Prehospital Access of Central Lines

[Carlos Danger]

Problem is, we don't have EZIO, just the manual ones.

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I'm no attorney, but at this point in the history, I would speculate that this potentially puts your service at some legal risk.

Not to mention the sheer idiocy of not using the EZ-IO, from a clinical perspective.

 

[Handsome Robb]

It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...

Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series? [emoji15]


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[VentMonkey]

Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series? [emoji15]

With the exclusion of our CCT division, yes.

As a side, I really love how the "cult" term transcends all threads in reference to Hall Ambulance, lol good times. I can't thank, @CALEMT enough.

 

[NPO]

Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series? [emoji15]


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Yes. Thats correct. We use manual IO needles, and while we are permitted to use Bougies, we don't have them.

E-Series is our monitor of choice. Our CCT division received X series monitors a couple years ago.

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[WolfmanHarris]

We're finally getting EZ-IO's at my service, just in time for me to start my precepting for ACP. Hoping we'll be getting the glidescope next, I know a neighbouring service is trialling them and our Service Quality Unit will probably advocate for them from a patient safety standpoint.

 

[TXmed]

The EZ-IO was meant to be put in manually, so that shouldnt effect success rates.

One of the inventors teaches a cadaver lab in san antonio, he is openly honest about it. he also says the only reason for the pedi size is for FDA approval and suggests using the adult needle even for pediatrics. pretty interesting class.

 

[VentMonkey]

There's also these. @NPO they come to California quite often TMK, and I am told they're quite insightful.
http://www.teleflex.com/en/procedural-lab-registration/usca.html

 

[Never2Old]

My Medical Director say's use an EZ-IO, don't touch the port.

 

[zzyzx]

You should follow your protocols, but there is no reason to be afraid of central lines.
With a little bit of education, I don't see any danger in paramedics using central lines. It's too bad some medical directors are not onboard. The last two places I worked allowed central line access.

 

[Tigger]

We have a similar "extremis" protocol, but given that I've never received any training on it, I think I'll just use the EZIO...

 

[zzyzx]

We have a similar "extremis" protocol, but given that I've never received any training on it, I think I'll just use the EZIO...

Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.

When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.

Again, not beating up on you personally, just saying that experienced people in the ER are going to be scratching their heads.

Why not do the right thing and question your EMS agency's QC officers about why you have not received proper training for something that is in your protocols and that you should therefore be responsible for knowing? If you haven't received this training, then your co-workers likely have not either, so here is a perfect way to improve the professionalism of you and your co-workers.

 

[NPO]

Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.

When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.

Again, not beating up on you personally, just saying that experienced people in the ER are going to be scratching their heads.

Why not do the right thing and question your EMS agency's QC officers about why you have not received proper training for something that is in your protocols and that you should therefore be responsible for knowing? If you haven't received this training, then your co-workers likely have not either, so here is a perfect way to improve the professionalism of you and your co-workers.

Worth noting, that PICC are not great for volume depleted patients. But then again, I've never achieved great flow rates from an IO either...

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[Tigger]

Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.

When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.

Again, not beating up on you personally, just saying that experienced people in the ER are going to be scratching their heads.

Why not do the right thing and question your EMS agency's QC officers about why you have not received proper training for something that is in your protocols and that you should therefore be responsible for knowing? If you haven't received this training, then your co-workers likely have not either, so here is a perfect way to improve the professionalism of you and your co-workers.

Perhaps where you work, but not here. We do not have Huber needles, nor does any other local agency. I cannot think of a recent time in which anyone I know has accessed a PICC line either. If it's already accessed I'd of course use it.

I am not going to drill a patient that is not quite ill, coincidentally such a patient's level of illness probably allows for the use of IO access. IO access is not looked at as cheating or a last ditch effort here, and is actually in the EMT scope of practice. Incidentally my partner and I recently caught some good natured ribbing from our medical director for not going to the drill sooner on a hyperK patient, who was awake and mostly alert.

 

[VFlutter]

Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.

When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.

I don't necessarily agree. As mentioned a PICC is far from the most perfect IV in terms of resuscitation.

A patient getting an IO is better than the hospital having to replace the central line, potentially having to perform a "line holiday" and requiring multiple PIVs, Abx, etc. We even go as far as replacing central lines placed at another hospital.

 

[zzyzx]

I don't necessarily agree. As mentioned a PICC is far from the most perfect IV in terms of resuscitation.

A patient getting an IO is better than the hospital having to replace the central line, potentially having to perform a "line holiday" and requiring multiple PIVs, Abx, etc. We even go as far as replacing central lines placed at another hospital.

Chase, why would a well trained paramedic not be able to properly access a PICC line? You and I both work as nurses and paramedics. What makes you think that a paramedic is going to cause a central line infection? I really don't understand your logic, but if you have a reasonable argument as to why that is the case, I'd like to hear it.

 

[zzyzx]

Worth noting, that PICC are not great for volume depleted patients. But then again, I've never achieved great flow rates from an IO either...

How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?[/QUOTE]

 

[zzyzx]

"Perhaps where you work, but not here. We do not have Huber needles, nor does any other local agency. I cannot think of a recent time in which anyone I know has accessed a PICC line either. If it's already accessed I'd of course use it."

Tigger, you don't need a Huber needle to access a PICC line. If central line access is in your protocols, I would encourage you to become more familiar with them.

 

[NPO]

How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?

[/QUOTE]
PICC lines do not allow for rapid infusion of fluids compared to large peripheral IVs. Combined with the fact that we do not have pumps, rapidly infusing fluids via a PICC is not ideal.

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[VFlutter]

Chase, why would a well trained paramedic not be able to properly access a PICC line? You and I both work as nurses and paramedics. What makes you think that a paramedic is going to cause a central line infection? I really don't understand your logic, but if you have a reasonable argument as to why that is the case, I'd like to hear it.

I am saying that central line infections happen even in "clean environments" with much care taken to prevent them so it seems prudent to only access these devices when necessary in the field. Risk vs Benefit. In extremis the risk is obviously outweighed however for routine infusions it is hard to justify. I am not saying that prehospital providers are incapable but there are many unknown factors. When was the last time the dressing/caps was changed? Did they change refulx valves after blood draws? When was the last time it was actually accessed/flushed? Was it heparinized? etc.

How many providers, Nurse or Medic, actually access lines correctly? Scrubbing the hub for a full 15 seconds, which is a long time, scrubbing the hub between each and every medication and flush? Actually performing hand hygiene and changing into clean gloves before accessing the line.

https://www.urmc.rochester.edu/medi...tions/documents/clabsipresentationdumyati.pdf

How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?

[/QUOTE]

PICC line has the slowest infusion rate of any access device, much slower than peripheral lines or IOs. PICCs can not be used with Rapid Infusers. Poiseuille's law; Flow rates are determined by the length and diameter of a catheter. PICCs are long and small bore.

http://emupdates.com/2009/11/25/flow-rates-of-various-vascular-catheters/

 

[zzyzx]

You don't need a pump to use a PICC line. Why do you think that you do?

You can run high flow rates through PICC lines and other central lines. Can you run infusions faster through a 16 gauge oeripheral IV? I don't; probably. But that is not what we are talking about. We are not discussing running on a GSW and finding that homeboy just happens to have a PICC line in his arm.

I don't mean to beat up on you guys and I understand that you don't have the experience with central lines that most nurses have. (I'm a paramedic, ER nurse, and ICU nurse). However, in the interest of furthering your education, I would encourage everyone to become familiar with the different types of central lines you may encounter as paramedics.