I.V. difficulties?

[TKO]

Hi, borrowing Terese's account here....I'm her partner, Meph, and I just want to take a dip in the pool of experience available if that is allright.

I'm having problems with my IVs. TK is helpful but she isn't having problems, her IV-kungfu is fine!

Where's my self-confidence gone? I'm stinking out loud with my IV starts. Well, I make it sound worse than it is....but my recent ability to get a successful IV is making me doubt myself. My hands are shaking so bad now after I get a poke and even when everything looks good, something happens, I push up against a valve or the catheter goes interstitial. I'm probably batting only 50/50 and I feel so ashamed when I don't get a successful start. I'm not doing the ACs because I need to get hardcore with the metacarpals or the cephalic/basilic veins.

I know what I am doing, but it isn't working all the time. I know IVs are never perfect but it is getting so frustrating. My confidence in myself is just so low now that my hands are shaking terribly. It's awful. My pts must be panicking to see my hands shaking like I'm having a seizure....that can't be good.

I'm practicing my IVs in endoscopy whenever I get the time and that's probably the worst place to look for confidence. These are people coming in off the street that have been fasting and are dehydrated....that makes for a quick temper and a complaint on the end of the tongue, not to mention the condition of their vessels, but otherwise they are fine. It's not like in the back of the bus when your pts have other issues to distract them. But I have to do 25 supervised IVs in endo for my license.

What do you do for boosting your confidence? I run my calls like clockwork and everything is great but I just can't get enough successful pokes. I've re-read the literature a few times and it says that this happens....but I need my confidence back.

 

[ffemt8978]

Practicing on drinking straws can help. How are you at starting IV's on critical patients? I've found that I'm more successful when I hesitate less, especially on truly critical patients.

 

[TKO]

That's the thing, I find myself praying a car will crash into the side of the building so that I can do something that will steady my nerves. I'm better when I am in charge than when I am taking direction.

Just playing with a catheter I have determined two flaws that I need to correct: first or which is that I do not advance the cathlon far enough. I get flash and then I drop the angle but I don't advance enough. I go a mm or so, but then when I am advancing I often see the tip of the cathlon come out. I know I am supposed to advance about a 1/4" in but for whatever reason, I just don't. I guess I think I am in and that's enough because I don't want to blow it from there or maybe I just don't want to hurt the pt any more than I already am. I don't know.

secondly, and this is partially responsible for the first problem and it is that I have been trying to advance the catheter in one motion which often forces me to adjust my hand position slightly. I didn't know that I could push on the outer casing to advance the catheter (instead of at the tip). I just now noticed that there are ridges on the casing for that purpose. See, before I would get to a point where I couldn't advance with my finger so I would flex my hand more and often instead of pushing forward with my index finger, I was actually pulling back with my thumb and 2nd finger (allowing the tip to come out).

So this is a big realization for me, sort of a revelation....penetrate the vein deeper and advance using the ridges on the casing in 2 motions of the index finger.


Now how do I get my hands to stop shaking so badly? Did anyone else have trouble with IVs at first and have suggestions? Does anyone have some bad experiences to share (to alleviate my fear that I am the suckiest of the IV suckers to ever suck)?

 

[Rattletrap]

Something I have been running into with the elderly is, I have had to start not using a tourniquet. Reason is they are blowing due to the amount of blood thinners they are on.

Another problem I was having is being solved by going to the eye doctor. I did not notice that my vision was starting to slip until a week ago.

 

[Tincanfireman]

Now how do I get my hands to stop shaking so badly? Did anyone else have trouble with IVs at first and have suggestions?

Meph,
Sounds like a bad case of the yips from up here in the cheap seats. The good news is that the worst is over, you've identified and accepted that the problem is real and you know that you have some work to do. First, grab some good practice media (I use oranges and apples, at least you can eat your mistakes...lol) or a practice arm and do some basic sticking. You know your procedures, just walk through them nice and slow, with emphasis on technique and what you're doing right and wrong. Next, work on your speed and rhythm to re-school your hands and mind on the right way to do things. If possible, could you get some in-service time with one of the local ER nurses or phlebotomists? You can tell them that you feel you're not working up to your ability and you'd like a little critiqueing from another person. Again, work on the procedures and rhythms that you have used in the past to accomplish successful sticks. Lastly, have you had a good comprehensive physical lately? It could be HTN, vision, meds, OTC stuff, caffeine, etc, etc. that is actually the culprit. We all go through cold spells and periods of doubt about our abilities from time to time; you're not the first, nor will you be the last. Was there a traumatic event recently (a bad call/outcome)that might be triggering an emotional response when you look down at an arm? These are just a few idea from my little toolbox, and everything here is just my .02, but I hope it helps. Best of luck...

 

[TKO]

Great suggestions everyone. The only reason my hands were shaking is low self-confidence. Every time I failed to get a start, I felt like everyone else in endo was going to look down on me and inevitably the doctors would say "thank you, but you need to go back and study your material some further, and then....don't come back." Of course, they never did, they were always very supportive and insisted that experience was what I needed....but I always felt like that was the warm up to the boot out the door. And that was killing my confidence and concentration.

I went into endo today and got a few good starts. Still not getting every one, but by the end of this morning I was.

I had a really great RN working with me and she gave me a .22 to use (instead of the 20) and then said I should make some changes to what the textbook said, such as placing the tourniquet about 6" above the entry, reducing the angle of entry to between 10-20 degrees (instead of 30) and advancing the needle in about half way (as opposed to a 1/4") because the catheter is so flexible that if it has to go further unguided it is more likely to go interstitial.

Those tips worked very well for me. My hands weren't shaking or anything. A good mentor that can make you feel comfortable with failure can really improve your confidence and ability.

I hope that some of this will help others too. Self-confidence is so important in EMS. I remember as a student seeing a classmate panic after a string of bad scenarios in PMI actually freeze up on a cardiac arrest and ask me (the bystander in the scenario) if I knew first aid. When the tester nodded that I did (to see where it would go) the student asked me to do something. HAHAHA! He failed....and it was his confidence that killed the "pt". I also had a real call early in my practicum where I was breathing harder than the pt and my preceptor took me aside and asked me what I was doing. I said, "Panicking" and he said, "right. What is that doing to the pt?" and I said, "Panic" and he said, "right. How does that help?" and I said, "It makes things worse."....so I switched preceptors. HAHAHA!

 

[Tincanfireman]

Glad things worked out for you!

 

[ffemt8978]

Meph,

If I may make one more suggestion...


Since you've found this site helpful (I hope), why not sign up for your own account? (Hint, Hint)

 

[Anomalous]

Try gripping the catheter using your preferred method then resting the edge of your hand on their arm. That way, when you hit a bump in the road or they move their arm, your hand moves in unison with their arm. Also, switching to a smaller gauge isn't necessarily easier. The larger gauge is less likely to flex. This is especially helpful on someone who works in the sun and has that extra tough skin. I hardly ever use less than an 18 (on a normal size adult).

 

[RescueShirts.com]

Like all skills... IVs take practice, practice, practice...

A large part of your success will come from your vein selection. I have seen many new medics try for the poor vein that they can see... as opposed to the good vein that can be felt but not seen.

Get in the habit of "feeling" everyone's arms... feel the veins... find out where they are, what they feel like in different people (skinny, frail elderly... obese... kids... healthy people... sick people...)

As time goes on... you will know where veins are "supposed to be"... and you will also figure out different techniques for different types of "veins".

The AC is NOT always the best. I have seen medics pass over an easy forearm vein just to try (and miss) a difficult AC.

Your confidence will come... it just takes time.

Good Luck!

 

[firetender]

...and ya know what? Sometimes you just get these BAD RUNS (not the loose bowel type) where on one particular therapy, every time you do it you blow it, or it feels like YOU blow it, anyway.

It's like a virus, it'll pass, but the freaky thing about it is no matter how long you've been in the field, sometimes this'll happen. It happened with me about five years into my career. I had about a one month period where I couldn't start an IV for squat! In one moment, I'd say it was the little stinkers, the next the jolting ambulance, the next, the next...

Truth is, you're right on the money about confidence, though. I now know that once I blew, say, the first three IVs in a row, no matter the reason, I started to put too much thought into #4, then, by the time #5 came, I was spooked, and on and on, a viscious circle, maybe for ten patients in a row, maybe more, not kidding...

...until one day, it was a cold day because I remember wondering if cold would make a difference, I started a 20 GA TKO for a medical transfer. First try, no sweat. Having suspected I was on a run by then, I congratulated myself on getting through it...just as I noticed a wave of urticaria bubbling up on the patient's arm and it looked like it was moving North.

"OHMiGod!" i thought, "She's allergic to the catheter and the one IV that I finally got right is killing her!"

If she was having an anaphylactic reaction, I really needed that IV, didn't I? Not knowing what to do, I threw the blanket off her to see if the urticaria was spreading and to make sure I was ready to get down to it if everything went to hell. I paid special attention to her breathing and vitals and got ready to call in. Her only comment to me was "I feel lousier!"

Before I could go much further in my evaluation, the urticaria literally stopped in its tracks and receded. I was later to find out she was allergic to the laundry soap used to wash our blankets!

That was the end of that run, Thank God(dess)!

I won't even mention the bad run of MIs.

 

[TKO]

More great tips!

I think of "Bringing out the Dead" where Nicholas Cage narrates, "Spreading the blame is an essential tool for a paramedic's survival....'the tube wouldn't go in', 'the elevator got stuck', 'a new partner today' " because taking it personally will gut you of your confidence and kill your pts.

Up north we can only make 3 attempts per pt (officially) and when we do a moving IV we are supposed to stop the bus for the poke. It makes sense for our own safety and to improve the chances of a successful poke. Not everyone follows it but the theory is sound: get everything together and be ready then stop the bus or wait for a red light, poke, go. Only takes a 20 seconds off of time, and that really isn't anything if an IV is your big concern ATM.

I had been using 20s and have used bigger before too, but 22 is a good size for starting on the metacarpals, cephalic and basilic veins. Just not the best choice for bolusing. But in endo where the pts have been fasting and are dehydrated (and often geriatric) 22s are ideal.

Probably the best thing I did was to take a catheter home with me and play with it. Just learning to hold it comfortably and looking at its mechanics was so vital to improving my technique.

And the most important thing, even though I knew it all along but just didn't take it against the lack of confidence, is that it is the mistakes that make us better at what we do. Lucky Louis may make every poke on his first try out of school but eventually luck runs out and when :censored::censored::censored::censored: is on the line, where will he and his pt be then? I consider it a good thing that I encountered so many problems because I found the solutions now....that's how skill is developed.

 

[chfite]

Just another look at technique: hold the cather with your hand, align your shoulder behind your hand, and advance it using your shoulder. Just as driving a nail is more accurate and less tiring when your shoulder is behind your hand, so is cannulating a vein. Moreover, your larger shoulder muscles won't quiver from stress, excitement, or fatigue as will the smaller muscles in your forearm or hand. This overall stability will help with bumps and jerks that may occur.

There are so many things they don't teach in school.

 

[Emtgirl21]

I've gotten to the point that when I know I am going to the ER for my asthma (which happens bout once a month) I will have one of the medics start my IV. If i don't the ER will stick me between 6 and 8 times and at some point go get ultrasound to start my IV. Whats sad is the two medics that usually start my IV can get it first try down the bumpy city street. Oh and Don't get me started on ABG's....but its always nice to have a medic that can nail a good IV.

 

[Aileana]

I'd say just practice. At first, on inanimate objects (the suggestion of a straw sounded really good), and then on willing (and supportive) volunteers. Practice will probably get your confidence up (yes i know, can be easier said than done..). Also, using the pt.'s body (forearm, etc) to steady your hand will (hopefully) reduce errors due to shaking, and make you and the pt more confident.

 

[TKO]

yay! I am all done my 25 starts as of today. I really feel that failed starts are good for experience and learning, while the successful starts are good for confidence.

 

[Ridryder911]

Congrat's .. remember
Practice
Practice
Practice...

Did I mention practice?

FYI: For neonates and infants, practice on oranges. The small veins, that run through the fruit... one can cannulate them with small IV needles such as 24g etc..

R/r 911

 

[Emtgirl21]

wonder what the guys will say when they catch me with a bag of oranges and a box of 24g.

 

[Rattletrap]

wonder what the guys will say when they catch me with a bag of oranges and a box of 24g.

I would hand you a 14ga and tell you it would make a better straw to et the juice out.

 

[Emtgirl21]

Rattletrap, I woke up to a really bad day.....(electric company shut off my power instead of my neighbors and then swore it was my fault) and you just made me laught. That was pretty freaking funny! Thank you