IV advice?

[Porta]

Today was my first ER rotation. Things went well, I had a good time and felt comfortable interacting with patients, pushing drugs (although I most def need more experience) etc. What I wasn't comfortable with was IVs. I'm okay with missing them, I'm okay with retracting the catheter and seeking the vein, but I'm most concerned with my patient's level of discomfort. Nobody likes to have someone rummage a catheter up and down their arm looking for a vein.
After the second try I would discontinue my attempts and hand off to my Preceptor to establish the line.
At what point would you feel it was appropriate to stop trying?
I understand that this is a tough skill to learn, and I'm not discouraged, I'm more concerned with what other providers feels is an appropriate amount of attempts before handing off to a more experienced provider.

 

[Jambi]

Depending on the patient my threshold was usually 2 trys. It really depended.

I know that's still vague, but judgement comes down to exerience, so I say keep doing what you're doing and stop worrying. Your preceptors will/should intervene if needed, and your discretion will develop as time goes on.

"stay calm and start IVs" LOL

 

[Porta]

No, no that's not vague to me at all. The nurses also said its patient specific. One of the pts I had tonight was already in enough pain, and I wasn't about to cause them more grief by turning them into a shishkabab.
After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to.
Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...

 

[STXmedic]

My typical rule of thumb is two. If they really need access after two attempts, my partner and I will both attempt, or move to an IO. If its an IV for a comfort measure, I'll talk to the patient about whether or not they want me to try again or if they can wait until we get to the hospital. If it's an IV more for hospital ease, or for something simple like addressing a mild dehydration, I won't go past two. Other things will come in to play as well, but that's the gist of it.

 

[Jambi]

Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...

I do not. It is against my personal ethics, and I also believe that it falls outside professional conduct standards.

Pt treatment should always be dictated by Pt condition and need.

I know people that would/will toss in large-bore IVs based on behavior, etc., but that's on them...

 

[mycrofft]

After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to.
Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...

That's called battery and malpractice. Churchill said when you're killing a man, being civil to him costs nothing. Same for starting IV's.

Where I worked two tries was the rule of thumb. Rarely we would make multiple tries drawing DNA forensic specimens because, for a time, if a subject didn't yield a specimen they had to wait out the rest of their sentence. I once stuck a willing guy fourteen times for a blood specimen.

 

[Tigger]

My training program allowed us one attempt and then we had to retract the cath and the preceptor or RN gained access. We also had to ask permission as students to gain access.

 

[Porta]

My training program allowed us one attempt and then we had to retract the cath and the preceptor or RN gained access. We also had to ask permission as students to gain access.

That's actually one thing I noticed tonight, I was the only one asking if I could physically touch the patient.

"Hi my name is Porta, I'm an Advanced student, would you mind if I started an IV on you/palpated your abdomen/etc?"
.

Thank you all very much for your responses. I feel more comfortable.

 

[NYMedic828]

Some people claim slapping the vein causes venospasm and may engorge the particular vein a bit but quite honestly it has never done anything for me... See nurses do it all the time but I think its just an old practice...

what does work is a solid, tight tourniquet and a good rub down with the alcohol swap. A tight tourniquet can be uncomfortable for a patient but it won't be as bad as if you have to stick them again. In the field, you can supplement a BP cuff pumped up nice and tight it works even better.

 

[JPINFV]

That's actually one thing I noticed tonight, I was the only one asking if I could physically touch the patient.

"Hi my name is Porta, I'm an Advanced student, would you mind if I started an IV on you/palpated your abdomen/etc?"

"Hi, my name is JPINFV, I'm the medical student on the _____ team."

At least at my current hospital, the treatment release that's signed for minimal and basic procedures (IVs and the like, in contrast to say... surgery or central lines) includes a line on the fact that students and residents are involved with the patient's care. Similarly, the consent form for major things (like surgeries) includes a line about students and residents being involved. Gotta learn somehow, and they're free to say no. However, I'm not going to specifically ask if I can do an exam, especially since my exams aren't just extra exams (our notes go into the patient's chart).

 

[Porta]

"Hi, my name is JPINFV, I'm the medical student on the _____ team."

At least at my current hospital, the treatment release that's signed for minimal and basic procedures (IVs and the like, in contrast to say... surgery or central lines) includes a line on the fact that students and residents are involved with the patient's care. Similarly, the consent form for major things (like surgeries) includes a line about students and residents being involved. Gotta learn somehow, and they're free to say no. However, I'm not going to specifically ask if I can do an exam, especially since my exams aren't just extra exams (our notes go into the patient's chart).

I didn't think of it that way, I was thinking more along the lines of "How would *I* feel?" But now that I see where someone else would be coming from I can understand why my fellow classmates kinda hung back.

I figured it would bode well for me if I was polite and asked for permission first, rather than just telling them what I was going to do to them. Granted this is in a learning setting, and in a controlled environment. I don't plan on being as polite (I guess you could say) in the field.

 

[JPINFV]

Granted this is in a learning setting, and in a controlled environment. I don't plan on being as polite (I guess you could say) in the field.

The attitude I approach patient care, as a student, is that I'm a member of a team (which is true). I work with my team to care for you. Yes, you can refuse. Yes, I'm properly supervised for what I'm doing (I don't need someone to watch me take an H&P or do a progress note, for example). Yes, the patient should know who is treating him, including students (one of the reasons I despise the title "Student Doctor JPINFV with _____" and use "JPINFV, the medical student on ___").

However I think there's a certain amount of confidence when the student presents himself as legitimately being there and performing a legitimate function instead of a "let me poke and prod you for the sake of poking and proding you." It's not about hanging back. It's about presenting yourself as being as essential as anyone else on the team. Granted, if I know something specifically will be painful, I'll defer to the resident or attendant's exam. There is no sense for causing pain for the sake of causing pain.

 

[18G]

When I was a Paramedic student I had an awesome RN in the ED who made me keep trying until I got the IV. Her philosophy was if I don't do it in the ED I won't be able to do it in the field.

Now as a Paramedic, I limit myself to three attempts unless a critical patient then I limit that and move on to another option. I don't usually have an ALS partner to help with an IV so its all me which is why I do three attempts.

Had a call a few days ago. Pt. intubated and paralytic onboard. Vancomycin infiltrated enoute and had to pull the line. Tried twice in the other arm without success. By this time patient is withdrawling, moving head slightly and sweating. So it came down to IO or EJ. Patient had a nice EJ so stuck that with an 18 no problem and got the Versed and Vecuronium onboard.

 

[EMSrush]

After the second try I would discontinue my attempts and hand off to my Preceptor to establish the line.
At what point would you feel it was appropriate to stop trying?
I understand that this is a tough skill to learn, and I'm not discouraged, I'm more concerned with what other providers feels is an appropriate amount of attempts before handing off to a more experienced provider.

I'd like to preface my response by saying that I believe the answer to your question will differ, depending on who you are talking about. For a student, I say two sticks per Pt max before you hand it off. For an experienced provider, Pt's condition and good clinical judgment will dictate how many attempts and which type of attempt needs to be made.

Regarding sticking Pts /c a large bore due to their behavior, I think that's really bad juju. I'd recommend you ignore those "suggestions" for a multitude of reasons.

 

[Handsome Robb]

People always hate me for saying it but why not practice your large bore IVs on the people that are so inebriated/high/unconscious/drug affected they either wont feel it, remember it, care about it or any combination of the above. When you actually need big bore IVs (read: 14 or 16 gauge) you need it on the first shot and quickly.

With that said, your treatments should never be punitive. If you're starting a huge line because "this guy is an :censored::censored::censored::censored::censored::censored::censored:" you need to check yourself.

I'll say it now and everyone can get upset about it, I often place or have my students place 16g IVs in extremely intoxicated people and don't lose any sleep over it.

As for the max attempts, as a student you get 2 shots unless it's a critical patient that I need access on quickly then it's only one opportunity before I take over.

I agree with what JP said about identifying yourself as a student.

 

[Veneficus]

People always hate me for saying it but why not practice your large bore IVs on the people that are so inebriated/high/unconscious/drug affected they either wont feel it, remember it, care about it or any combination of the above. When you actually need big bore IVs (read: 14 or 16 gauge) you need it on the first shot and quickly.

With that said, your treatments should never be punitive. If you're starting a huge line because "this guy is an :censored::censored::censored::censored::censored::censored::censored:" you need to check yourself.

I'll say it now and everyone can get upset about it, I often place or have my students place 16g IVs in extremely intoxicated people and don't lose any sleep over it.

As for the max attempts, as a student you get 2 shots unless it's a critical patient that I need access on quickly then it's only one opportunity before I take over.

I agree with what JP said about identifying yourself as a student.

I think I wrote a few volumes on this actually.

first, in my pseudo scientific experiment the difference in nociceptive pain pain from a large bore and a smaller guage is indistinguishable.
(a coworker and I each tried sticking the other blindfolded with both a 14g and an 18g) In 3 of the 4 cases neither of us could accurately tell. In the 4th my partner in crime actually picked the 18g as more painful.

The real difference is largely psychological. So starting a large bore IV on a drunk patient is probably only going to satisfy the anger of the provider. (Not exactly the moral ethical thing, but it happens.)

The other issue is that it takes a different technique to insert a large bore catheter. Like any skill, if you don't do it regularly, you will not be good at it when it counts. That means somebody, sometime, is going to get a larger needle than they "need." It is sort of like animal testing, at some point, there are acceptable losses.

As for the OP, trouble with IVs on the first ED rotation? I wouldn't worry about it at all. Now after 5 years in the field, well, maybe there is a problem then.

Every place I have been, there is a noncritical understood (not written in policy or the like) of 2 attempts before asking for help.

When the pt. is critical, then all bets are off and "whatever it takes" is the only rule.

Chances are on an ambulance, unless you are giving a med, the patient can make it to the hospital before an IV anyway.

As for improving, always ask to try to stick the hardest patients at your clinical location. It is the best way to build the skill.

As a hint, practice extensively on the Basilic and cephalic veins. They are not often visible, they are not on a joint, well above shunt placement, and because of human embryological development, have almost no anatomical deviation. Which means whether a newborn or 300kg 90 year old, it is a reliable option.

 

[james88]

No, no that's not vague to me at all. The nurses also said its patient specific. One of the pts I had tonight was already in enough pain, and I wasn't about to cause them more grief by turning them into a shishkabab.
After the nurse and my Preceptor said that if the pt is unconscious (or an a$$) , hit them as many times as I want/need to.
Which leads to my next question (bear with me) does a patient's behavior dictate your IVs (placement, size)? I've heard stories of Medics being pretty sadistic with unruly patients..but they're still people...

I was talking to a nurse the other day and she was telling me about a pt that came in with an IV in their forehead. lol

 

[Veneficus]

I was talking to a nurse the other day and she was telling me about a pt that came in with an IV in their forehead. lol

I saw an anesthesiologist put an IV inder somebody's eyelid to try and challenge himself after EMS and several ED staff couldn't get one.

I have yet to attempt such myself, but have used everything from the forehead, breast, and varicose veins.

Once saw a nurse put an IV is the penis after an abusive pt called her a worthless c***.

 

[mycrofft]

"I saw an anesthesiologist put an IV inder somebody's eyelid to try and challenge himself after EMS and several ED staff couldn't get one. "

Hate to see that one sclerose or infiltrate.

Yeah, gauge versus discomfort can be largely due to technician psycholgy. How about times you need a bigger needle, such as to avoid haemolysis? Or to introduce mui-lots-lots fluids STAT? (Mouth wide, here comes foot... ).

 

[18G]

Don't know if its true but one of my Paramedic instructors told the class that he knew a medic that placed an IV in someone's penis lol. The topic was get a line where you can when you really need one.

Hmmm.