Dear Stupendous Students 3,

It’s the moment you’ve been waiting for! That time of the blog when we talk about your two favorite things: Intubation and starting I.V.’s! I’ve pondered: why do Paramedic Students, and Paramedics, for that matter, have such a doting infatuation with these two skills? Sure, doing them, and especially doing them well is important but are they really worth writing home about? The best thing I can come with is these two skills are a couple of things that really separate Medics from Basics, Nurses, and other related health care providers, and elevate the practice. In this way our anxious, desperate little egos are sated and stroked with all the vigor of the overweight birthday boy eating cake!  

Because IV Chapters in most texts have to focus on more than just venipuncture, and the fact that its a skill that requires hands on practice, I see alot of students struggling. Mostly they make the same common mistakes, which are easy to correct. Over the years, I’ve developed some reliable tactics that have made a better puncture-er out of me, and will make a better puncture-er out of you! First, I’m going to challenge some of those narrow, tunnel visioned little minds out there with my IV philosophies: 

HEINOUS and BOGUS I.V. MYTH #1: “Go Big, or Go Home.”  When I hear the utterance of this faulty logic, my blood boils redder than the words they are typed in. I hear the distant wail of a cargo barge’s horn, and I have to block my ears so the steam doesn’t scald the person standing near me! That is the single most ignorant, uneducated, egotistical, pathetic, my-life-is-so-worthless-and-my-self-esteem-is-lower-than-a-dead-persons-blood-pressure-but-I-try-to-be-cool-to-impress-people *deep, cleansing breath,* declaration I could possibly hear someone say. The fact of the matter is, introducing intravenous catheters into the different arms, and different skin, and different vasculature, and different circumstances of different people (noting the pattern, here?) requires skill that goes beyond plucking the green package from the I.V. tray. Yes, I said it, in case you only inferred: Professionals who choose to blindly start large bore I.V.’s with no indication of necessity are weak, mindless robots who lack the skill to adapt to the situation at hand (no pun intended, lol).  For precisely the reason there is different sized catheters, there are different sized situations that justify them. 

A “shock trauma” pt with a significant mechanism and a pressure in the toilet, large bore I.V.? YES! 

A 90 year old female that weighs 85 lbs and has a tummy ache, and her arthritis is acting up, and she hasn’t moved her bowels in 3 hours, and....large bore I.V.? NEGATIVE. 

A 56 year old male, pale and diophoretic with persistent chest pain after fixing that gutter his wife has been nagging him about, radiating down his L arm, unrelieved post NTG, with ST elevations on the 12 lead, large bore I.V.? IF YOU CAN, 2 of ‘em, EN ROUTE and transport to a cath lab. If you can only get 1-2 20g, that is fine, you have lots more to worry about with this patient than sticking in an 18g, and a 20g works JUST AS WELL.

A 24 year old female with chronic abdominal pain d/t intestinal HAE requesting pain control (out of Percocets), otherwise in stable condition in no obvious distress, large bore I.V.? SERIOUSLY? Do you have to do it just because you can? Will you go big or go home? I would rather see you go home. Blood transfusions, fluid resuscitation,  and CT dye can all be infused just as easily through a #20 as they can a #18. Bottom Line: It is BARBARIC to use large bore I.V.’s outside of necessity, just because you can, especially in the hand. Get over yourself.

HEINOUS and BOGUS I.V. MYTH #2: “They pissed me off, so they got a 16 in the hand.” Ok, Romper Room is closed for today, come back in 9,742,886 hours after you grow up! I understand why some people say this, it’s to just to let off a little steam and vent a bit. I’m all about that, hey this is a tough job, right? It’s the folks out there who actually do it and brag about it that make me want to cannulate their sclera veins. Which I would do, because they “piss me off.” Haha, kidding! Seriously, students and medics: If you think saying or doing this makes you look ultra snazzy and powerful, it doesn’t. It is a naive and weak way to practice, even when you’re mad because American Idol just got interrupted to haul around the obtunded ETOH illegal citizen. Get over yourself. 

HEINOUS and BOGUS I.V. MYTH #3: “Well, they were gonna do it the hospital, probably.” This statement can go both ways, it can actually be applicable, or it can indicate Cookbook medic practice. What I want to emphasize is: Do it because you feel it’s appropriate, not because you know someone else will. Own your decisions, skills, and actions. Outside of gross incompetence or assault, I can’t think of many circumstances where starting an I.V. would be negligent, but I still want to encourage students to start developing confidence in their own assessments, interventions, and decisions. Get into yourself! 

Let me state clearly, I am not trying to bash my fellow medics, or single out any one person. I know plenty of Paramedics who I think are super fabulous, that I have learned alot from, who I have known to advocate one or more of these philosophies. Maybe they learned from their mentors, or maybe they have other arguments to support their convictions. These are solely the opinions of my own shattered, pea-brained little mind! ☺ 

Starting from the Top: 

1. Do a Skin Assessment: Does it look/feel papery thin? Use less pressure puncturing the skin. Does it look/feel thick and coarse, and the pt. tells you they are a construction worker, or someone who stays out in the elements alot? Use more pressure puncturing the skin. Is the pt. on coumadin/lovenox/other “blood thinners”? Be wary of the increased risk for bleeding/infiltration/hematoma. Is the pt. on Prednisone? Even a small gauge needle will obliterate the vein, it will look like subdermal vein implosion, be wicked careful! Is the pt. hyperglycemic? If so, their veins can be hardened and very difficult to cannulate. Think of it like this: high blood sugar=candy-coated veins. Doing a thorough skin assessment takes about 10 seconds, and will dramatically increase your I.V. success rate. 
2. Get Gabby: Nothing makes a patient, or any human for that matter, more uncomfortable than a muted caregiver performing foreign and painful procedures on them while they’re in pain, distress, or discomfort. If you’re feeling kind of nervous and awkward being a student with 2 or more medics, firefighters, and police officers watching and judging your actions, can you imagine how intimidated the patient feels with all of these unfamiliar people, plus the addition of painful or misunderstood interventions?! Use your voice: explain what you’re doing, talk about their complaint, give some feed back, use humor, etc...the more at ease you appear, the more at ease they will feel and trust me, you will get more thanks and acknowledgment for simply making someone feel comfortable than you will for “saving their life.” 
3. Applying the Tourniquet: I’ve found that applying the tourniquet about 4-5 inches above the elbow is the most practical and effective practice. It effectively engorges the veins from the distal end of the arm to above the AC. It also prevents unnecessary relocation of the tourniquet after unsuccessful attempts or poor vasculature. Also, that tight tourniquet hurts! If possible, tie it over the sleeve. A tip on using a blood pressure cuff as a tourniquet: I don’t advocate this as a rule, but it works in a pinch. Apply the cuff around the upper arm like you normally would, and pump it up slowly to about 40 mmHg or until veins are distended. Do not inflate it completely as it will cause pain and possibly bruising, and become an arterial tourniquet restricting blood flow to the whole arm. Also for veins that just refuse to appear, a second tourniquet placed distal to the initial tourniquet but proximal to the area you will be scouting works well. 
4. Get Prepared: Gather all of the equipment you expect to need for this I.V. start, including 2x2’s, tape, even the glucometer if you routinely check CBG’s with the sharps. Set up and prime the lock set, or drip set or whatever you use to flush the line. Open the alcohol prep, betadine swab, bioclusive dressing and whatever else you use, except the angio cath (for sterility). I cannot stress enough how this simple act of gathering, preparing, and placing your equipment next to you will help your success. It also gives that tourniquet time to work, and keeps you focused and organized. 
5. Find a Vein: Here is the single best I.V. tip I can offer, but it won’t help a lick in your internship: Learn how to feel the vein. Palpate it with the pads of your fingers. My absolute golden nugget of wisdom is to train one hand to have your palp fingertips. I use my non-dominant hand, so my L hand can feel a vein decades before my eyes can even see it. Start practicing with your “tactile vein hand,” on EVERY I.V. start, even when a vein is standing up and getting its flirt on, to get used the feel of them. It is described as “spongy,” “springy,” or that it “gives” under pressure. To me, they feel like little tubes of moon bounce material, and I visualize what the distended, engorged vein looks like underneath the skin. It won’t take long before your palp hand is heavy, and “this pt. has NO VEINS, dude,” will be a thing of the past. 
6. Prepare the Vein: Veins need love, too. Please do not forcefully slap, spank, thump, or flick them. Flattened veins may need a little help perking up, and I agree it is acceptable to use the pads of 2 or 3 fingers and tap to plump them a bit, but roundhouse kicking them in the face is not acceptable. Hanging the arm down and employing dependent gravity, having the pt. pump their fist, even using a few extra alcohol preps and rubbing briskly over the site (get some friction heat going) are all options to get that vein really engorged. Use care and discretion when applying brute force to a vein, and remember: it hurts!
7. Feel that Strrrrretchhhhh: The second most valuable tip I can offer is a simple one: Hold the skin taut! Whether you’re initiating in the hand, forearm, AC, or foot this rule applies:  Apply enough counter tension to the skin to anchor the vein, and set up a smooth surface for the needle to pierce through the skin. This is the most common mistake I see students make! HOLD THE SKIN TAUT. Be sure not to press into the vein causing it to occlude and collapse, just pull the skin with enough tension to anchor the tissue and vein underneath it. 
8. Venipuncture: Telling a patient “Ok, it’s going to be a biiig stick,” is the equivalent of telling the drivers seat “Ok, here comes my biiig butt!” Make it understandable or at least relatable, “This is going to feel like a pinch on your arm,” or “It’s going to sting/hurt for just a sec,” etc...just don’t say it’s going to be a “big stick.” A big stick comes from a tree limb, and if you go after a patient with one, you’ll have more to worry about then the semantics of your I.V. starts! On holding the angio cath: Familiarize yourself with the equipment you’re using. Too often I see students who are not holding the equipment properly, and we carry the same I.V.s as St. Luke’s where I just saw them for weeks doing hospital internship?! I don’t get it, but I am more than happy to happy to demonstrate and explain how to use the equipment I carry. Simply put: Bevel up, which coordinates nicely with the little tab sticking up near the top of the colored catheter hub. KEEP YOUR FINGER ON THAT TAB AT ALL TIMES, until it’s time to advance the catheter. 
9. Stay Focused: The rest is home plate material, but stay focused! At NBEMS we routinely use I.V. sharps to check CBG so don’t lose it, throw it on the floor, or get something all bloody with it. Hand to one of us, or set it near the glucometer. If possible, clean up after yourself!  Staying focused and following simple actions through to the end trains your mind to do so on auto pilot, even on the more complex actions, such as intubating. If you’re always cognizant of where you place the laryngoscope after ET placement, you won’t lose, cross contaminate, or damage it. Stay focused, and follow all tasks through to completion. 
10. I pick things up, I put them down: Or, in this case I put things in your vein, I take them back out. With the exception of discontinuing an unsuccessful or “blown” line, in the field we don’t pull too many I.V. catheters, but it’s still worth saying: When you do remove a catheter, apply pressure with the 2x2 directly after the catheter is out, not during the removal. If you apply pressure while removing the cath you risk complete transection of an already sheared catheter (causing a foreign body embolism, yikes!), and for a long dwelling cath, you basically squeegee off all of that biological goo clinging to the catheter and expel it into the pt. Eww! Plus, it plain old hurts more to apply pressure while pulling the line, so don’t do it!

Read, study, print these tips, if you like! I guarantee they will make a better “sticker” out of you! These tips are designed to enhance your skill, not teach it! Now, get out there and make me proud, EMT-Paramedic Interns! Tune in next week for my Intubation tips and tricks and blog!