When and When not to start IVs/saline Locks.

[KellyBracket]

There's actually some interesting research into IV placement rates by EMS, and how it affects the patient. Of course, there doesn't appear to be a good evidence-based answer to "When should I start an IV?" but there are some important results to consider.

For instance, one recent study found that patients transported by ALS who got an IV were less likely to die (after controlling for age, illness severity, etc...) than those who didn't get an IV. Another study found that IVs placed by EMS are used less often than IVs placed by RNs in the ED. On the other hand, maybe we need to put more IVs into kids.

For more explanation, check out The IV placed by EMS: Too much, yet not enough.

 

[Handsome Robb]

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.

I should have been more specific. In a rural service yes you may only get a few starts a month. Where I work and in the many other busy urban services you might be getting as many as 10-15 attempts/starts in a 12 hour shift and that doesn't mean everyone is getting a line either...

That's going to depend on the hospital as far as changing IV catheters. We have a good relationship with all of our hospitals so they tend to follow the 72-96 hour change guideline as recommended by the CDC* but your mileage my vary and as you said some systems pull EMS lines as soon as reasonably possible.

We use 2% chlorhexidine wipes for skin prep, not alcohol but again that's going to vary depending on the service you work for.

I've got no problems with nurses, quite the opposite actually. I have a lot of respect for nurses, more specifically ER or ICU nurses and what they do. Again, we have excellent working relationships with them so that helps quite a bit as well. Sure I don't like a few but you aren't going to get along with everyone, right?

* http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

 

[Handsome Robb]

For more explanation, check out The IV placed by EMS: Too much, yet not enough.

Thanks for that. Pretty interesting actually.

 

[OIFXGunner]

My only problem with the "hospital's gonna do it anyways" argument is that the hospital is also likely going to do blood draw when they start their lines and we don't have that capability in my agency. I had always thought that they could just pull blood off the line once they got the patient in, but my local hospital doesn't care much for doing that. So my rule of thumb is if they need IV meds/fluids or they have potential to crash, they get it. If not, I'll let the hospital take care of it so we're not sticking the patient any more than really necessary. Just my opinion

 

[ZootownMedic]

We had this argument in my Paramedic class and I was one of the only ones (along with most of the instructors) that said I wouldn't do a line on a pt 'just because'. My current preceptor wants lines on a lot of pts that I don't think need them. The way I look at it is that even though we do IV's all day everyday doesn't mean that its right. the ambulance is far from sterile and is an uncontrolled environment. Why risk infection/embolus or whatever if you don't have too? Of course I don't ever want to be that guy that needs a line NOW and didn't have one but that means I didn't do a proper assessment or this is the 1:1,000,000 pt that just went down the drain out of nowhere. I am a new medic(intern) and am finding my own way but I will probably end up in the middle ground and only start IV's on patients that have the POTENTIAL to head south. Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.

 

[STXmedic]

Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.

/grabs popcorn

 

[ZootownMedic]

/grabs popcorn

lol....I always treat pain. Doesn't mean I grab a line for every pt c/o some form a pain bc I am worried they are gonna circle the drain. Thats what I meant.

 

[Melclin]

We had this argument in my Paramedic class and I was one of the only ones (along with most of the instructors) that said I wouldn't do a line on a pt 'just because'. My current preceptor wants lines on a lot of pts that I don't think need them. The way I look at it is that even though we do IV's all day everyday doesn't mean that its right. the ambulance is far from sterile and is an uncontrolled environment. Why risk infection/embolus or whatever if you don't have too? Of course I don't ever want to be that guy that needs a line NOW and didn't have one but that means I didn't do a proper assessment or this is the 1:1,000,000 pt that just went down the drain out of nowhere. I am a new medic(intern) and am finding my own way but I will probably end up in the middle ground and only start IV's on patients that have the POTENTIAL to head south. Not the 'Im faking ABD pain bc I want meds' pt. Just my thoughts.

Okay I'll bite.

How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.

 

[OIFXGunner]

Okay I'll bite.

How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.

Hahaha the picture made me literally burst out laughing.

On a serious note, however, I think we should all be able to agree that there is such a thing as unnecessary ALS. Just because you can doesn't mean you should.

The whole aseptic environment thing... yes we should use aseptic technique. That's a given. However, most of our ambulances are nowhere near as clean as we would like to pretend they are. On the other hand, the same thing can be said about the hospitals. You know those little metal stand stands that they have in the patient rooms? Think back to the last time those were cleaned that you've seen. Or the ekg or pulse ox wires. There's plenty of potential for contamination in both environments. The trick is in reducing it.

I think this argument could be run in circles for days... I feel pretty safe in saying that as long as you can justify why you did or didn't start a line on a given patient to your omd you should be in the clear.

 

[Tigger]

Okay I'll bite.

How about you clean your ambulance once in a while and use proper aseptic technique then you won't have an issue putting lines in fake abdo pains.

The aseptic technique is the real preventer of infection, not that's any excuse for not having a clean ambulance. Yes the ambulance is not a sterile environment, but neither is pretty much any other area. Don't rub the catheter on your leg or the patient's arm on the bench seat and we should be fine.

 

[usalsfyre]

The same urban outdoorsman that puked in your truck later copped a squat in the corner of the ER room. If I'm not mistaken nothing has ever shown prehospital lines to have a higher infection rate.

The funny thing is I started as many or more "useless" lines working in the ED. Strangely enough they got used. Don't want a line to be wasted? Put a lock in it and don't hook it straight to fluid.

 

[Shishkabob]

Fact is, there hasn't been any real study to prove that field IVs are any more 'dangerous' than hospital IVs, and in fact, I have seen more say hospital IVs are more prone to infection.

Just like the IV nurses association came out with some silly statement stating that patients shouldn't be shaved because shaving causes "micro tears" that can cause infection. You know... more than the giant needle breaking the skin, or any other time the person shaves in the morning... or any other countless times that can cause 'micro tears'.




The one and only reason why pre-hospital IVs are DCd and re-done in the hospital is reimbursement. Money, pure and simple.

 

[VFlutter]

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.

I never used a stopcock or manifold until I was in the ICU. They are very useful when access is limited. Just make sure everything your running is compatible.

 

[Jeremy89]

I used to be an ER tech that was able to start IVs. The "fast-track" pt's who came in for the sore throat and cold/flu s/sx usually didn't get on. However, our MDs were generally pro-IV, meaning if they think the pt *might*, at some point need one, then they'll order it. They would rather have the pt stuck once with an IV versus once for phlebotomy, then having an IV placed if they needed to infuse IV K+, for example. The only pt's we just stuck for blood were psych pt's.

But this whole argument has another aspect I haven't seen anyone bring up yet- lets take, for example, that abd pain pt. Well maybe they don't need prehospital pain control or fluids (Doctors around here hate when pain meds are given since it diminishes their assessment), but when you get to the ED I can almost guarantee that pt will need a CT with contrast. Its all about critical thinking- "what *might* this pt need in the future?"

That being said, I agree with whoever posted about drawing blood from lines. If pt's have a prehospital IV, they'll likely be poked for blood from the ED staff anyway- we were taught never to draw out of lines unless it was at the time we started them. I think the risk for hemolysis almost doubles for blood pulled from pre-existing IVs.

Just my 2c

Edit: for the sake of this conversation, IV start=saline lock

 

[usalsfyre]

(Doctors around here hate when pain meds are given since it diminishes their assessment)

This piece of excrement myth is still around? Were they trained by Halstead himself?

http://www.nhmrc.gov.au/_files_nhmrc/file/nics/programs/Pain medication for acute abdominal pain [PDF%20120KB].pdf

 

[Shishkabob]

(Doctors around here hate when pain meds are given since it diminishes their assessment)

Then remind that doctor that at some point in his medical school, he was most likely taught about narcotic antagonist and about his ability to give one (such as Narcan) if he so pleases, when he takes control of the patient. Until then, it's your patient.

 

[the_negro_puppy]

Yeah I agree the whole 'no/not too much analgesia' for abdo pain patients is rubbish. Pain relief is one thing we can do,with measurable result well in the pre-hospital environment.

 

[Melclin]

Well maybe they don't need prehospital pain control or fluids (Doctors around here hate when pain meds are given since it diminishes their assessment)

 

[NYMedic828]

Most reputable doctors will tell you that with the introduction of new technologies like ultrasound,MRI, X-ray that diminishing pain is hardly a problem in the assessment.

If anything a patient will truly severe pain will be less distracted and able to provider a clearer verbal presentation of their condition.

 

[JakeEMTP]

Most reputable doctors will tell you that with the introduction of new technologies like ultrasound,MRI, X-ray that diminishing pain is hardly a problem in the assessment.

If anything a patient will truly severe pain will be less distracted and able to provider a clearer verbal presentation of their condition.

I guess that is one way to justify everyone getting an X-Ray, CT Scan or some other expensive assessment to make an ER visit cost over $2000 excluding all the specialists' fees to interpret the additional exams which are billed separately.

As for being able to clearly verbalize their pain would depend on the pain, the cause and what you gave them. Different meds react differently on different people which depends on age. other existing illness and current medications.