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Obtaining vascular access involves inherent risks to the clinician, including blood exposure and needlestick injury. Whether it is attempted on‐scene or in transit, the prehospital environment is often characterized by poor lighting, limited space, and movement in the rear of an ambulance. This offers less than ideal conditions in which to handle lancets, IV and IO needles, and other sharp supplies. A combative and/or confused patient can add to the difficulty. Transmission of HIV, hepatitis B, and hepatitis C remains a constant threat to EMS personnel, with the risks of infection following needlestick injury estimated at 0.3%, 6%–30%, and 1.8%, respectively [4]. Consistent use of universal precautions is imperative to reduce the likelihood of occupational exposures. Potential risks to the patient include bleeding, damage to adjacent structures, infection, and thrombosis, and these risks will be discussed later.

Establishing an IV is often part of EMS protocols. In many cases protocols allow for EMS clinician assessment and judgment regarding whether or not an IV is necessary. One study revealed that while over 50% of the patients who arrived at an ED via EMS had IVs in place, almost 80% of those IVs were not used in the prehospital setting. The tendency to err on the side of caution to avoid scrutiny for perceived undertreatment seemed to contribute to the discrepancy [5]. Another study similarly found that protocols seemed to drive the decision to start an IV, as opposed to an actual need for administration of medicines or fluids [6]. Medical oversight is indicated to continually evaluate the appropriateness of “precautionary” IVs in the contexts of potential risks and costs to the system and to patients.

Several studies in trauma situations have revealed a lack of significant benefit regarding prehospital vascular access. The classic EMS mantra of “two large bore IVs” for trauma patients has been muted by concern for increased on‐scene times and delayed transport to definitive medical care. Two studies have demonstrated high success rates when IVs were attempted in transit without delaying transport [7, 8]. However, guidelines provided by the Eastern Association for the Surgery of Trauma regarding prehospital IV placement or IV fluid administration for either penetrating or blunt injury patients are based on findings that no benefit is provided [9]. Multiple research studies have suggested that routine administration of IV fluids may not be helpful and, in fact, can be harmful in the prehospital setting [10, 11]. Another study endorsed “scoop and run” transport for EMS, as it found that each prehospital procedure before ED thoracotomy compounded a reduction in the odds of survival [12].