Having a hard time with IVs

[fiznat]

Just got back from clinicals in the ED tonight, upset yet again at my dismal IV performance. I'm still very new at this, but my record right now is something like 3 and 10. Terrible.

Seems like I keep getting the patients who's veins are extremely deep and hard to get at-- I usually dont have too much trouble with the folks who's veins are popping out and right there to see (although I've blown 2 of those also...), but those deep veins seem impossible to me. I can feel them there, but always seem to miss-- then I'm reduced to "hunting" around a little bit for them and torturing the patient, and even then usually dont end up getting them. Even the easy ones I've been missing-- either going too far through or something, I dont even really know what I'm doing wrong.

Just wondering if anyone has any IV advice for the beginner. How do you select your veins? How tight do you hold the skin (sometimes it makes the vein disappear if you pull too tight), what angle do you approach the vein from (on top or on the side? 45 degrees or less?) Do you really start distal and work your way in? Etc etc etc....

If there is anything at all you guys know that can help me... I really respect the opinion of you much more experienced folks and would like to hear what you've got to say. This poor performance of mine has kinda got me down .

---

Members don't see this ad.

 

[southerndoc]

I used to suck at IV's when I was a "basic" EMT in Georgia (actually a NREMT-I equivalent). I'm quite good at them now. When nurses can't get IV's (and they are supposed to be the pros), I can usually get a peripheral IV in probably 75% of the patients they ask me to get one in. Keep in mind though that I can go for the EJ, they can't. If the patient is truly sick, I just go straight to a central line (Cordis introducer sheath if they need volume resuscitation).

My trick for IV's (learned from the best -- an anesthesiologist, not a nurse):

- Learn to feel the vein

- Don't hold the skin too tight (you collapse the vein, either making it difficult to hit it all together, or making it more likely that you go through the vein)

- Always approach the vein from the top

- Enter around a 45 degree angle, but after you break the skin, drop your angle to 20-30 degrees

- Get a flashback and then advance it a slight bit (failure to do this will make it impossible to thread -- the needle may be in the vein just enough to get blood back, but may not have entered the vein fully thereby making it difficult to thread the cather)

If you are still having trouble, schedule a clinical shift with us if you can and I'll teach you how to start IV's.

 

[fiznat]

If you are still having trouble, schedule a clinical shift with us if you can and I'll teach you how to start IV's.

Yeah that would be absolutely awesome if I could come down there and do it at Yale as well. Our class works with St. Francis and Waterbury Hospitals, I'm really not sure that I would be able to schedule anything down there-- its probably more of an insurance/liability thing than anything else.

If you can think of a way to get me down there with you though I would do it in a second.

Thanks for the advice. A few of those I've heard but not others-- these tidbits are definitely helpful!

 

[southerndoc]

I'll ask our EMS division chief and see what he says.

 

[fiznat]

Thank you so much Southerndoc!! I sent you a PM with my contact info.

Anyone else have any IV pointers?

 

[jbar]

Thank you so much Southerndoc!! I sent you a PM with my contact info.

Anyone else have any IV pointers?

Yeah, I have a few:

1: If you can see the vein clearly without a torniquet, don't put one on. Stick without it. The torniquet can increase the pressure to the point where you are more likely to blow the vein. (Especially true with the elderly)

2: Make sure after you get the flash you lower the angle of the cath and advance the cath and needle about 1mm before threading the cath into the vein. A lot of beginners don't advance the needle and just try to thread it in as soon as they see the flash.

3. Wait for the chamber to fill completley before threading, if it fills only part way you may have just nicked the vein but aren't in. Go a little farther.

4. If you are having trouble try putting an IV into a section of IV tubing or extention set. It is about the same diameter and seeing the needle go in can help visualizing where you are on a real person.

5. Make sure you have everything laid out before starting, and close at hand. I've had IVs I've lost in the back of an ambulance becuase I am trying to hold the cath in one hand and reach for something I need like tape.

Hope that helps.

jbar

 

[a_ditchdoc]

1) It may seem obvious, but work a little harder to find a good vein. For obese people, I really like the underside of the wrist. There is virtually no fat there and the veins will almost always be visible.

2) When you find a good vein, try tapping or thumping it gently (I do it really rapidly and softly), you may be surprised at how much it dilates. Also, when you are done prepping, rub up the vein along its course, italso helsp occasionally.

3) For little old people on steroids, especially those already with bruises, release the tourniquet as soon as you get flsahback.

4) I use an angle less than 45 degrees. It lessens the liklihood that you will go through the vein. Too low however, and you are torturing your patient by digging into sensitive skin. I use about a 35-40 degree angle and then lower it to 10-15 degrees. The thinner the skin, the lower can be your angle and vice versa.

5) Don't be hesitant. It sounds counterintuitive, but, if you put the IV in in really slowly it hurts the patient and causes the veins to constrict. Get through the skin quickly...hopefully you will be in the vein. If not, feel for the vein and aim for it.

Otherwise, just find a good nurse to follow, especially if you have an IV team. These guys are usually pros.

Let us know how it goes...

 

[QuikClot]

I second the "work a little harder for a good vein." Selecting the right site is critical to IV sucess.

My tips for problem IVs:

1. Sit the pt. up if you can. Let the arms dangle. Gravity is your friend.

2. Tournq. both arms -- not just the near one. One arm is often VASTLY better than the other. Go high -- you may think you want a hand vein, but keep your options open.

3. If you have a good vein that is too short (like an inch or half an inch) go in distal to the vein and travel to it, so that the cath tip ends in the vein. Many people don't even know this is possible. You'll look like a hero.

4. Don't go too big out of ego, or too small out of fear. Few IVs need to be big -- a 22g in the hand works fine for most applications. If I can get an 18g, I usually go with an 18g -- esp. w/ African-Americans and diabetics, who tend to have thicken skin that can bend the smaller 20g neddle.

5. Have everything you need to secure the IV ready (tape, lock, op.s site, etc.) and in easy reach.

6. Position the patient, and yourself, such that you are comfortable, have the vein in front of you, have the site immobilized, and the skin taunt.

7. Some people just have sucky veins. Some days you just can't hit anything. Don't worry about it. Keep practicing.

 

[Mr. Freeze]

my record right now is something like 3 and 10. Terrible.

Kinda jumping in here late...

Are you getting flashes, just missing, or maybe having trouble finding them pre-stick?

When I go into an IV funk, I always try to think that baseball players make millions of dollars to be successful 3.5 times every 10. But then I think that if A-Rod strikes out, nobody dies.

 

[niko327]

The actual techiniques of advancing the needle that have already been given are right on. But before you actually plunge the needle you need to find a vein, so a little bit of advice I can offer would be about finding veins.

1. Take a look in an anatomy book and learn basic vein anatomy, so that you'll understand where the veins should be and the course they take.

2. Always look in these areas, but most importantly feel in these areas. I don't recommend rubbing your finger along the course of the vein, but rather dab (bounce) your index finger on the vein and along it's course.

3. When you find a vein pull the skin taut distally, but be gentle, and be sure not to tamponade the vein distally. If you use to much force, or if you tamponade distally you will cause the vein to collapse and disappear.

4. Sometimes you'll find a deep vein that you can't see, but can feel instead. Believe it or not these veins are quite good as they tend to be well anchored and of the non-rolling variety.

5. If you find a deep vein that you can feel but not see, take some time tracing a couple of inches of it's course using the bouncing index finger method I mentioned above. As you trace the course of the vein, visualize it's position, draw an imaginary line in your mind on the surface of the skin. Now STOP, look at the surface of the skin and the imaginary line you drew. Now dab/trace along it's course again, you should feel the vein again.

I know this probably sounds stupid, but if you practice doing this visualization technique, you will find your accuracy improving and you'll be able to "see" deep veins more clearly.

Hope this helps.

 

[joemedic]

I almost flunked out of paramedic school because I couldn't start IV's. I ended up scheduling a lot more ER time.

I found that practice, practice, practice is the best way to learn to do IV's. When I got out of school, I got a job in the ER where I did my clinicals. There, I start about 30-50 IV's in an 8 hour shift. In the field, I may start 3-6 IV's in a 16 hour shift and it's been over a month since I've missed a field IV.

You will find your own favorite places to start IV's and your own style of doing it.

The advice posted above is excellent and even I learned a couple of things. Remember though, practice helps a great deal.

Hope this helps,

joemedic

 

[beanbean]

All of these are great tips!

A couple more...

Practice using oranges or bananas when just starting out to get the feel of advancing the catheter.

When you have a vein that keeps hiding and can be felt but is difficult to see, mark it with the alcohol wipe that you just cleaned the skin with. Place the alcohol wipe proximal to the vein and use the corner of the alcohol wipe to "point" to the vein at the angle of the vein.

If you get flash and are able to advance the catheter only part of the way; you may have hit a valve. Attach you IV tubing and open up the line a bit. You may be able to use the running fluid to "float" the catheter in all the way. This is such a great thing when it works!

How long do you have left in your medic program? I will hopefully be doing my EM rotation at Hartford in August if the scheduling gods are good to me.

 

[joemedic]

Another thing that I've learned is that what hurts the patient is putting the needle through the skin. I pick the vein and quickly insert the needle past the skin. Then I go fishing for the vein.

This 'jabbing' techninque was taught to me by a ER tech who is very successful in his IV starts.

joemedic

 

[MissMuffet]

Personal experience: Fishing hurts too, a lot. It's also high-risk for making the pt vagal.

My only real advice, though is, not surprisingly, to offer buffered lido before you stick.

 

[greytmedic]

Just remember, when you start an IV on somebody else, it won't hurt you a bit.

 

[Mr. Freeze]

jab & fish > everything else.

Unless you're a phleb for a blood bank. I went the other day and thought hey I'll give my left arm a break and switched. She jabs, then says, "Hmmm...it kinda takes funny angle here." and throws her hook in the water. I would have gone for the fat rope next to it, but I just kept my mouth shut since she had a horse needle in my medial AC and still no juices flowing. She got it eventually, and I was no worse for the wear...

 

[a_ditchdoc]

I had a nurse jab a needle in my median nerve a few months back. I'll be damned if I know how she did it. I thought the needle was going a bit deep, but she just didn't stop.. When it hit the nerve all I could say, in a screaming little girl voice, was "Pull it out, pull it out!! You hit the nerve!" She said to me "Ma? Ani lo maveen." Which means "What? I do not understand" in Hebrew. She had to call someone from the other room to interpret, all the while my arm and hand are killing me and I am begging her just to get the needle out When she finally pulls it out, the interpreter tells me "You were just afraid...that's all, just afraid."

I stopped hurting after a week or two. Hmhppp...afraid....

 

[joemedic]

Personal experience: Fishing hurts too, a lot. It's also high-risk for making the pt vagal.

My only real advice, though is, not surprisingly, to offer buffered lido before you stick.

We don't have buffered lido in the field, probably better start learning how to do it without it.

Keep practicing. This is why I make all my students and new employee's start their IV's while in a moving ambulance. If you can do it while bouncing down the road with a stable patient, you sure should be able to do it with an unstable patient.

Starting IV's on others shouldn't hurt you a bit (except for when they clock you in the head.) Walk in there and act exactly like you know what you are doing.

At some point soon, something will click and everything will come together. You will then be an expert at starting IV's. This was what happened for me.

joemedic

 

[Karl_Hungus]

Not all services don't "have buffered lido in the field." Many do, and if you don't, it's probably a good thing to add. I work for a service that uses intradermal lidocaine prior to venipuncture for a vast majority of starts, even in a critical patient or trauma patient. Once you become proficient, it takes from 10-15 seconds to draw up, administer and take effect. Unless the person is completely unresponsive, I believe that starting a 16 or 14 gauge IV is just cruel without a local anesthetic first.
Even for smaller-bore IVs it is still beneficial. You learn if the person is really a "flincher," it gives you a sort of pilot hole if the person has thick skin and really reduces anxiety about a sometimes painful procedure. It can all be psychology: The patient believes you are doing all you can to make it hurt less, and voila, to them it hurts less.
In my opinion, for the use of lido locals, advantages far outweigh negatives, and it is a skill that should be in the repertiore of every good IV initiator.

 

[Karl_Hungus]

As long as I'm here, I'll post my own $0.02 to the OP's question.
It's the same thing I tell paramedic, EMT-I and nursing students (and current nurses, HA!) when I am helping them with IVs: In a word, traction.
It is taught as less than an afterthought usually. Books and instructors go into great detail about what angle to enter at, then to advance at, etc. Few stress the importance of holding really good traction on the skin. For me, when I started this practice myself, I really turned the corner on IV starts and became pretty good at it. This means holding the skin/vein not only distal to the puncture site, but proximal also. Get the skin stretched as taut as possible (obviously without collapsing the vein). For old, obese people, you may be pulling away a lot of skin. Use as many points of contact with the patient that you can, meaning fingers, heel of hand, etc.
Think about the old-timers who do pin-striping. They don't just hold a brush in one hand and run it down the side of the car. They get one hand in position with a couple fingers touching the car and the others holding the brush. Then they take the other hand and steady the first hand and the work surface. Apply this philosophy to IV starts.
As others have said, find someone who is very successful at IV starts and watch him/her do a number of starts. They will probably use many of the tips others and I have mentioned without even thinking about it.
The Anesthesiology section has tips threads, some about peripheral IVs. (Too lazy to link, they're easy to find)

But I'm not sure I agree with those who say that practice is the only way to get better: I know people who have been starting IVs for many years and still suck at it. There is something to be said for studying the masters to shorten that learning curve.

 

[MissMuffet]

Not all services don't "have buffered lido in the field." Many do, and if you don't, it's probably a good thing to add. I work for a service that uses intradermal lidocaine prior to venipuncture for a vast majority of starts, even in a critical patient or trauma patient. Once you become proficient, it takes from 10-15 seconds to draw up, administer and take effect. Unless the person is completely unresponsive, I believe that starting a 16 or 14 gauge IV is just cruel without a local anesthetic first.
Even for smaller-bore IVs it is still beneficial. You learn if the person is really a "flincher," it gives you a sort of pilot hole if the person has thick skin and really reduces anxiety about a sometimes painful procedure. It can all be psychology: The patient believes you are doing all you can to make it hurt less, and voila, to them it hurts less.
In my opinion, for the use of lido locals, advantages far outweigh negatives, and it is a skill that should be in the repertiore of every good IV initiator.

 

[viostorm]

Not all services don't "have buffered lido in the field." Many do, and if you don't, it's probably a good thing to add. I work for a service that uses intradermal lidocaine prior to venipuncture for a vast majority of starts, even in a critical patient or trauma patient.

In my opinion, for the use of lido locals, advantages far outweigh negatives, and it is a skill that should be in the repertiore of every good IV initiator.

Local lidocaine for IV's???????? In critical patient????? Interesting idea. Not necessarily a good one in my opinion! The lidocaine would probably hurt as much as the IV! I can see some lidocaine before putting in a central line or chest tube, but IV?

Come on, seriously ... IV sticks really don't hurt that bad. Even a 14 or 16.

What happens if some medic goes fishing and does tear up the median nerve but they don't know it until they can't move their fingers in 1 hour?

I seriously can't believe a service would do this.

If it is truly an emergency .... "Any port in a storm!"

 

[MissMuffet]

Local lidocaine for IV's???????? In critical patient????? Interesting idea. Not necessarily a good one in my opinion! The lidocaine would probably hurt as much as the IV! I can see some lidocaine before putting in a central line or chest tube, but IV?

Come on, seriously ... IV sticks really don't hurt that bad. Even a 14 or 16.

What happens if some medic goes fishing and does tear up the median nerve but they don't know it until they can't move their fingers in 1 hour?

I seriously can't believe a service would do this.

If it is truly an emergency .... "Any port in a storm!"

True. One wouldn't want to do it if the seconds it took were at all likely to make a difference in outcome.

But why resist at least offering it to all the others? All it takes is a tiny tb or insulin syringe, and a wheal of buffered lido is all but painless. I know some of y'all are tough guys , but for most people, the difference in pain is very significant.

Because of that, while 10 years ago it was uncommon in all but elective pre-op and peds, it is now very common in ERs and increasingly in EMS.

Our local EMS uses it. Not only is it an easy way to be more of a hero, but as you'll see noted in journals, the benefit of stress reduction on the patient makes it well worth it.

 

[viostorm]

True. One wouldn't want to do it if the seconds it took were at all likely to make a difference in outcome.

But why resist at least offering it to all the others? All it takes is a tiny tb or insulin syringe, and a wheal of buffered lido is all but painless. I know some of y'all are tough guys , but for most people, the difference in pain is very significant.

Because of that, while 10 years ago it was uncommon in all but elective pre-op and peds, it is now very common in ERs and increasingly in EMS.

Our local EMS uses it. Not only is it an easy way to be more of a hero, but as you'll see noted in journals, the benefit of stress reduction on the patient makes it well worth it.

So what is the "buffer" in buffered lidocaine?

Why does it need to be buffered?

Don't you just use 1% lidocaine for sutures perhaps w/ epi?

Anyone using "bacteriostatic saline" (0.9% NaCl) for anesthetic prior to IV start, reading online people we saying it is as good as lidocaine for anesthesia prior to IV start.

 

[Karl_Hungus]

viostorm --The overall tone of your posts (coupled with gratituous use of question marks) suggests more inexperience and ignorance rather than petulance and argumentativeness, so I'll try to explain...

The "buffer" in buffered lidocaine is sodium bicarbonate. It has been empirically shown to reduce the burning sensation associated with intradermal infiltration. Epi is not used because epi causes vasoconstriction (although this is desired during laceration repair, chest tube placement, etc.)
Yes, 0.9% saline can be used if the person has a known intolerance or allergy to lidocaine.

I'm sure that to some, like the tattoo and piercing crowd, a 14 gauge IV would be no big deal. I believe that for a large majority of the population, a small wheal of lido hurts far less than a 14.
As far as critical patients are concerned: They are in the most dire need of IV access, and anything you can do to increase the odds of success should be done. If the 10-15 seconds to do lido prevents flinching or movement, it is time well spent. And truthfully, in how many patients does delaying IV access by 15 seconds result in a worse outcome?

I also have never advocated using lido for all IVs. There are certainly situations where you just have to shove one in.
Pain is totally mental, and if a patient believes you are doing what you can to reduce pain, it really will hurt less. And isn't that what we are here for?

Finally, you assertion about medics "fishing" for veins and damaging the median nerve: No medics, nurses or doctors I know ever "go fishing" unless the patient is in cardiac arrest. No one uses lido to facilitate this in any other patient. Find a viable vein, give lido, then cannulate.

I hope this helps to clear up your misconceptions.

 

[viostorm]

I hope this helps to clear up your misconceptions.

My post really wasn't meant to be critical. Honestly, I was just shocked. We do IV's all the time without anesthesic and it really isn't an issue. I've had IV's done on me several times and its really not that bad.

Anectdotally ... maybe 1 in 50 patients seems to have a significant problem with the pain. We even do EJ's ... no problems ... so I guess I never saw the need.

But seriously, why the buffer? Any science behind it? I was saying you don't use buffer for sutures right? Then why would it be necessary for IV start?

When it comes to emergency prehospital care, it is absolutely critical to evaluate if a procedure actually improves outcome. Do the risks of lidocaine outweigh benefit? Not in my opinion.

I can see a medic drawing up dopamine or 1:1000 epi and giving that because the lido bottles look really similar. Medication errors happen all the time in EMS, and I'm sure any medic on the forum will echo this.

What if I get a needle stick/HIV while going down the road so the IV didn't hurt as bad? Was it worth it?

You are adding complexity and risks to a skill with likely no change in morbidity and mortality ... I just can't justify it.

Save that for the hospital with a controlled environment.

 

[southerndoc]

You can also use topical EMLA if you have time. We use it for children.

 

[southerndoc]

But seriously, why the buffer? Any science behind it? I was saying you don't use buffer for sutures right? Then why would it be necessary for IV start?

When it comes to emergency prehospital care, it is absolutely critical to evaluate if a procedure actually improves outcome. Do the risks of lidocaine outweigh benefit? Not in my opinion.

I can see a medic drawing up dopamine or 1:1000 epi and giving that because the lido bottles look really similar. Medication errors happen all the time in EMS, and I'm sure any medic on the forum will echo this.

The buffer does reduce the burning sensation of lidocaine. It does burn a lot when it goes in. However, I RARELY use buffered lidocaine (except in children). It takes more time to obtain and costs more money. To buffer lidocaine, I must manually mix it after a nurse obtains it out of the PIXIS system. Our regular lidocaine just sits on the shelf in a locked cabinet.

You are correct that there is absolutely positively zero need for buffered lidocaine or intradermal lidocaine in the field.

 

[Karl_Hungus]

Health care providers can, have and will form differing opinions on things based on education, experience and history. That is OK. I'm not trying to start a lido war.

Just as easily as you can provide anecdotal evidence that it is not needed, I can tell all the stories of people who request a local, and others who've never had it before that tell me that they greatly appreciate it. You can tell me all about the large bore EJs you put in: I'll tell you about the little old ladies who request and appreciate a local for a 20 in the forearm.

Anecdotal evidence=anecdotal evidence, regardless of who puts it forth. What does that mean? Not a dang thing.

The OP requested IV tips, and I shared some that increased my success rate. I'll go ahead and point out that the OP was in the ED, and even if you reject my claim that it is useful in the field, my tips and pointers on lido hold true for the OP's experiences in the hospital.

 

[Karl_Hungus]

To answer the questions on science: Here are a couple of citations where studies were done demonstrating decreased pain when buffered lidocaine was used--
Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med 1998;16:353-6.
Christoph RA, Buchanan L, Begalla K, et al. Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 1988;17 (2) :117–20.
Milner QJ, Guard BC, Allen JG. Alkalinization of amide local anaesthetics by addition of 1% sodium bicarbonate solution. Eur J Anaesthesiol 2000;17 (1) :38–42.

As far as the science: Buffering with sodium bicarbonate increases the pH, and this is the proposed mechanism for reducing the burning sensation:
Bancroft JW, Benenati JF, Becker GJ, Katzen BT, Zemel G. Neutralized lidocaine: use in pain reduction in local anesthesia J Vasc Interv Radiol 1992;3(1):107–9.

This is already a long post, but simple searches provide many articles about reducing procedure anxiety, and anethetic administration is a big one.

The med error one is system-specific: In your system obviously the vials look alike; in mine, epi is brown glass in the med bag, buffered lido is clear plastic and in the IV kit.

Finally, the simple claim that if something doesn't directly influence morbidity/mortality it doesn't need to be done is not one with which I agree. That is not a compelling argument against lido.

 

[southerndoc]

The OP requested IV tips, and I shared some that increased my success rate. I'll go ahead and point out that the OP was in the ED, and even if you reject my claim that it is useful in the field, my tips and pointers on lido hold true for the OP's experiences in the hospital.

I may actually consider lidocaine use in the ED for IV's for students who are trying to learn IV's (and frequently end up causing patient discomfort from frequent attempts). This is one situation where it might be useful.

 

[southerndoc]

To answer the questions on science: Here are a couple of citations where studies were done demonstrating decreased pain when buffered lidocaine was used--
Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med 1998;16:353-6.
Christoph RA, Buchanan L, Begalla K, et al. Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 1988;17 (2) :117–20.
Milner QJ, Guard BC, Allen JG. Alkalinization of amide local anaesthetics by addition of 1% sodium bicarbonate solution. Eur J Anaesthesiol 2000;17 (1) :38–42.

As far as the science: Buffering with sodium bicarbonate increases the pH, and this is the proposed mechanism for reducing the burning sensation:
Bancroft JW, Benenati JF, Becker GJ, Katzen BT, Zemel G. Neutralized lidocaine: use in pain reduction in local anesthesia J Vasc Interv Radiol 1992;3(1):107–9.

This is already a long post, but simple searches provide many articles about reducing procedure anxiety, and anethetic administration is a big one.

The med error one is system-specific: In your system obviously the vials look alike; in mine, epi is brown glass in the med bag, buffered lido is clear plastic and in the IV kit.

Finally, the simple claim that if something doesn't directly influence morbidity/mortality it doesn't need to be done is not one with which I agree. That is not a compelling argument against lido.

Nobody is doubting that buffered lidocaine causes less pain with injection when compared to regular lidocaine. I am arguing that there is no need for it in the ED or EMS.

 

[Karl_Hungus]

This is where I nod, smile and bow out of this thread gracefully.

There is no room in the ED or prehospital setting for lido locals, but we can wait 20 (+) minutes for EMLA.

HA! what a joke.

If the OP is still following this thread, I only put the lido thing in there as something to consider, another tool in the bag of tricks. It may help you become a more successful IV initiator, but it's something you should explore for yourself.

 

[southerndoc]

There is no room in the ED or prehospital setting for lido locals, but we can wait 20 (+) minutes for EMLA.

Keyword: children

You stick a child with a needle and cause pain, no matter how severe, and they're not going to let you stick them again. Even the 27g needle and the buffered lidocaine cause some pain, granted it's less than an IV needle. EMLA prevents all this, but its use should be reserved for children only.

 

[viostorm]

This is where I nod, smile and bow out of this thread gracefully.

There is no room in the ED or prehospital setting for lido locals, but we can wait 20 (+) minutes for EMLA.

HA! what a joke.

If the OP is still following this thread, I only put the lido thing in there as something to consider, another tool in the bag of tricks. It may help you become a more successful IV initiator, but it's something you should explore for yourself.

Karl ... don't take things too seriously. I learned something from this whole discussion. I think SouthernDoc is always very professional and neither he nor I were attacking you.

We were just disagreeing.

Please come back to EMS forum, I enjoyed the discussion.

 

[Karl_Hungus]

We were just disagreeing.

Please come back to EMS forum, I enjoyed the discussion.

I certainly hope that I didn't come off as defensive. I, too, appreciate a good discussion and am always open to new ideas/modalities even for routine things. Disagreement is often the start for changing ideas.

However, when I put forth what I felt was well-articulated advice for the OP and was responded to with something along the lines of "there is no place" in the ED or field (without any supporting arguments) I do get a little aggravated.

I look forward to future discussions!

 

[Genkitty]

As someone who is a difficult stick, reading this thread is quite interesting. My tip to the OP is: if it's possible, listen to the patient. My experiences with giving bloodsamples and taking IVs has taught me what works and what doesn't work on me. (For the record, butterfly needle, back of left hand, and 50% chance of needing to pull the blood with a syringe anyway) Techs and doctors who poo-poo me when I warn I'm a very difficult stick generally end up leaving massive bruises or panicking in the operating room (in the case of the oral surgeon who smiled patronizingly when the little woman gave her warning during the consultation....)

You can also use topical EMLA if you have time. We use it for children.

What is this EMLA stuff? If it kills the pain I'd love to be able to ask for it!

 

[Oats]

The actual techiniques of advancing the needle that have already been given are right on. But before you actually plunge the needle you need to find a vein, so a little bit of advice I can offer would be about finding veins.

1. Take a look in an anatomy book and learn basic vein anatomy, so that you'll understand where the veins should be and the course they take.

2. Always look in these areas, but most importantly feel in these areas. I don't recommend rubbing your finger along the course of the vein, but rather dab (bounce) your index finger on the vein and along it's course.

3. When you find a vein pull the skin taut distally, but be gentle, and be sure not to tamponade the vein distally. If you use to much force, or if you tamponade distally you will cause the vein to collapse and disappear.

4. Sometimes you'll find a deep vein that you can't see, but can feel instead. Believe it or not these veins are quite good as they tend to be well anchored and of the non-rolling variety.

5. If you find a deep vein that you can feel but not see, take some time tracing a couple of inches of it's course using the bouncing index finger method I mentioned above. As you trace the course of the vein, visualize it's position, draw an imaginary line in your mind on the surface of the skin. Now STOP, look at the surface of the skin and the imaginary line you drew. Now dab/trace along it's course again, you should feel the vein again.

I know this probably sounds stupid, but if you practice doing this visualization technique, you will find your accuracy improving and you'll be able to "see" deep veins more clearly.

Hope this helps.

I absolutely second this advice. If you know the anatomy of veins then even if you can't visualize them, you'll know where to feel for them. I had an extremely obese patient one day. There was absolutely no way that I was ever going to "see" a vein in this guy. His hands and arms were just so thick. I palpated his AC and, lo and behold, after a few seconds there it was. I couldn't see it at all but I could feel it plain as day. I traced the length of the vein with my fingertip to make sure of the exact direction of it, stuck it and got my flashback. Knowing the anatomy is going to help you a lot. Good luck!

 

[fiznat]

I know this is an old thread, but I wanted to revive it just to say thank you to everyone who posted and PMed me with all kinds of interesting and helpful advice! I've been working on IVs (both in clinical rotations as well as in the back of ambulances with some friendly paramedics) since I started this thread, and I have to say that I have really become MUCH better at this skill. Today I worked with a guy who let me start all his lines for him, and I didnt miss a single one. It reminded me of "back in the day" when I was nervous even when looking at a huge pipe in the AC-- these days I am cool, confident, and actually successful!

For future IV newbies, this is what I found helped me the most:

1) I found I wasnt clamping the vein very well. This was huge. I was afraid of the vein "dissapearing" once I pulled traction on the skin, and it often got me in trouble as the vein wriggled and rolled away. I am MUCH more successful now that I have learned to really take a good hold of the site, visualize the vein, and go for it.

2) It helped alot to insert the needle just a little distal to where I see the vein. When I was just starting I had the tendancy to insert the needle right on top of a small vein, and I often pushed it aside, or by the time the needle + cath were under the skin, I was away from the visible area of the vein. Starting slightly more distal allowed me to get a straight shot right into the area of the vein that I can see-- which made a huge difference.

3) Confidence made a huge difference. It seemed that once I got my first run of successful IVs, I started getting more and more. I used to get REALLY nervous when I got the needle in and still didnt see flash-- thinking "oh no, it blew, it rolled, I'm nowhere near it, etc" I would sabatoge myself before the battle was even over. With a little more confidence (and certanly experience), I'm no longer put right out when the flash doesnt come right away. Staying cool and calm does wonders for my IV's- and I've noticed, my patients, as well.

Hope this helps someone, and again-- thanks everyone!

 

[Doula-2-OB]

From a patient's perspective (sat in the hospital for a week with pre-eclampsia, swollen like a tick and blowing IV after IV), it's SO MUCH nicer w/a bit of lido. I am usually an easy stick but when I was sick I was so swollen even the anesthesiologist couldn't get me (I took sick pleasure in gloating that the peds nurse could stick me when he couldn't, right to his smug, cocky face ) - it took *nine* attempts, and I could handle the bee sting of lido knowing that I wouldn't have to feel them dig around in my arms.

I tell my clients to ask for lido. I have heard many women say that the most painful part of the birth was getting that damn IV!

 

[MissMuffet]

... it's SO MUCH nicer w/a bit of lido.... it took *nine* attempts, and I could handle the bee sting of lido knowing that I wouldn't have to feel them dig around in my arms.

I tell my clients to ask for lido. I have heard many women say that the most painful part of the birth was getting that damn IV!

(This probably should be another thread, actually, but...)

I wouldn't say it was the most painful, but it was, without doubt, the most upsetting. (same for ER visits and surgeries)

I always beg for that tiny stick of lido, because all my experiences are the same: I tell them I'm a difficult stick, but they refuse to believe me. They look at my veins and say, "No way. Those others just didn't know what they were doing. You'll be easy, I promise."

Then, after 3 failed attempts, they apologize profusely and get someone "even better"... who fails his/her 2-3 attempts, until they finally use lido or call the CRNA to do it.

Meanwhile, if I'm conscious, I'm wishing very ugly things upon them as I pretend I don't blame them. But they really should have listened. lol

My (and many others') problem with needles is not the pain, but that they make me vagal so badly the vaso-vagal response itself is what I, and now my doctors, fear most. What began in childhood with merely passing out turned into more serious and prolonged vasovagal responses - hypoxic convulsions, etc.

It truly sux, because people think you're just being a baby. But that isn't fair, considering I choose to go without any local for other much more painful procedures - as long as they don't entail a bigger needle.


There was a physician whose father (also a physician, but with needle phobia) died from it. He wrote an article about how prevalent and misunderstood it is in one of the journals.. i'll see if I can find it.

 

[MissMuffet]

As someone who is a difficult stick, reading this thread is quite interesting. My tip to the OP is: if it's possible, listen to the patient. My experiences with giving bloodsamples and taking IVs has taught me what works and what doesn't work on me. ...

Techs and doctors who poo-poo me when I warn I'm a very difficult stick generally end up leaving massive bruises or panicking in the operating room (in the case of the oral surgeon who smiled patronizingly when the little woman gave her warning during the consultation....)

What is this EMLA stuff? If it kills the pain I'd love to be able to ask for it!

Emla is a cream they can (if they choose, or if you're brave enough to demand) apply to your skin under a little patch. It numbs the skin like lido, just takes longer.

There is a faster way, using iontophoresis (sp). Insurance pays for it.

 

[QuikClot]

The trouble is that nine out of ten people who tell me they are a difficult stick are as easy as pie. I don't blame them -- I presume some other provider has been making excuses for their own lack of success.

So faced with that claim, what am I to do but reassure the patient? It's a risk -- if you miss, you look foolish -- but most of the time, the reassurance is both correct and comforting.

On the other hand, with CAO pt.s who look at all challenging, I always ask; "And where have they had the most success in the past?" People often know where their good veins are. If my protocols included lido, and the patient liked and wanted lido, I would certainly use it. But I have to say that the vast majority of my patients show very little discomfort from a stick au natural.

 

[QuikClot]

PS: My curses upon providers so ignorant as to reguard a needle phobia as evidence of wimpiness. It's called the DSM, jerk-offs; look into it.