Did you get the IV?
Sometimes it seems like your performance on the whole call can be reduced to the success or failure of the IV start. Rarely does the successful treatment of the patient hinge on a successful IV placement but sometimes it can certainly feel that way.
The best way to ensure that you’re ready when that make or break it IV start does come your way is to start a lot of them when the pressure is not on. If you wait until game day to practice, you’re a whole lot more likely to fail.
The single biggest factor that separates the IV virtuoso from the weekend hacker is practice and experience, so when the patient could use an IV, jump in there. The patient’s a kid. … Get in there. The patient is a frail, elderly woman on Coumadin. … Get in there. IVs are nothing to fear. Start practicing these six IV start tips. Before you know it, you’ll be an IV starting superstar.
1. Pick your IV site in 12 seconds or less
Sometimes we’re really looking for the best spot and sometimes we’re just stalling, but we tend to take to long to find the IV attempt site. It’s rare that the success or failure of an IV attempt hinges on finding just the right vein. It’s annoying for the patient and everyone else involved to watch you endlessly search for your IV site.
It’s not a halloween pumpkin. You don’t need to search until you find the perfect one that speaks to you just right. Put your flashlight away. When 12 seconds has passed, pick the best site you saw, swab it up and go.
2. Don’t just look, feel
Sometimes the very best veins the patient has to offer aren’t visible to the eye. If you get in the habit of simply looking for veins your going to miss some great pickins’. Start by getting in the habit of feeling the good veins that you can see. With a little time, you’ll learn to feel the ones that aren’t visible as well.
Another trick for developing this skill is to learn to find all the veins in your own arm by feel. You can practice this while watching TV or sitting through Keanu Reeves movies. (Yes, he’s playing the same character in this one too.)
In case you were thinking it, no, feeling for veins doesn’t give you an extra twelve seconds. Feeling for veins isn’t an excuse to spend even more time massaging the patient’s arm when you should be making the IV attempt. Once you feel something that’s acceptable, grab that needle and go for it.
3. Use solid traction
A huge percentage of missed IVs are poor traction issues. Once you’ve decided on the exact point of entry, get in the habit of placing a thumb a few inches distal to the site and pulling traction. Pull harder than you think is necessary. The patient should feel a firm pressure. You’re trying to anchor down all that flesh and eliminate the possibility of movement.
We neglect traction because it makes advancing the catheter more difficult. Finding a spare digit to help advance the catheter off the needle can be hard with one hand busy pulling back on the skin. This isn’t an excuse to let go of traction at the moment of advance. Maintain that traction till the catheter is fully advanced.
One telltale sign that someone is guilty of chronic traction neglect is that they complain about patients “rolly veins”. “All my patients today have rolly veins”. No they don’t. You’re just not holding proper traction. All veins roll. (They’re round and suspended in tissue.) It’s your job to hold them still before you insert the needle.
4. Use a shallow angle
If you’re getting a brief flash in the chamber that stops before you have a chance to advance the catheter, you’re probably inserting the needle at an improperly steep angle. Some folks get the idea that they need to insert the IV needle at a 30 degree or even 45 degree angle. You’re not trying to dive bomb the vein there Red Barron. You’re trying to insert the needle tip within the vein.
Shallow out that angle. The closer the needle approximates the actual angle of the vein, the easier it will be to land the tip inside the vein where you want it.
5. The catheter goes forward. The needle does not go back
I see this one A BUNCH. (Sorry for shouting in here.) It’s even more common with the newer safety-glide type needle sheths. If you feel like you have good needle placement and you get a great flash but you just can’t advance the catheter without blowing the IV, this is probably your problem.
Once you’ve achieved proper needle placement and you’re ready to advance the catheter remember that the hand holding the needle does not move. Not an inch. Not a millimeter. The catheter needs to advance forward off the needle. The needle does not move backward out of the catheter.
The difference is subtle. From outside the vein (Where we happen to be sitting) the two moves look almost exactly the same. We try to advance the catheter but that first little push off the needle hub can be difficult. So, to help the catheter along, we move the needle hand back ever so slightly to get the catheter moving. As a result we pull the needle out of the vein before the catheter has a chance to find its home.
6. Let the bad ones go
Give yourself permission to fail sometimes. It’s not the end of the world if you miss an IV. Dispite what your partner tells you, nobody out there gets em’ all the time … nobody. And nobody learns good IV technique without blowing a few veins.
Pop off the tournequet. Pull out the needle and apologize to the patient. “I’m sorry, that one didn’t go where we needed it.” Then start looking for the next site.
IVs are uncomfortable for the patient. We didn’t get into this business to cause people pain and discomfort. That can make the sting of a missed IV even more difficult. Ultimately the patients pay for our failures. And some of them aren’t terribly gracious about it.
Learn what you can from the failed IV attempt, but once you drop that failed needle in the sharps box, forget about it. The previous failure has no bearing on your next attempt. Don’t let it haunt you. Document it. Include it in your hand-off report and own it, but don’t let it affect the next attempt.
Your last IV attempt is already in the history books. The next one is still a question mark. That makes the next one immeasurably more important. Go get the next one.
What other IV tips do you have? Why not type in a comment and let us know before you move on.