What has changed since you started?

[Carlos Danger]

I also recall reading this article. It pretty much said that there were limiting factors which included the IV tubing, use of saline locks, length of IV cath, and I think maybe one or two additional factors.

I’ve heard that argument before, and it is true that there’s not a lot of sense in struggling to put in a huge line if you are just going to choke it off with a microbore saline lock or a 20gtt IV set.

However, that doesn’t mean large IV’s aren’t useful at times. I wouldn’t say it’s EMS’s responsibility to put in the biggest IV possible just because the OR staff might find it useful later, but in a sick patient, indications to infuse fluids and products rapidly still exist, so if you can easily place a larger IV, it just makes sense to. What is the downside?

Just like with ET tubes and rifle calibers, the larger the better.

 

[firecoins]

2 man stretchers that we had to dead lift into the ambulance.

I remember learning mast past. Never used it but I was tested on it.

 

[akflightmedic]

but in a sick patient, indications to infuse fluids and products rapidly still exist, so if you can easily place a larger IV, it just makes sense to. What is the downside?

The downside is failed attempts/time wasted due to the singular thinking of bigger is better so the Advanced or the Medic only grabs the 14/16 and thinks if they do not get that, then nothing else will suffice.

The downside is repeated failed attempts at a larger bore in a patient who most likely did not even need it to start with and then trying a 2nd or 3rd time with additional trauma before resigning themselves to a 20 0r 22 g in the hand because that is all that is left that is not destroyed.

The downside is the real time lost trying to gain access when we all know how fast the clock travels without us realizing it.

The downside is the data/evidence based medicine, does not support the routine placement or need for it.

There was a military study on the above points as well which showed field success rates for large bore vs smaller bore. Even though the fail rates were higher than expected, their conclusion was still to go big or go home...however that study was in a real time war environment and I do not think it is an adequate comparison to CONUS EMS.

Yes, I concede we all have had patients with ropes for veins you could drive a truck thru. I also concede we all have done those perfect IV placements of 10 seconds or less from start to finish...neither of these are the rule. Many providers get locked into the bigger is better and waste time accomplishing such when it could be better spent elsewhere.

 

[Carlos Danger]

The downside is failed attempts/time wasted due to the singular thinking of bigger is better so the Advanced or the Medic only grabs the 14/16 and thinks if they do not get that, then nothing else will suffice.

The downside is repeated failed attempts at a larger bore in a patient who most likely did not even need it to start with and then trying a 2nd or 3rd time with additional trauma before resigning themselves to a 20 0r 22 g in the hand because that is all that is left that is not destroyed.

The downside is the real time lost trying to gain access when we all know how fast the clock travels without us realizing it.

The downside is the data/evidence based medicine, does not support the routine placement or need for it.

There was a military study on the above points as well which showed field success rates for large bore vs smaller bore. Even though the fail rates were higher than expected, their conclusion was still to go big or go home...however that study was in a real time war environment and I do not think it is an adequate comparison to CONUS EMS.

Yes, I concede we all have had patients with ropes for veins you could drive a truck thru. I also concede we all have done those perfect IV placements of 10 seconds or less from start to finish...neither of these are the rule. Many providers get locked into the bigger is better and waste time accomplishing such when it could be better spent elsewhere.

Those aren’t downsides of large bore IVs, those are examples of poor judgment and tunnel vision on the part of clinicians.

Again, I’m not saying that EMS should be trying to place large IV’s all the time, but I also don’t think we should pretend that large IVs never have utility.

 

[akflightmedic]

One could argue the times an actual need for a large bore are far lower than the actual times a large bore is placed or attempted. With repeated mantras of go big or go home, or bigger is better, do you think that contributes to one's practice, right or wrong? Especially in emergent settings? Do you think that is now the fault of the clinician?