How to be successful at IV therapy – some advice for paramedic students

IV start
Image credit: Wikimedia Commons

In a recent thread at EMT Life a paramedic student wrote:

Just entering my 2nd semester of paramedic school. So far I’ve found the coursework to be the easiest part. Instead of being stressed over tests I’m stressed over IV’s. 170 sticks in overall my % sucks. Granted most of those were just “oh I wonder if that vein could be hit with this gauge” attempts to find what could and couldn’t be done. Now that I’m on the truck I know what veins are my go to. Still struggling mentally with it but over the last 45 sticks my % is approx. 75% first attempt success. I have no clue what is going on, it seems so easy but I wind up screwing it up somehow. From my standpoint I’m getting flash but I’m blowing it on insertion still. I know to still go that little bit more but I’m wondering if I’m pulling the needle back while inserting the cath. Anyone else struggle like this this late in medic school? Really tired of getting made fun of when I can’t secure access first attempt.

It seems to me that a 75% success rate on the first attempt (for a paramedic student in his second semester) is actually not too bad.

Here is the advice I offered.

The habits you develop right now will last your entire career (good or bad). Lay out your equipment and spike your IV bag using the proper aseptic technique. Shut down the roller clamp prior to squeezing the drip chamber. It helps prevent air bubbles in the IV line. There is no need to remove the cap when you charge the line. Lower the side rail on the gurney and take a knee alongside the patient. Place the arm in a dependent position (below the patient’s heart). Apply the tourniquet in such a way that the tails are pointing superiorly (not toward your work space). Cleanse the area with alcohol. Once that is done don’t palpate again without re-cleansing. Hold the skin taught with the thumb of your left hand below the target vein. Make your first “stick” count (you should strive to get a flash with the initial stick). Then give a “bump” to ensure that the bevel clears the lumen (omitting this step is a very common error). As you advance the catheter look for the secondary flash. If you always do it this way you will become highly skilled at IV therapy. Conversely, I have seen paramedics with poor technique after 5, 10, 15 years in the field.

I’d love to hear your tips in the comments section!

30 Comments

  • John Lufi says:

    The most important tip that I’ve learned: visual the needle and catheter entering and advancing in the vein. Try to get inside the skin and see the whole the thing before you even start the insertion.

    Secondly, always assume you will get it first try. The confidence factor is amazing. If you doubt you will get it, you will more likely miss.

    Those two tips get me a long way. Additional factors to consider, make sure you start distal and work proximal. Often I’ve seen good hand veins and forearm veins bypassed for a mediocre AC that was unsuccessful.

    When starting an IV in the back of the hand, bend the wrist down rather than keeping it straight. This pulls ALL the skin of the back of the hand taunt and really cuts down on rolling veins.

    Don’t be afraid to go smaller. Too many times we try to shove a 20 GA or an 18 GA simply because “bigger is better.” IV access is better than none. I’d rather have an intact 22 GA than a missed 20 GA. This is especially true if you don’t have to push high viscosity medications (D50) or really push the fluids.

    And final tip I’ll leave, sometimes, in older people it’s better to bypass the tourniquet. The extra pressure can cause thin veins to “blow” when you touch them with the needle, rather like a balloon.

  • BMB says:

    A few more things to consider.

    * Most of the time a 20 gauge is fine, you do not need an 18 gauge IV in most patients. There is a time and place for a large bore IV, know when that is and when it isn’t.

    * Please start at the hands and work up. Many new people go straight to the AC. If you blow that AC it is a bad idea to go distal to it for the second attempt. Additionally if your patient is admitted and has an AC IV, they have you to thank for being woken up all night by the “occlusion” alarm on the IV pump when they bend their arm. If the AC is the only show in town then go for it.

    * Have everything ready to go before you even look for a vein. I see new folks search for a vein, and then go to get their stuff ready and have to search again. Have everything ready to go and an alcohol wipe in your hand. Find the vein, wipe it and reach for you angiocatheter WITHOUT taking your eyes off the spot you intend to poke.

    * Learn to palpate. Just because you don’t see it doesn’t mean there isn’t a big juicy vein there.

  • Mike MacKenzie says:

    When I first started doing IVs, a very wise nurse (who was a former medic) told me to think of it this way. You are not “starting an IV”, you are “inserting a catheter into a vein”. That was the most helpful piece of advise I was given.
    And I agree with BMB, palpate, palpate, palpate.

  • Tim says:

    A guy named Bob Rynecki wrote “The art of the IV Start” that has been very helpful for me. Most of the information has been the same things my mentors have told me before; however, it is a good resource for when you don’t have anybody willing to mentor or don’t feel confident in asking questions.

  • Luke rumel says:

    in my experience, confidence starts with student/mentor relationship. If the student has had an opportunity to afford this critical element, then the propensity of success significantly increases.
    The last thing a student needs is a back seat driver instructing every angle change and depth suggestion whilst undertaking the manual task. It is a person on the other end of that needle, and only the student is in control until the task is complete.
    Asking for help after is important, if a miss occurs, that helps build trust and allows the student mentor relationship to grow.

    • margo bloomberg says:

      While stabilizing vein with one hand rest your iv hand against it. Go in at a 45 degree angle then as soon as you get the flashback drop flat. ..advance needle about 1 mm a push catheter off needle.

  • Dan says:

    All of the above, and clean until the wipes come back clean. Don’t treat the textbook “45 degree angle” as doctrine, almost all my IVs are started at a shallower angle. Practice with any new style catheter several times before you put it into a patient.

    Does your patient need an IV? If they have stable vitals and no need for fluids or meds there may not be a need for it. “Chest pain with cough x 2 weeks” might still get a 12 lead as an assessment but unless I plan to treat something (for example a fluid bonus for dehydration etc) I may defer the IV until the ER. It is routine in many hospital units for EMS IVs to be removed after 12-24 hours to reduce infection risk. If I’m not going to use it and the pt is stable I’d prefer they have fewer sticks.

    (clean your site better, don’t touch after cleaning, use your wrappers as a barrier to keep your equipment off the dirty bench seat)

    • Mike Nickerson says:

      Absolutely agree with Dan. I am a paramedic facilitator and hate the textbook teaching 45 degree angle for insertion. If you do that you will 9 times out of 10 blow the vein. Through and through. When I initiate my IV’s I get all my equipment set up and ready to go. Then I mentally prepare and say I am going to get this first try. When I am ready to puncture I am at approximately 10-20 degree angle. This seems to work well for me. I am not sure of my first stick success rate but I would say it is high. I hit many more than I miss. I still do miss and that’s ok too. Especially when you are learning. Best of luck hope this helps.

  • Brenda says:

    A very wise preceptor saw that I was having issues with my iv starts. He strung a length of iv tubing between the arms on a kitchen chair, pulling the tubing taut between them. My issue was the angle of insertion and then going through the vein on the other side. We pulled a few iv catheters out of the cabinet and talked about how the vein lays under the skin. He let me start the iv at a 45 degree angle. Then I felt the “pop” that we get lectured about once I got into the tubing. If you stop for just a second to allow for that first show of blood and then flatten out a little bit, you’ll be able to advance the needle a little further and then get a complete flash without going through the vein. Then advance the catheter and remove the sharp. This is a great visual as to how easily that needle penetrates the vein and I’ve used it many times for my students and interns.

  • Mike Vorpahl says:

    my major tip is to make sure the vein is secured and anchored. I have noticed this is the step that can make or break the iv attempt. Once you picked your spot and cleaned the area make sure you hold tension on the vein so that it doesn’t move at all. This will sometimes flatten the vein out enough to the point where it seems to disappear, but as long as you have a good visual on it the insertion will be successful.

  • Leslie says:

    i have been taught, and it holds true, when in a pinch, don’t ever under estimate your surface veins , they can be life savers until something else eventually “pops up”. ( usu after a fluid bolus)

  • Brent says:

    For the love of God. Stop putting cannulae, especially large bores into hands. Rehab starts day one. Immobilising a hand simply for a cannula is lame. If a hand is all you have then that’s what you use, but really only analgesia is worth the effort via 22 or similar.
    Importantly, make sure those that need them, get them and those that don’t..well don’t. Too many patients arriving with inappropriate cannulas or not at all when a patient clearly needs one.

    Lastly, two hands. Steady your guiding hand and feed the cannula with the second hand. Single finger feeding is prone to errors and infection introduction via the opening of the luer connection

  • Jack L. says:

    The trick is to give yourself the best possible chance. If you have two options, just do yourself a favor and take the easier of the two.

    Also, this little article changed my practice significantly. Don’t see anything you like? Pop on a BP cuff! (Just don’t leave it too long.)

    http://www.ncbi.nlm.nih.gov/pubmed/24485698

  • Jessica says:

    By far the most common mistake I see is not adequately securing the vein prior to or during insertion. The skin [and vein] must be held taut until the catheter is all the way in. From the description of the problem my guess is that the student is initially securing the vein, but loosening the tension once the initial flash is seen. When they try to advance further, the advancing catheter can actually push the vein right off of the end of the needle! Some veins are very awkward to hold secure, [like EJ’s….] but learning how to do this well will be invaluable!

    [BTW I also don’t think 75% first attempt success is bad for a medic student, but I applaud the initiative to try to get better!]

    This has nothing to do with IV technique, but here are a few things that I haven’t seen posted yet that I find helpful when starting an IV:

    1) I place the tourniquet first [on top of a sleeve if I can – a little more comfortable for pt]

    2) Then I prep my fluid & equipment, making sure I can reach some 4×4’s if needed.

    3) Lastly I choose my site: I use A LOT of alcohol preps! I can frequently see the contour of the vein in the light reflecting off of the wet skin. If I don’t see any good options on either side [or I really want a particular location for some reason] I will have the pt let the arm dangle for a minute or two, then look again. I also “tap” the veins with 2 fingers. Many times I have nothing on my first look, but between giving the vein time to fill, some tapping and plenty of alcohol I can find a viable vein, or make a difficult stick much easier.

    4) I recommend placing a towel under your chosen site: if you end up with a “bleeder” you don’t drip blood down the side of your cot or all over the pt’s clothes/bed/carpet. Makes clean up much easier. =)

  • Todd says:

    The best advice I got was from a doctor after watching him do an arterial line in the wrist, but it applies for IV access as well. He said it’s only the initial stick that hurts. After you’ve passed the dermal layer, you’re beyond most of the nerve endings and, as log as you don’t pull back too much, you can “fish” for the vein without much pain.

    Think about it this way: if you’re spear fishing, you aim just below the fish because of light refraction. If you aim at the fish, you’ll miss. Now, if the tip of the spear is already under the water, then you aim at the fish and not under it since it is also succumbing to refraction.

    For those that don’t get the analogy: the spear is the needle and the vein is the fish. :/

  • Andy says:

    I always start by asking the patient where there best access is. 9 times out of 10 the patient has been stuck before, why make searching hard on yourself and get all set up on one side when you have to move. Work smarter not harder.

  • Donna Opresik says:

    I teach my students to palpate the vein while looking at it then have them close their eyes and palpate, I bring in different people with different types of veins, it has helped them become very successful finding them. And just like mentioned above we don’t always need a tourniquet. Find a technique that works and stay with it.

  • Jake says:

    I agree with everything these other medics have said. However I think two of the most important things are: Breath and believe in yourself. Take a breath and tell yourself your going to be fine. That’s what helps me through my tough sticks.

  • Carlos Force says:

    Easy on the tourniquet, if it doesn’t flash be conservative on how deep you go, anchor each side of the vein by pulling the skin to the sides and distally, on rollers consider making entry next to the vein, anchoring and then going in slowly from the side, on elderly and infants / children when you don’t see an initial flash – give it a couple seconds to fill, think of all veins as running parallel, not angled down and treat them accordingly, get that initial stick in just under the skin – not too slow – and work from there on difficult patients like combative trauma and diabetics.

  • Christopher says:

    While I am not anywhere near as experienced as most medics who probably comment, I felt I could part these small pieces of advice which I have found useful.

    First, place your tourniquet and let the arm hang loose, and then prep the rest of your equipment. These extra thirty seconds I have found allow the veins to become very plump and juicy.

    Second, take your time, even the most emergent patient doesn’t require rushing, especially something that may be as critical as access.

    And third, if you miss, or you are having a bad IV day in general, move on. It happens…I remember during my post school internship I had a month where I don’t think I hit a single vein, but instead of calming down and reassessing what I was doing wrong. I became critical of myself, and put myself deeper into the hole, basically just creating a spiral until I finally hit a vein. You miss and move on, don’t take it personally. No one is perfect, and sometimes you get patients that have rough veins, or tough skin, or any other variable that can throw a medic off. Just know the feel of the skin and vein you are poking, it will help.

  • Pete V says:

    I find by decreasing the angle ( books reccomend like 15-20 degrees) I prefer to go in at much less of an angle-less likely to to go thru the vein once you get a flash,advance the length of the bevel ( make mental note how long the bevel is,that will help to assure you’re in vein.

  • Kevin says:

    On rolling veins, come in from the side that way you just push them until they will push no more, when you get flash, align the cath and send it in. Keep your fingers out of the way, visualize the needle going in, it’s just “putting a straw into a garden hose”. I personally have found that going bigger is easier to see the needle align with the vein. Went from 50% to 95% after given these tips by an old rusty Medic.

  • John C says:

    Best advice I can give is anchor your vein. If the vein can’t move your success rate will improve.

  • Ben Palm says:

    Older people past 60 don’t use a tourniquet unless you can’t see or palpate a vein.

    If you are getting a flash but blowing the vein you are moving the needle sideways more than likely and poking through the vein or to steep and going down through it.

    75 % is not bad but you can do better so keep up the good work.

  • Adam says:

    I find that visualization is one of the best predictors of success. I’ve started 1000s of IVs, and I still have to do it every time. This is where careful palpation comes into play (here’s a clue: almost every comment mentions palpation). You have to develop a picture in your head of the direction the vein tracks and its depth. For me, it always just follows naturally from that (with a careful, consistent technique). If I get lazy about this step, my success rate plummets.
    I see a lot of people who enter the skin with a quick jab, but I rarely find that to be helpful. If it’s a large vein, that technique is useful and often more comfortable for the patient. But in the majority of cases I enter the skin and the vein with a slow, controlled movement.

    The moment you get the flash is NOT the time when you can relax, that you’re in the vein, and everything is going to be OK. That’s the crux of the entire process. What you do in that moment is what will largely determine your success. Big vein, you have more leeway. But if it’s a more challenging stick, or a vein that’s small relative to the size of the catheter, that’s the moment when you’ll blow it. It is crucial that you know where the tip of your needle is.

    You have to follow the same careful process every time. Repetition will make it second nature to you.
    Enter the skin and the vein with as shallow an angle as possible for the situation, in a slow, controlled movement. Then drop the angle of your needle significantly (carefully so as not to back it out at all), then slowly advance a few more millimeters, Let the side of your hand rest on the patient’s arm or hand if possible to prevent movement of the needle, and slide the catheter off of the needle. Never retract the needle until the catheter is securely in the vein. Once you retract the needle, it’s over. If you’re not sure how far to advance the needle after seeing the flash and prior to threading the catheter, pull a needle out of the package and look closely at it. You can clearly see the distance from the tip of the needle to the end of the catheter. It will be different for different gauges too.

    I see other practitioners start IVs very successfully with different techniques, but when they run into difficulty, they often don’t know why, and they can’t recover from it. This technique works for almost every patient. Develop a very consistent technique, and then you will start to get a feel for what you need to tweak in unique situations.

    I would also add that as a student, make the most of your ER time to really develop your IV skills. When you’re on the street, you have a lot distracting you, and you have very limited time in most cases. In the ER, you have a controlled environment, no other aspects of patient care to be thinking about, and usually plenty of time to really be careful and organized. Also, every time you miss and someone has to come take over for you, watch everything they do very carefully. If you see anything different than what you would have done, ask them about it.

  • jenn says:

    Use the same finger each times you palpate, it will become more sensitive. If you are questioning if the veins are ‘good’ use 2 tourniquets. When you cleanse the site, cleanse your palpation finger too, you may not want to touch the site again but you can palpate above it if needed.

  • Ed Thomas says:

    I am left-handed. I find that I have an easier time putting an IV in the pt left arm than right-handed people do while sitting on the long bench beside the cot in the ambulance. If your ambulance is a center-mount, don’t be afraid to start your IV on the right arm while sitting in the “CPR” seat. That way your dominate, needle-wielding hand will be lined up naturally with the pt arm and the veins. Hope that made sense.

  • Dominic says:

    I learned from one of my field instructors to squeeze the arm on the opposite side of the insertion site rather than using your thumb to hold the vein straight/still. When you use your thumb you are more prone to not being able to drop the catheter to a proper angle, after flash, in order to advance the cath!

    In the AC for example, find your vein, clean it, then grab the elbow with your whole hand(opposite hand of the one you’re using to stick with). By doing this you will stretch the skin on the AC therefore securing the vein as you would with your thumb and allowing you to the ability to change angles of the cath, without obstructions, if you don’t get an immediate flash! Make sure you keep an eye on your vein when you do this because it can move when you stretch/tighten the skin. Of course once you get that flash advance the needle and cath just a little more in the direction of the vein before advancing the cath off the needle! This is critical or you will blow the vein regardless of technique! Also, don’t forget every attempt and vein is unique and you will need to use your thumb to stabilize a vein sometimes, such as in a hand vein!
    Hope this helps as it helped me become more confident and successful when I was in your position!

  • Judd says:

    It sounds to me like the major factor that was hindering success in this individual was confidence. If capable of initiating IV access 3/4 of the time it seems that he has a fundamental understanding of how IV’s are initiated but is simply lacking practice at honing in his technique. I agree that there are certainly medics in the field who, even after years of experience have developed poor technique, but it sounds like our friend here is simply feeling insecure in his ability. In time, in practicing using proper technique he will certainly improve his successful first attempts.

Leave a Reply

Your email address will not be published. Required fields are marked *