Musings on EJs

EJs (External Jugular veins IVs) have become a lost art form around these parts. A paramedic can’t get an IV, the medic reaches right for the EZ-IO and drills a hundred dollar needle into someone’s tibia like they are drilling a screw into a wall to hang a picture. Sometimes the medic reaches right for the EZ-IO, screw getting a peripheral IV. When I started you were a stud paramedic if you got the tube and the EJ on a cardiac arrest. We worked cardiac arrests differently then. If you were the paramedic, you went right to the head and set up shop there. Apply the monitor and angle it so you could see it while you knelt at the head to get the tube. Once the tube was secured, you went for your IV access. If the patient had a big AC, you usually went there because it was easiest, but some people just went right for the jugular. The benefit of the jugular in the code was you had everything in your same work space. You could monitor the airway, push drugs through the neck vein and reach over to the monitor to shock. Of course back then, it was one round of drugs, then board, collar and out the door. Having the jugular was great for the ride to the hospital. While an EMT did compressions, you sat in the captain’s chair, bagging, pushing epi, and leaning over to shock if necessary.

While medics have always been quick to jump at getting a tube, I have noticed a squeamishness about doing EJs. I mean, gosh, you’re sticking a needle in someone’s neck for goodness gracious. It is not as easy as popping a line in a bulging AC, but with practice, it is not that hard. EJs can be huge. Engorged is the proper word. If you see an old school paramedic looking at your neck more than likely the medic is thinking about how he’d like to pop a line in it.

Here’s the technique I use:

Make certain the patient is lying flat, or as flat as possible, their turn their head to one side, and locate the jugular vein. Place one finger on your left hand on the distal portion of the vein, and the thumb of the same hand as high up as you can go. You need to hold traction on the vein so it doesn’t wander when you strike it. Use a 16 or an 18. Go in on a bit of an angle, not in line with the skin or much deeper than 20 degrees. You want to go in with force. Go in too easy and the needle will bounce off the vein. You want to go in firmly like you are placing a spear into the center of a tunnel. If you go in too hard and too steep, you may go through the vein, which is bad. You’ll know right away if you are in or not. The chamber of the catheter fills up instantly. If it doesn’t fill up, you are not in. But don’t despair. Pull back a little, keeping the needle under the skin, and then attack the vein a second time, being certain to keep holding tension. You’ll get it.

Once you are in, and have your lock attached, it is a good idea to pull pack on the syringe just to confirm your placement. If you see blood come back into the tubing, you are good. If not, I would stop there. The danger with the EJ is you can be through the vein and flush easily into open space and not know your line is bad. Many years ago, I once put an amp of D50 into an unresponsive woman’s neck, thinking my line was good, but when her sugar stayed under 30, I could only believe the line was bad.

I have done upside down down EJs a number of times where I am on the body side of the head and I hold the needle inside out and bring it back towards me. I don’t like this method as well. It’s impressive, but not as reliable. I find it harder to be accurate coming back toward me and I don’t enter with enough conviction.

I used to do EJs quite regularly. I once did two EJs on the same call, which was not necessary, but I was altered at the time.

My partner and I responded to a report of a man unconscious in a garage with the car engine running. We arrived in time with the apartment complex supervisor, who opened the door to the condo garage, where we saw the car running and a man slumped over the wheel. A officer dashed by us into the garage and my partner and I ran in just behind him. I know, I know, but we weren’t thinking. I mean the garage door was open now. All that air. The officer and I grabbed him and pulled him out. We got him outside, and onto our stretcher. He was in cardiac arrest. Again in those days we did not tend to work people on scene. We did it lights and sirens to the hospital. While a police officer drove, my partner and I worked the man who was middle aged, and if I remember the story I later heard, a divorced man, whose life was on the ropes. I was at the head and I looked at his neck and my goodness, his EJ looked as wide as a railroad track. I fired one in, and hooked up a bag of fluid to it. I turned his neck and there was another one. Ditto for it. I could have done a gymnastics routine on it it was so big. I remember in the ED I presented him to the staff as if I were a magician, “I give you EJ number one and wallah, EJ number two. Thank you, thank you, I’ll take a bow.”

I was aware that I was acting strangely, but so too was my partner. I recall him pirouetting out of the room and down the hall like a ballerina or maybe that is merely my imagination years later.

It wasn’t until I drove thirty miles past my exit that evening, and then ran several lights after I’d gotten off the highway, and then lay on my bed in my apartment, and felt it rise off the ground like Aladdin’s carpet did it occur to me that I was likely suffering the effects of carbon monoxide poisoning.

That wasn’t the only time it happened to me. Once a partner and I walked into a house for an unknown and found a police officer in the kitchen with a woman with nausea. The house smelled like gas. I suggested we go outside. Again all the way to the hospital my partner and I cracked jokes back and forth. Everything either one of us said cracked us up. Despite five tries he was unable to back in straight and ended up conking a pole. Then we both got the giggles so bad imagining scenarios where the entire hospital collapsed around us, and we rose out of the rubble, brushed ourselves off and said, “our bad.”

I have not smoked marijuana for as old as I was when I first sampled the bud as an impressionable young teenager under peer pressure which I was quite willing to succumb to. It was in the 1970s when Steve Miller’s “The Joker” and Gary Wright’s “Dream Weaver” were big songs. It was at a Jerry Brown for President benefit concert at the Capitol Center in Washington DC, and Jackson Brown, Linda Ronstadt and The Eagles with Joe Walsh were playing. They just playing, and they kept saying “We ain’t done yet, we ain’t done!” because it was nearly one in the morning. Everyone sang together and life was beautiful. They finally turned the lights on and people joined arms and swayed as they sang “Stay” and beach balls were batted about. Some people become nasty when they are drunk or high, but I always fancied myself and was acclaimed among my friends for being a happy drunk or stoner, and I find it interesting that whenever I have been gassed at work either by carbon monoxide or once by noxious radiator fumes, I am like the dude in Mary Poppins movie who sings “I love to laugh” as he floats to the ceiling.

I have walked into scenes where the marijuana smoke has been as thick as cumulus clouds for a small plane at 3,000 feet. Walking in to a room in an abandoned house to find rastas smoking up their bongs, and KING OF KINGS, LORD OF LORDS written on the walls with drawings of lions and ganja leaves, and we had to find out why they called and take their fellow with bad spirits in his stomach to the hospital, and again giggle our way through triage. There used to be a Rastafarian takeout place in Hartford where the smoke was thick when it wafted out of the back room as we ordered soy patties or rasta pasta and Ital stew. We liked going there, but the place burned down a few years later. They relocated in the city, but now there is no marijuana smoke when you enter.

We’ve gone a bit far afield from talking about EJs, but I’ll try to bring it back around. EMS is about connection, and it involves a certain trust, trust the patients place in us and trust we place in them, that they mean us no harm and welcome us to care for them. I had a patient recently with sickle cell anemia. The poor girl was in bad shape. She could barely walk or stand up straight, and was on the edge of tears. She was in my mind the definition of pathetic, the poor dear. I had taken care of her before and her IV access was very poor. We can give Intranasal Fentanyl, but I had done that the last time I took care of her and it didn’t touch her. I asked her what worked, and she said only Morphine and Dilaudid. We don’t carry Dilaudid, but we do carry Morphine. You can put it my neck, she said.

I admit I was taken aback. I had only ever done EJs in extremis — cardiac arrest, unconsciousness, or true shock. Most people who are alert are not too receptive to the idea of a stranger stabbing them in the neck, but she was offering hers to us, and whether it was the pain or just the trust she had, she put the EJ into play. I nodded and said, as you wish. I popped the EJ in, and gave her a total of 20 mg of morphine, emptied the kit in her. I saw her later at the hospital and she came over and thanked me as she was being discharged. People with sickle cell get a reputation as being malingerers, but here she was now like any ordinary bright young woman you’d meet in your day. We only see these people at their worst, and here I was seeing the other side of the person. Bright and cheery, standing up straight. I told her I was glad it worked out.

You need encounters like that in this job. Over time, the wear and tear of life can get a hold of you and you can feel there is only misery and that you make no difference. The patients are diseases – sickle cell anemia, stroke, Parkinson’s, or hip fracture, and it can be hard to see them as who they are at their best. I mentioned Linda Ronstadt. She was at the height of her powers in 1976. Man, that girl could sing. One night, recently, I was flipping the channels and came across the 2014 Rock’n’roll Hall of Fame induction ceremony, when Linda Ronstadt was being inducted. Carrie Underwood came out and sang an awesome version of Linda’s “Different Drum,” a soaring song of a young spirit that refuses to be tied down. And then they marched out a number of great female singers Bonnie Raitt, Emmylou Harris, Stevie Nicks and Sheryl Crowe. I kept waiting for Linda to come out, but she never did although they did say she was at home and wishing everyone well. I remembered pictures I’d seen of her where she had put on some pounds and I wondered if maybe she didn’t want to come out all heavy and be compared to her dreamy young self. Then I Googled her and found that she had Parkinson’s and could no longer sing. I felt so sad, sad for the young girl that she had been and sad for life for what it does to people. I put Linda Ronstadt on my Pandora list of stations for shuffle play after that and every time I heard “Different Drum,” I heard that soaring defiance and the fact that she was still so alive in that song, made me less sad. It also reminded me of a similar Rock and Roll induction ceremony for Janis Joplin when Melissa Ethridge came out and sang “Piece of My Heart” (Ethridge had just survived breast cancer). She sang that song with such fierce lifeforce it brought me to tears and made my heart want to stand up and shout. We are all capable of such power in our limited time. Power and Will and Defiance.

Life beats people down and robs them of their strength. They need help. And while it is true, on many calls there is little we can do, such as the troubled man in the car in the garage whose life had crashed on him to the point that he saw no hope of ever again being the optimistic man of his youth with his whole life before him on his wedding day, there are other times we can make a difference. Sometimes you make a difference just by treating someone decently, by recognizing their better self in their battered condition, the young soul still in there. Other times, you help with your skill. You can’t get a much more direct pathway to the heart than through an EJ. You stick your needle in their neck and now you have a hotline in to their center. You can run a code from the head and deliver epinephrine to try to get a heart beating or you can give someone in pain analgesia so they can feel human again.

If the moment calls, go for the jugular to get the job done. Just like in life and in Rock’n’Roll.


  • Don says:

    Think I’m going to put together a drill soon and practice the whole working from the head thing with my shift. Ran a code the other day and wasn’t pleased with the set up of it. Everything got done in rapid fashion, I just felt it a bit messy. Not sure if an EJ would have happened, he had a big old neck. What are you experience with overweight folks and EJ’s?

    • medicscribe says:

      Overweight no neck folks can be challenge. If you don’t see an EJ, you can’t go for it blindly — at least I won’t. The danger with these people also is, if you go through the vein, you can dump a lot of fluid or drug into the neck and not recognize it. Always confirm you are in with the blood pull back. Sometimes the big person still has a beautiful EJ, and it all works well.

  • Christine Carroll says:

    The best EJ I saw was done by Brett Salafia on the scene of a cardiac arrest when I was a newbie in Hartford!

  • Jason says:

    Nope. Dislike. Welcome to 2015.

  • Brooks Walsh says:

    Peter –
    I wrote this on my FB post about your post:
    “In my medic program we practiced on each other. So I tell patients “Hey, I’ve had it done to me. Hurts less than the wrist.”
    But as Peter highlights, it’s a much more, well, intimate IV placement than jamming a line in the AC, or a tube in the tibia. You are literally face-to-face with your patient for a few minutes (albeit upside-down). You have to coach them continuously through the procedure, since you can’t man-handle someone’s head like you do the arm. Many time, you have to get them to valsalva or hum to get the IV in – it’s a cooperative effort.
    So Peter hit something on the head here, far beyond describing how to perform a less-popular procedure. “

  • medicscribe says:

    Thanks, Brooks. Interesting points on the valsalva and humming. I will give it a try next time.

  • Brett says:

    And still a lurker on your blog. Thanks for the kudos Peter and Christine

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