Tunnel Vision, ignorance or both

[boeingb13]

Tunnel vision is something you are taught to get past while your in emt and/or paramedic school. Though every now and then your in a rescue/ambulance or on scene and you see someone who is stuck on one thing, as opposed to looking at the whole situation.

A few weeks ago my partner did a swap shift with a guy from another station, this guy has been a paramedic for 6 years on private ambulances. We were sent to a patient presenting with altered mental status, we got him in the truck, I started getting him hooked up to the monitor while my partner checked his BGL. It came back at 52, his BP was 96/54.

So the paramedic starts getting verything out of the IV tray to start a line, he automatically goes for the left ac, and misses. He procedes stick the guy in the same vein 4 more times, all the while i'm telling him, "you need to look somewhere else". The paramedic is sitting there sweating profusely going through needle after needle refusing to look anywhere else, and saying " we have to get a line" I tell him , i know but he needs to LOOK SOMEWHERE ELSE. At this point we are down to one 18 ga, a few 22's and a few 23 ga butterflies. The paramedic sits up after I tell him he's ran through everything, finally I yelled at him one more time, " we have one 18 ga and you have destroyed this guys arm" I had already checked his other arm, and there was just nothing to work with, I look at his neck, and there was a huge vein right in front of us. The paramedic put the 18 in and starting getting fluids in this guy, afterwards i jumped up front and we were off.

If that wasn't tunnel vision with a bit of ignorance I dont know what is. Afterwards on the way back to the station I asked him, " why did you just keep stabbing him in the same spot" his reply " he needed a line, besides I got an EJ". Some people amaze me at the dream world they live in, not recognizing when they have screwed up, or not wanting to admit to it.

[itku2er]

Sounds to me like some one needs a refresher course in IV Starts. If you dont get it in the first couple tries no need to keep going back to the well when it is dry. When I was in nursing school and later getting my EMT I when we did IVs we were taught that once you try a spot and dont get it you should try another site. Maybe that is just nursing thing. But he should have looked somewhere else, or let someone else try. Tunnel vision I dont think so but a poor lack of skills and sense might be a better way of looking at it.

just my

[boeingb13]

Thats not just a nursing lesson, thats what we are taught in paramedic school, and in the hospitals where we do our clinicals.

[spenac]

Tunnel vision is a horrible thing. In fire if to focused on one point rather than the big picture you can get cooked. In the case you presented your EMS partner may have had that one focus and missed the big picture, or perhaps just a bad day. This is a classic example of the need of two paramedics on an ambulance at all times so all the pressure is not on one person. Two IV attempts each, if no success move on to another option for example EJ or IO if patients condition warrants. In the case you describe the paramedic had no one of equal certification to fall back on when trouble arose which may have actually contributed to the tunnel vision and perceived mistakes.

[vs-eh?]

Started an EJ on a hypoglycemic paitent?

Urgh...

It was the same guy who apparently tried 4 times in the same spot with the same gauge catheter?

Urgh...

I know that some people just don't have any veins, but at least try a smaller gauge, the foot, anything before an EJ. The patient would have to be VERY VERY ill for me to start an EJ (which I have never done, not even on an arrest).

I had a similar patient a month or so ago. Altered hypoglycemic, had bilat AV shunts in her forearms and very torturous veins all around. Attempt 1 - 24 in the arm that blew as soon as I administered the dextrose. Attempt 2 - 20 in her saphenous, she kicked, I was like forget it just give her glucagon. We gave her a sandwich at the hospital, and even the ER nurse was like "I'm not even going to bother with a line on her".

[ccmedoc]

Started an EJ on a hypoglycemic paitent?

Urgh...

I know that some people just don't have any veins, but at least try a smaller gauge, the foot, anything before an EJ. The patient would have to be VERY VERY ill for me to start an EJ (which I have never done, not even on an arrest).

.

I think, in diabetics especially, the EJ would be better for IV access. Most diabetics have extremely poor circulation in their lower extremities, along with some degree of neuropathy. This could lead to some potentially nasty repercussions from jabbing at veins and possibly blowing them, potentially contributing to ulcer formation.

EJ cannulation is fairly common around here. I certainly have no problem with it. We have low instance of hematoma or other complication. I just believe in being extra careful with a diabetics lower extremities...thats all..

About the tunnel vision...... :?:....maybe having a bad day....

[spenac]

I think, in diabetics especially, the EJ would be better for IV access. Most diabetics have extremely poor circulation in their lower extremities, along with some degree of neuropathy. This could lead to some potentially nasty repercussions from jabbing at veins and possibly blowing them, potentially contributing to ulcer formation.

EJ cannulation is fairly common around here. I certainly have no problem with it. We have low instance of hematoma or other complication. I just believe in being extra careful with a diabetics lower extremities...thats all..

About the tunnel vision...... :?:....maybe having a bad day....

An EJ is very common as an alternative site. Yes there are risks just as with any procedure including starting an IV in the arm. Weigh the risks vs the benefits and do what is best for the patient.

[Mateo_1387]

...This is a classic example of the need of two paramedics on an ambulance at all times so all the pressure is not on one person. ... In the case you describe the paramedic had no one of equal certification to fall back on when trouble arose which may have actually contributed to the tunnel vision and perceived mistakes.

I do not think that dual medic would have helped overall in this case. From the Original Poster's comments the medic appeared to be very nervous. On top of the he also does not appear to be on top of things. I think this is where a dual medic system can be a bad thing. It is easy to get reliant on another medic to pick up slack. As a single medic provider you are forced to be on top of the game and be proficient at skills.

[akroeze]

So just to clarify, the majority of you would go for an EJ before you would administer glucagon?

I'm just curious because personally I would go the glucagon route first and if no response then I'd consider an EJ.

[Scaramedic]

The thing with Diabetic patients is that the IV is going to be a short term IV 90% of the time. Also once you get the IV and give D50 the patient will be wide awake, and during the transition from decreased LOC to alert they tend to be a might combative.

So you pop in an EJ, give D50, and restrain the patient. You hope he doesn't pull at the pain in his neck, and then you have a patient A&O with a very painful IV that you might have to pull because they don't want to go to the hospital. So you now have to pull an IV in a major vessel that is dangerously close to the airway. You pray the pressure is enough that it doesn't create a very nasty hematoma that can show up twenty minutes after you leave.

I'm sorry I disagree, I am all for using EJ's when necessary but an EJ is not an IV to be taken lightly. It is much more dangerous then peripheral veins. It is also painful and not a great place to have an IV in a moving and alert patient.

In this case I would have searched for alternative sites. I've done finger veins for diabetics. Keep in mind you do not have go with the D50 mixture, pop the D50 into a 50ml bag of D5W and run it in as D25. It is easier to run into small veins. I personally would look at all options including Glucagon before I placed an EJ in a Diabetic.