When and When not to start IVs/saline Locks.

[usalsfyre]

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.

Multiple reviews have shown no outcome difference based on physical exam. The patients are likely going to get imaging regardless of opioids due to defensive medicine. Analgesia in this case is not terribly complicated.

 

[Jeremy89]

Okay, maybe its not because of the MD's assessment. I guess I'm not 100% sure to be honest, but I would have to guess its between this and the short transport time in the Phoenix metro area. I haven't seen prehospital narcs given more than 3 times in the 4+ yrs I've been in this field. I'll ask around to see if I can get a better answer for you. But it goes with the original discussion- unless they need a line for prehospital use, or can foresee the use of medical imaging in the ED, most Fire-Medics around here won't throw one in "just for fun".

 

[NomadicMedic]

... I haven't seen prehospital narcs given more than 3 times in the 4+ yrs I've been in this field. "...

Wait a second. You've only seen narcs given THREE times in 4+ years? Is this only for abd pain or in toto? I see you're not a medic, so do you normally attend ALS patients with a medic? Maybe you've missed the administration....

I find that I use pain meds at least one or twice a tour, and the majority of those uses fall into one of three areas; Abdominal pain. Back pain. Traumatic injury (ie: femoral head fx or isolated fx/dislocation)

 

[Jeremy89]

Wait a second. You've only seen narcs given THREE times in 4+ years? Is this only for abd pain or in toto? I see you're not a medic, so do you normally attend ALS patients with a medic? Maybe you've missed the administration...

I work in the ED as a tech so I hear every report given to the RN/MD. Can't say I've ever heard "I gave him 2 of morphine for the pain on the way over"...

Usually its "We've given 0.8 of Narcan with no response". Lol

I do some volunteer work at a Collegiate Squad and we had a head injury once at a standby event. Got xported by private ambo as an ALS trauma. When the crew returned I askedif he gave him anything for pain and he said no because of the head injury.

 

[KellyBracket]

... Can't say I've ever heard "I gave him 2 of morphine for the pain on the way over"...

Well, I hope not. Unless they weigh 20 kg.

 

[Jeremy89]

Well, I hope not. Unless they weigh 20 kg.

Exactly- even if they do give anything its something minute like that.

Had a resident on the floor the other day that didn't wanna give a pt Tylenol for pain for whatever reason. So he ordered 1 of morphine with 4 of Zofran Then he wimped out and didn't end up giving the guy anything for pain. Absolutely ridiculous...

 

[NomadicMedic]

Not ripping on you, but I hope I never get hurt in your neck of the woods.

I have no problem giving 100mcg of Fentanyl to someone who's in pain... Especially if we're driving on a bumpy road.

I had a recent call where a logger had a huge branch fall on his shoulder. He denied pain meds for the entire 2 mike carry out... Once I got him in the truck and talked him into some fent, he was a happy camper. He said, "damn, I shouldn't have kept saying no..."

If you've got the drugs and your patient is in pain, USE THE DRUGS.

 

[Milla3P]

If you've got the drugs and your patient is in pain, USE THE DRUGS.

This!
Especially if you have Fent, double Especially if you can give it Up the nose.

Though during a recent state truck inspection I was informed by the inspector that pain meds were optional and all the trucks in my fair Capitol city were without...

Back to topic: I start locks regularly and give fluid about 1% of the time. I generally take bloods 99% of the time or more. Chest pain gets a line and bloods, abdo pain gets the same, as well as AMS, diabetics and all unknown unconsciousnesses. Though that's not the whole list. If we feel it's warranted well even bring in a green tube on ice for a VBG or a grey top for a lactic.

Always before analgesics or benzos incase they want a Tox screen.
Were also pretty lucky, we use these fancy "BD Nexiva" catheter systems an they're pretty much set up to draw bloods instantly.



Who are we to determine who has real pain and who's pretending for meds? The fun thing about pain is that there's no real test for it and everyone's threshold is different.

Heck, if we DO think they're faking the pain, what's terribly wrong with finding out if the Abdo hurts more or the 18g?

Like it was said earlier, we should be looking further down the line, clinically, for our Pts. If we think this pt might need that line for SOME reason in the next 2 to 96 hours (depending on your hospital's inclination to change the line) why withhold it?

If vascular access is mentioned in prehospital standing orders and The scenario fits the orders, why would you withhold it? (The "Follow your local protocols" argument)

Lastly, Practice Makes Perfect. Coming up with reasons to not start a line generally means that you could come up with reasons why you could of. The more you do, the better you will be for when someone really is circling the drain and you need to kick it into high gear.

P. S. I am for IV access.

 

[VFlutter]

Does any place actually use local anesthetic for IV insertion? I saw it a few times during my OB clinical.


Although not entirely relevant, there is nothing more frustrating than responding to a RRT or Code for a patient without a patent IV. Yes, most can get one established fairly quickly or if the need arises, an IO but things can go south fairly quickly and sometimes on "stable" patients that is not expected.


Personally, even the small potential for a future need justifies IVs in most situations

 

[Tigger]

Does any place actually use local anesthetic for IV insertion? I saw it a few times during my OB clinical.


Although not entirely relevant, there is nothing more frustrating than responding to a RRT or Code for a patient without a patent IV. Yes, most can get one established fairly quickly or if the need arises, an IO but things can go south fairly quickly and sometimes on "stable" patients that is not expected.


Personally, even the small potential for a future need justifies IVs in most situations

Wen I had my last line started on me at a tiny ED in Vermont, the nurse used some sort of "numbing swab" (her words), I think it was lidocaine but I can't be entirely sure.

 

[NomadicMedic]

If a patient complaints and whines that the IV is "gonna hurt"... I usually offer some of this, PO, first. (especially if it's a big biker dude or someone covered in tats and piercings.)

 

[VFlutter]

If a patient complaints and whines that the IV is "gonna hurt"... I usually offer some of this, PO, first. (especially if it's a big biker dude or someone covered in tats and piercings.)

Oh :censored::censored::censored::censored:! You mean those are not suppositories? I've been giving them wrong....

 

[EMTNJA]

In my system all ALS protocols call for establishing IV access. But it boils down to do they need one, and if they don't does the medic feel like he needs one for that particular patient. So bottom line ALS gets IV, and BLS no IV. Also very few medics in our system will do a saline lock, must hang a full liter whether or not pt needs fluids.

 

[EMTNJA]

Not ripping on you, but I hope I never get hurt in your neck of the woods.

I have no problem giving 100mcg of Fentanyl to someone who's in pain... Especially if we're driving on a bumpy road.

I had a recent call where a logger had a huge branch fall on his shoulder. He denied pain meds for the entire 2 mike carry out... Once I got him in the truck and talked him into some fent, he was a happy camper. He said, "damn, I shouldn't have kept saying no..."

If you've got the drugs and your patient is in pain, USE THE DRUGS.

Amen!

 

[OIFXGunner]

In my system all ALS protocols call for establishing IV access. But it boils down to do they need one, and if they don't does the medic feel like he needs one for that particular patient. So bottom line ALS gets IV, and BLS no IV. Also very few medics in our system will do a saline lock, must hang a full liter whether or not pt needs fluids.

That seems like a waste of supplies to me... so you're telling me that the CHF patient with his lungs full of fluid is going to have a bag of the very thing that is causing his problem hung anyways?

 

[NomadicMedic]

For what it's worth... my paramedic instructor, Mike Smith, was adamant about what he called "building a safety net".

If you think you may need IV access, get it early. Don't get behind the eight ball. If you feel that patient may need multiple lines, START multiple lines. You may not ever hang a bag of fluid, but at least get the access before things start going down hill...

And really, the only way you get and stay good at any skill is by practicing. That's why I start a lock and draw blood on almost* everyone. They may not need fluid or meds right now... but I'm ready, just in case.

*there are exceptions to this rule.

 

[EMTNJA]

Yep. The Resp. Distress algorithim line for CHF/Pulmonary Edema/Rales goes: Inital Medical Care>Establish IV Access(whcih as above to most medics means a bag)>Nitro>Lasix

Gross over simplification but there it is.

 

[STXmedic]

I don't think he's arguing about the IV. Just seems a bit ridiculous to hang a liter on everybody when they're typically only TKO anyway. Fairly wasteful and pointless versus a lock or even a 500cc bag

 

[EMTNJA]

I don't think he's arguing about the IV. Just seems a bit ridiculous to hang a liter on everybody when they're typically only TKO anyway. Fairly wasteful and pointless versus a lock or even a 500cc bag

I know. Just trying to point out that the protocols only mention access, and to most *cough* fire *cough* medics thats a full blown liter. (ALS-Fire based system)...

 

[usalsfyre]

That seems like a waste of supplies to me... so you're telling me that the CHF patient with his lungs full of fluid is going to have a bag of the very thing that is causing his problem hung anyways?

Look up the current thinking on the patho of CHF to see why fluid may actually be indicated in HF.