Vent: "I should warn you, I'm a tough stick..."

Specialties Emergency

Published

Seriously? If I had a dollar for every time I heard this and got it on the first stick, I'd be retired.:smokin:

Okay, for the five hundred and sixty two gazillionth time:

The catheter size and vein selection for PIVs are the result of clinical decision making, based upon considerations such as presenting signs and symptoms and probable course of diagnostics and treatment.

I have observed a pattern of assumption that AC placements are the result of laziness, lack of skill or clinical judgment, lack of consideration for the floor nurses, and other such misinformed and negative assumptions- the main assumption being that we just slam an IV into the AC without any thought into it at all.

There are some patients I don't even start an IV in, because based upon my clinical judgment, they don't need it, and 9 times out of 10, the physician agrees. If I need blood, I can do a lab draw; if they need meds, they can take it PO or IM. There are a few patients who get whatever I can get into them, because they are so dehydrated and have such small/tortuous/fragile veins that I'd be lucky to get ANYTHING in there. There are some patients who get an 18g in each AC. It just depends on why they are there, what they look like, and what I think we're going to be doing for them.

What is the best access for that particular patient in that particular situation is what drives my decision making; what the nurse on the floor thinks is the last thing on my mind.

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Specializes in Emergency Dept. Trauma. Pediatrics.
Lots of nice other veins don't always work for some of the tests we do. Having to stop and go back and restick someone because they ended up needing an AC line for the third time that night.... after awhile you learn to just go for the AC the first time. Also, we rehydrate a lot of people and send them home, and that AC runs really well, as well as getting labs drawn easily. Sometimes those other veins show up much better after I've dumped a liter or two into the AC, suddenly ALL those veins are very accessable, where they weren't before.

Yes, I know I can get blood off other sites, and run fast IVs in the forearm, but in the long run, that AC will remain my favorite. I've worked the floors, and the ED; we just have different priorities and needs.

I get it, I just found it odd that the other poster was saying you can tell the IV's done in the other units because of them being in the AC unlike the ED. Most places I have ever found AC's started were field sticks and ED. I have actually never done an IV in an AC. Never attempted there.

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Specializes in Emergency Dept. Trauma. Pediatrics.
Okay, for the five hundred and sixty two gazillionth time:

The catheter size and vein selection for PIVs are the result of clinical decision making, based upon considerations such as presenting signs and symptoms and probable course of diagnostics and treatment.

I have observed a pattern of assumption that AC placements are the result of laziness, lack of skill or clinical judgment, lack of consideration for the floor nurses, and other such misinformed and negative assumptions- the main assumption being that we just slam an IV into the AC without any thought into it at all.

There are some patients I don't even start an IV in, because based upon my clinical judgment, they don't need it, and 9 times out of 10, the physician agrees. If I need blood, I can do a lab draw; if they need meds, they can take it PO or IM. There are a few patients who get whatever I can get into them, because they are so dehydrated and have such small/tortuous/fragile veins that I'd be lucky to get ANYTHING in there. There are some patients who get an 18g in each AC. It just depends on why they are there, what they look like, and what I think we're going to be doing for them.

What is the best access for that particular patient in that particular situation is what drives my decision making; what the nurse on the floor thinks is the last thing on my mind.

I think you are reading way to much into my post. No need to be snarky.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I have found that when someone tells me they are a hard stick....... they have either been told that by someone who can't start an IV to save their life OR they really are a hard stick. I usually ask them what I ask the truest hardest of bad sticks.....an IV drug user.....Do you have a better arm? or where's your best vein...;)

The AC in the field or the ED are sometimes the best and quickest to get. People are cold, scared, dehydrated, exsanguinated which makes them vasoconstricted to the max. Add that to being in the field or in a moving ambulance and you aim for the largest target you can sucessfully get to stablize them, get them warm and give them volume. Other wise I start low and work my way up the arm as you can't start an IV below an infiltration.:)

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Funny enough when we would get patients from the ED one of my pet peeves was the AC IV's when there were lots of other nice veins. (I really like the side of the arm). Always ended up having to redo those IV's because they were constantly getting messed with from the arm bending which caused the pumps to constantly go off, or we had to board the arms which my patients hated. That and having kids sent up with koban sp? on. Things I said I will try my darndest to avoid when I get in the ED. Now I will see if I can stick to not doing it.

What am I reading that you didn't write?

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I have found that when someone tells me they are a hard stick....... they have either been told that by someone who can't start an IV to save their life OR they really are a hard stick.

Agree with this. I think there must be an awful lot of bad IV starters out there...

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Specializes in being a Credible Source.
I just wish I could start an IV with confidence. Lately, I haven't been able to stick anything. I am a fairly new nurse and always try, but I am thinking I will never get it.

You need to float to the ED. During my M/S year, I felt about the same as you (though I'd had some success, too)...

Once I went to the ED and started doing it all the time, my skills developed very quickly.

The only way to get better is to do it over and over again. M/S often provides limited opportunities.

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Specializes in Emergency Dept. Trauma. Pediatrics.
What am I reading that you didn't write?

Ummmm the fact that you went on this big rant after my post about people thinking others use the AC because they are lazy and lack judgement and whatever else you said. I never implied any of that. Hence reading into what I said. You came up with a good deal of assumptions in your post which I coincidently came after I brought up my pet peeve with the AC.

My post was in response to the the other poster who made a comment about non ED units always using the AC. It's always been the opposite from what I have seen. I have had to change many IV's for bad placement. Field sticks have to be changed regardless within 24 hrs at all the places I have been so it's not a big deal. My neigbor who works on the IV team has this as a big pet peeve of his too and he worked many years in the ED.

We all have our opinions and preferences and have a right share them without the rudeness.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Ummmm the fact that you went on this big rant after my post about people thinking others use the AC because they are lazy and lack judgement and whatever else you said. I never implied any of that. Hence reading into what I said. You came up with a good deal of assumptions in your post which I coincidently came after I brought up my pet peeve with the AC.

My post was in response to the the other poster who made a comment about non ED units always using the AC. It's always been the opposite from what I have seen. I have had to change many IV's for bad placement. Field sticks have to be changed regardless within 24 hrs at all the places I have been so it's not a big deal. My neigbor who works on the IV team has this as a big pet peeve of his too and he worked many years in the ED.

We all have our opinions and preferences and have a right share them without the rudeness.

I hear what you are saying.......:D I hate the AC too but sometimes you can't avoid it. I once worked as a Cardiac Anesthesia Nurse (wet nurse for cardiac anesthesia fellows keeping them from hurting someone...LOL) and we used the AC bilaterally for ease of asccess and large bore IV's. The surgeons wanted #14G bialterally for hot lines (or level one infusers) and you had to be able to have them flow freely when the patient is tucked and draped. Many inexperienced nurses use the AC for the ease of insertion....I wish more nurses could go the the ED or float to the OR for a few days to get a ton of practice on starting IV's but many places have stopped that practice because it costs money.....very sad.

Mnay facilities have the policy to restart IV's from the field within 24 hours to document when and where any phlebitis has occured since reimbursement ceases with hospital acquired infections and phlebitis.

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Specializes in Emergency Dept. Trauma. Pediatrics.

Perfectly understandable that sometimes you have to get it in and go for what you can or need a large vein.

The hospital I work at and the one I got a job in the er at the floor nurses will often do the IV's . Another hospital where my neighbor works they have a full time IV team and so the floor nurses there rarely if ever will do them outside if the ED.

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Specializes in Emergency & Trauma/Adult ICU.
Funny enough when we would get patients from the ED one of my pet peeves was the AC IV's when there were lots of other nice veins. (I really like the side of the arm). Always ended up having to redo those IV's because they were constantly getting messed with from the arm bending which caused the pumps to constantly go off, or we had to board the arms which my patients hated. That and having kids sent up with koban sp? on. Things I said I will try my darndest to avoid when I get in the ED. Now I will see if I can stick to not doing it.

Lots of nice other veins don't always work for some of the tests we do. Having to stop and go back and restick someone because they ended up needing an AC line for the third time that night.... after awhile you learn to just go for the AC the first time. Also, we rehydrate a lot of people and send them home, and that AC runs really well, as well as getting labs drawn easily. Sometimes those other veins show up much better after I've dumped a liter or two into the AC, suddenly ALL those veins are very accessable, where they weren't before.

...

Ummmm the fact that you went on this big rant after my post about people thinking others use the AC because they are lazy and lack judgement and whatever else you said. I never implied any of that. Hence reading into what I said. You came up with a good deal of assumptions in your post which I coincidently came after I brought up my pet peeve with the AC.

My post was in response to the the other poster who made a comment about non ED units always using the AC. It's always been the opposite from what I have seen. I have had to change many IV's for bad placement. Field sticks have to be changed regardless within 24 hrs at all the places I have been so it's not a big deal. My neigbor who works on the IV team has this as a big pet peeve of his too and he worked many years in the ED.

We all have our opinions and preferences and have a right share them without the rudeness.

Either I am dense, or your responses have been contradictory, mi vida loca.

As JBudd points out ... looking at a patient after they've been admitted to the floor and deciding that it was unnecessary to use the AC site for IV access is short-sighted at best ... what did the patient look like on arrival to the ED, before some hydration?

It is interesting how your perspective evolves as you change specialty areas. Good luck in the ED.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
As JBudd points out ... looking at a patient after they've been admitted to the floor and deciding that it was unnecessary to use the AC site for IV access is short-sighted at best ... what did the patient look like on arrival to the ED, before some hydration?

Exactly!! :) It's amazing how you'll see veins that didn't seem to exist earlier after a patient gets a couple liters ....

For some CT studies, like PE studies, we are required to put something large-ish (preferably 18g) in the AC. It seems like everyone's d-dimer is always elevated, ugh (highly sensitive, non-specific, and highly ANNOYING lab test, LOL). In my current facility, it has to be in the right AC -- that's the radiologist's requirement, and this is the only facility where I've encountered that (right side only). Anyone else have that requirement?

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