When and When not to start IVs/saline Locks.

[xrsm002]

I was wondering I had two abdominal pain calls on the truck we started an IV on the first one but the 2nd one we didn't start one. I am a paramedic student and my preceptor told me the 2nd patient didn't need one. I am assuming because it was a <6 min transport time to the ER. The first one was about 15 min transport. Or it could be cuz the first one was bent over, and the 2nd one wasn't. Any suggestions on when and when not to start lines? or at least a saline lock?

 

[Epi-do]

I start IV's if I need to give IV meds, fluids, or have a patient that has the potential to head south and need either of those things while on our way to the ED. When I do start an IV, I almost always do a lock. I only hang a bag if fluids are needed.

I work with a handful of medics that will start an IV on a pt simply because "the hospital is going to do it when we get there, anyway." It's not something I do, but that comes down to personal preference, I guess.

If you are looking for specific signs/symptoms that will cause me to start an IV, it really varies widely from patient to patient, depending upon their complaint.

 

[NYMedic828]

I start IV's if I need to give IV meds, fluids, or have a patient that has the potential to head south and need either of those things while on our way to the ED. When I do start an IV, I almost always do a lock. I only hang a bag if fluids are needed.

I work with a handful of medics that will start an IV on a pt simply because "the hospital is going to do it when we get there, anyway." It's not something I do, but that comes down to personal preference, I guess.

+1

There are tons of people who will start an IV on everyone they can and use the "what if scenario" in their defense.

If the patient could potentially head south or is already down under then they get an IV.

Next time, ask the preceptor for a clear reason why.

 

[STXmedic]

That is highly subjective, and you will hear many different opinions.

As far as your patient today that did not get one, maybe your preceptor:

-didn't think he could hit a vein without turning the patient into a pin cushion

-felt it was too short of a transport time

-did not want to increase the patients chance for infection

-felt the patient's pain was not severe enough to warrant one

-wanted you to step in

-forgot

-was lazy

-flipped a coin

It's impossible to say.

For me, if I have a patient with abdominal pain, they are likely getting some meds for that pain, and therefor a line. It is all dependent on patient condition and needs. There is no discernible line on when to give an IV or some Tx and when to withhold it. You have to look at your patient, assess him/her, and use your own clinical judgement. Medicine is not black and white; it is all different shades of grey.

And +1 to epi's comment.

 

[Shishkabob]

If they currently need fluid / medications, will need fluid / medications, or could potentially need fluid / medications, they get an IV from me.



Broad and vague? Yes, but welcome to medicine where it's as much science as it is art.

 

[the_negro_puppy]

- The actual or foreseeable need to administer intravenous drugs.

We don't have saline locks, we either start and IV with a bung, or hang fluids TVKO.

Having said that, it is difficult to know if a patient's condition is going to change during transport. If something happens it you alone in the back. The more prepared you are, the easier it will be if there's a problem. Having an IV started can be part of this. It's not like at a hospital when you can call a medical emergency/code blue and have 4 doctors and 3 nurses at your side starting IV's, doing CPR and preparing defibrillators.

 

[Melclin]

In addition to the actual or foreseeable need:

-I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc.

-I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. Why do people have a problem with this idea?

 

[abckidsmom]

In addition to the actual or foreseeable need:

-I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc.

-I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. Why do people have a problem with this idea?

What is a bung?

I have nothing to add to these excellent lists of thoughts except that if I put someone on the monitor because I suspect I might see something there that's interesting or relevant, that usually wins them an IV too.

It's a vague rule, but it's my rule, and I like it.

 

[TransportJockey]

I start them if I feel the patient will need fluids or meds, or does need fluid or meds. If I can justify it, I'll do it. But we don't carry locks, so I have to hang a full bag when I start a line.

 

[Smash]

What is a bung?

A bung is a saline lock.

 

[the_negro_puppy]

In addition to the actual or foreseeable need:

-I don't use bungs. I've skimmed some research suggesting that complication rates are higher because of all the movement occurring so close to the IV site. Anecdotally, I've found them to be less comfortable for pts, harder to secure well and especially moving around a lot in the back, I see the potential for pulling the line accidentally going over a bump etc.

-I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. Why do people have a problem with this idea?

What do you guys use down in Vic if you are not using bungs?

What is a bung?

A plastic port that crews onto the end of the catheter, can be used to attaching tubing or inject drugs through

 

[abckidsmom]

Never heard it called that. We call that a "luer lock plug."

Extremely effective, that one. No one has a good word for it around here.

A saline lock, to me, is that same thing except with 3 inches of tubing between the hub of the catheter and the luer lock plug.

 

[Akulahawk]

If I'm going to put in a lock, it's going to be done like abckidsmom's going do to it - a 3" extension with a luer-lock plug on the end. I can understand why some people might want to put the luer-lock plug right at the end of the cath, but... I just don't want to potentially pull the cath out because I'm attempting to attach the tubing to the cath... while in a moving truck. Both have their uses.

 

[the_negro_puppy]

these are IV bungs

If we attach IV tubing to them we secure the tubing to the patients limb with tape

 

[Melclin]

We have 3 options.

1) Reflux valve or "a bung".

2) Three way tap

3) Three way extension

I prefer the three way extension for the reasons mentioned.

I've also heard there are some types of blood work that shouldn't be drawn through the reflux valve but its only hear-say. Never really looked into it because I don't use them.

 

[the_negro_puppy]

QLD, the poverty state. We get bungs only. Some ICPs carry around 3 way extension taps + tubing, but they probably plundered them from hospital.

We've only just recently changed to the bungs used by most of the hospitals. Before that we were using the non-leur lock ones that you had to penetrate with blunt/plastic tip. Every cannulated patient brought in had to have their bung changed. Madness

 

[Handsome Robb]

-I start IVs on anyone who will need access for fluid, medications or blood work, regardless of whether or not it will be me giving/taking those things. Essentially its for practice, but the nurses also seem to like it when that box is already ticked. Why do people have a problem with this idea?

Emphasis on the bolded part. I always hear people say "the hospital is going to need one" is a bad reason. I have yet to hear why. Infection rates in prehospital vs in hospital is a defunct argument. It's been shown there is a negligible difference.

Another argument I've heard is "nurses are better". Bull:censored::censored::censored::censored:, we start more lines than they do so inherently we will better. At least at the hospitals here the paramedic techs start lines much more often than nurses do. Call it anecdotal but personally I'll take a line from a medic/EMT over a nurse any day.

This is a "team sport". We are all working towards the same end goal. I have one patient, rarely two, even more rarely three in the box while ER nurses have 3-5 plus helping other nurses with critical patients. If I can make their job easier by starting a line I'm absolutely going to do it. With that said I feel pretty confident in my ability to establish a good line without taking more than one or two attempts. After two ill let it be unless I need that line for something right now.

 

[xrsm002]

Let me add this my I was reaching for the IV to at least start a lock and my preceptor said this patient didnt' need one.

 

[Akulahawk]

Let me add this my I was reaching for the IV to at least start a lock and my preceptor said this patient didnt' need one.

Give it time, and you'll just start picking up on which patients will need one and which ones don't. The majority of patients require only BLS level care. Those typically won't need a line or a lock right away. If my patient is in need of some sort of intervention above that, then they're likely to get a line or a lock, but not always. What it boils down to is whether or not I can articulate a specific need for starting a line on the patient... and it's not because I need the practice or "just in case" or "precautionary," at least in those instances where protocol doesn't direct that a line be placed.

 

[JakeEMTP]

Emphasis on the bolded part. I always hear people say "the hospital is going to need one" is a bad reason. I have yet to hear why. Infection rates in prehospital vs in hospital is a defunct argument. It's been shown there is a negligible difference.

Another argument I've heard is "nurses are better". Bull:censored::censored::censored::censored:, we start more lines than they do so inherently we will better. At least at the hospitals here the paramedic techs start lines much more often than nurses do. Call it anecdotal but personally I'll take a line from a medic/EMT over a nurse any day.

That's some broad statements and probably not true everywhere. I would say there are alot of places where the number of IV starts for the Paramedic is the same as the number of intubations which might be 1 or less per month. I know alot of ER and OP nurses that can do 20 IV starts a day easily. If you are doing more than that as a Paramedic then you are probably putting a line in anybody and everybody. Alot of ERs don't have ER Techs so the nurses do their own lines.

The infection rate is also hard to prove since hospitals have a policy of changing out any lines started in the field or even emergently in the hospital within 24 hours. The one study that always get kicked around as showing neglible was done by a couple of RNs get their Masters and the numbers on it actually is not that impressive but most just read the summary and not look at the rest. If hospitals are having a hard time with infections, what makes you think it is any better in the back of a truck or on the street. Most Paramedics still just use an alcohol swipe and rarely let that dry before sticking. I personally wouldn't want a field IV to stay in me or my family any longer than it takes to get another one done. Just because you have a problem with the us against them bull:censored::censored::censored::censored:, nurses still have the infection control stuff drilled into them. Alot of Paramedics can't get cleaning a truck right just for taking out their own garbage for their shift. They don't call some of the ambulances Roach Coaches for nothing. What about the medic who has worn his gloves up front touching everything for every patient call and then starts IVs? Nurses do that :censored::censored::censored::censored: and they are busted by their IC managers.