The IV Difficulty Scale

At the hospital one rainy afternoon, out front of the sea of ambulances waiting to return to the streets, I got into an animated discussion with another paramedic about which one of us had the more difficult IV stick on the last run. Neither of us would back down. With no way to determine the winner, we decided we needed an intravenous difficulty scale. This is what resulted.

 In the same way as an Olympic diver gets a higher score if they pull off a more complicated dive, you too can earn a higher score by increasing the difficulty of your IV sticks. The beginning score for any IV stick is a 3, assuming you are starting a 20-gauge or 18-gauge in an AC or dorsal hand, holding still and in good light. We will call this the “nursing stick.” This is our baseline. Then you add and subtract points as follows.

• Add 1 point if you are in a moving vehicle. This is not always the safest of procedures, but when we need access en route, it has to be done and can get tricky.

• Add 1 point if you are reaching across the patient. Sometimes their left arm just isn’t in the mood.

• Add 1 point if the lighting is less than optimal. This includes rooms with only one bulb, behind you, and being outdoors at night with a police officer standing over you more interested in lighting the patient’s face than where you are working.

• Add another point if you have a flashlight in your teeth. We’ll discuss the sanitary issues another time, but add this point to the dark-room point, and if you’re in the dark completely…you’re lying.

• Add 2 points for a nondominant hand technique. Even though you should always choose a day to switch, sometimes the day picks you and you can’t physically use your chosen technique.

• Add 1 point if you are inserting the needle toward yourself. This does not include the over-the-head-forearm-from-the-head-of-the-backboard stick, but refers to a combination of reaching and twisting that will only allow you access if the needle is pointed back at your face when you insert it.

• Add 1 point for directing someone else to hold traction.

• Add 3 points for being upside down (you, not the patient).

• Add 1 point for each gauge above 18 on any person over 80. Then document why you are shocking their fragile system with so much fluid so fast.

• Add 2 points for a neonate stick, simply because you deserve it.

• Add 1 point for an EJ.

• Subtract 1 point for an IO. That bone is huge, seriously.

• Subtract 1 point if you say any of the following: “It rolled!” “I lost the flash!” “It blew out!” “I’m against a valve!” “He has no veins!” “It’s a blind stick!”

• Add 1 point if, because of the patient’s size, position or desire to be close to you, you must physically contact a part of their exposed body to achieve the stick. Ewwww. But a point.

So, let’s see how we score the following imaginary stick:

Known diabetic, altered, in a wheelchair in a hallway jammed into a doorway. Inside the doorway is a shower room with water running, so no access from the front. The chair is stuck, so no side access. The hallway is lighted from above and behind—light is tough, but no flashlight needed. The imaginary patient is in a larger-than-normal wheelchair for obvious reasons and is clothed consistent with someone about to shower. You obtain IV access reaching over the patient, in contact with bare skin, using your nondominant hand, the needle facing toward you while you’re standing over the seated patient and brushing up against him.

SCORE: Base 3, plus 1 for reaching across, 1 for needle direction, 2 for nondominant hand, 1 for poor lighting, and 1 for contact. That’s a +6 degree of difficulty for a final IV difficulty score of 9.

What’s the score from your last stick?

When not working as a firefighter/paramedic with the San Francisco (CA) Fire Department, Justin Schorr spends most of his time blogging at HappyMedic.com or hosting the Chronicles of EMS.?