saline-lok opinion

[8jimi8]

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

Quoted for posterity's sake. I can't believe you admitted that. Now I officially understand and defer to Ventmedic's adamant advocacy for higher education for paramedics.

I feel extremely humbled.

Vent, i have arrogantly chastised you for triumphing education with a passion and fervor that is unsurpassed. I exetremely apologize for my previous comments and I vow to follow in your footsteps.

 

[Veneficus]

Before you get carried away

Sometimes I find, as I am sure other teachers do as well, when explaining concepts to the less initiated sometimes we take some liberties with simplifying the topic.

It sounds like the case here as there is a reaction time involved with the alcohol, it is why we measure the velocity of reactions. Another memory aid persists where the original knowledge was lost. (if ever known)

(When explaining immunology to paramedic students, I have found covering the concept of MHC isn't part of the curriculum and doesn't exactly win applause from the people listening, so I try not to take it to that level)

How do you fault skills based providers from not knowing something other than what they are taught? If we really were serious about educating EMS providers, they would have to take chemistry and biology before EMT class. Good luck with that. (but if you succeed add biochem to the list too, especially for nurses)

 

[cookiexd40]

Quoted for posterity's sake. I can't believe you admitted that. Now I officially understand and defer to Ventmedic's adamant advocacy for higher education for paramedics.

I feel extremely humbled.

Vent, i have arrogantly chastised you for triumphing education with a passion and fervor that is unsurpassed. I exetremely apologize for my previous comments and I vow to follow in your footsteps.

well ok to spare myself as much as i can....the way alchohol attacks the "nasties" has never been taught to me nor have i taken the oppritunity to learn it on my own. im still new enough in my career that i wish to work on skills and a basic knowledge level of wtf im supposed to do and how to treat pts. when i get a few years under my belt i would love to open my knowledge base up to the details and the science of our careers.

 

[mycrofft]

We're swerved afield, but one more step...

cookiexd40, I get it. Not to worry. It's good to get a response to my rambles.

I took a "statistics for health professionals" course and it has stood me i good stead. I think there ought to similarly be classes in public health, microbiology, etc. geared towards the busy working/family EMT. And in the bioethics of decision making (risk versus benefit versus profit of blanket IV starts, for instance).

As useful a tool as a saline lock is, if you start one on me without need and try to charge me for it, you're going to be in small claims court and also find a copy of a letter of complaint to as many agencies and newspapers as my retired fingers can shoot 'em.

 

[8jimi8]

well ok to spare myself as much as i can....the way alchohol attacks the "nasties" has never been taught to me nor have i taken the oppritunity to learn it on my own. im still new enough in my career that i wish to work on skills and a basic knowledge level of wtf im supposed to do and how to treat pts. when i get a few years under my belt i would love to open my knowledge base up to the details and the science of our careers.

Cookie, please accept my apology to you as well, I intended no disrespect towards you. Let me explain it this way. If you DON'T have the education to back up your "skills," you really have no place practicing them. You see what you have done is learned a potentially life threatening procedure, incompletely and backwards. Education should come before implementation. I was blinded by this because I was halfway though nursing school when I started my ems training. So I came to this field with a baseline of education and basically took for granted that people had done the requisite education beforehand, as I did. You see I had 4 semesters of education before anyone trusted me with a sharp and someone else's health in my hands.

 

[audreyj]

I agree that you have to know why you're doing it before you're doing it. And that starts with why you use alcohol, iodine, or clorihexidine, before doing any form of venipuncture. Just saying, "I rub with alcohol because that's how I always do it", isn't good enough, you need to know the reasoning behind why you do it.

As for the saline lock vs bag debate, we have a choice to do either. Certain standing orders require a 200cc bolus, in our suspected cardiac if the BP is high enough to give Nitro we're told to withhold a 2nd dose if there is no IV access. I'm not going to start a drip on a hypertensive pt with a diastolic of 120 or higher, I'm going to lock it in case I need to push a drug. Not every ALS patient requires an EKG, same goes for IVs. I'm not going to use someone as a pincushion if I can tell they have poor veins.

Our hospitals like when we start IVs in the appropriate situation. They don't take too kindly to someone coming with an IV that could go to triage. Also, depending on the facility, some EMS lines only have a 12-24 hour window before their changed. If I were transporting to a facility that pulled out EVERY EMS IV, I wouldn't waste my time putting one in unless they absolutely positively needed it.

 

[irish_handgrenade]

My partner and I both prefer to use locks, because our protocols call for an iv if possible for all ALS calls prior to dropping them off at the er. This being said not every pt. needs fluid or drugs, and I'm sure the pt would rather be charged for the lock and the flush rather than a bag of fluid, tubing, iv maintenance and all that other :censored::censored::censored::censored: that comes with it. Also if we deliver to a different hospital they might use different tubing and then they would have to dc at the hub and risk losing the iv or infecting the site. Bottom line locks are never a bad idea.

 

[zzyzx]

I recently read a study that compared IV starts in the field vs. healthcare settings. The conclusion was that field starts did not result in a greater number of IV-site infections.

I just spend a while looking for the article, but I couldn't find it. I'll keep searching...

 

[cookiexd40]

plz do id like to read it

 

[zzyzx]

Field-Started vs. Hospital-Started IVs

The risk of complications may be no greater in IVs inserted outside the hospital.

Researchers have reported conflicting results in
trying to determine if peripheral IVs started
“in the field” by emergency services personnel
(EMTs and paramedics) result in a higher incidence
of complications than those started by hospital
staff.
The Centers for Disease Control and Prevention
(CDC) offers extensive guidelines for the use of
any intravascular device, including peripheral IV
lines (http://www.cdc.gov/ncidod/hip/
iv/iv.htm).1 Based on current research into
intravascular device–related complications such as
phlebitis and infection, these recommendations
are used by health care facilities in writing their
own policies. The CDC advises that all fieldstarted
IVs (sometimes called prehospital IV starts)
be discontinued and new IVs placed after hospitalization.
But the CDC has acknowledged that
there’s no evidence that field-started IVs carry a
greater risk of infection2; furthermore, most
researchers have assumed that such IV starts occur
without aseptic technique. But this assumption is
flawed.
The Intravenous Nursing Standards of Practice
regarding peripheral IV lines give more weight to
what clinicians observe.3 These state that if there
are no signs of complication in the patient or of IV
contamination, the IV shouldn’t be discontinued,
regardless of who started the line and where.
They also state that signs of IV contamination,
phlebitis, or infection warrant immediate discontinuation
of the line.
The latest research supports these recommendations.
One study of peripheral IV–related phlebitis
examined 305 IV sites in 188 adult patients at a
Midwestern hospital.4 There were 10 occurrences
of phlebitis, but none was associated with the five
field-started IVs.
Researchers at a level I trauma center in Ohio
found no compelling data for the mandate that all
field-started IVs be discontinued and restarted at
hospital admission.5 The researchers developed an
algorithm to help nurses decide if a field-started IV
should be discontinued or could be left in place
for up to 72 hours (as IVs started in the hospital
were). Findings of two older studies conflict, yet
neither found high enough complication rates with
field-started IVs to warrant hospital mandates that
would change all such lines on hospitalization.
Lawrence and Lauro found that the risk of complications
increased when IVs were started in the field
by emergency personnel.6 But the study was small
and flawed—one EMT’s use of nonaseptic technique
was deemed responsible for most of the
complications. And a retrospective study by Levine
and colleagues established a lower infection rate
in field-started IVs than in hospital-started IVs.7
Hospitals should allow nurses to assess all IV
lines—both field started and hospital initiated—to
determine whether an IV is compromised. And
nurses should consider the circumstances under
which a line was started. For example, if EMTs
inserted a line while extracting a patient from a
wrecked vehicle, aseptic technique was probably
not used; in such cases, the IV should be discontinued
and restarted. In general, though, in the
absence of contamination or complications, an IV
change—an often painful procedure—isn’t necessary
for all field-started IVs. A more judicious policy
toward field-started IVs will save time and
reduce costs.—Rosalyn Gendreau-Webb, BSN,
RN, an ED staff nurse at Mercy Hospital,
Portland, ME
REFERENCES
1. O’Grady NP, et al. Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control
and Prevention. MMWR Recomm Rep 2002;51(RR-10):1-29.
2. Pearson ML. CDC guideline for prevention of intravascular
device-related infections: Part 1. Intravascular device-related
infections: an overview. Part 2. Recommendations for prevention
of intravascular device-related infections. Infect
Control Hosp Epidemiol 1996;17(7):438-73.
3. Infusion nursing standards of practice. Journal of Intravenous
Nursing 2000;23(6S):S56-S69.
4. White SA. Peripheral intravenous therapy-related phlebitis
rates in an adult population. J Intraven Nurs 2001;24(1):
19-24.
5. Shreve WS, Knotts FB. Quality improvement with prehospital-
placed intravenous catheters in trauma patients. J Emerg
Nurs 1999;25(4):285-9.
6. Lawrence DW, Lauro AJ. Complications from IV therapy:
results from field-started and emergency department-started
IVs compared. Ann Emerg Med 1988;17(4):314-7.
7. Levine R, et al. Comparison of clinically significant infection
rates among prehospital- versus in-hospital-initiated IV lines.
Ann Emerg Med 1995;25(4):502-6.

 

[MGary]

Lock vs Line is our judgement call here. A Line can always be screwed onto the lock later. On drunk/non-cooperative/dependent patients I try to throw on a lock first since as a CNA I know how much of a pain it is to try and change someone from street clothes to a gown when they have a line in. Being able to take the line off and go with just the lock during the change of clothing makes the nurses far happier with you. I also throw locks on anyone that might go to surgery or need a contrast CT or MRI later but who doesn't need a bolus.

 

[RDUNNE]

We have locks at my service, but due to the transport times (no hospital in our area, min. 30 minute transport) most of the medics go ahead and start fluids. We also have blood draw kits but they are almost exclusively used for drawing blood at the local jail.

 

[PotashRLS]

This is an excellent thread. It really shows how the same procedure or intervention can be so differently viewed or used in various areas of the country.

 

[1badassEMT-I]

We use saline-loc's more than anything. If the patient does not need fluid than why hang a bag, waste the fluid, and have one more thing to get tangled up during patient transfer?

A loc will ensure venous access in case a patient needs a med or if they later do need fluid ran its as simple as plugging the tubing into the loc.

I do not agree with hospital's pulling EMS IV's on an emperical basis. I would like to see research that say's EMS IV's are more prone to infection than those started in the hospital. If anyone knows of any research in this area I would love to read it.

Finally another WV person here I have found!

 

[Lone Star]

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

This has got to be the worst 'justification' for poking a patient I've ever heard!

These are people, not training aids! To simply do something 'to keep your skills up' amounts to nothing more than abusing your patient. This is NOT why we do what we do!

I can understand starting an IV if the patient NEEDS one, but to simply do it to 'keep the skills up' is akin to intubating a patient 'just because'....

 

[reaper]

You mean you dont intubate most of your Pt's, just to keep freash on it?

Maybe that's why my Pt's don't like me!!!!!!!!!