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Sea Sick: IVs best left to medical pros

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Sea Sick: by Keith Murray

I have been asked by several yacht captains if I offer onboard training for crew on how to properly insert an IV.  Always a little hesitant to reply, I follow with a few questions of my own – namely, how experienced are the crew and how far will the boat be from medical professionals.

It is always best for IVs to be administered by trained medical professionals in a hospital setting. But if the boat is far from help, an IV may possibly save a life.

For this article, I consulted someone who inserts IVs into patients many times a day: Tracy Thomas, a registered nurse with over 20 years experience.

We will assume the yacht is far from medical help, there is a seriously sick or injured person aboard, and a medical doctor is on the telephone giving orders.

There are several reasons to administer fluids intravenously, ranging from dehydration to blood loss or treatment of an infection with antibiotics. Types of IV fluid for treatments often include water with electrolytes, sugar or medications. The exact makeup and concentration depends on the patient’s individual needs. The rate and quantity of fluid administered also depends on the patient’s medical condition, body size and age.

Generally, IVs are started at a peripheral site that is most available and appropriate for the situation. The preferred sites in most emergency situations include the forearm and the median cubital vein in the fold of the arm. This is the vein often used when you donate blood because it lies relatively close to the surface of the arm and is easy to see when pressure is applied.

These sites will generally accommodate a larger IV size for larger amounts of IV fluid administration. If these veins are not accessible, the veins of the foot or lower leg can be used. When inserting an IV, however, there are several problem areas to avoid, such as the affected side of someone with a mastectomy, the side of the body affected by a stroke, and an AV fistula for dialysis.

For the sake of this article, we will be focusing on IVs in the arm. Once the doctor has said to proceed, the next step is to get the vein to “stand up,” meaning to fill with blood and expand, making it easier to feel and see. This can be done by applying a rubber tourniquet 6 inches above the insertion site. Then dangle the arm to allow the blood to run downhill and gently tap the vein.

Next, palpate (examine) the vein with the index or middle finger. If the vein feels hard, choose another vein; if the vein feels bouncy, use it. Release the tourniquet and gather supplies.

As always, Universal Precautions must be used and Personal Protective Equipment (PPE) must be worn, including medical exam gloves and safety glasses. The potential for contact with a patient’s blood while starting an IV is high, and blood also may splatter, so consider wearing a medical gown.

Gather materials as instructed by the doctor. These items will be needed: appropriate size IV catheter – 18G, 20G or 22G; tourniquet; alcohol swabs; transparent film; sterile tape; flush solution of 0.9 percent sodium chloride; and a sharps container to dispose of the needle (NEVER recap a needle.)

Scrub the insertion site by wiping the area with antiseptic solution in a circular motion, moving outward 2-4 inches from the insertion site. Allow the area to dry, then hold the skin taught, stabilizing the vein. Grasp the catheter bevel side up. Inform the patient that you are ready to insert the IV. Insert the device through the skin directly over the vein at a 30- to 40-degree angle. Advance the needle slowly and steadily until you meet resistance. Lower the needle to a 15- to 20-degree angle, then slowly pierce the vein. You may feel a “pop” when the needle enters the vein.

Observe for flashback (blood return); this ensures the catheter is in the vein. If you fail to see flashback, pull back the catheter slightly and rotate. If still no flashback, then remove the catheter and try a different site with a new catheter.
If blood return is present, advance the catheter device so that the needle is held stationary, withdrawing the needle while holding the catheter at the hub for stability. Release the tourniquet. Dispose of the needle in the sharps container. Apply sterile tape and transparent film over the insertion site to secure. Connect IV tubing and run fluids, or flush with a 0.9 percent sodium chloride flush.

EMT Keith Murray provides onboard CPR, AED and first-aid training as well as AED sales and service. His company can be found at TheCPRSchool.com. Comments are welcome below.

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