Placing IV's

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greenbean

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Hi everyone
I'm a new CA1. This is sorta open to anyone. I have not had a lot of experience placing IVs(maybe did 1 in med school and 2 in internship). I see alot of the attendings placing IVs in our patients when they IV is too small or not fx-al enough for the case we are doing, or the pt just needs another IV. Sometimes, the IV nurses cant get the and then its up to anesthesia to get it.

Well thats where my problem lies. I am not good at putting iv's in; in fact im pretty terrible. I tried to put them in with one of nurses in preop in the AM before my first cases of the day, but im slowing them down and they dont really want me around b'c of that reason. So far i have tried maybe 10 total. I do watch alot of iv;s being placed. I mentioned this to my attending and he said it was unacceptable that I was not placing IVs and I should be doing 4 a day. But when I ask to put IVs in our pt's after we put them to sleep, he usually makes up some excuse so it doesnt happen. Sometimes he puts in the iv's himself, even after knowing i want to do them so badly(and no, they are not the impossible, last ditch scenarios where if the iv doesnt go , the **** hits the fan b'c if that were the case i'd totally understand)


im curious how the upper levels have faced this situation; or does every1 training nowadays just blow off this time traditioned skill and its something that the 'oldies' had to deal with
any help or suggestions?

thanks,
green :(
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I am wondering also why it is so hard for med students to learn that skill as well. I rotated with some German med students and they have the whole rotation dedicated to doing "nursing" skills. I wouldn't mind spending a month learning how to put IVs etc. Instead, residents, attendings and nurses are just scared if students want to do any of that. I have done spinals but have not placed an IV yet!
 
greenbean said:
Hi everyone
I'm a new CA1. This is sorta open to anyone. I have not had a lot of experience placing IVs(maybe did 1 in med school and 2 in internship). I see alot of the attendings placing IVs in our patients when they IV is too small or not fx-al enough for the case we are doing, or the pt just needs another IV. Sometimes, the IV nurses cant get the and then its up to anesthesia to get it.

Well thats where my problem lies. I am not good at putting iv's in; in fact im pretty terrible. I tried to put them in with one of nurses in preop in the AM before my first cases of the day, but im slowing them down and they dont really want me around b'c of that reason. So far i have tried maybe 10 total. I do watch alot of iv;s being placed. I mentioned this to my attending and he said it was unacceptable that I was not placing IVs and I should be doing 4 a day. But when I ask to put IVs in our pt's after we put them to sleep, he usually makes up some excuse so it doesnt happen. Sometimes he puts in the iv's himself, even after knowing i want to do them so badly(and no, they are not the impossible, last ditch scenarios where if the iv doesnt go , the **** hits the fan b'c if that were the case i'd totally understand)


im curious how the upper levels have faced this situation; or does every1 training nowadays just blow off this time traditioned skill and its something that the 'oldies' had to deal with
any help or suggestions?

thanks,
green :(
Click to expand...
Blow it off? lol no it is part of your basic skill set to be very deft with PIVs.

Goto work earlier and get your setup done then go to preop and do your IV before heading to your OR with the Pt. If you want more throughout the day and the attending is placing the second one while you are taping the tube. Then just wait till later in the case and place a third.
 
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In the PACU where I work, nurses often need to place additional IV's post-op and would be more than happy to let someone else do it. When you have time between or after your cases, you could probably go there and do some post-op as well.

At my program, our patients show up outside the OR before the case, usually with no IV. So we have to do them all (more or less). I sucked at them when I started as a CA-1, and I'm still not great, but I've done a couple hundred anyway... In your case it's too bad your program has a pre-op holding area where they do everything for you.

I also agree with placing them on your anesthetized patients, just be reasonable about it...

BNE
 
i'm not sure I understand. You say you're a CA1, it's mid-september, and you've tried 10 iv's? our CA1s have done hundreds by now. This doesn't smell right. Where are you training?
 
cchoukal said:
i'm not sure I understand. You say you're a CA1, it's mid-september, and you've tried 10 iv's? our CA1s have done hundreds by now. This doesn't smell right. Where are you training?
Click to expand...

He's training at University of Chicago...

Do you think he's really gonna say?
 
climbingdocs said:
I am wondering also why it is so hard for med students to learn that skill as well. I rotated with some German med students and they have the whole rotation dedicated to doing "nursing" skills. I wouldn't mind spending a month learning how to put IVs etc. Instead, residents, attendings and nurses are just scared if students want to do any of that. I have done spinals but have not placed an IV yet!
Click to expand...

um,
yea..
in THIS business,
IV skillz are NOT merely
nursing skillz...
please!
 
dfk said:
um,
yea..
in THIS business,
IV skillz are NOT merely
nursing skillz...
please!
Click to expand...


right, when anesthesiologist puts IV it's anesthesia skills, when nurse puts IV it's nursing skills....
 
climbingdocs said:
right, when anesthesiologist puts IV it's anesthesia skills, when nurse puts IV it's nursing skills....
Click to expand...

gee, i never thought of it like that.
thanks for showing me the light medical student.
 
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On neuroanesthesia it was great b/c the pts head was usually at the other end and my resident would let me try to get some iv's in the feet. Sometimes I caused a hematomato and other times we used the line. The nurses here let the residents get the iv in holding but once it starts to reach 715-730, they start placing them.

Thanks for the comment above, PlanktonMD.
 
You took the first step of noting your areas for improvement. Next you need to make sure you seek out more opportunities to improve on these areas. Nothing wrong with placing an extra IV during the case and capping it off. Or going in early to get some practice with the IV RN for that matter. They will likely want to show you more idiosyncratic BS to placing the perfect IV than you're wanting to listen to, but get the practice. You better be able to start a line large enough to induce your patient STAT when that Emergency Ingrown Toenail Removal rolls into your OR at 2AM when you're on call and all hell is breaking loose.:eek:
 
All I was trying to say that learning "nursing" skills for a MONTH out of 4 years would not be a bad idea, EVEN if you have to wipe someones behind. Some ***** wiping never killed anyone :laugh: Plus learning some humility is good for everyone.

Plank, thanks for the comment above.
 
cchoukal said:
I guess my point was that it's so unlikely that a CA1 in september would've been able to do so few by now that, golly, maybe this guy's not really a resident.
Click to expand...

This is why most of us DO NOT post here. WTF, why would someone WASTE their time here if they had another vocation?

*****************************************

"When you are calling him "medical student" is that supposed to be an insult?
This forum is dedicated to medical students and residents, everyone else here is basically THEIR guest."

Planktonmd, you big stud - that was very kind of you to say.
 
BubbleHead said:
Nothing wrong with placing an extra IV during the case and capping it off.
Click to expand...

If i were a patient i wouldn't want to look like swiss cheese at the end of surgery. 1 iv per case should be plenty considering you'll be doing upwards of 600 cases/year. If you need more training find time to place more iv's in holding...
 
dhb said:
If i were a patient i wouldn't want to look like swiss cheese at the end of surgery. 1 iv per case should be plenty considering you'll be doing upwards of 600 cases/year. If you need more training find time to place more iv's in holding...
Click to expand...

We are talking about a peripheral IV. Not a cut down or something. And especially if he is having trouble with something like this he should take every excuse to place more until he is better.
 
dhb said:
If i were a patient i wouldn't want to look like swiss cheese at the end of surgery. 1 iv per case should be plenty considering you'll be doing upwards of 600 cases/year. If you need more training find time to place more iv's in holding...
Click to expand...

Are you a resident?

If you have not seen a case where a second IV is needed then either you are not a resident or you have not done enough cases.


If the pt. has any need at all for a second IV then it is completely acceptable to place another one once they are asleep. The number of attempts should be commensurate with the need for the IV. Another IV can have some "soft" indications however there are many cases when a second IV is strongly indicated.
 
cchoukal said:
I guess my point was that it's so unlikely that a CA1 in september would've been able to do so few by now that, golly, maybe this guy's not really a resident.
Click to expand...


Im a CA1, and I have no more than 10 attempts so far. The moment our pt's arrive in preop, they have an IV placed by one of the preop nurses. I guess I could try doing them more often intra op, even if not absolutely necessary. We are spoiled here I guess.
 
cchoukal said:
i'm not sure I understand. You say you're a CA1, it's mid-september, and you've tried 10 iv's? our CA1s have done hundreds by now. This doesn't smell right. Where are you training?
Click to expand...

Your program must be an exception. Hundreds of IV's by now seems like a whole lot unless your preop nurses do not start them at all (which may be the case). Hundred, maybe where I trained by this time of the year.

We were responsible for starting an IV if the pt. came from home, but only for the first pt. - nurses started them all after the first case of the day. If the pt. was inhouse they normally already had one.
 
yup, same for us. first IV of the day. nurses placed thereafter. Better practice now though. Gotta be good for when YOU get called when the nurse cant get the IV or for when you start peds with those lil chubby babies. then you get to play the "that shadow might be a vein" game.
 
greenbean said:
I have not had a lot of experience placing IVs(maybe did 1 in med school and 2 in internship).
Click to expand...

After your next 50 healthy patients are asleep, put a second IV in them.

I know some people argue that it's unethical to subject patients to "unnecessary procedures" but be honest - a second IV is not unreasonable and is essentially zero risk. Most of us did our first by starting IVs in each other. I taught my wife to start IVs using my own veins simply because she was interested - at the time she wasn't even working in a health related field. Putting an extra 20 g IV in an anesthetized patient is not an evil thing to do.

Sure, it's poor form to turn them into bruised pincushions covered with tape and gauze, but go ahead and stick 'em once or twice. It's a good idea to do a few reps with EJs too, once you're comfortable starting IVs.
 
dfk said:
gee, i never thought of it like that.
thanks for showing me the light medical student.
Click to expand...

what's up with you? I know you're a nurse...I get that...I respect that. In a thread where your input as a nurse could be extremely helpful you choose to take a shot at one of us rather than help out. This is a forum geared towards medical student and physician education, so in that light it won't get easier for you from here on out....be helpful or move on.
 
climbingdocs said:
I am wondering also why it is so hard for med students to learn that skill as well. I rotated with some German med students and they have the whole rotation dedicated to doing "nursing" skills. I wouldn't mind spending a month learning how to put IVs etc. Instead, residents, attendings and nurses are just scared if students want to do any of that. I have done spinals but have not placed an IV yet!
Click to expand...

I've had this same conversation numerous times with fellow students and residents. When I was on my home anesthesiology rotation I volunteered to help the pre-op nurses start IVs since I needed practice (I had none), and they asked if I was board-certified. I was like no, umm, I'm a student. I couldn't help but laugh as nursing students are down there constantly getting practice with IVs.

In any case, I'm on my away rotation right now and tell every resident that I work with that I'd love to work on basic skills like this when the opportunity arises. Today my resident let me try 3 IVs while patients were asleep. During the case is really a great time for us to practice as patients are vasodilated both from the volume we give them and from the anesthetic.

Since med students don't get nearly as much practical experience as they did in the good ole' days, I think it's necessary for us to be more proactive and volunteer our services whenever possible.
 
climbingdocs said:
right, when anesthesiologist puts IV it's anesthesia skills, when nurse puts IV it's nursing skills....
Click to expand...

20ga or 22ga = nursing skill

14ga or 16ga = anesthesiologist skill

At our place we place all IV's on pre-op pt.s. Resident does first one of the day and the attending usually does the rest unless there is a lag in-between your cases and it won't hold up the room by waiting for you to place it. As a down side to this, we now have a lot of pre-op and PACU nurses that think it is "hospital policy" that they are not allowed to place IV's. Lazy b#$%@*&.

On a side note, I am a CA-1 and I placed my first 14ga IV the other day. I probably would have been fine with a 16ga or 18ga as a second IV but I had never placed a 14ga, I needed a second IV after we induced, and I love putting in huge IV's.
 
i agree that it's sketchy to have tried fewer than 10 IV's over 2 months into anesthesia residency. We generally only place first IV's of the day plus all additional IV's, but I probably did something like 100 by this time my CA-1 year. Even doing the math on first case IV's would give you like 40 IV's so far. Maybe my institution is conservative, but most people who have their arms tucked get a second IV after they're asleep. If someone may benefit from a second IV or an arterial line (but probably doesn't NEED NEED NEED one right now) invoking the principle of MRB (maximal resident benefit) leads to a lot of procedures for the young ones. Seriously, now is the time to do it. In my program, CA-2's and CA-3's don't sit a lot of rooms and you really don't do that many intubations/IV's after CA-1. We do s*&tloads of spinals/epidurals/blocks/central lines as seniors, but the bread and butter stuff gets left to CRNA's and junior residents for the most part.
 
Do you know how much money you get paid to start an IV?

When you're in PP, do you want some friggin ward nurse to page YOU at 3 am because they can't get a IV, and they think you're the BEST at it?

Do you want the Internists and other doctors in the hospital to page YOU to start IV's because they think you're the BEST at it?

If you do...and don't mind getting PAID....ZERO dollars and ZERO cents for getting paged at 3 am to go start some IV that a nurse should be doing....then all the more power to you.


I make clear to EVERYONE, that I SUCK at starting Peripheral IV's....The surgeons know it...the internists know it...I make it CLEAR to the nurses that I SUCK at IV's.

No one EVER calls me for IV help...Why? Because I SUCK at them....If i need access, I stick a wire in either the IJ or SC and go from there.......When I get called, I'm putting in a central line....for which I can bill the 3rd party payors and collect 50% of my bill.
 
wow, i must be really terrible if u guys are doubting that im actually an anesthesia resident

lets say that im at a program on the east coast if that helps and im not going to say more than that

for the 1st 2 mos, all the iv's were put in by nurses in preop, occasionally when the attg didnt like the iv, he would put it in himself and if i asked to do a 2nd id get a runaround answer, some attendings let me put a second one in

for the past week, ive tried going to preop early, i wake up at like four am to get to OR early and set for my cases, then in preop, the nurse usually says its too busy for her to watch me(and someone needs to be around b'c i am so terrible at placing them that i usually dont get the access and the rn fiddles with and then gets it) . and the attg i work with this month is the same as the first one i had ; he always gives me bs about not putting a second one in whenever i ask, this morning i wanted to start an IV on MY pt, i told the nurse in preop so she could watch me, but the pt's veins were hard for me to see. i kept tapping after i put the tourniquet, the pt needed to also have T/C. in the corner of my eye i saw my attending whispering to the rn so that i shouldnt do the iv, so the rn put it in. i presented my pt and went to my room; i swear i was so humiliated i was about to cry and thats the first time thats happened in QUITE a while

but thanks for the suggestions, maybe i should F@ck it and just stick to intubating, and when they cant get an iv, ill say dont look at me call the nurse
 
oh and heres another reason why its tough for me to do place the second iv: after the ETT is in, everyone ELSE(circulators, scrubs, surgeons/etal) is in this big rush to prep,drape and attack, ...well what happens to the pt's arms? either they get tucked, or a nice giant bair hugger with 3 blankies gets ploughed onto them and then they drape. and that's the end of that
 
Just hit em with some 1% lidocaine with a 25-27g needle. Then you can dig around all day. Keep some gauze and tape near by to compress all the hematomas you'll cause.

We've all been there. You'll get it.
 
greenbean said:
oh and heres another reason why its tough for me to do place the second iv: after the ETT is in, everyone ELSE(circulators, scrubs, surgeons/etal) is in this big rush to prep,drape and attack, ...well what happens to the pt's arms? either they get tucked, or a nice giant bair hugger with 3 blankies gets ploughed onto them and then they drape. and that's the end of that
Click to expand...

Dude, are you serious? Turn the hugger off move the blankets or put them on the floor since with the hugger they dont help much. Then do your IV. Whats the big deal?
 
well, the major reason barrier is my attg, in my prev posts, i said that they usually give me a runaround when i want to start a second one, here are the ones i get
1) oh dont worry u'll get plenty of chances later in the year
2) nah, this case will be quick(it goes on for another hour)
3) i think this pt might complain

and the list goes on

and how the heck am i gonna move the bair hugger and blankets when my attg is standing there and just gave me one of those reasons? whatever
 
greenbean said:
well, the major reason barrier is my attg, in my prev posts, i said that they usually give me a runaround when i want to start a second one, here are the ones i get
1) oh dont worry u'll get plenty of chances later in the year
2) nah, this case will be quick(it goes on for another hour)
3) i think this pt might complain

and the list goes on

and how the heck am i gonna move the bair hugger and blankets when my attg is standing there and just gave me one of those reasons? whatever
Click to expand...

Your attending stands there with you through the entire case? Why even ask them about starting another one? Maybe my program is more liberal than yours Im not sure but we have a ton of autonomy to make whatever decisions we want. Sorry you dont seem to have that at your program.
 
You know, I bet one of your fellow residents would let you start one on them. When a med student is with me I let them try three per hand. I do say nothing bigger than an 18 though, and they have to use lidocaine. If it was a classmate they would get quite a few more shots than that, and get to use a bigger needle.

Ask a friend, you will probably be surprised.

Or, you could go out on the street and help a junkie out.
 
Greenbean:
I have a few things I want to tell you:
1- Your attendings are obviously not good teachers, and this is a very common problem in academic anesthesia unfortunately.
2- In our business there is a very important rule:
Never show fear, and always appear confident (even if you are not).
There are people around you who are like sharks, they smell fear and they will eat you alive if you let them, examples: Preop nurses, PACU nurses, OR nurses, Surgeons, Attendings, other residents, secretaries, cleaning services..... all these people will just step all over you if you give them a chance.
So, please, Do Not ask a nurse to come and watch you start an IV :eek:, DON'T DO IT !
They don't care if you learn and they will do their best to make you look stupid.
3- Here is 2 pearls that if you apply you will become a champion of IV's:
A- Apply the tourniquet as tight as you can, and apply it closer to where you are starting your IV (if you are starting a hand IV put the tourniquet on the forearm not on the arm). You will know it is tight enough when the patient shows discomfort and give the veins time to fill up.
B- Stretch the skin tight with your non dominant hand distal to where you are inserting the needle.
If you do these 2 things and you stop asking nurses to guide you, you will get better very fast.
I feel sad that I have to guide you here on the internet, this is the job of your attendings but they obviously don't care.
And one more thing: Never allow them to make you cry, (you are a girl I am assuming) but regardless, no one should be able to make you cry, period.
 
TrustMe said:
20ga or 22ga = nursing skill

14ga or 16ga = anesthesiologist skill

At our place we place all IV's on pre-op pt.s. Resident does first one of the day and the attending usually does the rest unless there is a lag in-between your cases and it won't hold up the room by waiting for you to place it. As a down side to this, we now have a lot of pre-op and PACU nurses that think it is "hospital policy" that they are not allowed to place IV's. Lazy b#$%@*&.

On a side note, I am a CA-1 and I placed my first 14ga IV the other day. I probably would have been fine with a 16ga or 18ga as a second IV but I had never placed a 14ga, I needed a second IV after we induced, and I love putting in huge IV's.
Click to expand...

lay off the nitrous.
i'm sure i've dropped more
hoses than you ever have or will.

lemme clap for your first 14 g.
 
toughlife said:
Ban that CRNA.
Click to expand...

yea, ban 'em all there tough.
can't handle a little confrontation?
b/c you're a doc, you got it all?
you know it all?
you've experienced it all?

for a man with such a plight,
i'd have considered you for
someone with a bit more understanding.
 
Southpaw said:
what's up with you? I know you're a nurse...I get that...I respect that. In a thread where your input as a nurse could be extremely helpful you choose to take a shot at one of us rather than help out. This is a forum geared towards medical student and physician education, so in that light it won't get easier for you from here on out....be helpful or move on.
Click to expand...

hey look,
in a thread where i believe
i have extensive knowledge
and experience,
i feel i could offer some advice.
however, when someone (i don't care who)
offers cheap shots,
isn't it only fair to rib back?

i've watched attendings fumble at IVs.
does that make them wooses?
or 'nurse-like'?

c'mon.
IVs are not profession,
but a skill.
 
dfk said:
yea, ban 'em all there tough.
can't handle a little confrontation?
b/c you're a doc, you got it all?
you know it all?
you've experienced it all?

for a man with such a plight,
i'd have considered you for
someone with a bit more understanding.
Click to expand...

Friend, you are walking a tightrope here. As stated previously this site is for DOCTORS and medical students. Your petty comments are not welcome.
 
dfk,
dude! When I said "when nurse places IV it's nursing skill and when anesthesiologist places IV it's anesthesia skills" I was being sarcastic. I don't know why the h.ell you are being so defensive about. Some people!!! :mad:
 
we wait for advice
but instead we get haiku
take your skill and go
 
Last edited by a moderator:
So why then do you hang out on a Student DOCTOR network? It seems a resident or medstudent would be a little more humble or at least less inflammatory.
 
Last edited by a moderator:
Please. Back on topic. I'm sure we can find some ways to discuss "placing IV's" and help this dude without ruining yet another thread with the same old crap.

My two cents.

BNE
 
militarymd said:
Do you know how much money you get paid to start an IV?

When you're in PP, do you want some friggin ward nurse to page YOU at 3 am because they can't get a IV, and they think you're the BEST at it?

Do you want the Internists and other doctors in the hospital to page YOU to start IV's because they think you're the BEST at it?

If you do...and don't mind getting PAID....ZERO dollars and ZERO cents for getting paged at 3 am to go start some IV that a nurse should be doing....then all the more power to you.


I make clear to EVERYONE, that I SUCK at starting Peripheral IV's....The surgeons know it...the internists know it...I make it CLEAR to the nurses that I SUCK at IV's.

No one EVER calls me for IV help...Why? Because I SUCK at them....If i need access, I stick a wire in either the IJ or SC and go from there.......When I get called, I'm putting in a central line....for which I can bill the 3rd party payors and collect 50% of my bill.
Click to expand...

This has got to be the best, most unexpected answer that I have ever read here on this forum. MilitaryMd, you have some of the most straightforward advice--I think it's awesome!!
 
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