Is Venous Cutdown in the Paramedic Scope of Practice

[Doczilla]

This brings up a good question.

For those starting central lines in the field, are you taught landmark techniques or are you required to use ultrasound guidance?

None of our residents are taught landmark techniques in my center. And it worries me that we have become so reliant on ultrasound. I'm not even allowed by hospital policy to teach them landmark techniques (subclavians excepted) on live patients, though they are expected to know it for written boards.

For the one femoral I did, it was landmark. Same for the femoral nerve blocks I did, (for tourniquet pain), landmark only.

 

[ERDoc]

I was taught how to do a cutdown back in 2002 on a dog but have never done one on a person and 13 years later will probably never try to do one. I was taught how to do central lines in the days before US so I prefer to do them by landmarks. I will say though, when you can get the IJ or femoral artery by landmarks, the US is a life saver. There is nothing better than being able to watch the needle go right into the target. Doczilla, give it a try when you have a chance or watch a resident do it. I was never formally trained how to do it but had to learn in the moment at my rural shop when 3 docs couldn't get it on a crashing pt. As long as you know your anatomy, it's pretty easy. The hand coordination is a little strange at first.

For those putting central lines in out in the field, what are you using? I can't imagine anyone (except for maybe flight services) use triple lumens or a cordis (though I have been surprised many times).

 

[medicsb]

I'm at a hospital that sees a lot of penetrating trauma arrests and we do femoral lines by landmark only, which can be very fast. There are times you nail the vein on the first pass of the needle, but other times you're poking around forever and getting nothing. The trauma service doesn't use US for fem lines as they want their residents and us (EM residents) to learn by landmark. No cleansing the site, no sterile technique - clothes removed and line placed ASAP. Subclavian is the the 2nd site if femoral is not possible and by that point a cut down is initiated most frequently in the proximal thigh. But cutdowns are not easy (and infrequent) and I have seen trauma surgeons with decades of experience have difficulty getting access in a patient that has bled out. For noncoding, nontrauma patients, all lines should be done with US guidance. I'm not opposed to CVC placement in very select patients in the prehospital setting, but I have no idea how a non-physician would ever get enough experience with them during training to give them enough proficiency to place them.