by Mike Rubin http://www.emsworld.com

Is there a task more fundamental and, at times, more frustrating to paramedics than establishing IVs? I don’t think so. The Art of the IV Start, by RN and former medic Bob Rynecki, is a noteworthy attempt to address mechanical and psychological issues associated with this most basic ALS skill. If you’ve endured streaks of not being able to cannulate veins the width of a cannoli or can’t get flashback from anything narrower than a garden hose, this book is worth reading.

Starting IVs was sometimes a struggle for me; never more so than on day one as a paramedic intern when I missed my first three sticks. I thought my preceptor was going to banish me to the back of the bus—the kind where you have to pay to get on. I wish I’d had a practical guide like The Art of the IV Start to reassure me I wasn’t the only student convinced he’d never master prehospital psychomotor skills, and to offer real-world advice beyond the do-as-I-do approach taught by career paramedics who could secure IVs while hanging from the B-post of an overturned Tahoe.

Here’s a sample of the pearls you’ll find tucked into Rynecki’s narrative:

Wear tight-fitting gloves

Assuming you wear gloves at all (I mostly didn’t), pick a size smaller than loose and comfortable. You’ll find it easier to palpate veins when your gloves don’t get bunched up at the fingertips.

Mark your site

Use your finger, not your pen. When you feel something spongy, mark it superficially with any unbitten fingernail. Then disinfect the site. You shouldn’t have to keep touching and swabbing.

Maintain blood flow

This one never occurred to me: You want blood to keep flowing around whatever you stuff into a vein; otherwise your IV fluids and meds can’t travel upstream. That means you’ll have to use a smaller catheter than you could possibly squeeze into that vessel. So much for go big or go home.

Hold firm traction on either side of the vein

Until I saw a photo, I couldn’t imagine how to do this with the customary number of hands issued per paramedic. Here’s a hint: You’ll have to use one or two of the least dexterous fingers on your dominant hand.

Be patient, wait for flashback

Why didn’t anyone ever tell me this when I was an impressionable EMT? Yes, I’m speaking to you, Phil, and to you, Mike. And to Tom, John and that guy who said I looked like Frank Perdue. Think of all the IVs you wouldn’t have had to restart for me.

Advance the catheter with two fingers

Sometime after I got out of medic school in the mid-90s, it became avant-garde to nudge the catheter hub proximally with the index finger of the hand holding the needle. That never felt comfortable to me even when I was actually in the vein. Rynecki suggests cannulating with the thumb and forefinger of your non-dominant hand.

This is all good stuff, and Rynecki has many other helpful suggestions, but you’re going to want to use your judgement on some of them. Particularly when you have three seconds to do your stick before your driver finds another pothole. For example:

Give bacteria a chance to die after swabbing your site

According to Rynecki, bacteria expire exponentially, meaning they cross their little rainbow bridge faster as time marches on. I don’t know how many more confirmed kills you’d get after only a few seconds, but that’s about as long as I’d care to wait for the little beasties to slither into the light.

Release, then reapply the tourniquet

Rynecki claims veins weaken and become less reliable when they stay engorged for too long. I’m not sure what “too long” is, and neither is the author, but I suppose you could try unclamping the targeted vein briefly before skewering it.

Even those of you who tell me you “never miss” will find The Art of the IV Start a worthwhile read. It’s only 66 pages long, so you won’t have to worry about putting aside Gray’s Anatomy for more than an hour or so. The style is street-collegial and the content won’t force you to keep a Taber’s handy.

Best of all, The Art of the IV Start will reassure you you’re not alone when your third miss in a row makes you feel worthless and weak. As Rynecki says, “this skill is lacking now more than ever.”

I feel better already.

The Art of the IV Start is available for purchase on amazon.com.

Mike Rubin is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.