Tuesday, November 23, 2010

IV Starts

Today in clinical we are learning the fine art of I.V cannulation. 

This oughtta be interesting. 

Last year I had to just about bite my tongue off when we were taught to aspirate before injecting in IM and SC injections. When I was in nursing school *cough* 11 years ago that had already been turfed thanks to evidence based medicine that demonstrates the only area where this is indicated is in dorsogluteal IM's (even there it is debatable but certainly NOT indicated with SC injections). 

Ok well initially I didn't bite my tongue and said it to another student but the bat-like hearing of our clinical skills prof exposed me and I was told in no uncertain terms I would fail the OCASE if I didn't aspirate. Sigh. I muttered something about doing it for the exam and never again. (BAD medical student!! BAD!!!)

Anyway, I am interested to see how the IV starts are going to be taught. I wonder how many I may have done in my career as a nurse? Hard to calculate but based on rough figures...7 years, 200 shifts per year (with great variation in # of starts per shifts) maybe averaging 6 starts per shift...that comes out to 8400 starts. Okay even if that is a gross over-estimation, I am well past the 5000 mark. Hey! That is kinda cool. I never actually figured that out before. 

Below is a comment that I left on Rob's blog ages ago when he wrote about learning how to start IV's. They are some of the little tips/tricks I've gleaned mostly from other nurses, much more experienced than I. 


I love IV starts. These are some of the rituals I go through when I am starting an I.V. 

First off, most people believe that there is a metal needle in their arm. When people are really anxious about it (esp PEDS) I show them how it works with a demo needle that I chuck. It seems to really calm a lot of folks down. I only usually show adults if they are going to have the IV in for a long time, it makes them more relaxed about moving the tethered limb around. 

Some tricks I use for tough starts (I am sure you know these already but in case you don't):

-In the elderly with the feathery skin and veins don’t use a tourniquet as you are more likely to have it roll or blow with the induction. Just anchor the vein above the site with the thumb of free hand and go at a very superficial angle. As soon as you get flashback take the needle out and gently advance the catheter. 

-For tough starts go for the radial vein near the wrist (usually very juicy as not many people use it).

-Warm people up with either warm blankets or (my personal favorite) 100cc saline bags that you put in the microwave for 10-30 sec. This is great with PEDS also, I warm the bags up then kling wrap the bags to their hands and feet–go off and do some other task and when you return–BAM! the veins are waiting for you. (Just make sure you hold the bag on your own skin for about 10 sec to make sure it is only warm not hot. I think that hot wet towels are a bad idea because as soon as you take them off it cools the limb down a lot and if you get caught up doing something else then you have a cold, wet limb to try and salvage a start out of. Dry heat is better.)

-Drop people’s hands so that their arm is hanging below the chair. 

-Don’t slap the veins as sometimes that causes them to flatten out.

-Take your time. 

Really. I spend as much time as I need just chatting with the patient while I palpate around for the best vein. The longer I take to find a good one, the greater the likelihood I’ll find one on the first poke.

-Don’t be afraid of small guage needles on hard starts. No matter what they tell you blood *will* run through a #20, even a #22 in a pinch. Not everyone needs a #16 in the pinky to prove your abilities.

-If you hit a valve going in, you can try to gently push through or just pull back a bit and if the line is good just secure it there. 

-Tape is our friend. Use paper tape on the elderly, especially if you don't feel like tearing their skin off when you d/c the I.V. 

-And finally, feet are sometimes better than you think. Esp in people who’ve had lots of chemo or alternative drugs (ahem) in specific veins.

So there you go blogworld. My free, unsolicited advice on I.V starts. Now I am off to learn how to do it! There may be some major tongue biting today as well, but must go and see what the gold-standard-medical-school-OCASE-way of doing it is. 

I won't mention my aversion to gloving with difficult starts!


Grumpy, M.D. said...

Wow. You change a few words in the post and it gets kind of kinky.

Grumpy, M.D. said...

Seriously, I remember doing IVs, and ABGs, and blood draws.

I did the required number of IVs and ABGs, then never again.

When I worked VA in residency and med school I had to do my own blood draws, and got reasonably good at them.

Albinoblackbear said...

Grump----HAHAHAH! Ewwwwwwww! I had to go back and read it again. Let me say again...ewwwwwwww! =)

I think I like blood draws, ABG's IV's because I dig procedures, great and small. Just love doing things with my hands and getting instant results. It's also nice to see patients relax when one does a good job and it wasn't as bad as anticipated.

OMDG said...

ABB -- Thanks so much for the tips! I experienced a moment of extreme irony during my ED shift a few weeks back where two nurses couldn't get an IV on a guy, and then the protocol is that the doctor is supposed to try? Anyhow, I said that if they couldn't do it there was *NO WAY* I'd be able to. I think a paramedic came in and was ultimately successful. I look forward to hearing about "learning" about IVs again today.

Cartoon Characters said...

I first learned as a student nurse 30 years ago... and never looked back. The worst veins were the prisoners when I worked at Medium security... but usually there wasn't a vein I couldn't get into... I loved IV starts. I think I only had to put one into a foot once. The challenge was always fun.
Your tips are very good ones. Sometimes I use a BP cuff to visualize....

Albinoblackbear said...

OMDG--No prob! Hopefully one of them will come in handy!

Yes, I always thought that was a hilarious policy as well. If no ED nurse can get it (which is a thankfully rare event) I find PEDS nurses/NICU are great backup. Some places I've worked have anesthetists that are amazing at IV starts as well.

The class today was actually fine, the clinical skills instructor we had is a HILARIOUS emerg doc who I really like. She is one of those people that teaches the 'real world' side of things. I helped out people who asked for tips etc. but tried to stay quiet and out of the way so that I didn't annoy the hell out of everyone telling them how to do it. Some people want help from classmates and other loathe it so, I just hold back as a default setting.

CC--Thanks! Yes! I forgot about the BP cuff--that is a great one with the elderly as well, just slightly inflated so you don't blow the veins. Good point!

There is something gratifying about getting a good line in, or being the person who gets it when no one else can (and then I usually miss the next 5! hahahah)

Maha said...

"Don’t be afraid of small guage needles on hard starts. No matter what they tell you blood *will* run through a #20, even a #22 in a pinch. Not everyone needs a #16 in the pinky to prove your abilities."

This is my favourite tip of all. I see too many residents pick up #18 and aim for the TINIEST veins possible. I also wish that was the first tip I got when I learned to start IVs.

Keet said...

ABB - I was there when we were learning all this stuff so long ago, and strangely, despite my forays into mental health nursing, the tips, tricks, and skills we picked up are still ones I use today in my tricky veinless speedball injecting clients. And if all else fails, there is always the jugular or femoral. I actually had a 2nd year med student shadow me today, and it was interesting because the program they are doing has no clinical skills until year three! I was expressly instructed not to let her near a needle. Which I think is too bad, as the poor thing could probably use a good nurses guiding hand to back up her biochemistry degree and volunteer work at the hospital experience when it comes to those clinical skills that are hard to teach on a mannequin, and harder to learn on a real person... anyway, I hope your experience is paying off babe!

One thing i find useful, (with drug injectors) is asking them where they can get blood. They might not know, but they might, and it can save some time digging for veins that are long-gone or insta-blown when the needle touches them.

Unknown said...

When I worked as a nurse I found that advancing the catheter with a syringe of saline helped things along greatly in dehydrated or very elderly people. (the trick with not using a tourniquet is golden and saved my bacon many, many times.)
I my hospital if you couldn't find a vein, we would hunt down a chemo nurse. They could start IVs on the trickiest people without batting an eye.

Anonymous said...

I need you to be my personal blood draw person. I used to be an easy stick, now my veins are in a witness protection program. WHen I had some hand surgery, it took them *17* sticks to get an IV going --- I was dehydrated, no veins around, it was horrible. Ended up with it in my neck...

Robert said...

I rarely use tourniquets at all anymore. Once I figured out how to stretch the vein tight and occlude it with my off hand thumb my "win" percentage went way up.

I've floated catheters through valves using the saline syringe trick too.

CardioNP said...

Having been on the receiving end of an angiocath a few too many times when dehydrated and NPO for surgery, one mistake I've had nurses repeat is to put the tourniquet on WAY too tight. Tried to explain to one RN that the goal was to obstruct venous flow not arterial flow; that you actually wanted the arterial flow to fill the veins. She thought I was being a smarta$$ (didn't know I was an RN), asked if I wanted to place my own IV. I told her sure, I'd do it. She shut up quickly when she realized I was serious and could actually put in my own IV.

RH said...

Great tips ABB! Now to go hit up some friends to torture...I mean practice on.

Gelfling said...

I was a phlebotomist before I became a nurse, and it was so nice in school to have SOMETHING that came naturally and easy to me when all the other clinical skills felt so clumsy and unnerving!