You're called over to the other main ED bay area. People are yelling. Someone needs an IV for a upper GI bleed, and the family is upset. Three nurses have tried, the PA and a junior EM resident and the attending have tried with the ultrasound. The ICU team won't take her upstairs until she has access. The patient and family are refusing a central line or an IO; plus GI is demanding a CTA before they will scope her.
You meet the patient, an elderly african american female, crying in bed, with a fistula on the left arm, and an army of bandages and oozing wounds down the right arm. She is hypotensive and tachycardic, holding a bucket of coffee ground emesis. You spend 30 minutes calming down the angry family, and convince the patient to let you try. They tell you, you have ONE chance. They are firm on this. If you fail they are refusing all further attempts at vascular access and will sign her out and go to a "real" hospital.
No pressure right?
First off, I should point out that after 10 IV sticks it's time to make a plan instead of slowly going up the training ladder. A senior EM resident or attending should be aware of all chained failures for access on a sick patient. It's incredibly hard to undo the lost trust with family after that many attempts, and its even harder after 20 (this patient literally had 20 attempts). Every failed attempt also takes away a vessel, making it even harder to obtain access on a complex patient. Yet, I find myself in this spot at least once a month.
Here are the steps I take every time, and I haven't failed to get a line in over 2 years. It's not for a lack of modesty, it's from a mountain of practice.
Prepare to do the ONE-PASS SUCCESS Ultrasound guided IV:
- Talk to the patient, they have to agree to entire process, which takes time, tell them everything you are going to do as you do it.
- Give them options, if you find 2 vessels that are comparible, let them pick! Giving them power in this difficult experience is insanely good for trust building. In general these patients feel powerless.
- Get them (AND YOU) comfortable. Get a table, pad it with a towel, lay out their arm, clear wires & clothes out of the way; make space so you can stand and work at chest height.
- Put the ultrasound, arm, and equipment where you want it. I spend 10 minutes setting up, 5 minutes looking for a vessel, and 30 seconds placing the IV. Preparing is where nearly everyone fails.
- Apply a gentle tourniquet correctly. It takes less than 10cm (H2O) to close a vein; so apply the tourniquet correctly! If you do it right the patient will sit still far longer.
- Sweep up and down from the AC; tracking any circular and compressible vessels you find. My favorite vessels are just proximal to the AC and slightly inferior.
- Avoid vessels under muscles. Try to go for shallow vessels under fat only.
- Measure the depth to the vessel; this is important to know how deep to EXPECT the needle to travel. Identify the direction it is taking in long axis, and make sure you can approach it at the angle without knocking into other objects.
- When you have everything ready: literally everything, nothing should be opened, flushed, twisted, cleaned or capped once you start)....only then do I touch the site with the blunt end of the IV (and tell them, here is where the needle will enter the skin, it will sting, temporarily, and I will slowly advance the needle). I tell them there will be no surprises, no jerking movements, no 2nd insertions through the skin. I make eye contact when I say this.
- Now for the hard part, be good at ultrasound guided IV placement BEFORE you attempt it on a patient.
- Using an ultrasound guided IV phantom, practice short and long axis approaches to the vessel. Enter slowly, identify the tip, switch angles (short and long). Put the probe down while keeping the needle still, as if interrupted. Never remove the needle tip, not fiddle with materials, just keep advancing, identifying, advancing, identifying. The goal is to never retract, never remove the needle tip, and prepare each approach and entry point carefully before starting. Try entering at a steep angle, and dropping the angle after you end the vessel. See how far your can advance the needle before sliding out the angiocath.
- The goal is to minimize movement of the needle; but be comfortably moving the probe in every direction and angle. It's harder to do than you think, most people move their left arm when the right moves (and vice-versa).
- Place the ultrasound phantom at the same height you would perform the procedure on a patient; using the same equipment, and do it standing! When the procedure takes 30 seconds, and feels easy/quick, and you get 20 in a row, then your ready for a real person.