Imagine a busy evening shift interrupted by the news that the unstable dialysis patient still has no access. Begrudgingly, you drag the ultrasound into the patient’s room. Buried beneath a layer of muscle, a tiny vein lurks below an intimidating artery with a nerve nestled close by. Making matters worse, the patient is becoming increasingly more frustrated. “This always happens. I told them not to remove my last PICC line,” he notes. The use of ultrasound-guided IV improves successful cannulation and decreases complications, but cases like this have caused many emergency providers to resent, even fear, this basic procedure.^​1–4​ Below, we provide additional techniques to increase your success and to avoid the risks associated with central line placement.