Intubation trick, subclavian trick.

Tube trick!

When you intubate a patient, and you're not sure whether or not your tube is in the trachea, and the only stethoscope you have available just *sucks* and you can't hear breath sounds for crap, blow up and deflate the balloon on the endotracheal tube a couple of times, while palpating the trachea (basically, put your hand on the patient's anterior neck). If you can feel the balloon -- or, more likely, the friction of the balloon against the tracheal rings -- you know you're in position.

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Subclavian line tricks!

1. This is revolutionary and yet ridiculous: Curve your needle, the needle you use to find the subclavian; I guess it's a long (2.75", say some of the websites I'm checking) 18 gauge. Point the bevel up (as always), then just put a very soft curve in it. I'm talking a *very* soft curve; you're not hockey-pucking it. Pretend you're bending the needle around, say, a very large (cylindrical) pickle jar. Great! *Now* find your landmarks -- 1/3 of the way into the clavicle from the sternum, and aim for the sternal notch, perpendicular to the long axis of the patient's body, and go. The curve of the needle will keep you fairly shallow, and therefore from dropping the lung.

2. Let's say you're called upon to insert a subclavian, and as you're advancing the guidewire, you meet resistance. The wire continues to feed, but you're just not sure of the positioning: Is the wire feeding down into the chest (yay!) or has it kinked, and now you're feeding into the jugular vein instead? Fear not! Pull the needle you've just inserted the guide wire through but leave the wire in place (so that the wire is the only equipment that remains in the patient). Then, take a flexible angiocath (there should be one over one of the needles -- I think it's the 20-gauge - in your triple lumen kit) and feed the angiocath over the wire. Then -- and this is scary -- pull the wire. Blood should continue to flow out of the angiocath, indicating that you're in a vein. More importantly, though, the angiocath is soft and flexible, and should travel in the direction of least resistance (down, not up). And! And now you can make sure your wire doesn't have any kinks in it. Reinsert the guide wire *backwards* (don't insert the flexible J-bit end, but the other side). Sometimes that J-shape curls up in the vein and it's too big for little people.

Ta-da! Pull the angiocath and proceed as you would normally. You can now be at least somewhat more secure that your line is heading where it needs to be. Plus, you haven't lacerated the subclavian with unnecessary guide-wire mucking.

Difficult IV Access Trick

Ok, they call you because they can't get an IV in someone. You think, What the hell? They couldn't do it, and I just started so somehow they think I can?

I suck at IVs, I sucked at them for a long, long time. Lately, it's been going better. One day it just suddenly got a lot easier.

But for the truly hard stick - here's my favorite tip. Get a towel and run it under hot water (not too hot to burn, but hottish).

Put the hot part of the towel on the place you want to stick - antecubital, hand, whatever. Leave it there for a few minutes.

This causes vasodilation - often a good vein will pop up, and if not, a bad vein will still be easier to stick.

It has the added benefit of calming things down a little. The patient has been stuck probably several times by an increasingly irritated nurse, and is probably increasingly irritated himself...the time that the towel sits there gives a little break for everyone to relax.

And - when really screwed - you can get a tiny IV from pediatrics. Unless you are in a serious resuscitation situation, it's probably fine. If people bitch about this, tell them that smaller IVs allow better blood flow around the cannula and are less likely to get infected.