FireEMT2009 Posted December 10, 2011 Posted December 10, 2011 Hello all, As many of you know I have had many concerns and questions about EJs. Well in my last clinical rotation of my paramedic program I was given the chance to do an EJ in front of my OMD. The hospital I was at uses the Nexiva closed system IV catheters if you are familiar with it. The other hospital in the area uses the protectacath (Jelco) needles. The hosptial I was in that uses the nexiva keeps a couple of the Jelcos around just in case and for large bore IVs due to not having the nexivas in 14s or 16s but I digress. We had a patient that had been stuck numerous times and could not gain peripheral IV access. So I asked my OMD if he would allow me to do an EJ (It is a doc only skill in that hosptial). The doctor came and attended my EJ. During the proccess we could not "see" the EJ but it could be palpated and a slight buldge appeared (dehydration/hypovolemic). I stuck at the site with the nexiva and never got flash, after about a minute of searching the needle was withdrawn and peripheral access was finally obtained elsewhere. I have heard that the nexiva needles are not the best for doing EJs, has anyone ever heard of that before and if so do you know why they aren't the best IVs for it? And can anyone give me any EJ IV cannulation tips as well. I occluded the base of the vein so that it would stick up more during the procedure. Any advice is welcomed with a clear and open mind. Thanks! FireEMT2009
mobey Posted December 10, 2011 Posted December 10, 2011 I am sure you did... But elevating the legs/lwr torso can help, as well as turning the pt's head 30degrees, Too far and it flattens, too little and the skin is too loose. Other than that..... well, go IO 1
DwayneEMTP Posted December 10, 2011 Posted December 10, 2011 Really not being a smartass brother, but I don't know what any of those caths are... Some people seem really good at knowing the names of the caths, or the types of ambulances and such. I'm more of a "That's my ambulance? Does it have something in it that pokes into veins? Some O2 tanks, a couple of small ones and a big one? Yeah? Awesome, lets roll..." kind of guy. Likely a weakness, but it is what it is. If you can explain I'll certainly give you my thoughts, though there are many, probably most, that are more qualified to do so than I am. Dwayne
akflightmedic Posted December 10, 2011 Posted December 10, 2011 jelcos do not have any sort of safety device on it...the other brands all have either retractable needle or a plastic safety piece which caps the needle.
HERBIE1 Posted December 10, 2011 Posted December 10, 2011 I'm with Dwayne. I don't know the names of the various brands of angiocaths, but I do know starting an EJ is easier WITHOUT a protective version. Problem is, in many places you have no choice. I'm old school- I simply do not like those protect catheters. That said, it's certainly not impossible, but often trickier simply because of the angle and surrounding anatomy and structures. One thing you should have is a longer catheter- it makes accessing the vein easier
FireEMT2009 Posted December 10, 2011 Author Posted December 10, 2011 I am sure you did... But elevating the legs/lwr torso can help, as well as turning the pt's head 30degrees, Too far and it flattens, too little and the skin is too loose. Other than that..... well, go IO We did the tilt the patient but it did not improve anything but I will look more into the 30 degree thing through. Thanks! Really not being a smartass brother, but I don't know what any of those caths are... Some people seem really good at knowing the names of the caths, or the types of ambulances and such. I'm more of a "That's my ambulance? Does it have something in it that pokes into veins? Some O2 tanks, a couple of small ones and a big one? Yeah? Awesome, lets roll..." kind of guy. Likely a weakness, but it is what it is. If you can explain I'll certainly give you my thoughts, though there are many, probably most, that are more qualified to do so than I am. Dwayne jelcos do not have any sort of safety device on it...the other brands all have either retractable needle or a plastic safety piece which caps the needle. I'm with Dwayne. I don't know the names of the various brands of angiocaths, but I do know starting an EJ is easier WITHOUT a protective version. Problem is, in many places you have no choice. I'm old school- I simply do not like those protect catheters. That said, it's certainly not impossible, but often trickier simply because of the angle and surrounding anatomy and structures. One thing you should have is a longer catheter- it makes accessing the vein easier Its easier to show you a picture so here is the Nexiva closed system I was talking about: The needles the other hospital must not be a jelco but it is the one that the needle retracts into the barrell like this: For the EJ I used the first picture one, except in a 20 gauge not a 22.
HERBIE1 Posted December 10, 2011 Posted December 10, 2011 One of the local ER's here has switched to a system similar to that first picture, but they still stock standard angiocatheters for EMS replacement. To me, those are definitely not the best for EJ use, but like anything, I guess you get used to them.
Kaisu Posted December 10, 2011 Posted December 10, 2011 Unfamiliarity with the specific catheter was an issue with me, especially when I was first getting started. In medic school and clinicals, we used the angiocath (that's the one with the button you push that retracts the needle). I got used to it and liked it a lot. First job and we had and still have jelcos. I practiced on oranges and it still didn't help the first few times in the field. Now, I'm good. After a year with those, I did a deployment to Mississipi.. different catheters again (and different skin). Once again, first few times in the field till I got the hang of it. I would like to think that I've been doing them enough that I can be as indifferent to the cath as some of the previous posters, but I tend to doubt it. So you missed the EJ. Doesn't mean you are incompetant, but you are a beginner, and even experienced providers miss the stick from time to time. I wouldn't blame it completely on the catheter but I do believe unfamiliarity with it was one of the factors in your missed stick. 1
croaker260 Posted December 11, 2011 Posted December 11, 2011 Here is an old school trick... Place the patient in shock position ( legs elevated) and press firmly but gently on the liver. This produces JVD boys the hepatic jugular reflex and will increase the chance of success.
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