It is an ego thing. Lots of folks think they're God's gift to paramedicine when they first sew on their paramedic patch. They worked hard to become a medic and hate to admit they still have rough edges. They brag (to everybody but their partner) about how many lives they've saved and how many IVs they nailed on the first stick. They never sit around the bar at night telling their buddies how many carpets they stained that day with the bloody aftermath of their fishing expedition in the antecubital fossa of three patients. They rarely place the blame for their poor IV technique on themselves.
ALS egomaniacs use cheap excuses to cover their obvious deficiencies. I've heard plenty of them:
- I got in the lady's vein OK, but then I hit a valve;
- The guy pulled his arm away just as I advanced the catheter;
- I was advancing the needle when you went over those railroad tracks;
- I punctured her skin, but the vein just kept rolling away from me; or
- I could've plugged a line in, but we were pulling up to the ED entrance.
My all-time favorite excuse: "That lady didn't have any veins!" That one makes my blood boil. I just want to stand in the middle of the ED and shout, "Hey everybody, my partner's famous. He just treated an alien life form. The lady he worked on had no veins in her body!"
Whenever I miss an IV, I take it personally. I feel like I failed the patient because if they need a rapid medication bolus I can't give it to them. I also feel I failed myself.
Poppin' in an IV is a critical skill your partner must master. You can't let his poor technique slide or the people he treats will all look like they fell on a porcupine. Besides, if your partner has a hard time admitting he has an IV problem, how are you ever going to trust him to do an external jugular stick or pop a catheter in a patient's chest to relieve a tension pneumothorax?
You better sit this cowboy down and tell him you won't sign him off until he admits he has an IV problem and works with you to improve it. I use a three-step process with newbies who have IV problems:
Step #1-I make them hold a 14-gauge catheter (bevel side facing up), close their eyes and puncture the skin of a banana a couple dozen times to learn how it feels when the needle pops through the lumen of a vein and encounters reduced resistance. Why use a 14-gauge catheter? Two reasons. No. 1: Like driving a truck, once you learn to use a 14-gauge, everything else feels like a sports car in your fingertips. No. 2: It doesn't get clogged as quickly with banana guts as an 18-gauge does.
Step #2-I use an IV arm and ensure they know my 45/5 IV rule:
- Scout the best vein they can see or feel;
- Advance an 18-gauge catheter (with the bevel side facing up) at a 45º angle until they feel the pop; and
- Lower the catheter to a 5º angle with a slow, deliberate action-like a hydraulic lift being lowered-and advance the needle.
Step #3-I interlock (end to end) three or four extra-thin, small-diameter party straws and tape them at the joints. Then I tape the straws to the top and bottom of a heavy-duty sheet protector (the plastic ones you buy in Office Depot to protect your precious protocol pages). I mold that sheet around my hand/wrist or antecubital region and tape it securely in place. I spread gobs of KY Jelly over the straws and lay a piece of an old, thick, plastic shower curtain over the area. Then I make the problem child stabilize the "vein," establish a few lines and flow some fluid to see that they've succeeded. It feels realistic, and the fact that it's on my arm adds just the right amount of stress.
Hope this helps you out.
