Whats your "criteria" for starting iv access on a pt?

AusPara

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That particular patient? The crew didn't want to transport and wanted to go back to station. That was the flight crews interpretation anyway.

That service is known for lazy and poor standard of care. I can't attest to much about their actual quality, but it's incidents like that, that given them a poor reputation.
Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient?

The risk, the expense and the opportunity cost or that resource....boggles the mind.
 

NPO

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Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient?

The risk, the expense and the opportunity cost or that resource....boggles the mind.
I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".

In either case, it may not be appropriate, but it happens.
 

AusPara

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I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".

In either case, it may not be appropriate, but it happens.
My education continues.

Thanks :)
 

DesertMedic66

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Hahaha oh my god. That is abysmal. I’m a little confused as to why their request was granted. Did they straight up lie about the condition of the patient?

The risk, the expense and the opportunity cost or that resource....boggles the mind.
I've never seen a for profit air transport company deny a scene flight. Many have the policy that they don't. It may be that the ground paramedic was not competent and he was calling his version of "ALS backup".

In either case, it may not be appropriate, but it happens.
This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.
 

AusPara

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This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.
Yeah I guess the for profit stuff makes sense.

Oh my goodness. You have a box for that. America (I assume it's America) never fails to amaze.
 

Akulahawk

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Partly to get things back on topic... Something that I don't think I indicated earlier is that if I was left to my own devices to determine when/if I would place an IV in a particular patient, I'd basically use an "anticipated clinical course" approach. If I thought it more likely that the patient would need IV access for meds or fluids, then I'd place at least a saline lock. The location and size of the line would basically primarily depend upon what I anticipate the patient would need.

On a slight tangent from this, there are a few patients that I'll grab the ultrasound right away to have in the room and a patient or two that I won't bother attempting a line without the ultrasound. I'm not exactly a fan of ours but at least it'll allow me to get the job done.
 

StCEMT

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This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.
Why the **** would they think that is even remotely reasonable or appropriate?
 

DesertMedic66

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Why the **** would they think that is even remotely reasonable or appropriate?
Those specific hospitals do not care. It’s all about getting the patients out. We ended up closing the bases that would respond there due to a huge number of unpaid transports.
 

GMCmedic

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This. A for profit company will never deny a flight. We actually have a box we check if the patient didn’t need to be flown. We have a huge issue with some hospitals in a certain area that call us out to fly psych holds.
I would add, that though we would not deny a patient transport, we have been known discourage it. Its situation dependent and a balance between doing what's right for the patient and not alienating EMS. Often times its just true that the ground crew isnt comfortable, whether its an education gap, laziness, or a gut feeling.
 

CanadianBagel

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I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC.

I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.
 

Tigger

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I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC.

I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.
Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...

Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.
 
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mrhunt

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He's obviously had some run-in's with the "dr helpers".....and havent we all? Ive had nurses abuse me Just because they were obviously bored at 2am with no pt's. And it sucks. and i def appreciate your view of doing whats Right for the pt....However, I typically (especially on IFT's) wont ever place a second line unless my pt appears unstable and Im seriously thinking i need additional access ENROUTE. Once they get to the hospital....Who cares if they JUST have a 22 in the ac........Access is access and sometimes thats all you can get.

keep in mind that above statement is JUST on IFT's and my rules are different for 911's and i think Myself and other posters have covered those (traumas, Chest pain of cardiac nature, Stroke, Seizure, Hypovolemia or any need for fluids or medications)

Hell, Ive had to show up with 22's in peoples Feet and the nurses couldnt do any better and that was the access they used the whole time. Ideal? Not hardly. But for sure better than no access at all.
 

Akulahawk

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I give them one if I feel like they need one. Whether that is because of vital signs, symptoms, medical history, or projected clinical course; I do what I feel is prudent. I do a lot of transfers, and I will give second IV’s if I don’t like the size and placement of a certain line. A 22g in an AC is not adequate for someone being transferred to a definitive cardiac center for aortic surgery in my eyes. So I give them an 18 in the other AC.

I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.
Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...

Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.
Generally speaking, hospitals are going to pull field-start lines on admitted patient, including those going for surgery, unless the patient is going to require urgent/emergent surgery upon arrival. This is because they cannot control the procedure/policy that you follow for ensuring as clean insert of the line as they can within their own facility and if another facility started the line, it is properly documented and such that proper procedure was followed. In short, they're not going to trust your line and therefore they'll pull it ASAP. As an ED RN and previous Paramedic, I will test and verify that a field start IV is patent before I'll use it. I'm also not going to pull an existing line until I've placed a new one. That being said, by you placing a line in the AC, you've basically removed a lot of potentially good sites from consideration at the other facility. Most IV lines I place aren't in the AC. They're usually in the wrist, hand, or upper forearm, just distal to the AC space. If you've blocked all those with your AC-placed line, I'm going to have to do an USGPIV if I need to pull your line.

Something also to consider, the receiving facility knows what vascular access the patient has. This is one of the things that is discussed during the RN-RN report. If they're OK with a 22g in the AC and I don't expect any additional need for vascular access, I'm sending the patient with the 22g in the AC. There have been times that I've been asked to place a 2nd line (and sometimes a 3rd line as 2 are already in place) before the patient leaves my facility. Otherwise I expect that they'll place an additional appropriate line if it becomes necessary. Another thing that will be discussed (and probably brought up in report to you) is whether or not that other arm is available for IV lines. I have seen some wonderful veins on a given side but can't place a line on that side because doing so is contraindicated.

Sometimes I'll place another line in the ED because I know the patient is likely to get (or has orders for) medications that are Y-site incompatible.
 

CanadianBagel

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Generally speaking, hospitals are going to pull field-start lines on admitted patient, including those going for surgery, unless the patient is going to require urgent/emergent surgery upon arrival. This is because they cannot control the procedure/policy that you follow for ensuring as clean insert of the line as they can within their own facility and if another facility started the line, it is properly documented and such that proper procedure was followed. In short, they're not going to trust your line and therefore they'll pull it ASAP. As an ED RN and previous Paramedic, I will test and verify that a field start IV is patent before I'll use it. I'm also not going to pull an existing line until I've placed a new one. That being said, by you placing a line in the AC, you've basically removed a lot of potentially good sites from consideration at the other facility. Most IV lines I place aren't in the AC. They're usually in the wrist, hand, or upper forearm, just distal to the AC space. If you've blocked all those with your AC-placed line, I'm going to have to do an USGPIV if I need to pull your line.

Something also to consider, the receiving facility knows what vascular access the patient has. This is one of the things that is discussed during the RN-RN report. If they're OK with a 22g in the AC and I don't expect any additional need for vascular access, I'm sending the patient with the 22g in the AC. There have been times that I've been asked to place a 2nd line (and sometimes a 3rd line as 2 are already in place) before the patient leaves my facility. Otherwise I expect that they'll place an additional appropriate line if it becomes necessary. Another thing that will be discussed (and probably brought up in report to you) is whether or not that other arm is available for IV lines. I have seen some wonderful veins on a given side but can't place a line on that side because doing so is contraindicated.

Sometimes I'll place another line in the ED because I know the patient is likely to get (or has orders for) medications that are Y-site incompatible.
idk where you work, but there’s only one hospital I know of in my area who won’t use EMS lines. Most of my transfers have EMS lines that are from anywhere from 4-24 hours old. Nurses here use whatever is established.
 

CanadianBagel

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Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...

Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.
I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta, I do another IV because I’m thinking about what I would do if the patient crashed in route. BP was skyrocketing as well. The patient’s best interest was to have a second IV.

Idk where you are, but where I am an EMS IV is only pulled if it’s over 24 hours old. And when it comes to my attitude and being “that guy;” People like working with me, my bosses like me, and most importantly my patients like me and the care that I give them. It’s fine if you don’t agree with my way of doing things, but I’m secure in who I am, and the kind of provider I am. Cheers
 

Bishop2047

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I start IVs based on what will most likely be needed, either en route or in the ER. I don't like waiting for a patient to sour, and veins to start disappearing. If the probability is high that they will need something or if my a few of my possible diagnosis would require it, you are getting a poke.

I am not a homer for 14/16 gauges and don't consider their placement the badge of honour that some do. Most people just need access and if your patient will only be getting meds and most likely won't need 4 Liters and blood, she will just be getting a smaller gauge (22s are often plenty). Traumas are pretty up in the air and I don't mind going big and placing 2 or 3 lines if there is a decent probability that I (or the destination) will need them.

I work flight, in facility, and on car, I don't think I change up this way of thinking regardless of where I am working that day.

I work in Canada, and most provinces now keep a field poke as long as possible. Until it is showing signs of infection or infiltration. Peds can be the exception, but still will often stay in place for a week. Access is access, it is not rocket science. The Vein doesn't know if it was poked by a EMT or an anesthesiologist, and sterility is not so much due to the environment but the practitioner's method. That is why I don't understand this prejudice towards field pokes.
 

mgr22

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I don’t care what the doctor helpers at the hospital think. I do what I feel is right for my patient, and they just have to deal with that.
I was with you until I read that. Would it be too radical to suggest that an MD or RN might have advice for you worth considering?
 
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mrhunt

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I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta, I do another IV because I’m thinking about what I would do if the patient crashed in route. BP was skyrocketing as well. The patient’s best interest was to have a second IV.

Idk where you are, but where I am an EMS IV is only pulled if it’s over 24 hours old. And when it comes to my attitude and being “that guy;” People like working with me, my bosses like me, and most importantly my patients like me and the care that I give them. It’s fine if you don’t agree with my way of doing things, but I’m secure in who I am, and the kind of provider I am. Cheers
Again, It sounds like you probally have some ****ty nurses where your at. attitude mostly, Skill wise i have no idea. and we've ALL been there but they arent all like that. Hell, ive been that way (and still am to some degree) with the fire department who's bls and helps us out here but they arent all bad :)
 

CanadianBagel

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I was with you until I read that. Would it be too radical to suggest that an MD or RN might have advice for you worth considering?
You have no idea how ****ty the hospital staff is in my area. I’ve seen a MD try to intubate a two year old with an an adult sized blade. First pediatric arrest I worked and they literally stopped chest compressions for a solid minute to check tube placement with an X ray. Couldn’t even find the right sized ET tube in the crash cart. Same hospital also refused to give any sedation to a pediatric GSW to the face until one of our critical care guys demanded that someone get propofol for the kid. It’s pretty bad when the medics have to tell the ED staff, who are supposed to be higher levels of care; how to do their jobs.

I have a bias, and I understand maybe it’s not always justified; I’ll admit that. I learned how to do IV’s from nurses exclusively, and there are a few that I like.. but in general I’m just not a fan of hospital staff. I don’t really trust them after seeing them hurt so many people.
 

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