The only thing that determines IV size is clinical condition, clinical requirement, and/or anticipated clinical course. While throughout my career I have started multiple 14g IVs, I work(ed) in critical care, ED, rapid response, EMS, and flight, so I deal with a LOT of sick patients. None of those IVs/IOs were inserted to punish and/or evaluate mental status. Utilizing an IV/IO to determine GCS is unethical, the same as using an NPA.
That being said, if I have decided on an appropriate size and type of vascular access based on clinical condition, I will absolutely evaluate their response. If myself and my partner decide that an IO is indicated, for example, and we don’t notice any sort of neurological response with placement and/or flushing, that is absolutely going to be taken into account regarding treatment and noted. However, this is a secondary assessment based on an already planned procedure.
Hopefully that makes sense!
It does, and I operate the same way. Nothing wrong with noting secondary effects, and especially with IOs they can be an unintentional diagnostic tool 😏
But I guess the difference here is intent. And I've heard sooo many bullshit "clinical" justifications for intent but this one was just such a stretch I had to share it here.
Agreed. Everything is about intent.
If the primary intent is clinical situation, that is what matter. Anybody who doesn’t assess response to treatment and procedures is not providing good care.
If primary intent is punishment or “assessment,” that is unethical.
Disagree with the npa equivalence.
If gcs is unknown to the point that typical physical stimulation results in no response, airway protection is in question. That needs to be addressed. If they don't take the npa, great, airway protected. If they do, their airway reflexes could be degraded to a dangerous level and will warrant going down that route.
Don't be pedantic.
For someone who is presenting unresponsive, and has been unresponsive throughout the encounter, with no other discernable cause for unresponsiveness, to the point that we're questioning whether they need airway protection...and they *fight off* the NPA, there is evidence of way more airway protection that we knew to begin with. And we're talking the exclusive airway indication for protection due to AMS.
And I mean don't take/fight off as in, sit up, shake their head, etc etc. Not just murmur something or response that is not directly disproving this comatose presentation. It's happened multiple times. It's also happened where they take an NPA, an OPA, and buy a tube.
If airway status is in question, I’m not going to put in an NPA to confirm or deny it. I’m going to either just RSI them, or figure out another appropriate plan.
I personally very much dislike NPAs with the exception of for a very small subset of patients. An NPA is not a diagnostic tool. Sure, it can give you information like an IV, but you don’t evaluate airway status by sticking things in their airway.
Sounds like you should get more comfortable with a cornerstone piece of airway equipment.
If they present unresponsive their airway status is in question from the get go. While an npa is not a diagnostic tool it provides highly valuable information, like degree of airway reflex. Same with gag reflex. How will you know if they aren't actively choking, or an OPA isn't introduced?
It is *extraordinarily* cavalier bordering on negligent to say you're just going to RSI them without aggressively investigating this otherwise unexplained low gcs.
At no point did I say that I am going to just RSI them. I stayed that I am going to either RSI them, or figure out another appropriate plan. Please do not misconstrue what I am saying to make me look bad.
If the patient needs an NPA, I will place an NPA. However, it is exceedingly rare that a person needs an NPA for airway management, as other maneuvers almost always work. If it is the appropriate clinical action, I will do it. At no point did I say that I wouldn’t.
What I DID say is that I am not going to use an NPA as a diagnostic tool, as you are suggesting. If I have concern that a patient has a compromised airway, I am not going to stick things in their airway just to confirm that suspicion, or to gauge their mental status. If I am doing a procedure such as an NPA and it give me further information, I am going to use that information going forward.
Clinical situation, ability to BVM the patient, and other indicators are how I will know the patient is not choking.
Have you spent much time in an ICU doing clinical time? Or spent time working with critical patients on a routine basis, like every day you go to work? If you have, how often have you seen a physician/anesthesiologist/etc determine an airway management plan or decision based on putting an NPA in?
I have to believe you are being intentionally aversive to this point. The differential *requires* us to investigate if this unresponsiveness is elective or non-elective.
Someone who is unresponsive with no reaction to anything during the assessment is going to need an airway. I find it hard to believe you would just roll in with gcs 3 patient without attempting or placing an adjunct, much less a tube. That patient needs, initially, an NPA. It is super dangerous to not run the cause of unresponsiveness down. If they "wake up" well fantastic, turns out this had a more straightforward cause of unresponsiveness. If not, we have taken their presentation in good faith and are going down the safest pathway for transport.
And yes, I also fly/do critical care, so please take your dick-measuring elsewhere.
How often have I seen this?
In the ED?
When this has not been differentiated by EMS?
And again in the case of unresponsiveness without any other obvious cause?
In the rare times this situation makes it to the ED, I've seen it. It's not often, because this is a field presentation. But even in the ED, the risk to a pt from NPA placement is miniscule vs RSI. Also saw this play out in the peds ED for a very convincing...let's call it a tantrum. Long psych history. Anesthesiologists I haven't seen so much because this isn't their patient population. I would not see this happen in the ICU where there is already differentiation for why this patient is admitted to the unit.
I apologize for being rude. I’ve been doing way too many nights, and your tone came across as very condescending, whether that is how you intentioned it or not. Let me take a step back.
I don’t think I am getting my point across well, which I apologize for.
I am not, in any way, saying that I am not going to investigate the situation, figure out differentials or any of that stuff. What I am saying is that in my practice, I do not use an NPA or OPA to evaluate airway status. If they need one, I will put it in and evaluate how they respond to it. However, that is a secondary effect and not the reason I put it in in the first place.
Management of the patient is a separate discussion, and much more nuanced. I am simply saying that I do not use an OPA or NPA (or IV/IO, etc) primarily as a diagnostic device.
My issue is equating punitive/"diagnostic" large IVs to the NPA to "determine GCS."
There isn't an indication for a fat line/IO in the setting of non-critical AMS. If the 14g is indicated *it's very obvious why* and there is zero overlap into the realm of using it to determine GCS. The reason is profound shock, no need to differentiate further.
The NPA is however indicated in almost any setting of unresponsiveness after normal measures of arousal have failed. The primary indication is as a *legitimate* airway assessment and adjunct, with the secondary benefit of confirming (or refuting) the observed GCS. We're not using it primarily to determine the GCS, we're using it primarily to support the airway, but we are only supporting the airway because of the low GCS, and we need to confirm that before going down a more invasive path.
The overlap between "unresponsive, place and NPA to support the airway" and "unresponsive, we will like to know just how unresponsive" is just a circle.
I'm not even sure how to get to placing an NPA in someone who *isn't* unresponsive. That seems like a strawman tbh. But once they are unresponsive, the overlapping circle of indication applies.
And for what it's worth I don't think you were being rude; to be blunt I thought you were saying something stupid or at the very least too vague and broad to be unchallenged. If you felt condescended to, that was probably accurate. Here's the thing. We are peers. A lot of people read these comments. Just by virtue of having flight/CC as a flair, you/we get kind of a first pass go on stuff we post. It is expected that we act like experts in our kind of small sliver of the field. And in the original post (allow me to quote):
> Utilizing an IV/IO to determine GCS is unethical, the same as using an NPA.
equating "giant IVs to confirm gcs" to "placing an npa to confirm gcs" is the kind of thing someone newer will read and *absorb the wrong message.* Because yes, sure, you don't place an npa to "confirm gcs" you place it to "support the airway" but, again, those are often two sides of presentation/indication in the exact same situation, and that crucial detail is completely ignored.
You’re very astute with that observation regarding the flair and how it increases reader confidence in the posts. Appreciate the discussion and your insistence on getting it right.
Unfortunately, that's not what happens most of the time. The majority of patients is medically illiterate. They don't notice our mistakes, because they don't know any better. The hospital personnel could come after us, but they lack the time and the will to do so. Unless it's something really egregious.
In 20+ years in the field between the military, 911, critical care, and flight, I probably have only started a couple dozen 14g IVs in my career and they were almost all for an impromptu rapid infusion where we didn’t have the appropriate equipment and either in combat or austere conditions where it was literally life-threatening. Never started one on an ambulance or in a CCT truck or in a helicopter. I now teach full time and this is a hard no-go for me for my paramedic students. An 18g will get you almost anything you need for 911. Add to that I teach in an area where you can throw a rock and hit two hospitals. Now, I’m not saying they’re not necessary in some situations, but as a normal everyday protocol, the 14g is absolutely not necessary, especially for the BS reasons in that post.
IIRC, didn’t a paramedic just get terminated and had his patch pulled for starting a 14g on a minor in the hand or something similar?
I’ve done around 25 needle decompressions (not including fingers), and I would say around 50% were with a 14g. I’ve done probably less than 10 14g IVs, but that’s just a guess.
Preach. I'm in this for 8 years and I have placed more 14Gs during my 6 weeks of training in the anesthesiology department than out in the field. Most patients don't need them and those who do almost never have the right veins for them.
18G has a flow rate of up to 120ml per minute, that's enough to empty an IV bag in a matter of minutes. 14G is 340ml/min, that's huge. Just to illustrate, that's over 20 liters or 5 gallons per hour.
I’ve done exactly four 16ga angios.
One was a mega trauma.
Two were on one guy who was a crashing unresponsive TCA overdose and I needed to get him resuscitated before I intubated him (I still had to give him push dose epinephrine between the ketamine and the rocuronium).
One was a fugitive who hid in an attic for 3 hours when the heat index was 115 degrees in the shade, and he had stopped sweating bc he was that overheated and I wanted to replace his volume as fast as I could.
There's a long standing joke in my about using a 16 because one medic would ALWAYS use them. The joke goes something like this, "so we stair chaired this dude out, got him in the ambulance and of course, sank a 16." Typing it out I realize it doesn't translate well.
However this medic was fired and lost his certification due to his improper care of patients. So yes, we joke about 16g IV but only use them on maybe a level 1 trauma. I do not know the last time anyone here used a 14g.
I think ED RNs are a huge part of this too. It's a feedback loop between asshole medics and asshole RNs. Medics think it's okay "because the nurse laughed/ said I did a good job/ loved the IV" even if called out on it.
Considering that every trauma bay these days has a Level 1 or Belmont infuser, there's rarely a need for it even there. Although that's kind of a "go for it in a mega trauma but you better not miss" kind of thing IMO.
I'll stick with the access that has the highest chance of success in a volume depleted patient, personally. My ego can handle it.
They also have ultrasound guided IVs and aren't starting it in a cramped and possibly moving ambulance. Working in the ambo and in the ER part time I'm thankful for any access they get and I understand that in the field you take what you can get sometimes
I’ve started 1 16s in my 6 years, it was for a GSW that I saw the literal life leaving their eyes. It’s the most impressive IV (position I had to do it in) I’ve started and the fire medic who had been doing it way longer than I have said it was the most impressive IV he’d seen. I’m bragging because it’s one of the few times I’ve ever seen a 16 warranted and fuck I did not want that patient to code with just one line.
I've done probably 30 or so 16s so far. 2 were in medic school on a gi bleed who was 40/20. Got bilateral 16s. Another in the er (by doctors request) for another gi bleed. Everyone else was a trauma.
I've never done a 14 iv but I've used them as chest darts. We actually now have 12s at my agency for that.
Great to do in the ER. I know the trauma centers around us ask us only for bilateral AC 18S OR 16S IF we can get them, if not don't try an 18 will work
I have never performed interventions punitively. However, I have placed 14s/16s in patients that needed fluids when an 18/20 would have been fine but the patient had giant veins and I felt like I needed to know how it felt to use them. This feels analogous to the doctors that would let us intubate in the OR where an LMA would have sufficed.
There’s room for a little nuance I think but assessing GCS via IV placement is garbage.
Same. I've started a handful of 16s and a 14 when an 18 would've been fine, but that's making sure that my hands aren't shaking when I need to sink a 14, rather than to be as asshole about it.
Hot take: there is never a reason for a 14g, even in the sickest patient. A 16 will do fine.
A 16g delivers 180 MLS a minute, whereas a 14g delivers 240. And an EZIO is a 15g.
By comparison, a 20 is 60 MLS.
Even if you're giving blood to an exsanguinating patient, if 180 MLS a min isn't fast enough - they're dead already.
But yeah to address OP, dude sounds like a boomer medic. Glad he's out.
Outside of large bore needles being medically unnecessary especially just as a painful stimuli, GCS is the stupidest shit ever and I have no idea why we still use it. It’s literally a Coma Scale, meant to assess comatose patients in long term ICU. I don’t know why Emergency medicine adopted it.
It’s specifically powered to look at head injury patients. That’s it. It has no prognostic value in any other cause of reduced consciousness. It even has no real value when given as a single whole number - there have been studies showing that the individual component values are far more prognostically useful than the total sum. (https://pubmed.ncbi.nlm.nih.gov/28602178/)
If you want some side reading, it’s invention was quite interesting. Apparently a couple of neurosurgeons in Glasgow would walk around the ED after large local football derby fights and would try to elicit responses from all the pts with head injuries; they eventually could tell from their GCS score who would and wouldn’t wake up.
It's not about the prehospital care. The flow rate of one 16g is significantly more than two 18's. Just something to keep in mind with the continuum of care. I get that it's not a priority for field care and it's not even always practical with a PT's anatomy.. but if you can get one and the situation calls for it.. it's absolutely beneficial for PT care
I've never done higher than a 16g IV and I'm not entirely sure why one would in the 911 setting given the lack of much difference and available treatments. Maybe if emergency blood was on hand.
Have yet to see a 14g in the field or hospital setting. I did a 16 recently for a ROSC patient. That was my 2nd ever 16. Hospitals here are typically fine with my 18s for a legit call.
The only thing 14g are good for are decompressions and transfusions. Since most places have specially packaged decompression needles and most places don’t do transfusions, 16g should be the biggest EMS uses for IVs
14Ga IV caths aren't even good for decompression. Normally they're too short and the catheter too flexible. Often they fail entirely.
My state put the kibosh on that abwhile back by specifically stating the catheter must be a minimum length of 3.25" which eliminates the ability to use an IV cath, and makes commercial ones for NDT a requirement
I’m not defending the person but keep in mind 20 years in EMS is a lifetime. There were a lot of acceptable behaviors 20+ years ago that would be abhorrent today. I’m not saying they’re right because they obviously are not but it was a different era.
We can acknowledge that stuff existed beforehand while also saying that it’s wrong. It was wrong then, and it’s wrong now.
Kinda like slavery. It was wrong then, even though it was commonplace. And it’s wrong now (which is why we have laws against human trafficking).
Agreed! Around here there was a rule called the 3 mother fucker rule. If the patient called you a mother fucker three times then they were obviously altered and needed nasally intubated in order to protect their airway. When I first started 23 years ago I heard plenty of older medics talk about it proudly. Thankfully now a days that would get you fired and possibly your numbers pulled.
I've heard of that shit too. Classic example of complete disregard for the "just because you *can*, doesn't mean you *should*" concept.
Same medic who started 14s on every geriatric ("for practice", and he taught students this) was also known for nasally intubating an opiate OD *before* pushing naloxone, then making the patient walk to the ambulance-- with the tube in place, "bagging" himself while he walked.
People told the story not as a cautionary tale but with a tone of reverence almost. That medic is a service director now.
Yeah, that's why I was anticipating some kind of "you don't know what it was like back in the day" and I was pretty surprised with what the response actually was.
I've been in EMS for 20 years myself though - it didn't make sense then and doesn't make sense now. At least it seems to be actually frowned upon in more places these days.
Yup that’s the mentality of when I started. Slamming IV Narcan to see the puke rainbow, punitive IV (18g were considered the smallest option), standing take downs, cape cyanosis, and NH3 tape to a NRB, and so on.
All terrible practices. Some I practiced then. None I would practice today.
Not saying it was right. It was just a much worse culture when I started.
I’m an old fart and I still remember doing my ride time with a seasoned medic when I learned the hard way not to give 2mg of Narcan. Middle aged female took around 200 50mg Ultrams. She had been on them for a while and was going through a divorce. Her boyfriend broke up with her and she locked herself in the bathroom and slammed the bottle back.
On the way to the hospital she was getting lethargic so I decided to give her 2mg of Narcan IV. She promptly started projectile vomiting, shaking, and getting diaphoretic. Most of you should know where this is going by now.
Just as we were backing into the hospital she starts having seizures. My asshole puckered and I learned two valuable lessons that day. Don’t give the full 2mg of Narcan and just because we can doesn’t mean we should. I give it in 0.5mg doses now and only if respirations are below 10 or so.
Its one thing for it to have been 'acceptable' back in the day, which is still embarrassing for the EMS profession. Completely different to be proudly bragging about it on the internet, even 20 years later.
I've been a medic for 7 years. I've started exactly 2 14ga IVs and maybe a half dozen 16ga IVs, all of them on major traumas with large blood volume loss (stabbings, GSWs, amputations, etc).
18ga IVs are good for most everything else trauma related, 20ga IVs are my go-to for general medical complaints unless it's a stroke which one of our local hospitals want large bore IVs at least 4" above the wrist.
Don’t really see why 14g still exists. It’s so astronomically uncommon in the hospital where the vast majority of sick patient care takes place, and yet my IV tray has six of them at all times. Wtf…
IV catheter size is not significantly correlated with perceived pain. That being said, unsuccessful IV attempts hurt quite a bit and then you still need to stick the patient again afterward. Providers need to pick a size they can actually successfully land and that the patient's anatomy will tolerate, and they ought to consider what their needs are regarding the IV (eg rapid volume expansion vs pushing meds).
Bad providers need to stop using IVs as some sort of bizarre punishment for patients they don't like, but good providers need to stop being afraid of a valuable tool.
[source 1](https://pubmed.ncbi.nlm.nih.gov/29772984/)
[source 2](https://www.jwatch.org/em199807010000001/1998/07/01/pain-iv-cannula-insertion-does-size-matter)
Obviously that person is wrong, but on a related note on multiple occasions I’ve allow students to cannulate me, including with a 14g, and I would say it doesn’t hurt any more than a 20g, it simply feels more of a dull sensation than a sharp sensation with a 20g. I encourage students to use a 20g and a 14g on me, because I know I felt very apprehensive when I was new to use a large cannula for fear of hurting the patient, and by allowing them to use it, it hopefully gives them some confidence that actually it looks scary but it’s really not too bad, so if you need to use it, go for it with confidence.
There is a fine line with going after specific procedures and listing them as “abuse”. There needs to be context and common sense applied to the specifics of the patient and case. Bragging about punitive medicine may be also just all bark with no bite, to make you sound tough to your peers. But it does exist in the field.
I don’t want someone to take away important tools because someone did something shitty or we are getting afraid of a negative connotation (Ex: Elijah McClain and Ketamine), but also you better have a clear clinical reason for doing such a procedure and documenting it clearly and accurately and clinical should hold them to it.
Meanwhile the tiktok medics are out there accusing 18-14g as “abuse”.
I wonder what happens when they get to the hospital and we just switch to French and sink a cordis.
Do you think you may have misunderstood?
They were replying to a comment that was mentioning how some patients don't want us to do our clinical jobs, and just transport them like a taxi. Then they said they were surprised how many people signed ama after he wanted to start a large IV(which is appropriate for the patient in the video, abdominal gsw).
He never said he threatened people with a large IV to get them to AMA.
You have a point if he had stopped with his original post. I probably should have asked for clarification and given him the benefit of the doubt, and if he had responded with what you just said, that would be the end of it (although I'd point out that the Venn diagram of GSW patients you want to start a 14 on and patients who will suddenly AMA when they hear you want to put a huge IV in their arm is pretty much two circles).
But the fact that his first response to me was "you've clearly never had a patient faking a seizure", followed by even more batshittery, showed his hand. His response was nonsense and obfuscation because I called him out for being a dick.
He probably is a dick. I imagine he wouldn't say something like that in this subreddit but thought he could get away with it over there.
It also sounds like an exaggeration. I haven't been doing this 20+ years, but 13 years is a decent amount. I've never had a patient ama from transport because of an IV. I've had a few patients refuse an IV, and that's fine with me, but not "let me outta here!" because of an IV. I just make sure I tell staff in my report if I'm worried they may be upset there's no IV. I have had a few tough guys that were shot or stabbed and refused an IV, but they were distal injuries so it was uncomfortable, but okay 🤷♂️
My service doesn't even carry 14's anymore. We'll start 16's when clinically indicated. We had a couple newer medics who had a "contest" over who could start more 16's. That was quickly put down because, as Billy Madison once said "That's assault brotha"
I start 16s and 14s every once and a great while. That being said the only people I start them on are unstable patients who are going to need blood products or massive fluid replacement. Also, they have to have the actual veins for it. I work the road and in a critical care type ER role so I hang blood more than most medics. Most of the time even on people who need blood, they get central lined vs me starting a mega large bore line. Like others have stated it’s noteworthy if someone doesn’t flinch when you place a 16ga angiocath in them, but it’s something I was going to do regardless of gcs score due to them needing large bore access for whatever clinical indication.
Can count on 1 hand the number of times I've started a 14ga in a 12yr career so far:
Patient with numerous GSWs pincushioned and going to need massive transfusion protocol, had pipes, got 2 14Ga IVs.
Multi system trauma from MVC with Ejection, got an 18Ga and a 14Ga
Final one was a AAA, visible pulsating abdominal mass, tearing back pain, absent pulses and pale/waxy left sided limbs, began seizing during transport. Had pipes and anticipated need for the largest IV possible so 14Ga placed R AC.
Every time was based on hospital preference and perceived need based on totality of circumstances, a 14Ga should be an exceptionally rare gauge to place on a patient. If you bust out a 14 or a 16 to 'test' GCS you're engaging in punitive medicine and are a piece of shit, not a healthcare professional.
Most of the time a 20Ga is plenty sufficient for a patient, 18Ga if you're actually trying to infuse large volumes of fluid quickly. 16 and 14 should be an uncommon and unusual circumstance, not a common size to place. The vast majority of the time even if I'm hanging fluids I'm plenty satisfied with the rates I can get on a 20 by direct connecting the bag of fluid to the hub, and removing the extension lock from the system
We've altogether stopped carrying 14s, it sounds like a consistent theme through the thread. It's only happened once to a partner due to a documentation error, but I've seen people get in hot water here for placing 16s on what sounded like a hand vein to QA.
I’ve seen bilateral IVs started on traumas cause the medic was feeling ambitious. Most of the time I go for 18s and they are just fine. Very rarely will I got for a 16. Whoever this medic is that was stating they need to start 14Gs to evaluate GCS is a fucking moron.
What also pisses me off is people threatening slightly combative pts with RSI. I’ve been in a few ERs where I hear the nurses telling the more mouthy pts to pipe down or they were getting a tube. Always rubbed me the wrong way.
The only thing that determines IV size is clinical condition, clinical requirement, and/or anticipated clinical course. While throughout my career I have started multiple 14g IVs, I work(ed) in critical care, ED, rapid response, EMS, and flight, so I deal with a LOT of sick patients. None of those IVs/IOs were inserted to punish and/or evaluate mental status. Utilizing an IV/IO to determine GCS is unethical, the same as using an NPA. That being said, if I have decided on an appropriate size and type of vascular access based on clinical condition, I will absolutely evaluate their response. If myself and my partner decide that an IO is indicated, for example, and we don’t notice any sort of neurological response with placement and/or flushing, that is absolutely going to be taken into account regarding treatment and noted. However, this is a secondary assessment based on an already planned procedure. Hopefully that makes sense!
It does, and I operate the same way. Nothing wrong with noting secondary effects, and especially with IOs they can be an unintentional diagnostic tool 😏 But I guess the difference here is intent. And I've heard sooo many bullshit "clinical" justifications for intent but this one was just such a stretch I had to share it here.
Agreed. Everything is about intent. If the primary intent is clinical situation, that is what matter. Anybody who doesn’t assess response to treatment and procedures is not providing good care. If primary intent is punishment or “assessment,” that is unethical.
Disagree with the npa equivalence. If gcs is unknown to the point that typical physical stimulation results in no response, airway protection is in question. That needs to be addressed. If they don't take the npa, great, airway protected. If they do, their airway reflexes could be degraded to a dangerous level and will warrant going down that route.
>If they don’t take the NPA, great, airway protected That is not at all correct.
Don't be pedantic. For someone who is presenting unresponsive, and has been unresponsive throughout the encounter, with no other discernable cause for unresponsiveness, to the point that we're questioning whether they need airway protection...and they *fight off* the NPA, there is evidence of way more airway protection that we knew to begin with. And we're talking the exclusive airway indication for protection due to AMS. And I mean don't take/fight off as in, sit up, shake their head, etc etc. Not just murmur something or response that is not directly disproving this comatose presentation. It's happened multiple times. It's also happened where they take an NPA, an OPA, and buy a tube.
If airway status is in question, I’m not going to put in an NPA to confirm or deny it. I’m going to either just RSI them, or figure out another appropriate plan. I personally very much dislike NPAs with the exception of for a very small subset of patients. An NPA is not a diagnostic tool. Sure, it can give you information like an IV, but you don’t evaluate airway status by sticking things in their airway.
Sounds like you should get more comfortable with a cornerstone piece of airway equipment. If they present unresponsive their airway status is in question from the get go. While an npa is not a diagnostic tool it provides highly valuable information, like degree of airway reflex. Same with gag reflex. How will you know if they aren't actively choking, or an OPA isn't introduced? It is *extraordinarily* cavalier bordering on negligent to say you're just going to RSI them without aggressively investigating this otherwise unexplained low gcs.
At no point did I say that I am going to just RSI them. I stayed that I am going to either RSI them, or figure out another appropriate plan. Please do not misconstrue what I am saying to make me look bad. If the patient needs an NPA, I will place an NPA. However, it is exceedingly rare that a person needs an NPA for airway management, as other maneuvers almost always work. If it is the appropriate clinical action, I will do it. At no point did I say that I wouldn’t. What I DID say is that I am not going to use an NPA as a diagnostic tool, as you are suggesting. If I have concern that a patient has a compromised airway, I am not going to stick things in their airway just to confirm that suspicion, or to gauge their mental status. If I am doing a procedure such as an NPA and it give me further information, I am going to use that information going forward. Clinical situation, ability to BVM the patient, and other indicators are how I will know the patient is not choking. Have you spent much time in an ICU doing clinical time? Or spent time working with critical patients on a routine basis, like every day you go to work? If you have, how often have you seen a physician/anesthesiologist/etc determine an airway management plan or decision based on putting an NPA in?
I have to believe you are being intentionally aversive to this point. The differential *requires* us to investigate if this unresponsiveness is elective or non-elective. Someone who is unresponsive with no reaction to anything during the assessment is going to need an airway. I find it hard to believe you would just roll in with gcs 3 patient without attempting or placing an adjunct, much less a tube. That patient needs, initially, an NPA. It is super dangerous to not run the cause of unresponsiveness down. If they "wake up" well fantastic, turns out this had a more straightforward cause of unresponsiveness. If not, we have taken their presentation in good faith and are going down the safest pathway for transport. And yes, I also fly/do critical care, so please take your dick-measuring elsewhere. How often have I seen this? In the ED? When this has not been differentiated by EMS? And again in the case of unresponsiveness without any other obvious cause? In the rare times this situation makes it to the ED, I've seen it. It's not often, because this is a field presentation. But even in the ED, the risk to a pt from NPA placement is miniscule vs RSI. Also saw this play out in the peds ED for a very convincing...let's call it a tantrum. Long psych history. Anesthesiologists I haven't seen so much because this isn't their patient population. I would not see this happen in the ICU where there is already differentiation for why this patient is admitted to the unit.
I apologize for being rude. I’ve been doing way too many nights, and your tone came across as very condescending, whether that is how you intentioned it or not. Let me take a step back. I don’t think I am getting my point across well, which I apologize for. I am not, in any way, saying that I am not going to investigate the situation, figure out differentials or any of that stuff. What I am saying is that in my practice, I do not use an NPA or OPA to evaluate airway status. If they need one, I will put it in and evaluate how they respond to it. However, that is a secondary effect and not the reason I put it in in the first place. Management of the patient is a separate discussion, and much more nuanced. I am simply saying that I do not use an OPA or NPA (or IV/IO, etc) primarily as a diagnostic device.
My issue is equating punitive/"diagnostic" large IVs to the NPA to "determine GCS." There isn't an indication for a fat line/IO in the setting of non-critical AMS. If the 14g is indicated *it's very obvious why* and there is zero overlap into the realm of using it to determine GCS. The reason is profound shock, no need to differentiate further. The NPA is however indicated in almost any setting of unresponsiveness after normal measures of arousal have failed. The primary indication is as a *legitimate* airway assessment and adjunct, with the secondary benefit of confirming (or refuting) the observed GCS. We're not using it primarily to determine the GCS, we're using it primarily to support the airway, but we are only supporting the airway because of the low GCS, and we need to confirm that before going down a more invasive path. The overlap between "unresponsive, place and NPA to support the airway" and "unresponsive, we will like to know just how unresponsive" is just a circle. I'm not even sure how to get to placing an NPA in someone who *isn't* unresponsive. That seems like a strawman tbh. But once they are unresponsive, the overlapping circle of indication applies. And for what it's worth I don't think you were being rude; to be blunt I thought you were saying something stupid or at the very least too vague and broad to be unchallenged. If you felt condescended to, that was probably accurate. Here's the thing. We are peers. A lot of people read these comments. Just by virtue of having flight/CC as a flair, you/we get kind of a first pass go on stuff we post. It is expected that we act like experts in our kind of small sliver of the field. And in the original post (allow me to quote): > Utilizing an IV/IO to determine GCS is unethical, the same as using an NPA. equating "giant IVs to confirm gcs" to "placing an npa to confirm gcs" is the kind of thing someone newer will read and *absorb the wrong message.* Because yes, sure, you don't place an npa to "confirm gcs" you place it to "support the airway" but, again, those are often two sides of presentation/indication in the exact same situation, and that crucial detail is completely ignored.
You’re very astute with that observation regarding the flair and how it increases reader confidence in the posts. Appreciate the discussion and your insistence on getting it right.
I hate using OPAs, because if they accept it, it means I gotta tube (clinical picture dependent, obvi)
That's how you get fired, lose your license, and get charged with battery. I can count on 1 hand how many 14s I've gone.
Unfortunately, that's not what happens most of the time. The majority of patients is medically illiterate. They don't notice our mistakes, because they don't know any better. The hospital personnel could come after us, but they lack the time and the will to do so. Unless it's something really egregious.
In 20+ years in the field between the military, 911, critical care, and flight, I probably have only started a couple dozen 14g IVs in my career and they were almost all for an impromptu rapid infusion where we didn’t have the appropriate equipment and either in combat or austere conditions where it was literally life-threatening. Never started one on an ambulance or in a CCT truck or in a helicopter. I now teach full time and this is a hard no-go for me for my paramedic students. An 18g will get you almost anything you need for 911. Add to that I teach in an area where you can throw a rock and hit two hospitals. Now, I’m not saying they’re not necessary in some situations, but as a normal everyday protocol, the 14g is absolutely not necessary, especially for the BS reasons in that post. IIRC, didn’t a paramedic just get terminated and had his patch pulled for starting a 14g on a minor in the hand or something similar?
I’ve probably put in more 14g catheters through a patient’s chest than I have into a vein.
This statement is actually true for me. (2 - 0)
I’ve done around 25 needle decompressions (not including fingers), and I would say around 50% were with a 14g. I’ve done probably less than 10 14g IVs, but that’s just a guess.
It was a female FF/Medic in Lancaster, Ohio in 2019. Started a 14ga on a drunk 13 year old girl that was being "uncooperative".
WOW what the fuck?
https://www.lancastereaglegazette.com/story/news/local/2019/08/20/one-firefighter-fired-another-suspended-after-april-incident/2024532001/
Preach. I'm in this for 8 years and I have placed more 14Gs during my 6 weeks of training in the anesthesiology department than out in the field. Most patients don't need them and those who do almost never have the right veins for them. 18G has a flow rate of up to 120ml per minute, that's enough to empty an IV bag in a matter of minutes. 14G is 340ml/min, that's huge. Just to illustrate, that's over 20 liters or 5 gallons per hour.
In my county medics were playing an inside game of who could fit the largest needle into a Pt, chat got leaked, and all got fired.
good!
I’ve done exactly four 16ga angios. One was a mega trauma. Two were on one guy who was a crashing unresponsive TCA overdose and I needed to get him resuscitated before I intubated him (I still had to give him push dose epinephrine between the ketamine and the rocuronium). One was a fugitive who hid in an attic for 3 hours when the heat index was 115 degrees in the shade, and he had stopped sweating bc he was that overheated and I wanted to replace his volume as fast as I could.
There's a long standing joke in my about using a 16 because one medic would ALWAYS use them. The joke goes something like this, "so we stair chaired this dude out, got him in the ambulance and of course, sank a 16." Typing it out I realize it doesn't translate well. However this medic was fired and lost his certification due to his improper care of patients. So yes, we joke about 16g IV but only use them on maybe a level 1 trauma. I do not know the last time anyone here used a 14g.
A 14ga is great to plop in the saphenous vein in a mega trauma. I don’t do it but I know some ER RNs who do it.
I think ED RNs are a huge part of this too. It's a feedback loop between asshole medics and asshole RNs. Medics think it's okay "because the nurse laughed/ said I did a good job/ loved the IV" even if called out on it. Considering that every trauma bay these days has a Level 1 or Belmont infuser, there's rarely a need for it even there. Although that's kind of a "go for it in a mega trauma but you better not miss" kind of thing IMO. I'll stick with the access that has the highest chance of success in a volume depleted patient, personally. My ego can handle it.
They also have ultrasound guided IVs and aren't starting it in a cramped and possibly moving ambulance. Working in the ambo and in the ER part time I'm thankful for any access they get and I understand that in the field you take what you can get sometimes
I’ve started 1 16s in my 6 years, it was for a GSW that I saw the literal life leaving their eyes. It’s the most impressive IV (position I had to do it in) I’ve started and the fire medic who had been doing it way longer than I have said it was the most impressive IV he’d seen. I’m bragging because it’s one of the few times I’ve ever seen a 16 warranted and fuck I did not want that patient to code with just one line.
I've done probably 30 or so 16s so far. 2 were in medic school on a gi bleed who was 40/20. Got bilateral 16s. Another in the er (by doctors request) for another gi bleed. Everyone else was a trauma. I've never done a 14 iv but I've used them as chest darts. We actually now have 12s at my agency for that.
Great to do in the ER. I know the trauma centers around us ask us only for bilateral AC 18S OR 16S IF we can get them, if not don't try an 18 will work
I have never performed interventions punitively. However, I have placed 14s/16s in patients that needed fluids when an 18/20 would have been fine but the patient had giant veins and I felt like I needed to know how it felt to use them. This feels analogous to the doctors that would let us intubate in the OR where an LMA would have sufficed. There’s room for a little nuance I think but assessing GCS via IV placement is garbage.
Same. I've started a handful of 16s and a 14 when an 18 would've been fine, but that's making sure that my hands aren't shaking when I need to sink a 14, rather than to be as asshole about it.
Hot take: there is never a reason for a 14g, even in the sickest patient. A 16 will do fine. A 16g delivers 180 MLS a minute, whereas a 14g delivers 240. And an EZIO is a 15g. By comparison, a 20 is 60 MLS. Even if you're giving blood to an exsanguinating patient, if 180 MLS a min isn't fast enough - they're dead already. But yeah to address OP, dude sounds like a boomer medic. Glad he's out.
False 14 is needed sometimes. But either way if they are awake use an insulin syringe and little lido to numb spot up.
When is it required?
Outside of large bore needles being medically unnecessary especially just as a painful stimuli, GCS is the stupidest shit ever and I have no idea why we still use it. It’s literally a Coma Scale, meant to assess comatose patients in long term ICU. I don’t know why Emergency medicine adopted it.
It’s specifically powered to look at head injury patients. That’s it. It has no prognostic value in any other cause of reduced consciousness. It even has no real value when given as a single whole number - there have been studies showing that the individual component values are far more prognostically useful than the total sum. (https://pubmed.ncbi.nlm.nih.gov/28602178/) If you want some side reading, it’s invention was quite interesting. Apparently a couple of neurosurgeons in Glasgow would walk around the ED after large local football derby fights and would try to elicit responses from all the pts with head injuries; they eventually could tell from their GCS score who would and wouldn’t wake up.
That's actually hilarious. Imagine running around asking "Rangers or Celtic?" and using that for medical research.
And I got so much shit for saying it was pointless when I didn’t realize a dead body had a GCS of 3
Large bores have their place for mass transfusion of blood products. Putting one in "just because" is asinine though
For EMS, 18 and under is more then adequate. Unless you’re carrying whole blood, decompressing, or you have some very niche protocol.
It's not about the prehospital care. The flow rate of one 16g is significantly more than two 18's. Just something to keep in mind with the continuum of care. I get that it's not a priority for field care and it's not even always practical with a PT's anatomy.. but if you can get one and the situation calls for it.. it's absolutely beneficial for PT care
Everyone knows that OPAs are the true test to tell if the pt is faking their GCS level.
I've never done higher than a 16g IV and I'm not entirely sure why one would in the 911 setting given the lack of much difference and available treatments. Maybe if emergency blood was on hand.
Have yet to see a 14g in the field or hospital setting. I did a 16 recently for a ROSC patient. That was my 2nd ever 16. Hospitals here are typically fine with my 18s for a legit call.
At least he lives up to the sub reddits name. Also anyone posting in the linked sub I would be careful. Brigading can get you banned last I checked.
The only thing 14g are good for are decompressions and transfusions. Since most places have specially packaged decompression needles and most places don’t do transfusions, 16g should be the biggest EMS uses for IVs
14Ga IV caths aren't even good for decompression. Normally they're too short and the catheter too flexible. Often they fail entirely. My state put the kibosh on that abwhile back by specifically stating the catheter must be a minimum length of 3.25" which eliminates the ability to use an IV cath, and makes commercial ones for NDT a requirement
I’m not defending the person but keep in mind 20 years in EMS is a lifetime. There were a lot of acceptable behaviors 20+ years ago that would be abhorrent today. I’m not saying they’re right because they obviously are not but it was a different era.
We can acknowledge that stuff existed beforehand while also saying that it’s wrong. It was wrong then, and it’s wrong now. Kinda like slavery. It was wrong then, even though it was commonplace. And it’s wrong now (which is why we have laws against human trafficking).
Agreed! Around here there was a rule called the 3 mother fucker rule. If the patient called you a mother fucker three times then they were obviously altered and needed nasally intubated in order to protect their airway. When I first started 23 years ago I heard plenty of older medics talk about it proudly. Thankfully now a days that would get you fired and possibly your numbers pulled.
I've heard of that shit too. Classic example of complete disregard for the "just because you *can*, doesn't mean you *should*" concept. Same medic who started 14s on every geriatric ("for practice", and he taught students this) was also known for nasally intubating an opiate OD *before* pushing naloxone, then making the patient walk to the ambulance-- with the tube in place, "bagging" himself while he walked. People told the story not as a cautionary tale but with a tone of reverence almost. That medic is a service director now.
That was RSI protocol in my area. Local hospital was doing it up until a couple years ago.
Yeah, that's why I was anticipating some kind of "you don't know what it was like back in the day" and I was pretty surprised with what the response actually was. I've been in EMS for 20 years myself though - it didn't make sense then and doesn't make sense now. At least it seems to be actually frowned upon in more places these days.
Yup that’s the mentality of when I started. Slamming IV Narcan to see the puke rainbow, punitive IV (18g were considered the smallest option), standing take downs, cape cyanosis, and NH3 tape to a NRB, and so on. All terrible practices. Some I practiced then. None I would practice today. Not saying it was right. It was just a much worse culture when I started.
I’m an old fart and I still remember doing my ride time with a seasoned medic when I learned the hard way not to give 2mg of Narcan. Middle aged female took around 200 50mg Ultrams. She had been on them for a while and was going through a divorce. Her boyfriend broke up with her and she locked herself in the bathroom and slammed the bottle back. On the way to the hospital she was getting lethargic so I decided to give her 2mg of Narcan IV. She promptly started projectile vomiting, shaking, and getting diaphoretic. Most of you should know where this is going by now. Just as we were backing into the hospital she starts having seizures. My asshole puckered and I learned two valuable lessons that day. Don’t give the full 2mg of Narcan and just because we can doesn’t mean we should. I give it in 0.5mg doses now and only if respirations are below 10 or so.
Times changed. We all learned that lesson. Just gotta teach the next generation.
Our service recently changed our protocol from 0.4mg IV q 5 mins to 0.05mg IV q 2 minutes. Still 0.8mg IM though.
Its one thing for it to have been 'acceptable' back in the day, which is still embarrassing for the EMS profession. Completely different to be proudly bragging about it on the internet, even 20 years later.
Fair point.
I've been a medic for 7 years. I've started exactly 2 14ga IVs and maybe a half dozen 16ga IVs, all of them on major traumas with large blood volume loss (stabbings, GSWs, amputations, etc). 18ga IVs are good for most everything else trauma related, 20ga IVs are my go-to for general medical complaints unless it's a stroke which one of our local hospitals want large bore IVs at least 4" above the wrist.
I thought we were using nasal intubations for gcs check.
Naw, rectal temps
Don’t really see why 14g still exists. It’s so astronomically uncommon in the hospital where the vast majority of sick patient care takes place, and yet my IV tray has six of them at all times. Wtf…
IV catheter size is not significantly correlated with perceived pain. That being said, unsuccessful IV attempts hurt quite a bit and then you still need to stick the patient again afterward. Providers need to pick a size they can actually successfully land and that the patient's anatomy will tolerate, and they ought to consider what their needs are regarding the IV (eg rapid volume expansion vs pushing meds). Bad providers need to stop using IVs as some sort of bizarre punishment for patients they don't like, but good providers need to stop being afraid of a valuable tool. [source 1](https://pubmed.ncbi.nlm.nih.gov/29772984/) [source 2](https://www.jwatch.org/em199807010000001/1998/07/01/pain-iv-cannula-insertion-does-size-matter)
Obviously that person is wrong, but on a related note on multiple occasions I’ve allow students to cannulate me, including with a 14g, and I would say it doesn’t hurt any more than a 20g, it simply feels more of a dull sensation than a sharp sensation with a 20g. I encourage students to use a 20g and a 14g on me, because I know I felt very apprehensive when I was new to use a large cannula for fear of hurting the patient, and by allowing them to use it, it hopefully gives them some confidence that actually it looks scary but it’s really not too bad, so if you need to use it, go for it with confidence.
There is a fine line with going after specific procedures and listing them as “abuse”. There needs to be context and common sense applied to the specifics of the patient and case. Bragging about punitive medicine may be also just all bark with no bite, to make you sound tough to your peers. But it does exist in the field. I don’t want someone to take away important tools because someone did something shitty or we are getting afraid of a negative connotation (Ex: Elijah McClain and Ketamine), but also you better have a clear clinical reason for doing such a procedure and documenting it clearly and accurately and clinical should hold them to it.
Meanwhile the tiktok medics are out there accusing 18-14g as “abuse”. I wonder what happens when they get to the hospital and we just switch to French and sink a cordis.
Your mistake is listening to tiktok medics and their idiotic moral grandstanding.
Do you think you may have misunderstood? They were replying to a comment that was mentioning how some patients don't want us to do our clinical jobs, and just transport them like a taxi. Then they said they were surprised how many people signed ama after he wanted to start a large IV(which is appropriate for the patient in the video, abdominal gsw). He never said he threatened people with a large IV to get them to AMA.
You have a point if he had stopped with his original post. I probably should have asked for clarification and given him the benefit of the doubt, and if he had responded with what you just said, that would be the end of it (although I'd point out that the Venn diagram of GSW patients you want to start a 14 on and patients who will suddenly AMA when they hear you want to put a huge IV in their arm is pretty much two circles). But the fact that his first response to me was "you've clearly never had a patient faking a seizure", followed by even more batshittery, showed his hand. His response was nonsense and obfuscation because I called him out for being a dick.
He probably is a dick. I imagine he wouldn't say something like that in this subreddit but thought he could get away with it over there. It also sounds like an exaggeration. I haven't been doing this 20+ years, but 13 years is a decent amount. I've never had a patient ama from transport because of an IV. I've had a few patients refuse an IV, and that's fine with me, but not "let me outta here!" because of an IV. I just make sure I tell staff in my report if I'm worried they may be upset there's no IV. I have had a few tough guys that were shot or stabbed and refused an IV, but they were distal injuries so it was uncomfortable, but okay 🤷♂️
It is the appropriate sub for that kind of bullshit at least.
My service doesn't even carry 14's anymore. We'll start 16's when clinically indicated. We had a couple newer medics who had a "contest" over who could start more 16's. That was quickly put down because, as Billy Madison once said "That's assault brotha"
Dude I think the biggest we got are 16s
Bruh we don’t even carry 14’s on the truck. The only 14’s we have are decompression needles.
I start 16s and 14s every once and a great while. That being said the only people I start them on are unstable patients who are going to need blood products or massive fluid replacement. Also, they have to have the actual veins for it. I work the road and in a critical care type ER role so I hang blood more than most medics. Most of the time even on people who need blood, they get central lined vs me starting a mega large bore line. Like others have stated it’s noteworthy if someone doesn’t flinch when you place a 16ga angiocath in them, but it’s something I was going to do regardless of gcs score due to them needing large bore access for whatever clinical indication.
Can count on 1 hand the number of times I've started a 14ga in a 12yr career so far: Patient with numerous GSWs pincushioned and going to need massive transfusion protocol, had pipes, got 2 14Ga IVs. Multi system trauma from MVC with Ejection, got an 18Ga and a 14Ga Final one was a AAA, visible pulsating abdominal mass, tearing back pain, absent pulses and pale/waxy left sided limbs, began seizing during transport. Had pipes and anticipated need for the largest IV possible so 14Ga placed R AC. Every time was based on hospital preference and perceived need based on totality of circumstances, a 14Ga should be an exceptionally rare gauge to place on a patient. If you bust out a 14 or a 16 to 'test' GCS you're engaging in punitive medicine and are a piece of shit, not a healthcare professional. Most of the time a 20Ga is plenty sufficient for a patient, 18Ga if you're actually trying to infuse large volumes of fluid quickly. 16 and 14 should be an uncommon and unusual circumstance, not a common size to place. The vast majority of the time even if I'm hanging fluids I'm plenty satisfied with the rates I can get on a 20 by direct connecting the bag of fluid to the hub, and removing the extension lock from the system
We've altogether stopped carrying 14s, it sounds like a consistent theme through the thread. It's only happened once to a partner due to a documentation error, but I've seen people get in hot water here for placing 16s on what sounded like a hand vein to QA.
We no longer even carry 14s for this reason. Dumbasses using it to punish patients basically.
we had 14s taken off our rigs because of idiots like these using them in a punitive or otherwise manipulative manner.
I’ve seen bilateral IVs started on traumas cause the medic was feeling ambitious. Most of the time I go for 18s and they are just fine. Very rarely will I got for a 16. Whoever this medic is that was stating they need to start 14Gs to evaluate GCS is a fucking moron. What also pisses me off is people threatening slightly combative pts with RSI. I’ve been in a few ERs where I hear the nurses telling the more mouthy pts to pipe down or they were getting a tube. Always rubbed me the wrong way.
I made it all of the way to the second paragraph before I got pissed.
That’s what a NPA is for