Prehospital IV Starts

[docB]

There were some interesting articles in the recent Annals of EM about EMS IV policy.

This article by Seymour, et. al. found that placement of an IV by EMS was associated with a reduction in mortality. Reasons for this were unclear but were speculated to be due to more and sooner resuscitation.

Interestingly this was followed up by an editorial by Samuel Stratton (which I thought was quite good) that recommends against the placement of IVs prehospital unless there is an immediate reason. He notes that many prehospital IVs are placed because they might be needed and that this is inappropriate.

Unfortunately you have to be a subscriber to see the editorial which is why I haven't given a link. He notes that a lot of EMS lines are placed without an immediate need, that IV access is associated with some complications and that the above study finds a decrease in mortality but does we don't know why or in which patients it is most beneficial. So he recommends against placement without a need.

---

Members don't see this ad.

 

[Dwindlin]

It's interesting that this very topic is being discussed on an EMS message board I frequent. I guess I err on the side of placing one in certain complaints even if I don't use it all (chest pain, dyspnea, a lot of belly pains, seizure, syncope, etc). I rationalize it by telling myself it may be easier while the patient is stable, however I do limit to 2 attempts if they are stable, and avoid ACs if possible.

 

[deleted92121]

I may be in the minority but I am going to say that most EMS patients should have an IV established. It should go without saying that all patients with dyspnea, cardiac symptoms, syncope, etc should have lines placed prehospital. My reasoning follows along the lines of "what if" or "could be". IV placement, generally speaking, is easy and low risk with proper aseptic technique.

I must say though, I have lost a lot of respect for many medics now that I work in the ED. I see so many potential areas for education and improvement but a significant number of them have no want, need, or desire to learn and better themselves. Paramedics want to be considered professionals, make more money, earn more respect, and so on then they need to step it up a notch.

Sorry for ranting, just frustrated lately.

DU

 

[AlmostJesus]

I tend to start them more liberally in the field than we do in the ER where I work. I stay away from making a major argument about it, if the patient isnt in an immediate need of an IV and they are a consenting adult, I won't put one in if they dont want one. The patient just needs to bear in mind, if anything happens and they crump, they will be getting an EZIO rather quickly.
The prevalence of the EZIO in prehospital medicine makes the routine establishment of lines in patients who may not need them a little harder of an argument. If they crash on you, zip an EZIO in an you wont be out that much time.
I have noticed that compared to when I was on my clinicals at a level II trauma center, we start a LOT less IVs in the small town I work at. It would be interesting to use that as a control in a study.

 

[jbar]

It does bother me that a fair amount of times the patient comes in with a line, but the medics can't draw bloods. Maybe the stuck the person two or three times to get that line. So now the 2 or three best veins have already been used, and we still need to draw blood. I know that you can use a butterfly rather than start a second IV, but when I need a lot of blood (like I'm getting cultures as well as tubes) there is a better chance to get them all with an IV. I also have a bit of a problem with this "IV at all costs" attitude that some people have. It's nice to have an IV in case the patient needs meds, but putting a 22 ga in the hand doesn't help me much.

 

[ljpm8224]

I tend to start them more liberally in the field than we do in the ER where I work.

^^ yah. this. Cuz if we don't bring them in with a line, we inevitably get sassed about it when we show up at the ER! I've gotten "omgwtf y u no start line?!?oneONE!" from nurses for the most mundane chief complaints.

 

[leviathan]

It does bother me that a fair amount of times the patient comes in with a line, but the medics can't draw bloods. Maybe the stuck the person two or three times to get that line. So now the 2 or three best veins have already been used, and we still need to draw blood. I know that you can use a butterfly rather than start a second IV, but when I need a lot of blood (like I'm getting cultures as well as tubes) there is a better chance to get them all with an IV. I also have a bit of a problem with this "IV at all costs" attitude that some people have. It's nice to have an IV in case the patient needs meds, but putting a 22 ga in the hand doesn't help me much.

This is probably a silly question, but why can't you draw bloods from an IV line that has been started already? Can't you secure an IV with an extension set, and then attach the vaccutainer system to that later on? I've never drawn blood before so I don't know specifically how it works.

 

[ljpm8224]

edit: more like, BEANDIP STOP BRINGING US THESE PEOPLE!!

 

[joeDO2]

This is probably a silly question, but why can't you draw bloods from an IV line that has been started already? Can't you secure an IV with an extension set, and then attach the vaccutainer system to that later on? I've never drawn blood before so I don't know specifically how it works.

as long as you waste a red top or two before drawing off the line it should be fine to use the existing line (although some institutions have policies that don't allow this). in any case, really the medics shouldn't have a problem drawing when they start the line....usually it is just a problem of not having the hospitals equipment....different hospitals use different tubes. i've drawn tubes several times only to have them thrown in the trash because the tubes are the wrong type or the nurse is afraid they have hemolyzed in the field. if hospitals want labs drawn the easiest thing would be to provide sets of their own tubes to the ems agencies. its well within most paramedic scope of practice and fairly easy and quick to accomplish usually.

 

[jbar]

My problem with just wasting a tube is that while it works in theory, if the values are off I don't know if the patient has a problem or their is still dilution from the IV. So we have to redraw the bloods. At which point about 2 hours has been wasted (our lab is slow).

I think patients who are critically ill or who you think you probably are going to have to give a medication should have an IV placed on scene. But if you aren't going to give meds just wait till the hospital.

 

[Dwindlin]

To add to what I said above, yeah I am quick to place a "what if" IV, however I saline lock everything I start. Even if I give meds, I don't typically hang a bag. Only time I pull out the saline is if I think they actually need the fluids. I can't imagine a 3mL bolus to flush my lock is going to cause enough dilution to mess with lab draws.

 

[AlmostJesus]

One of the underlying reasons for all the IV starts is likely due to billing. An ALS level assessment is subjective, but an IV line is objective, thus, it is a lot easier to bill medicare for ALS level I if they can see that the patient had an ALS intervention.
I am sure the ALS assessment as a criteria was meant to avoid this, but if audited, will your employee's charting hold up to review?
Just a thought.

 

[deleted92121]

There are a lot of good ideas floating around on this but really keeping it simple is the best bet. Lines go in people with chest pain, dyspnea, syncope, and significant trauma. Everything else is based on the patient and circumstances. We have all gotten the call for the elderly lady with weakness for a week. She probably does not need a line in the truck, she can last the ten minute ride to the hospital. But sometimes you get what you think will be a bull-crap thirty-something guy being a wuss and he ends up looking grey and like death warmed over him. This guy needs a freaking line.

So really it all comes back to good clinical judgement. Starting with a good assessment based off a solid understanding of pathophysiology will help you determine what needs to be done and in what order.

 

[FiremedicMike]

Unfortunately you have to be a subscriber to see the editorial which is why I haven't given a link. He notes that a lot of EMS lines are placed without an immediate need, that IV access is associated with some complications and that the above study finds a decrease in mortality but does we don't know why or in which patients it is most beneficial. So he recommends against placement without a need.

The most immediate need in my book is so that we don't get nasty looks and bitchy attitude from the ED nurses when we arrive with our patient

In all seriousness, I'll be the first to admit that we're not the cleanest environment in the world, and it's safe to say that our technique is anything but sterile. I see more of a value in educating the masses on how to be cleaner in our processes than disallowing IV therapy altogether.

 

[FiremedicMike]

There are a lot of good ideas floating around on this but really keeping it simple is the best bet. Lines go in people with chest pain, dyspnea, syncope, and significant trauma. Everything else is based on the patient and circumstances. We have all gotten the call for the elderly lady with weakness for a week. She probably does not need a line in the truck, she can last the ten minute ride to the hospital. But sometimes you get what you think will be a bull-crap thirty-something guy being a wuss and he ends up looking grey and like death warmed over him. This guy needs a freaking line.

So really it all comes back to good clinical judgement. Starting with a good assessment based off a solid understanding of pathophysiology will help you determine what needs to be done and in what order.

With all due respect, an elderly female with weakness for a week is cardiac until proven otherwise.

 

[FiremedicMike]

It does bother me that a fair amount of times the patient comes in with a line, but the medics can't draw bloods. Maybe the stuck the person two or three times to get that line. So now the 2 or three best veins have already been used, and we still need to draw blood. I know that you can use a butterfly rather than start a second IV, but when I need a lot of blood (like I'm getting cultures as well as tubes) there is a better chance to get them all with an IV. I also have a bit of a problem with this "IV at all costs" attitude that some people have. It's nice to have an IV in case the patient needs meds, but putting a 22 ga in the hand doesn't help me much.

With all due respect, I would encourage you to do some time in the field before you allow that to bother you. With all the things that need to be done as quickly as possible, drawing blood doesn't always have an opportunity to get done. To put it bluntly, there's only so many things we can do in a certain amount of time in order to minimize our effect on overall morbidity and mortality by spending way too much time with the patient. On one hand you have studies that state rapid transport with minimal interference in the golden hour, on the other hand we are expected to gather quite a bit of data with limited manpower/space.

Again, I don't mean to try and argue with you, just give you a different perspective.

 

[docB]

The most immediate need in my book is so that we don't get nasty looks and bitchy attitude from the ED nurses when we arrive with our patient

This actually is the reason for a lot of lines. It's a poor reason. There was a study years ago about why residents order tests. The #1 reason hands down was "Because the attending might want it." That's a bad reason. It resulted in huge unnecessary expenses and some morbidity. Similarly the fact that a nurse might want something isn't a real justification. Nurses (and doctors) are busy, overloaded and grumpy when new work appears in the ambulance bay. They are often a poor gauge of what was really indicated. The goal here would be to study this further and then give EMS some data to refute a nurse who says an IV was indicated in a certain situation. Or better still gather enough data to justify integration into the protocols, that will shut the whole complaint down quick.

In all seriousness, I'll be the first to admit that we're not the cleanest environment in the world, and it's safe to say that our technique is anything but sterile. I see more of a value in educating the masses on how to be cleaner in our processes than disallowing IV therapy altogether.

No one is talking about stopping IVs in general. The editorial is saying we should limit our IV starts to patients who have a need for an IV.

With all due respect, an elderly female with weakness for a week is cardiac until proven otherwise.

Do we have to have an IV on every cardiac patient? Particularly one who has no active chest pain, stable vitals and normal mentation and skin signs? That's the point of the editorial. If we need to push Zofran or morphine then an IV is indicated. If we're starting it just because it might come in handy later on then we may need to change.

 

[deleted92121]

With all due respect, an elderly female with weakness for a week is cardiac until proven otherwise.

Respectfully I disagree. Weakness for a week, with no other symptoms, makes me think either general illness such as flu, cold, or infection. If it were a malignant cardiac issue such as MI or dysrhythmia, most likely something bad would've happened before a week had passed.

However, in order to come to this conclusion a good history needs to be obtained. Weakness along with GI bleeding, pedal edema, etc would definitely warrant an EKG and IV. But simply just not feeling well for a week with no N/V/D, bleeding, chest pain, dyspnea, dizziness, etc makes me less likely to buy into "cardiac until proven otherwise". At least this is a reasonable pre-hospital approach. And we have all gotten the general malaise without other symptoms call and muttered to ourselves "wait a whole freaking week for this bull, blah blah blah".

Really, most of our patients could make it to the ED sans ALS intervention. That is the point of all this. But with our knowledge and training, we attempt to mitigate the potential badness that could creep up. I don't look at it as being hypervigilant or overcautious, rather I view it as being proactive.

 

[deleted92121]

Do we have to have an IV on every cardiac patient? Particularly one who has no active chest pain, stable vitals and normal mentation and skin signs? That's the point of the editorial. If we need to push Zofran or morphine then an IV is indicated. If we're starting it just because it might come in handy later on then we may need to change.

Man this one has me going in circles. I totally understand your point and in a way agree, but in the end I am going to have to say I just don't know. With almost complete certainty I can say that a patient with true cardiac issues such as MI, Angina, or arrhythmia will show signs and symptoms. Therefore if I have a patient with normal V/S, good skin color, lack of diaphoresis, etc than I would have to say this patient is likely not cardiac. Even a patient who has been through a minute or so of SVT will feel exhausted and beat to hell and back. So if I have a stone-cold normal patient with CC of quasi-cardiac issues should I start an IV?

I don't know. Maybe grabbing some V/S and keeping them on the monitor during transport is enough. In fact, it probably is. But is it really wrong to put that line in just in case that patient does have some screwed up episode? Statistics show it is not required but I think the patient normally feels better and for some providers, they may as well.

But when push comes to shove, do what your medical director says. They make sure you continue to play organic furniture mover.

 

[ljpm8224]

This actually is the reason for a lot of lines. It's a poor reason. There was a study years ago about why residents order tests. The #1 reason hands down was "Because the attending might want it." That's a bad reason. It resulted in huge unnecessary expenses and some morbidity. Similarly the fact that a nurse might want something isn't a real justification. Nurses (and doctors) are busy, overloaded and grumpy when new work appears in the ambulance bay. They are often a poor gauge of what was really indicated. The goal here would be to study this further and then give EMS some data to refute a nurse who says an IV was indicated in a certain situation. Or better still gather enough data to justify integration into the protocols, that will shut the whole complaint down quick.

I love your posts so much (srsly). I wanna be a medic in your county and be your fangirl. Wanna come be the medical director in SF??

+++5++++ for common sense.

 

[FiremedicMike]

This actually is the reason for a lot of lines. It's a poor reason. There was a study years ago about why residents order tests. The #1 reason hands down was "Because the attending might want it." That's a bad reason. It resulted in huge unnecessary expenses and some morbidity. Similarly the fact that a nurse might want something isn't a real justification. Nurses (and doctors) are busy, overloaded and grumpy when new work appears in the ambulance bay. They are often a poor gauge of what was really indicated. The goal here would be to study this further and then give EMS some data to refute a nurse who says an IV was indicated in a certain situation. Or better still gather enough data to justify integration into the protocols, that will shut the whole complaint down quick.

Oh, I know, and it was slightly in jest that I even made the nurse comment. At this point in my career most of the nurses I encounter know I'm not a ***** and don't really question me that much. I agree with your point that the system needs changed, but like a previous conversation on these boards about c-spine, until the standard of care is changed, then we are all putting ourselves slightly out on a limb when we don't do what everyone else would do.

Do we have to have an IV on every cardiac patient? Particularly one who has no active chest pain, stable vitals and normal mentation and skin signs? That's the point of the editorial. If we need to push Zofran or morphine then an IV is indicated. If we're starting it just because it might come in handy later on then we may need to change.

Yeah, I suppose that point is valid.

Respectfully I disagree. Weakness for a week, with no other symptoms, makes me think either general illness such as flu, cold, or infection. If it were a malignant cardiac issue such as MI or dysrhythmia, most likely something bad would've happened before a week had passed.

Personally, I think that's a dangerous assumption to make.

However, in order to come to this conclusion a good history needs to be obtained. Weakness along with GI bleeding, pedal edema, etc would definitely warrant an EKG and IV. But simply just not feeling well for a week with no N/V/D, bleeding, chest pain, dyspnea, dizziness, etc makes me less likely to buy into "cardiac until proven otherwise". At least this is a reasonable pre-hospital approach. And we have all gotten the general malaise without other symptoms call and muttered to ourselves "wait a whole freaking week for this bull, blah blah blah".

Oh, don't get me wrong, I utter that daily, but I personally feel any elderly patient complaining of weakness deserves an immediate 12-lead, no matter how long the symptoms have persisted or what other symptoms may or may not be present. Knowing full well that a normal 12-lead still doesn't rule out MI, I still maintain an index of suspicion that there may be a cardiac event taking place.

Really, most of our patients could make it to the ED sans ALS intervention. That is the point of all this. But with our knowledge and training, we attempt to mitigate the potential badness that could creep up. I don't look at it as being hypervigilant or overcautious, rather I view it as being proactive.

Most of our patients don't need the ED at all, but I'm past that point in my career of attempting to educate these people.

 

[deleted92121]

Mike, talking about elderly folks needing an immediate 12-lead with actue weakness or weakness for a week with no other symptoms brings up a very simple issue. Even if your index of suspicion is low for a cardiac event, does an EKG really hurt anyone? The answer is absolutely not. Perhaps doing an EKG will reveal something, perhaps it won't. It is an easy test and if nothing else will help direct your treatment. Despite my low concern of a malignant cardiac issues in a patient with weakness for a week, the EKG provides an easy tool to help guide treatment plans.

 

[jwk]

Mike, talking about elderly folks needing an immediate 12-lead with actue weakness or weakness for a week with no other symptoms brings up a very simple issue. Even if your index of suspicion is low for a cardiac event, does an EKG really hurt anyone? The answer is absolutely not. Perhaps doing an EKG will reveal something, perhaps it won't. It is an easy test and if nothing else will help direct your treatment. Despite my low concern of a malignant cardiac issues in a patient with weakness for a week, the EKG provides an easy tool to help guide treatment plans.

Not if you have a short transport time. This is part of the problem with medics trying to diagnose in the field. I see some stuff posted on an EMS board that absolutely drives me crazy - so far past the "look for horses not zebras" concept it's absurd.

Just because you CAN place an IV doesn't mean it needs to be placed on every patient or even most patients, or worse, "just in case". Just because you CAN do an EKG on someone with very non-specific complaints is not an indication it needs to be done.

 

[deleted92121]

Not if you have a short transport time. This is part of the problem with medics trying to diagnose in the field. I see some stuff posted on an EMS board that absolutely drives me crazy - so far past the "look for horses not zebras" concept it's absurd.

Just because you CAN place an IV doesn't mean it needs to be placed on every patient or even most patients, or worse, "just in case". Just because you CAN do an EKG on someone with very non-specific complaints is not an indication it needs to be done.

There are a lot of "Ifs" and there is no black and white answer to this type of situation. Short transport times changes a lot, that is a given. Also there is no disagreement on horses vs zebras.

But nothing I said in my post that you quoted indicates overstepping bounds or attempting to diagnose something out of nothing. In fact, I would argue that in practice I am much more likely to do nothing for the hypothetical patient we are discussing except transport to the ED. But I do stand by my conviction that if something just convinces me enough to an EKG, than I will. It is low risk and potentially useful. Though nine times out of ten it is stone-cold normal.

As far as the IV thing goes, once again, in practice I normally elect not to unless I believe it necessary. But I refuse to fault another medic who puts an IV in the aforementioned patient. Why? Because it is neither right nor wrong despite what we want to argue. And we play a game that is governed by risk stratification. So we are in many ways forced to err on the side of doing too much rather than doing too little. This is why I stated in an earlier post that "most EMS patients should have an IV established . . . due to what ifs or could be". It may not be the most appropriate way to do things except my medical service and director prefer it this way and I need to keep my job. But as always, we work for different services with different directors most likely in other states or at least other counties. So what is good for the goose in not always good for the gander.

Really, it all comes down to gestalt and experience. Good medics keep it simple and do what is best for their patient. They don't freak out, yell, etc when the crap hits the fan. They adapt to their situation and are able to develop a good plan based on a good assessment of the patient, location, capabilities, and so on. I'm never going to say "well as long as you don't hurt the patient". That is a BS line of thinking. Having reasons, evidence, or sometimes just that gut instinct about something should be the motivation for carrying out our treatment plans. But we should never do something "just because we can".

DU

 

[Deranged Medic]

He notes that a lot of EMS lines are placed without an immediate need, that IV access is associated with some complications and that the above study finds a decrease in mortality but does we don't know why or in which patients it is most beneficial. So he recommends against placement without a need.

Since I'm probably the newest person on here and will probably say something stupid (I have seen how some posts get completely torn apart on here!), I will stay brief. However, as a new medic who runs at several lower volume departments, I start one on 90% of my patients, just because I need to get better at starting them.

On another note, I would equate our education as being a large reason patients who don't need an IV end up getting one. It is almost impossible to pass medic class or national registry without stating "IV/O2/Monitor" on nearly every patient. We aren't fully educated on which patient truly needs IV access, just like we aren't fully educated on which patients actually need to be seen in the ED. Therefore many EMS patients get an IV, and most EMS patients are transported to the ED-even if the ED triages them with an ambulatory care-sensitive condition-and transportation to an urgent care or clinic would have been more appropriate.

 

[drmwvr]

The biggest hassle is the IV bag and tubing. Big waste of money too. Split the difference and just put in a heploc/saline loc thingy if access is so/not so important.

 

[NotAnOperator]

I get an 18 in pretty much any person who isn't musculoskeletal. We do follow the 2 attempt rule though but I can count on one hand the number of people we couldn't get at least a 20 in on scene. It's so low risk, I really don't see why not.

 

[frosted_flake]

It's interesting that this very topic is being discussed on an EMS message board I frequent. I guess I err on the side of placing one in certain complaints even if I don't use it all (chest pain, dyspnea, a lot of belly pains, seizure, syncope, etc). I rationalize it by telling myself it may be easier while the patient is stable, however I do limit to 2 attempts if they are stable, and avoid ACs if possible.

Hi @Dwindlin, I am an EMT-B about to begin my medic class. Is there a reason in which you would avoid ACs? I personally think that the medial wrist veins are usually pretty good to establish a line. I was just wondering if that was a personal preference or an actual reason behind it!

 

[alpinism]

Hi @Dwindlin, I am an EMT-B about to begin my medic class. Is there a reason in which you would avoid ACs? I personally think that the medial wrist veins are usually pretty good to establish a line. I was just wondering if that was a personal preference or an actual reason behind it!

You should always start distally if they have good veins in case you blow a vein and need a second attempt.

 

[frosted_flake]

You should always start distally if they have good veins in case you blow a vein and need a second attempt.

Thanks @alpinism !