have had. There are two downsides to this:

1) The vein is now gone (especially in the heparinzed/anti-coag'd patient) and the hospital staff at the receiving cath cant try in a more controlled setting (IE not the back of a bouncing ambo)

2) There are a few invasive monitoring devices (PCWP is the first that comes to mind) that are fished in through some of the larger veins in the AC (ones that are often stuck by EMS). Also, internal temporary pacemakers are inserted the AC up into the atrium or the ventricles and directly pace the myocardium. If these veins are damaged then the flight team or the cath team wont be able to insert these necessary devices.
If you're transporting to a cath lab, all of these devices are commonly used in some of our more complex cardiac cases.

If I were you, I'd insist that better IV access be initiated before leaving incase the patient deteriorates. If they say no, there is a good reason. Document this finding. If the patient deteriorates, then stick away or IO away. Personally, I dont think its worth the liability risk of freelancing additional IV's on the way without first consulting with the sending facility.

 

[Jersey]

And also, one of the OTHER risks is pissing off the cardiac cath team (ESPECIALLY the interventional cardiologist!) some of these guys can be complete control freaks and a blown IV attempt (especially in the AC w/o consulting the sending or receiving) could set off a temper tantrum. :censored::censored::censored::censored: rolls downhill, and the call to the bossman will eventually get back to you. I've been there!

 

[rmellish]

the only valid reason i see for creating "more" venous access would be a situation where the pre-existing venous access is insufficient.

If this is truly the case, the IV should be started in the most controlled environment possible, probably after consulting with all the necessary powers that be.

 

[8jimi8]

Both hospitals where I work, IVs that were done in the field have a 24 hour life. If EMS inserted it, it gets yanked before 24 hours is up. Not any bad on the part of EMS, just infection control.

 

[DrParasite]

Kind of a stupid question from someone without a CCT background:

why??? if the patient needs more IV access, why not let the sending facility do it? or the receiving hospital do it? if they want to, they can.

unless it's a STAT procedure where time is of the essence, why not let the CATH team do it, where they want to, at the size they want to, where they have all the light, resources, and other options in case something goes wrong?

if the patient is stable at point A, is is your job to maintain stability until point B? as in not make the patient worse if you can avoid it?

unless the doctor wants it done, and tells you that it needs to be done during transport, why not let the cath team do their job?

 

[ivanh3]

It is not a rarity to get a poorly packaged patient on IFTs. That 24 might be the best they can do or they might not even realize they only have a 24. If the patient's condition warrants better access then by all means get better access. In that case, you are not doing it for the receiving facility, you are doing it for the patient. Coagulation issues and blowing good IV sites should always be a concern, but again you have to weigh risk/benefits. It won't do the cath lab/trauma center any good if you couldn't properly resuscitate a patient because of poor access. Now with technology like the EZ-I/O maybe getting that quick/fast/in a hurry access might be easier, but not all systems carry such equipment.

 

[Jersey]

It is not a rarity to get a poorly packaged patient on IFTs. That 24 might be the best they can do or they might not even realize they only have a 24. If the patient's condition warrants better access then by all means get better access. In that case, you are not doing it for the receiving facility, you are doing it for the patient. Coagulation issues and blowing good IV sites should always be a concern, but again you have to weigh risk/benefits. It won't do the cath lab/trauma center any good if you couldn't properly resuscitate a patient because of poor access. Now with technology like the EZ-I/O maybe getting that quick/fast/in a hurry access might be easier, but not all systems carry such equipment.

I completely agree. I've gone to/flown to many receiving facilities where we've essentially called it a "scene call with walls" because of the limited care that has been provided by the ER.

However, I'm still not a fan of starting a bigger IV on a difficult stick "just in case" if you have patent access, even if it's a 24 that's enough to get first line ACLS in while you're looking for another IV or starting an IO.

I've seen it all too many times with private transport medics (not knocking them, I've been there and served my time) stick away because they think the patient "might" be sick (but really aren't) and then we're left with a mess at the cath lab or trauma. Oftentimes as well, these units see a lot of "routine" transfers and when something borderline emergent gets transported, they get hyped up beyond the level of sickness of the patient (once again, been there).

Like was said above, you're not going to do anyone any good by arriving with a dead patient, but if your starting an EXTRA IV w/o consultation just because you can, or you think they may need it, dont. Not only does it do the patient harm by potentially eliminating a venous site but it harms your reputation and the reputation of your company for "unskilled cowboyism" (something we have to deal with no matter what in EMS). Stay safe.

 

[ivanh3]

I hear you. I have no problem with a 24 guage per se. I can give just about anything I need in terms of core 0 meds. Just no fluid challenges/blood products. Again, I let patient condition guide me.

 

[redcrossemt]

I suppose it kind of comes down to "knowing your audience". Some facilities I've done transports into and out of have been happy about it... others would just rather do it themselves.

I've started IV's on-scene at hospitals and enroute to tertiary facilities before, but only when I know what the deal is. If the patient is being transferred emergently from a community hospital for a head CT to evaluate a CVA and only has a 22 ga in the AC despite having good veins, I will absolutely start another larger line. Same thing going to cath labs or pre-op, especially from the floors of community hospitals. You need to know your tertiary facilities though, and what their specialty teams want/need for access for certain expected procedures.

Gaining IV access before or during transport can save your butt in the ambulance when it hits the fan, and can also expedite the patient's access to the services they need (surgery/cath/CT/etc).

By the way, "scene call with walls" for the win.

 

[VentMedic]

is. If the patient is being transferred emergently from a community hospital for a head CT to evaluate a CVA and only has a 22 ga in the AC despite having good veins, I will absolutely start another larger line. Same thing going to cath labs or pre-op, especially from the floors of community hospitals.

Do you ask if the patient was getting contrast or what size and location was preferred for the procedure? Sometimes the community hospital gains whatever access they need and then leaves the other site for a PICC or the IV preference of those doing the procedure. There have been times when the procedure must be delayed until another IV of preference to the staff at the other hospital can be started or a central line placed because of multilple sticks.

Generally when report is given, IV access is a key issue mentioned and the receiving hospital can make suggestions or state they'll start whatever is necessary since they may already have had some bad experiences with chewed up arms from multiple IV attempts.

 

[redcrossemt]

Do you ask if the patient was getting contrast or what size and location was preferred for the procedure? Sometimes the community hospital gains whatever access they need and then leaves the other site for a PICC or the IV preference of those doing the procedure. There have been times when the procedure must be delayed until another IV of preference to the staff at the other hospital can be started or a central line placed because of multilple sticks.

Generally when report is given, IV access is a key issue mentioned and the receiving hospital can make suggestions or state they'll start whatever is necessary since they may already have had some bad experiences with chewed up arms from multiple IV attempts.

LOL and sometimes the sending facility doesn't know if the patient was actually NPO or not in their hospital, and/or the difference between a portacath/mediport and a dialysis catheter/line that has been accessed! (Heard these both this week.) I understand what you're saying, and completely understand that there has been a physician to physician (or nurse) report given, and that access is a part of that report and the transfer plan. At the same time, I used to walk into the cath lab with patients who had a 24 gauge IV in a huge AC vein to have them start a 16 in the opposite arm. Now I typically do it for them if it's an emergent cath, and they are happy about it. Same thing for contrast CT, expected transfusions, and so forth.

Again, it's about knowing your receiving facilities. If I don't know the facility, and it's an emergency where a few minutes may count, I'll call and ask if they need additional access, and if they'd like me to attempt to place an IV.

 

[MS Medic]

Kind of a stupid question from someone without a CCT background:

Why is that a stupid question?

Some of us who work in rural areas regularly do IFTs with critical pts for upgrades in care, having transports of 30 min to an hour, if not more. I do agree though that there is no reason to start an additional IV en route on a IFT. Examin the pt before transport and ensure the sending facility has apropriate access. Otherwise it can wait and be left for the recieving facility.

 

[FLEMTP]

I think this is a situation where you need to know the facility you are transporting the patient to, and what they are going there for. If you are taking a trauma patient, for example from a level III or level II trauma center to a bigger level I trauma center for surgical intervention, and you can get larger access, and you are SURE you can get the line, why not help get the patient prepped for surgery a little quicker? If you're in doubt, call the receiving MD and discuss with him.

On the other hand, patient condition dictates you do what you need to do. If you have a patient that is stable, and there is little chance of deterioration, then leave sleeping dogs lie, and let the patient have a comfortable ride. If you feel the patient will need intervention on your part, and you cannot adequately do it with the IV line in place, then do what you need to do in order to stabilize the patient.

I have noticed here too, many of the threads started here, are asking for cookie cutter answers to problems that need something more than a cookie cutter solution to. You should always always always assess your patient, reassess your patient, consult with a doctor should the need arise and you're not familiar with something, and provide the best treatment you know how, and know when to think outside the box, and when to follow the rules. Its not always easy in medicine... thats why they call it PRACTICING medicine...its never an exact science!