By Michael Morse
Firefighters are far more comfortable charging, advancing, or flaking a line than they are starting one, but gaining intravenous (IV) access has equal importance in today’s firefighter toolbox. Our EMS engine companies are staffed with EMTs and paramedics and equipped with everything the ALS ambulances carry, so it is reasonable that we do everything we can to treat a patient prior to the ambulance’s arrival. A patient with chest pain, weakness, hypotension, bradycardia, slow respirations, abnormal skin color, or any symptoms that lead us to believe a cardiac event is likely benefits from IV access and any medications we are authorized by protocol to administer. Trauma patients need IV access, as do people suffering from life-threatening or potentially disabling conditions.
Considering infection rate is 0.18 percent (nearly two infections per 1,000 IVs)1 for hospital-placed peripheral IVs and with little data to suggest prehospital lines differ, there is no good reason to wait for the ambulance to start a line on a patient who you believe needs one. Common sense dictates much in the fire service; the decision to start a line depends on any number of unpredictable circumstances. A crew returning from a dumpster fire may want to consider the need for invasive procedures. If the patient’s condition merits IV access, and that access is imperative, then by all means clean up and get to it. If not, a little extra time before treatment may not be such a bad thing.
Proficiency at “starting a line” comes from practice and the only way to get that practice is by starting lines. The better we are at what we do, the better chance we have of making a difference for our patients. EMS is no different than firefighting when it comes to experience. The more experienced, the better the firefighter, and the better the firefighter, the better the outcome of the job.
People are not pincushions, even when they’re unconscious. Care must be taken with every patient contact, especially with something as invasive as putting a catheter into a vein. It is imperative to remain calm and focused prior to, during, and after gaining IV access. Patients tend to frown when their EMS provider excitedly shouts, “Got it!” and high fives their partner after a few unsuccessful attempts. Starting a line should be business as usual, and we should expect to be successful the first time, every time, and not be surprised when we actually pull it off. The only way to get to that point is to practice. The only way to practice is to stick people.
I have found that by encouraging firefighters with little or no field IV starting experience to step up and sharpen their skills on patients whose demise is not imminent greatly lessens the stress that accompanies the act of sticking a catheter into another human being who is watching everything you do. Unconscious patients who require IV access are less likely to present an inexperienced firefighter with problems associated with missed sticks. I became proficient at starting lines in large part because Providence, Rhode Island, is a college town, and college students away from their parents for the first time often drink themselves into unconsciousness and need IV access. Suffice it to say that there were more than a few college kids in my district waking up in the ED on Saturday mornings with a few extra holes in their arms.
Everything we do–every fire, every hazmat response, extrication, or even box alarm–is an opportunity to sharpen our skills. EMS is no exception. The more we do, the more we can do, and the better we become at what we do. We are never through learning on this job. The firefighter who knows it all and lets the junior people do all the EMS stuff has a whole lot to learn.
Michael Morse is a former captain with the Providence (RI) Fire Department (PFD), an author, and a popular columnist. He served on PFD’s Engine Co. 2., Engine Co. 9, and Ladder Co. 4 for 10 years prior to becoming an EMT-C on Rescue Co 1 and Captain of Rescue Co. 5.