saline-lok opinion

[mycrofft]

Another angle or two.

1. Someone said don't run fluids if not needed. Bravo. My local EMS standard specifically prohibits starting an IV unless indications for IV treatment are met, NEVER for "just in case". If you do so, you are faced with the worst punishment they can offer, "Death by Mumbo".<_<

I think a saline lock would be better if you were teetering on the need to go parenteral but fluid balance was an issue, like a burn victim or seizure pt with CHF.

2. When I worked ER, along with removing all field dressings and splints, we would D/C all field IV starts UNLESS we could not find another vein....usually due to the antecubes looking like they were attacked with a sewing machine. If a venous oriented problem arises, and that field start is still in place, someone would pay.

Really side bar: my vet charges $125 to use a saline lock for euthanasia. Pretty good for $0.50 worth of hardware. Wonder if HE would accept a field start?

 

[The-Reaper]

I know when I worked as EMT-I any pre-hospital got a lock for three reason.
1. keeps your skills up
2. They will need it at the hospital
3. You pt could take a turn for the worse

 

[mycrofft]

So in my county theoretically you would lose your permit.

My (soon to be former) cohorts will flail and thrash and finally start a butterfly 22 ga as the paramedics are under 100 ft away.h34r:

 

[boingo]

The saline lock is useful for extrication purposes. How many lines have been pulled while carrying a patient down several flights of stairs? You can always hang a bag later if needed. Also, the hospital use our lines, but change out the bag and tubing, a lock makes that a whole lot easier than trying to disconect the IV tubing at the hub of the angio.

 

[MrBrown]

I know when I worked as EMT-I any pre-hospital got a lock for three reason.
1. keeps your skills up

That's why we have an IV arm at the station.

2. They will need it at the hospital

Not true

3. You pt could take a turn for the worse

If they are crook then yeah but I'm not gonna go cannulating every single patient I come across? Whats the point? Waste of resources, unnecessary procedure and causes the patient pain they do not need.

 

[reaper]

Exactly right Mr. Brown, Those were the 3 worst reasons I have ever heard.

 

[wyoskibum]

Love Em!

so at my service everyone that gets an iv gets hooked up to a 10drop and 500cc of either LR or NS. my question is...how good or bad of an idea would it be to attemp to get the equipment to do saline locks in the back of the truck for pts that get an iv? we dont run medics here just emt-b and emt-i...so iv tx in prehospital is limited to narcan,D50, and fluid bolus. i feel that pts not neccessarily requiring any of these but could use iv access for further tx in the ER could use a saline lock. but i dont have any opinions other than my own and i havent even asked anyone about it. just curious i guess....any input would be great!!!

I've been lucky and have always had saline locks available. Even if I'm going to be administering fluids, I always use the locks for the initial IV start. I find it much easier to secure the IV once established, especially if I'm doing the IV enroute. I know the hospitals that do use field IV's appreciate it as it make it easier to switch out IV's and tubing. (Pump tubing, blood tubing).

 

[cookiexd40]

heck im proud of myself for coming up with a good informative thread for a change lol ...all very good responses guys and gals...keep'em coming

 

[mycrofft]

The "three-worst-reasons" thing...

Rural squads used to get on the radio in eastern Nebraska to find a receiving hospital which would allow them to start IV's enroute. The distance to any hosp was basically the same when you lived in Emerald or Ashland and were driving to Lincoln.

Maybe bad reasons, but in an earlier age they were part of the prehospital EMS culture.

 

[Veneficus]

Some more logic from microbiology

Well.......even if EMS IVs are more prone to infection, does leaving it in there increase that risk any? I mean the cath is already in place so any "unwanted stuff" is already in and washed into the person's system, right? If I am wrong, let me know. But it just seems logical to me.

Certain microorganisms can form biofilms, particularly on indwelling catheters of various types, which protect them against the bodies natural defenses as well as medical therapy.

In field conditions, particularly with improperly cleaned/stored equipment and improper short cuts in procedure, there is an increase in the chances of introducing extra amounts of microorgansims. Consider as well, that the back of an ambulance is actually a medical facility and maybe colonized with more resilient organisms. The synthetic catheter provides and excellent medium for growth. Removing the contaminated medium, removes any potential biofilm that would form over hours to days, reducing the risk of pathogenesis.

http://www.emsresponder.com/web/online/EMS-Education-and-Training/MRSA-Colonization-in-Ambulances/5$5711

Roline CE, Crumpecker C, Dunn TM: “Can methicillin-resistant staphylococcus aureus be found in an ambulance fleet?” Prehospital Emergency Care . 11(2):241-244, 2007.

The real danger is not in the introducing of small amounts of microorganisms, but in introducing them on a nonshedding medium that can be colonized in a way that renders host defense ineffective.

Restarting these IV lines in a cleaner (if not sterile) way, and changing them often is the best way to reduce biofilm colonization.

a few extra needle sticks to reduce the chances of developing a resistant sepsis seems like a very reasonable trade to me.

 

[18G]

I've started many lines in the ED and the aspetic technique is the same. Unless EMS is starting a line in the middle of a farm field just spread with manure or starting one in a ditch, I really don't think there is any difference from starting a line in a hospital versus someones living room.

Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.

 

[TransportJockey]

I've started many lines in the ED and the aspetic technique is the same. Unless EMS is starting a line in the middle of a farm field just spread with manure or starting one in a ditch, I really don't think there is any difference from starting a line in a hospital versus someones living room.

Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.

The primary reason that field sticks get pulled is that it's not a controlled enviroment when sticking. Combined that with the fact that some EMS providers have made a bad name for field IVs and the staff didn't see it started and can't see that it was done properly. Besides, if you have to stick for labs, why not just start a line you can be sure of while you're in the ED.

 

[lightsandsirens5]

The "nasties" might be in their system, but the problems may not manifest until later. You may only see localized pain in your prehospital patient care, but if left untreated, the phlebitis can cause edema to the site, blood vessel wall deterioration, extravasation of what is being infused - which could cause tissue necrosis....it's not just about the initial phlebitis, but what can result from it.

OK. I think I get it. Thanks.

 

[Veneficus]

Think about it... how many microorganisms are present in a hospital versus your very own living room? The ones in the hospital are more virulent. A ambulance that is properly disinfected on a regular basis is every bit as clean as a hospital.

86 living naturally on your skin.

Quantity is only part of the infectious equation. With a few exceptions the organisms crawling around a home are generally opportunistic infections. What may be surviving in a hospital or an ambulance has been specially selected for its pathogenicity. Those organsisms are very resiliant to start with and do not compete for resources with other organisms. (because the weaker ones are dead) It is the same as in the hospital.

I remember reading somewhere (but I forgot where or I would post it) that the healthcare location found to have the most microorganisms was dialysis clinics.

by the numbers if you start 1000 lines and only 1% gets an infection, that is still 10 people.

I am not suggesting that hospital providers are better or worse at preventing infection, but considering the hospital will be eating the cost of treating patients, it is reasonable to think they want control over who is starting the line and taking every precaution they can to minimize the risk.

Can we honestly say or be sure that every field provider is taking every precaution when performing procedures? Can we say the place the trucks are kept in is relatively clean? Can a hospital fire a consistently negligent field provider who constantly costs them money?

Can this be said for a majority of agencies?

It is all about prudent precaution.

 

[EMTinNEPA]

I am very fond of locks, as are most medics at my service. Some medics will actually start a lock and, if the patient needs fluid, will connected the drip set to the lock via an alligator clip.

 

[8jimi8]

Well i thought i didn't have much to offer to this conversation, but it just dawned on me, the differences in practice between lines I have started in the field and lines I have started in the hospital.

In the field, we are taught to cleanse the area vigorously with 2 alcohol wipes. You know... the little 1inch squares...


In the hospital we use chlorhexidine scrubber pads. I mean how much cleaning and friction can you actually get with a tiny little 1 inch square of alcohol impregnated gauze.

 

[18G]

In the hospital I started lines the most, we used the little glass ampule of alcohol that you crush which allows the alcohol to saturate the gauze at the end of it.... that was because that is what came in the IV start kit. Phlebotomy used the chlorhexidine sometimes. Usually the chlorhexidine was used when they were obtaining blood cultures. For routine venipunture they used alcohol wipes.

The alcohol disinfects by its drying effect. The wiping motion obviously will physically remove some of the nasties but ultimately its the drying effect that kills the pathogens (least this is what I was taught).

We get out IV start kits from the hospital so we use the glass ampules of alcohol to disinfect.

Again, I would really, really love to see some real statistics on this issue. We may all be surprised by the research. Nonetheless, it would be very interesting!

 

[8jimi8]

The alcohol disinfects by its drying effect. The wiping motion obviously will physically remove some of the nasties but ultimately its the drying effect that kills the pathogens (least this is what I was taught).

This is WRONG. Alcohol only kills until it evaporates and that is when it stops killing.

This is why you have 70% isopropyl alcohol because any higher percentage evaporates too quickly to kill anything.

forgot to add... and it depends on which IV start kits you get because ours come with the chlorhexidine scrubber pads.

 

[mycrofft]

Alcohol "dries cells out" by chemical processes.

Alcohol attacks the cell walls and any lipids involved, chemically draws out the water; 70% with water solutions seem to be most effective. You can see the cells wither. More importantly from the aspect of cleansing a site, the friction and the solvent properties disrupt the substrate (film of sweat, oil, dirt, spooge, and biofilm) on the skin so if it is wiped off (say, with a nice sterile gauze pad) most of the little beasties and plantses are removed with it. "Wither goes the substrate, goeth the microflora and fauna". I've used straight Clorox in a pinch (scratched by pus-innoculated cat claws) and the wound healed with no scar.

SO....to the post...much of what we do is tradition and empiric practice immortalized in protocols. It still is impossible to sterilize skin without destroying it, but some approaches leave the site cleaner than others. In house risk managers want everything to be accountable to the hospital. This is almost ludicrous seeing as how the simplest way for germs to get in/on a patient is off of US, the scrubs we wear from home, the shoes we wear from the car into the hospital, the hands which we "wash" with a squish of scented hand lotion with a bit oif alcohol.

If you take the time (like, tomorrow), and CLOSELY inspect many sterile supplies in your ambulance, you are going to find a percentage which are no longer air tight due to tiny friction spots created by being driven around all the time, thermal breakdown of pkg adhesives, and etc. You might even find, as we used to in the old Chevy van units in USAF, that actual road dust and exhaust particulates make their way into storage compartments.

Once again, also, there is no medical rationale for universal IV starts. Practicing your skills on someone is a tort. Not to be rude, but that sort of willfull malfeasance is unprofessional, childish, and actionable.

OK, so I DID mean to be rude. <_<

 

[cookiexd40]

i agree on how bad "practicing" your skills is not a good idea. and the cell wall, alchohol attacking. blah blah blah...lol no dis respect but i had to read it 5 times jsut to understand it..lol im just a new intermediate and the knowledge base is quite minimal at this point but iteresting to say the least