ultrasound IVs

[bearstanley]

i'm looking for some moral support for USIVs. i am bad at them, having done fewer than 20, and my success rate is about 50%.

they are really beating up my procedural confidence. unlike some other procedures, i don't have a sense of stepwise improvement- it's very binary: either i get the line or i don't.

the patients that tend to require USIVs are also not the easiest to work with. today i failed at two, one on an IVDU pt with no veins who was screaming profanities at me while i tried, and the other on a pt with CP who was so contracted that my only option was to basically attempt it upside down.

i understand the procedure from an intellectual standpoint. i'm open to your tips and tricks, but that isn't really the issue here. now when i get asked to do a line, i have zero confidence and i approach it expecting failure. i know that i just have to keep showing up, keep trying, and eventually the skill will come, but it is just wearing on me to keep trying and failing at this one procedure (especially considering all my peers seem completely facile).

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[RustedFox]

The tip that helped me the most was to remember that you need to keep the US probe *juuuust* ahead of the needle, so you can tell the depth of the TIP (just the tip), and not some random point on the shaft of the needle.

 

[theseeker4]

i'm looking for some moral support for USIVs. i am bad at them, having done fewer than 20, and my success rate is about 50%.

they are really beating up my procedural confidence. unlike some other procedures, i don't have a sense of stepwise improvement- it's very binary: either i get the line or i don't.

the patients that tend to require USIVs are also not the easiest to work with. today i failed at two, one on an IVDU pt with no veins who was screaming profanities at me while i tried, and the other on a pt with CP who was so contracted that my only option was to basically attempt it upside down.

i understand the procedure from an intellectual standpoint. i'm open to your tips and tricks, but that isn't really the issue here. now when i get asked to do a line, i have zero confidence and i approach it expecting failure. i know that i just have to keep showing up, keep trying, and eventually the skill will come, but it is just wearing on me to keep trying and failing at this one procedure (especially considering all my peers seem completely facile).

I was probably 50% for the first 50-75 of them that I did, then I am almost 100% after that. Really, once you do enough and learn enough tricks, you will almost never fail. Until then, just remember and stick to the basics
- move either the needle, or the probe, never both at once
- Use long angiocaths, the longer the better, for any vein that is not right at the surface
- tiny movements are necessary
- identify and avoid the nerves, you will never get to a vein that you have to go through a nerve first to reach, unless the patient is comatose (obviously it still isn't ok).
- movements of the needle need to actually move it into the skin, I have had patients with skin so tough and scarred that I felt like I was moving forward when the needle was just moving/tenting the skin and not sliding through it.
- When first puncturing the skin, push through the skin in a smooth motion NOT watching on the monitor. If you try to watch everything from the moment the needle first touches the skin on the monitor, you will be sitting there pushing a sharp needle through tenting, tough skin bit by bit, which patients do NOT appreciate. Slide the needle a nice ways into the skin, at least a few milimeters, visually ensuring you actually went through the dermis, THEN find the tip with the probe and do everything else focused on the monitor
- Don't get impatient and try to advance the angiocath too soon; if it isn't far enough into the vein, it can kink as you try to advance it, and it is all over then, have to start again. If you have to keep advancing the needle until it is hubbed against the skin, with the tip visualized inside the lumen, that is perfectly fine
- Don't get frustrated and pull the needle out if you can't clearly see the tip. You can use jiggling motions, small adjustments, and look at surrounding tissue deformation from your movements to guide the tip to the vein. Once you are tenting the vein with the needle tip, you will eventually get it into the lumen, and it is very clear where your tip is after that
- If you have trouble finding the needle, try adjusting the angle of the probe in relation to the needle. The strongest signal will be when the probe's beam is perpendicular to the shaft of the needle (or bevel at the very tip). It is very easy to inadvertently have the probe held at a sub-optimal angle, especially if you are staring at the screen trying to find where you are.
- Anchor both hands on the part of the patient you are accessing, not on the bed, the rail, the table, or the patient's torso.
- Don't be afraid to tie/tape down the patient's arm if they are so out of it that you can't get them to cooperate.
- Don't put yourself in danger, if the patient is so agitated/combative that you feel you are at a high risk to get a needle stick, don't do the procedure. Insist that someone (or multiple someones) help hold, or sedate the patient first if you need to do so to get IV access. If the patient has capacity to the point you cannot sedate them against their will, don't do the procedure if they won't cooperate with it.

Don't let this kill your confidence. Some patients are very challenging, and you just need to get enough of them in to start feeling confident. Try to do as many as you can early on, and other US-guided procedures will come much more easily.

 

[boomshaketheroom]

- Don't get impatient and try to advance the angiocath too soon; if it isn't far enough into the vein, it can kink as you try to advance it, and it is all over then, have to start again. If you have to keep advancing the needle until it is hubbed against the skin, with the tip visualized inside the lumen, that is perfectly fine

This is the best tip I got. If you can visualize the tip inside the vein (which you should be able to do), just keep advancing (your long angiocath) until it is more or less hubbed. I think as long as you go slow and steady it shouldnt be too hard to get better

 

[carbonizedeyesockets]

Practice, practice, practice. Biggest tip is to not lose the tip. When learning, take your time. Other good tips above. Not much to add here, but keep it up and you'll get to the point that you rarely can't get a peripheral.

For me, I almost never look distal to the AC. Nurses have looked there and usually have poked around. Also, the veins typically are tiny. The medial upper arm by the brachial artery is where I look first and place probably 95% of IVs.

 

[MechEDoc]

Practice on some easier patients too! Especially if you have a slower shift where it is less of a hassle.

 

[alpinism]

Good advice from seeker above.

I'll add a few more pointers:

- Hit the zoom bottom to center the vein in the middle of the screen and decrease the gain as much as possible
- Start at a shallow angle since its much easier to see the needle if its at 30 rather than 45 degrees
- Enter the skin with just the needle tip a couple cm distal to the US probe
- Bring back the probe slowly until you see the needle tip
- Finally "walk the dog" until you see the tip within the vein

"walk the dog" = Advance the probe forward until to lose the tip then advance the needle until you see the tip again. Keep repeating using slow steady movements so that you never lose track of the tip and are able to follow it directly into the vein. Once inside the vein keep going by centering the tip within the blood vessel lumen until you hub the needle.

Also remember if the patient is sick and you need access fast the brachial vein is your friend.

 

[MechEDoc]

Initiating, but not fulling turning on M-Mode will give a center line on the screen that can be used to nicely center the vein under the probe, then anchor the probe to the patient's skin using on the ulnar aspect of your hand and place the needle in the center of the probe. This may be helpful for attaining initial alignment.

 

[OB1🤙]

Dropping in here from the anesthesiology world.

Using an Arrow a-line kit with the built-in wire makes U/S PIVs easy, regardless of insertion angle.

Find your vein in short axis, get your needle tip in there, get your venous flash, advance the wire, thread catheter, and boom, you have a 20g PIV.

 

[MechEDoc]

Dropping in here from the anesthesiology world.

Using an Arrow a-line kit with the built-in wire makes U/S PIVs easy, regardless of insertion angle.

Find your vein in short axis, get your needle tip in there, get your venous flash, advance the wire, thread catheter, and boom, you have a 20g PIV.

Can you power inject through those catheters?

 

[tkim]

today i failed at two, one on an IVDU pt with no veins who was screaming profanities at me while i tried

This is not acceptable. They either stop yelling at you, or you up and leave and return when they are ready to be an adult. Or you offer to do an EJ or IO. Their choice.

 

[Psai]

Dropping in here from the anesthesiology world.

Using an Arrow a-line kit with the built-in wire makes U/S PIVs easy, regardless of insertion angle.

Find your vein in short axis, get your needle tip in there, get your venous flash, advance the wire, thread catheter, and boom, you have a 20g PIV.

Sometimes I take the wire out and do through and through. 50℅ of the time, it works every time.

 

[SpacemanSpifff]

OP: EJ's > US IV's all day, if they're available. While US IV's are a great skill to have, being able to pop in an EJ without having to track down the US will save you a lot of time.

Dropping in here from the anesthesiology world.

Using an Arrow a-line kit with the built-in wire makes U/S PIVs easy, regardless of insertion angle.

Find your vein in short axis, get your needle tip in there, get your venous flash, advance the wire, thread catheter, and boom, you have a 20g PIV.

Have you ever used a femoral arterial line catheter for a peripheral venous line? I've been thinking about this for my bigger patients who need more catheter than the 1.75" 18g's we have. When I have said this in the past, some attendings have balked, but it's basically a midline.

 

[24GaugeEJ]

You can do it, man. Took me doing over a hundred or so to get really comfortable. After a couple thousand you’ll be unstoppable. I always use the 1.88 inch 18gauges (don’t listen to anyone else, they’re not too big and are easier to find on the screen), or bigger for shocky patients. Make sure you’re lined up, then go for it. Don’t watch your hands or the angio (ie don’t look for flash) once you pierce the skin - watch the screen. Take your time and find the tip. Once you’ve found it, pretend your hands are tied together like Rocky’s legs when Mick is teaching him footwork — as you advance the needle, advance the probe and always keep that tip on the screen. A lot of times I’ll hub the angio before I pull the needle out. You can watch it go all the way in.

Then, hum terrapin and stroll away in the glory of victory. Don’t go down the road feelin’ bad.

Gonna listen to 2/26/77 on my way to class now.

 

[KGflyboy]

I would never be doing a procedure in someone yelling profanities. That's not safe. Aside from that, I don't have good advice for you. I'm not great and US IVs. But that's ok with me. I don't want everyone asking me to put in their IVs, which is exactly what happens to people known for getting difficult IVs.

 

[gro2001]

i'm looking for some moral support for USIVs. i am bad at them, having done fewer than 20, and my success rate is about 50%.

they are really beating up my procedural confidence. unlike some other procedures, i don't have a sense of stepwise improvement- it's very binary: either i get the line or i don't.

the patients that tend to require USIVs are also not the easiest to work with. today i failed at two, one on an IVDU pt with no veins who was screaming profanities at me while i tried, and the other on a pt with CP who was so contracted that my only option was to basically attempt it upside down.

i understand the procedure from an intellectual standpoint. i'm open to your tips and tricks, but that isn't really the issue here. now when i get asked to do a line, i have zero confidence and i approach it expecting failure. i know that i just have to keep showing up, keep trying, and eventually the skill will come, but it is just wearing on me to keep trying and failing at this one procedure (especially considering all my peers seem completely facile).

As others have said, please never do this again. It's not safe. The moment a patient starts yelling at you, get up and walk out of the room. There is no part of the Hippocratic oath that requires one to become a martyr. Also, this is not punitive and you are not denying them care, as they can immediately make the situation safe for you by not being threatening any more. Now, if they are not in control of their own behavior because of acute psychosis or intoxication, I would recommend treating their agitated delirium with IM medications prior to trying to place an US guided IV.

Regarding the technical competency, just keep at it. 20 is not that many. Try doing it on patients who are not going to be difficult (your next patient who is intubated, for example. Every critically ill patient should have two IVs anyway). Also, I find that the in plane view (aka long axis) has a way higher success rate. Try that maybe?

 

[GonnaBeADoc2222]

Solid solid technical advice above. Follow that tip.

U/S IV is such a great skill to have. I love the brownie points it scores you with nurses and even other attendings who need help getting access! Unfortunately I think it's one of the most difficult EM skills to master. In PGY 1-2 year I missed nearly 85% of these. By the end of PGY2 and in PGY3 I approached ~90% success rate and was barely ever missing by PGY4. I think it took > 100 attempts to start to get good.

Long IV cath is an absolute must. Positioning is so key. Raise stretcher to comfortable height. Prop up arm w towels. I always go for cephalic vein as I find that's usually the biggest and also untouched. Have RN or tech told patient's hand still.

I've always found the psychology of procedures among trainees to be interesting. I'd be willing to bet your colleagues are over reporting their success rate, and that their experience is closer in line to your's.

Also, combative patients do not receive elective procedures. If there is an intoxicant involved, they get IM ketamine so that you can do what you need to do. If there is not, they get shown the door unless they can behave. The risk to you and staff is too great.

 

[witzelsucht]

i found it useful to practice technique on people with good veins before moving to people who actually need an u/s IV. as above, pretend the person is a difficult stick and use strict technique, following needle tip until you are hubbed

 

[Groove]

Ah yes, the dreaded "Doc, we can't get an IV and a gazillion people have already tried...and the skin on their neck is like cooked whale blubber....THEY GONNA NEED A CENTRAL LINE!"

I like to put on an extra venomous, sourpuss face and...sigh, glare and bark "have you exhausted all peripheral attempts?! Has X or Y tried yet? Who's the best in the dept right now and have them give it a shot." Better yet, I'll say "Well it looks like they were here a week ago and the nurse was able to get a line then!"

When it comes down to it though, US IVs are not too difficult once you get the hang. I just don't like to condition the nurses to think that I am always available to place one since I've noticed the "failed IV" rate seems to increase exponentially depending on the nurse.

 

[Fox800]

I've started to push back on these more as a senior. The nurses try to walk over the PGY-1's and 2's saying they've tried "multiple times" and can't get an IV.

Then when I ask, they've really only tried twice, haven't asked another nurse to try, haven't tried ultrasound yet, etc. It's just a huge time suck.

My personal rule is 4 attempts between two nurses, with one of them trying ultrasound. Then I'll try. If not, do that and get back to me.

 

[RoyBasch]

Dropping in here from the anesthesiology world.

Using an Arrow a-line kit with the built-in wire makes U/S PIVs easy, regardless of insertion angle.

Find your vein in short axis, get your needle tip in there, get your venous flash, advance the wire, thread catheter, and boom, you have a 20g PIV.

I'm going to try this next time I get a chance.

 

[Amazingmuzmo]

The tip that helped me the most was to remember that you need to keep the US probe *juuuust* ahead of the needle, so you can tell the depth of the TIP (just the tip), and not some random point on the shaft of the needle.

Very good advice. You should in fact be able to trace the movement of the tip of the needle once you get good enough. Most people I see with difficulty with these lines see what they think is the needle tip but in fact the needle has gone far beyond that point. Once your skill level increases, try doing the US guided lines in the long axis view. If you are able to keep the needle exactly along the correct plane, you can view the entire trajectory of the needle entering the vessel (assuming the vein is straight). Check youtube for some examples.

 

[Amazingmuzmo]

OP: EJ's > US IV's all day, if they're available. While US IV's are a great skill to have, being able to pop in an EJ without having to track down the US will save you a lot of time.


Have you ever used a femoral arterial line catheter for a peripheral venous line? I've been thinking about this for my bigger patients who need more catheter than the 1.75" 18g's we have. When I have said this in the past, some attendings have balked, but it's basically a midline.

I have done this. Very similar concept to using the radial a-line kits for a US guided peripheral IV. Very easy, and long enough to get to those deeper veins in the upper medial arm of heavier patients.

 

[deleted547339]

Agree with almost all that was said before except: do NOT jiggle the needle. This is a crutch to make up for bad technique. Just learn how to use US appropriately and you should never have to.

Other tips:
1) practice. Cannot be overstated. Once you’ve done 100, you’re great.
2) SIT DOWN! If it’s tough, take your time. Patience is a virtue.
3) anchor both hands
4) do them on all intubated/sedated patients
5) never do them on someone who isn’t ok to sit still
6) sometimes you’re in the vein but don’t get flash - if so, just drop your angle and advance the angiocath without the needle
7) try long axis
8) follow your needle tip. Know where that is, not the barrel.
9) practice.

 

[SpacemanSpifff]

I have done this. Very similar concept to using the radial a-line kits for a US guided peripheral IV. Very easy, and long enough to get to those deeper veins in the upper medial arm of heavier patients.

Did you do it semi-sterile (i.e. gloves, prep, towels)? The few attendings I've discussed this with seemed uncomfortable with the idea

 

[GonnaBeADoc2222]

Did you do it semi-sterile (i.e. gloves, prep, towels)? The few attendings I've discussed this with seemed uncomfortable with the idea

Seems like a weird thing to be uncomfortable with. The biggest downside to this is I don't think you can't infuse contrast through it if you need it for a CTA or something.

 

[Mizzou_EM]

Rapid IJ all day

 

[sylvanthus]

Long axis for the win.

 

[Amazingmuzmo]

Did you do it semi-sterile (i.e. gloves, prep, towels)? The few attendings I've discussed this with seemed uncomfortable with the idea

No. I do this as a way to quickly get a line without having to go to the next step (central line). If I'm gonna take the time to prep and glove up, I might as well grab a midline kit/central line kit and just put in a midline/IJ. In my experience they haven't been particularly more susceptible to infection than most other PIVs.

 

[scummie]

Thanks for making me laugh out loud, need it before my shift.

Ah yes, the dreaded "Doc, we can't get an IV and a gazillion people have already tried...and the skin on their neck is like cooked whale blubber....THEY GONNA NEED A CENTRAL LINE!"

I like to put on an extra venomous, sourpuss face and...sigh, glare and bark "have you exhausted all peripheral attempts?! Has X or Y tried yet? Who's the best in the dept right now and have them give it a shot." Better yet, I'll say "Well it looks like they were here a week ago and the nurse was able to get a line then!"

When it comes down to it though, US IVs are not too difficult once you get the hang. I just don't like to condition the nurses to think that I am always available to place one since I've noticed the "failed IV" rate seems to increase exponentially depending on the nurse.

 

[miacomet]

At my shop the nurses and techs do the US IVs. Why are docs stuck doing this? Seems like a waste of physician time.

 

[Groove]

I also do a lot of "Easy IJ's" with ~2" angio's. Takes 2 secs and bills like a central line.

 

[hoot504]

I can't help but laugh at some of these numbers. Really? You've been a resident 2 years and change and have done ~75 of these? Jesus. I felt I was getting asked to do these every shift in residency but if I'm really honest with myself, I don't think I've done more than 25 - 30. Even with this I can't remember missing one in a while. I've yet to do one in the community (shop dependent I'm sure).

Hold the probe like a beer can, that way you can rest the medial edge of your hand on the patient. That will eliminate all of the unpredictability from the U/S side of things. Once I'm in the vessel, I level out my needle to be in plane with the vessel and keep advancing until I know I'm anchored in there. I only do that if I know I have some real estate to play with, otherwise you can blow right through the back of whatever you're in. Once I've done that, advance whatever few mms of catheter you have left and take the needle out. Done.

 

[southerndoc]

I also do a lot of "Easy IJ's" with ~2" angio's. Takes 2 secs and bills like a central line.

How can you bill this as a central line?

CPT guidelines (CPT 36555-36571 for insertion) are very strict with what qualifies as a central venous catheter: “the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium.”

This can be either centrally inserted or peripherally inserted. It is the termination point that counts as a central line.

A 2" catheter does not qualify as a central line insertion.

 

[Tenk]

I just shove long 18s and 20s into the IJ now when nobody can get access. Super fast. Super easy. Can get the most beautiful CTAs too.

 

[Groove]

How can you bill this as a central line?

CPT guidelines (CPT 36555-36571 for insertion) are very strict with what qualifies as a central venous catheter: “the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium.”

This can be either centrally inserted or peripherally inserted. It is the termination point that counts as a central line.

A 2" catheter does not qualify as a central line insertion.

It’s 16-18cm to the cavoatrial junction. You don’t think 5.1cm(2”)-6.4cm(2.5”) would at least put the tip near the subclavian? If not, it’s got to be damn close. Those are long catheters, I bet it terminates much deeper than you realize. I’ve always just documented my easy IJs as a central line.

 

[southerndoc]

Near the subclavian doesn't qualify. It has to reach the subclavian. The internal jugular isn't listed as a termination point for a central line.

 

[Groove]

Near the subclavian doesn't qualify. It has to reach the subclavian. The internal jugular isn't listed as a termination point for a central line.

Well that's my point. 5-6.5cm should theoretically put it within the subclavian, hence it qualifies. I don't see where they require you to prove the termination point on the CPT definition. I mean, how do you document those procedures? Does it feel like peripheral IV to you when you push a "2+ catheter into someone's internal jugular? It sure doesn't to me. If someone wants to audit my chart and try to make an argument that my central line wasn't within the subclavian, I'd like to see them prove to me that it wasn't. Until then, I'll bill all these as central lines.

 

[Alvarez13]

Here is my favourite video:

 

[24GaugeEJ]

Here is my favourite video:

That’s pretty good. Doing what he did at the end (just taking the probe off and using his other hand to slide off the catheter) will result in the occasional kinked line, though. Have watched other medics/nurses do this, then looked at it with the sonosite and can see the bent cath, usually stuck in the bottom of the vein wall. Or, they didn’t make it all the way through but were watching their hands, saw flash, and assumed it was in without verifying on the screen. He definitely holds the angio strangely too, like a syringe w/needle. Take the two extra seconds to guide it in a little further before sliding off the cath (make sure to follow the tip — just the tip — on the screen). Also can use long axis to be sure it’s in.

 

[southerndoc]

Well that's my point. 5-6.5cm should theoretically put it within the subclavian, hence it qualifies. I don't see where they require you to prove the termination point on the CPT definition. I mean, how do you document those procedures? Does it feel like peripheral IV to you when you push a "2+ catheter into someone's internal jugular? It sure doesn't to me. If someone wants to audit my chart and try to make an argument that my central line wasn't within the subclavian, I'd like to see them prove to me that it wasn't. Until then, I'll bill all these as central lines.

Revisit this if you're audited. Hopefully you never will be.

They do not require you to prove the termination point. More than likely they will accept intent, but the documentation doesn't state that. The intent to place a central line is in the SVC not the IJ.

If you're documenting these as central lines, I'm assuming you're documenting that you used a sterile probe cover, gown/cap/mask/sterile gloves, and a sterile drape? Failure to document all that while documenting a central line results in a MIPS fallout which will affect your overall reimbursement from Medicare next year.

Not trying to argue with you. Just wanting you to be aware of the risks of this.

 

[Groove]

Revisit this if you're audited. Hopefully you never will be.

They do not require you to prove the termination point. More than likely they will accept intent, but the documentation doesn't state that. The intent to place a central line is in the SVC not the IJ.

If you're documenting these as central lines, I'm assuming you're documenting that you used a sterile probe cover, gown/cap/mask/sterile gloves, and a sterile drape? Failure to document all that while documenting a central line results in a MIPS fallout which will affect your overall reimbursement from Medicare next year.

Not trying to argue with you. Just wanting you to be aware of the risks of this.

You just gave me a High Sparrow level MIPS whipping.

I even measured the average distance from my IJ entry point to the SC junction on a CTA Neck today and it's about 6.1-6.4cm, so I suppose it would have to at the very least be a 2.5" angio every time. Fine, all you MIP nazi's win. However, if that's the case then shouldn't it be the coders job to identify that it should code as a 36400 instead of 36556? I mean, I just use the same line procedure built into Cerner, except I document that it was a 20g 2" or 2.5" angio inserted in the IJ under sterile technique, etc. I just assumed it was alway billed as a central line. I guess, I'll have to look back on my CMGs website and see if they are being listed as such.

Please no more MIPS shaming though... I can't take it.

 

[southerndoc]

Sorry, it's part of my job to monitor the MIPS.

The coders do not look at what you place. Remember, they are not medically trained. If you document you placed a central line, they are going to bill for a central line. They may or may not know that it must terminate in a certain portion of the vein, and chances are, you aren't documenting where it terminates (I don't). They aren't going to look at a confirmatory x-ray to see where it terminates. I doubt you get x-rays on these people after placing an easy IJ.

I have an EJ template in Epic that gets me a 36410 code, which reimburses like $3. Not that much money, but they aren't hard to place, and multiply that by around 1 per week and you have $150 to spend on something. I don't bill the 36400 code since I do not see kids.

 

[lymphocyte]

Long angiocath.
M-mode.
Measure distance to the vein.
Eye-ball that same distance from the probe tip along the skin.
Needle in at 45 degrees.
Advance needle about 1.4 times that distance.
You're whiz-bang on target.
Tilt the needle back (like you're trying to scoop up the vein) and slide the catheter in.

 

[thegenius]

You can do it, man. Took me doing over a hundred or so to get really comfortable. After a couple thousand you’ll be unstoppable. I always use the 1.88 inch 18gauges (don’t listen to anyone else, they’re not too big and are easier to find on the screen), or bigger for shocky patients. Make sure you’re lined up, then go for it. Don’t watch your hands or the angio (ie don’t look for flash) once you pierce the skin - watch the screen. Take your time and find the tip. Once you’ve found it, pretend your hands are tied together like Rocky’s legs when Mick is teaching him footwork — as you advance the needle, advance the probe and always keep that tip on the screen. A lot of times I’ll hub the angio before I pull the needle out. You can watch it go all the way in.

Then, hum terrapin and stroll away in the glory of victory. Don’t go down the road feelin’ bad.

Gonna listen to 2/26/77 on my way to class now.

That is a world class show right there. You could get in 3 PIV's just listening to PITB. So nice.

 

[24GaugeEJ]

That is a world class show right there. You could get in 3 PIV's just listening to PITB. So nice.

Haha! Probably more than that! It is a great one.