Clinical tips for intern year

[oudoc08]

---

Members do not see this ad.

Damn. For 15 minutes of sleep to be lost it has to be an ICU patient. A placement patient gets a three liner.

PT s c/o
AFVSS
Placement pending
-Dr.Mcninja

Not for a new MS3 who's still trying to find the chart.

 

[telenurse]

Intermittent needle therapy should suffice. If you aren't sick enough to receive IV meds, you aren't sick enough to be on a med/surg floor. At least, that's my opinion. Unfortunately, for every family that can't do wound changes it is different.

Yeah...I'm a nurse, but as a nurse with hospital experience
...if you are sick enough to warrant cardiac monitoring in the hospital, then you are sick enough to need IV access. That's the rule for the telemetry floor unless you are 48-72 hour STABLE NSR post CABG.

I've also seen too many people pop their groin puncture site up to 3 or more days post cardiac cath with no warning...and it's not pretty when it happens. IV access is sometimes very difficult to get on pt with chronic medical conditions, their veins are all used up, especially if they've received a lot of IV antibiotics in the past.

Pt's with limb fx's, even fairly young pt's, are at high risk for emboli. Even if they are tolerating po food/fluid and pain is managed on po meds, they will need an IV in the event they have a PE. Fat emboli have been known to occur in otherwise healthy people with fx.

If someone is in the hospital with an infection, frankly if the infection is bad enough to be hospitalized, they are probably on IV abx, they are also at risk for SIRS or sepsis syndrome

Surgical pt's, fluid deficit, bleeding, infection, ARF,

Diabetics...hypoglycemia, DKA, etc.

This is my experience on the wards of medsurg in the hospital...I don't work ICU, I don't work nursing home, extended care, rehab, or psych. I work telemetry, and get floated to regular medsurg.

Yeah...sometimes it takes 30 seconds to put an IV in...but if the pt has crappy veins it can take forever, and everyone who has experience with IV's knows that. It's better and safer practice to have it in already, IMO.

 

[telenurse]

Fine. If something is without risk, go ahead. However, IV access, while routine and fairly safe, is most certainly not without risk. Besides potential hazards to any procedure, there are cost issues as well as patient discomfort. If you're immune to those, then fine, but I'm not. I'm willing to weigh the fact that any unneccesary procedure which causes one of my patients discomfort, is a variable which will be weighed into my decision to treat or not to treat.

The next time one of my "stable pt's" with an order to "leave IV out" goes south with a manual BP of64/36, HR 28, and he's popped his 4 day old groin access site, has lost approximately 300 ml of blood, has a lemon size hematoma, is diaphoretic, obviously vagaling, and I can't push atropine because THERE IS NO FVUCKING IV SITE PER YOUR ORDERS!!!!!! I invite you to come to his room and save the day.

Sorry just venting...it's been a crappy week...see my posts in the RN/NP forum

 

[tkim]

And none of those equal more than a week or two of clinical work as a med student. Any med student who's still hanging their hat on their "experience" as a paramedic is pretty sad. By your third year of school you should recognize that.

Please, tell me that in a week or two of rotations, you, as a MSIII tubed and shocked people, or ran codes. C'mon.

I don't get it, is that supposed to impress anyone other than a premed? I did BLS, ACLS, PALS, and NRP as a CNA. Hundreds of thousands of nurses, techs, RTs do it every year as well. It means nothing. These are algorithms for care, which is what everyone in health care does other than physicians. We are trained to make decisions, not follow flow charts.

But did you ever run a code as a CNA - I doubt it. Have you ever used any of the skills you learned in all those classes you took? Place an IO? If you did, there's some risk management guy losing sleep over what your hospital allowed CNA's to do.

You had the cards, but did you use them like some of us did?

Seven years of work as a paramedic, six years as a CNA, thirty years as an RT, I don't care. None of those have any bearing on the clinical insight required to make decisions on the wards. Again, that's my only point.
This is Student Doctor Net. I'm happy to tell paramedics how great they are when I see them in the ER or hang out with them at the bar. But there's no way that, on a board populated by MDs/DOs or those soon to be, I'm going to pretend like they have anything other than a bare-bones education heavy on skills training and light on clinical judgement.

There's where you're wrong - especially when it comes to people who have more clinical experience than you do. You're a military guy, so the analogy of the green officer and the experienced non-com is appropriate to bring up.

Please tell me that two years on the wards and that sheepskin give you sharper 'clinical judgement' - your words, than someone who has been doing their job for many more years.

Sorry if that bothers you, but paramedics aren't doctors on wheels. And their experience is useless when it comes to the topic at hand.

There are two problems I see. One is that oucom thinks he's going to pick and choose which admitted patients gets IVs. Perhaps, but as much as EMS is protocol-driven, so is floor medicine, and he will most likely make a tick on the "IV saline lock" order just like the rest of us because it's institutional policy.

The other problem is you devalue any knowledge that doesn't come from the beginning of ward time, as if that's the only valid experience that makes a good physician or clinician. That's pretty troubling.

Perhaps I've misread you, but I don't think I have. Are you really one of those physicians ... or officers, who dismisses the valuable input of the support staff around you?

 

[GoodMonkey]

So the "D/C PIV" order goes along with the "Pt may go home now" order, in my book.

same here. there is no d/c iv order unless it's written right in front of order for d/c home.

 

[Blade28]

same here. there is no d/c iv order unless it's written right in front of order for d/c home.

👍 👍

 

[GoodMonkey]

honestly, I don't see patients staying days or weeks on end for placement/social/financial issues, so I've never had to deal with that.

count your blessings. it seems like there's a great deal of surprise regarding issues similar to what s/he said about these patients on the prev page (my friends at private and foo-foo academic facilities can hardly believe it,) but here at a county facility with an almost entirely non-insured (medi-cal doesn't count) patient population with a HUGE immigrant base, every service in the hospital from medicine to psych to colorectal surgery has at least one of these "rocks," who seriously stay in the hospital for weeks to months (totally not exaggerating) because of "placement" issues, be it social or financial or the phase of the moon. we can't send them out if they have nowhere to go and/or are demented and/or need wound care or a daily medicine and they have no family around or willing to take them and they have no way of paying for assisted living. can't just kick them out - it's illegal - so they literally stay in our hospital for what seems like forever. (i can think of 4 offhand right now who have been here since last summer.) it's not that uncommon. we have had to call immigration and threaten deportation on occasion before a family would show up to take home their 85 year old grandmother who is demented but medically stable and completely recovered from her broken hip, but is still a fall risk so can't go home, especially if the family isn't willing to care for her, if it's not safe, and ohbytheway - an undocumented immigrant.

like i said, be happy you don't have to deal with that. i'm like what, 9 months into intern year and i swear i've already gotten my MSW for the amount of social work i have to do on patients. (our social workers here - the one or two that are any good, anyway - are so overburdened as it is, a lot of this stuff falls on the intern. **** slides downhill .......) it is incredibly frustrating and sucks the life out of me.

anyway, sorry for the tangent

 

[Winged Scapula]

Oh, I'm well aware that it happens having heard about it from others.

But yes, I was lucky to train in a suburban hospital without a lot of these patients. We had the random prisoner (although they generally went to the downtown city hospital) and of course, the Amish weren't insured but they were NEVER a burden. And as an intern, I did my fair share of social work calls although we had a pretty good team albeit a few who you would have to push as the weekend got closer.

My experience tended to be limited to the LOL, demented and the family took their surgical condition as an opportunity to dump granny and then turn their nose up at all placement offers for her.

Point being that not all hospitals are filled with these types of patients and that some actually have sick people who might need an IV from time to time.

I write:

D/C home
D/C IV when transportation home arrives and patient ready to leave

 

[Blade28]

Unfortunately at our county hospital we have entire services where at any given time, 20-30% of the patients are just waiting for placement. 👎

 

[GoodMonkey]

Point being that not all hospitals are filled with these types of patients and that some actually have sick people who might need an IV from time to time.

oh, the point wasn't missed. i agree with your pov, actually, i just was tangentially supporting the idea that it's not uncommon in some hospitals to have, as blade pointed out, about 25% of the service = social placement rocks going nowhere fast.

 

[Blade28]

Do you keep lines in them?

Unless there's a clear reason not to, yes. Absolutely. Very often an IV is needed up until time of discharge - for IV fluids, antibiotics, etc. - and many of these patients are tough sticks in the first place, so it behooves us to have access available at all times.

You don't want to be running around trying to place a line in a difficult-habitus patient when things are suddenly going south!

So I almost NEVER write "D/C PIV" until the patient is about to be discharged to home/LTAC/nursing home/rehab/other hospital/hospice/etc.

 

[buckley]

Unless there's a clear reason not to, yes. Absolutely. Very often an IV is needed up until time of discharge - for IV fluids, antibiotics, etc. - and many of these patients are tough sticks in the first place, so it behooves us to have access available at all times.

How many days do you keep the IV line in? Do you change it every three days? If so, those hard sticks would be really difficult...

I believe we're having this debate on-going because as pointed out there is an incredible variety of patients out there, an incredible variety of hospital settings, and an incredible variety of personal experiences. So nobody is "wrong" and I think we should really refrain from the my-experience-is-better-than-yours stance. The dialogue is good. Just my thoughts.

 

[tkim]

To repeat: my point was that I believe every ward patient should have an IV, even if "just" waiting for placement. I believe this because I manage these patients, and have been screwed by ward teams who think it is appropriate to pick and choose who to leave IVs in. The med student's response was (to summarize) "I was a paramedic for seven years, so that clinical experience makes me competent to intelligently discuss this topic."

It doesn't. Paramedics know nothing about making clinical decisions on the wards (which is what we're talking about).


As far as the second issue you bring up, which I think can be accurately summarized as "You disagree with me, so you must be a bad intern!!! 👎". Thank you for importing this inane argument from the Premed forum.

Do I dismiss the input of support staff? Frequently. I listen to what they say, sometimes ask for an explanation of their reasoning, usually receive none (other than "Well, that's how I've seen it done other times"), then do what I think is required based on the situation at hand. If you want to run things by committee, feel free. I do what I was trained to do, then call the person above me.

Also, if I'm going to get input from the support staff, it's going to be from a nurse or occassionally an RT. Never from a tech or paramedic.

Actually, I'm going to agree with you that having paramedic experience doesn't give one insight into the routine placement of IV on inpatients.

The rest I'll chose to disagree with you on.

 

[Blade28]

How many days do you keep the IV line in? Do you change it every three days? If so, those hard sticks would be really difficult...

I think most nurses here have a policy to change the PIV every 3-5 days.

 

[oudoc08]

Paramedics know nothing about making clinical decisions on the wards.

You're probably right. Then again, an intern wouldn't have a clue what to do with a sick patient in the back of an ambulance, either.

 

[DoctorFunk]

You're probably right. Then again, an intern wouldn't have a clue what to do with a sick patient in the back of an ambulance, either.

Airway, breathing, circulation, rinse & repeat. It's not rocket science.

(Now whether the intern would have the manual skills to get the aforementioned steps accomplished is another story...)

 

[fab4fan]

I think most nurses here have a policy to change the PIV every 3-5 days.

It's q 72h unless the pt has SFV and the IV is still patent. The it's just up to the doc's discretion.

 

[oudoc08]

Yes, because I've never run a code or taken ACLS & ATLS. 🙄

I used to have 4th yrs and EM residents come ride out with me. Comical to say the least.

 

[SexPanther]

Yep, if I have a doc on the way for symptomatic hypotension, the pt's already in trendelenburg...and extra bags of NS are spiked are ready to go wide open at the word...

Trendelenburg position is a perpetuated myth, Marino does a good job of debunking it in an understandable way physiologically. That book (The ICU Book) is a good read.

 

[Raidergate]

count your blessings. it seems like there's a great deal of surprise regarding issues similar to what s/he said about these patients on the prev page (my friends at private and foo-foo academic facilities can hardly believe it,) but here at a county facility with an almost entirely non-insured (medi-cal doesn't count) patient population with a HUGE immigrant base, every service in the hospital from medicine to psych to colorectal surgery has at least one of these "rocks," who seriously stay in the hospital for weeks to months (totally not exaggerating) because of "placement" issues, be it social or financial or the phase of the moon. we can't send them out if they have nowhere to go and/or are demented and/or need wound care or a daily medicine and they have no family around or willing to take them and they have no way of paying for assisted living. can't just kick them out - it's illegal - so they literally stay in our hospital for what seems like forever. (i can think of 4 offhand right now who have been here since last summer.) it's not that uncommon. we have had to call immigration and threaten deportation on occasion before a family would show up to take home their 85 year old grandmother who is demented but medically stable and completely recovered from her broken hip, but is still a fall risk so can't go home, especially if the family isn't willing to care for her, if it's not safe, and ohbytheway - an undocumented immigrant.

like i said, be happy you don't have to deal with that. i'm like what, 9 months into intern year and i swear i've already gotten my MSW for the amount of social work i have to do on patients. (our social workers here - the one or two that are any good, anyway - are so overburdened as it is, a lot of this stuff falls on the intern. **** slides downhill .......) it is incredibly frustrating and sucks the life out of me.

anyway, sorry for the tangent

At the hospital I did most of my clinical rotations, they actually bought an illegal immigrant a plane ticket back to Mexico and flew him down there accompanied by two nurses. The dude had 3 separate GSW's and had spent a combined total of over 7 months in house in the past 2 years, so they made the decision it was cheaper to pay for a transfer to a Mexican hospital, rather than keep him sitting around in house any longer.

 

[buckley]

At the hospital I did most of my clinical rotations, they actually bought an illegal immigrant a plane ticket back to Mexico and flew him down there accompanied by two nurses. The dude had 3 separate GSW's and had spent a combined total of over 7 months in house in the past 2 years, so they made the decision it was cheaper to pay for a transfer to a Mexican hospital, rather than keep him sitting around in house any longer.

this saddened me...medicine in the real world! sometimes i feel like i could be a professional student, i would...of course i know i can't.

 

[Purifyer]

Depends on the patient population to a certain extent, but to make blanket statements about every patient in hospital being sick enough for an IV line is bordering on the ridiculous, what another person said about IV lines for every rest home client is equally as rational. Maybe it's a different culture in the US given that nurses perform most IV insertions, and that an intern or junior doctor may feel uncomfortable having to insert an IV line in an acute situation. In general, in a post op patient, eating and drinking well, no iv meds, no PCA/fluids.. no reason for an IV line.

I've been in many situations where a patient has deteriorated without IV access and its been a pain to reinsert. Only once did it really fluster me. I was an intern on a general med rotation, (massively obese) patient told to go home, patient retaliated by taking week's worth of metformin/s/c insulin. Patient had foresight to remove IV line first... kind of nerve racking having a patient with BSL 1.2mmol/L, unconscious, unable to secure IV access). Glucagon became my friend after that, but I digress.

 

[Winged Scapula]

Unlike Oz, the majority of patients here are obese.

And you haven't seen "massively obese" until you've seen some of the patients here. I never ONCE saw a patient in Oz who even approached the size of some of our bariatric patients.

 

[StickMe]

This was such a helpful thread for us soon-to-be interns at first. Unhijack this thread!

 

[Blade28]

Unlike Oz, the majority of patients here are obese.

And you haven't seen "massively obese" until you've seen some of the patients here. I never ONCE saw a patient in Oz who even approached the size of some of our bariatric patients.

You're right, it's eye-opening to see how morbidly obese some of these bariatric patients are.

We've had to push two beds together in order for these patients to lie comfortably in their rooms/ICU beds.

 

[Raidergate]

this saddened me...medicine in the real world! sometimes i feel like i could be a professional student, i would...of course i know i can't.

Why does it sadden you? The dude had been fine for 3+ weeks, and was just hanging around the hospital waiting for placement that was never, ever going to happen. He didn't have a home address, so they couldn't send him "home".

Honestly, after being shot 3 times in the past two years, with all three being in very shady circumstances (he had several tats claiming allegiance to MS-13 if that gives you any indication of his nocturnal activities), and using up probably a half mil in hospital bills with no intention of paying any of it back, he's lucky they were willing to fly him home. I wouldn't have blamed the admins one bit if they'd told him to walk.

Such is life in the real world, not the idealized, romantic version premeds and 1st/2nd years would like to believe.

 

[deleted109597]

In general, in a post op patient, eating and drinking well, no iv meds, no PCA/fluids.. no reason for an IV line.

To which the logical extension is....no reason to be in the hospital. Seriously, that patient does not need inpatient care. They may need rehab/restorative/whatever, but they don't need a bed in my hospital taking up valuable space while hip fractures sit in the "hallway bed". We have those on our floors now, not just in the ED.

 

[Winged Scapula]

To which the logical extension is....no reason to be in the hospital. Seriously, that patient does not need inpatient care. They may need rehab/restorative/whatever, but they don't need a bed in my hospital taking up valuable space while hip fractures sit in the "hallway bed". We have those on our floors now, not just in the ED.

Purifyer works in a country with socialized medicine...patients stay in house for longer than they do and are less sick in many cases than they are here in the US.

 

[smq123]

At the hospital I did most of my clinical rotations, they actually bought an illegal immigrant a plane ticket back to Mexico and flew him down there accompanied by two nurses. The dude had 3 separate GSW's and had spent a combined total of over 7 months in house in the past 2 years, so they made the decision it was cheaper to pay for a transfer to a Mexican hospital, rather than keep him sitting around in house any longer.

* Gasp * I knew it!

We had a patient in our hospital for a while too. Illegal Mexican immigrant in his late 20s - absolutely no PMHx until one day he got a bad cough and stomach ache and came in to the ED. After the initial workup, the crap hit the fan - we found that he had wildly uncontrolled diabetes (I think he was in DKA - I didn't admit him), he was HIV positive, the cough was from pneumonia (because of PCP), he had a CD4 count of 50, and syphilis.

After we got him all cleaned up (which took about 2 months), we found out that he lives with friends who all work 2 jobs, and are rarely home - so he doesn't have anyone to take care of him. And he is so wasted (HIV-wasting) that he can't stand up to use the bathroom without assistance.

Because of all that, we figured that we should send him back to Mexico to be with his family. But case management said that in order to send him back to Mexico, he "would have to apply for a US visa, wait for approval, and then apply for permission to fly back to Mexico." When I tried calling them on their BS ("Uh...he's a Mexican citizen trying to re-enter his own country...and the US government has a problem with that?!?"), they stuck to their bogus story. 😡 Even when my attending called them, they still stuck to their story. (Whenever they answered their pages - which wasn't often.)

I knew that damn social worker was lying to me! 😡😡😡

[/venting]

 

[OB1🤙]

We had a really hard case kinda like this as a med student- illegal dude from El Salvador comes in with generalized badness and we dx him with lymphoma. Nice guy. Needs expensive chemo. Our hospital says no way Jose (his name actually was Jose), if we give you a $50,000 treatment plus hospital expense out of pocket, we have to do it for everyone, and we'd be bankrupt. Sorry.

Told him he could go back to El Salvador for tx, but it turned out that country somehow or other didn't have the kind of chemo he needed, or at least they claimed not to.

So it was a pretty craptastic situation- we had the drugs to treat this guy, but wouldn't because he was illegal. We offered him transport back to his native country, but that country didn't have the treatment he needed. And I, as his half-azz-Spanish speaking med student, got to explain all this to him.

I still don't know what I think about that situation, other than that it sucked for all involved parties.

 

[buckley]

I still don't know what I think about that situation, other than that it sucked for all involved parties.

Amen. To answer the question directed to me, this is why it saddened me...

 

[smq123]

I would have called INS (I guess they're called ICE now), explained the situation, and I'm sure they would have been more than happy to assist you in an appropriate transfer.

I actually considered this. I figured it was the fastest way to get him home.

But it seemed like a crappy way to send him off, particularly after the less-than-stellar treatment he got from the hospital here.

The nurses rarely recorded vitals on him. I'd have to do the vitals myself.

The nurses would routinely order the incorrect labs on him, or forget to send off others. Part of the reason why he was here so long was because they kept forgetting to send off for Toxo IgM. You know, trivial labs like that...

The nurses couldn't be bothered to use the translator phone when addressing him. They just resorted to the "I WILL TALK LOUDLY, BECAUSE MAYBE YOU UNDERSTAND ENGLISH WHEN IT IS SPOKEN AT A HIGH VOLUME" approach.

The nurses couldn't remember the guy's name. They would sometimes call him by his last name (which always brought out the funniest look of utter confusion on this guy's face), or else they'd call him by whatever name popped into their heads.

And for some reason, the nurses couldn't remember that the letter "J" is pronounced like an "H" in Spanish. Yes, even in this day and age, there ARE still people who will pronounce "Juan" as "Jew-wan."

 

[Blade28]

The nurses couldn't be bothered to use the translator phone when addressing him. They just resorted to the "I WILL TALK LOUDLY, BECAUSE MAYBE YOU UNDERSTAND ENGLISH WHEN IT IS SPOKEN AT A HIGH VOLUME" approach.

We get that a lot here too. 🙁

 

[Winged Scapula]

smq123 - unfortunately, that experience (the ignorance about anything not white bread Americana) seems to be common where you are at...even in the relatively urban environments.

I never ceased to be amazed when our nursing staff would call me on our Hispanic patients (admittedly few in white bread Hershey) and bungle their names.

 

[telenurse]

Maybe it's a different culture in the US given that nurses perform most IV insertions, and that an intern or junior doctor may feel uncomfortable having to insert an IV line in an acute situation. In general, in a post op patient, eating and drinking well, no iv meds, no PCA/fluids.. no reason for an IV line.

I attended a workshop this week, and the MD director of the clinic affiliated with my hospital made the much cliche'd comment that "15 years ago the pt's in the hospital were in the ICU and 15 years ago the pt's we now have in the ICU were dead." But it's true.

No fluids, taking po, no IV meds, pt's are discharged home. Women are discharged home sometimes within 24 hours of a double mastectomy with JP drains hanging out of her. It kills me to refuse these women IV pain meds when they are in agony because insurance won't pay for longer hospitalizations, so they have to have po pain meds.

I've discharged pt's home with dobhoff tube feeds, I don't know how the pt was supposed to guarantee the tube didn't migrate. I've discharged pt's home with CHEST TUBES (having brain spasm, can't remember the name of the valve, BLADE28 probably knows).

If these pt's are well enough to go HOME by US standards, imagine how sick the pt's are that are staying on the general med-surg wards.

In the US, nurses insert IV's, NG/enteral tubes, foleys, rectal tubes, with certification nurses can insert PICC's, pull venous and arterial sheaths from cardiac caths and various other procedures. Nurses also routinely auscultate lung and heart sounds, which I understand they don't in the UK.

 

[smq123]

smq123 - unfortunately, that experience (the ignorance about anything not white bread Americana) seems to be common where you are at...even in the relatively urban environments.

I never ceased to be amazed when our nursing staff would call me on our Hispanic patients (admittedly few in white bread Hershey) and bungle their names.

You're right - it's sadly common. Even in an urban area - like the one that I live in.

I bet my post made you miss the great ethnic diversity of NJ, eastern PA, and (everyone's favorite) Penn-tucky. 🙁

 

[DoctorFunk]

You're right - it's sadly common. Even in an urban area - like the one that I live in.

I bet my post made you miss the great ethnic diversity of NJ, eastern PA, and (everyone's favorite) Penn-tucky. 🙁

Careful how much we complain about ethnic ignorance around here...the academic medicine illuminati will notice and force us to endure even more cultural competence training. 😱

 

[Smurfette]

I attended a workshop this week, and the MD director of the clinic affiliated with my hospital made the much cliche'd comment that "15 years ago the pt's in the hospital were in the ICU and 15 years ago the pt's we now have in the ICU were dead." But it's true.

No fluids, taking po, no IV meds, pt's are discharged home. Women are discharged home sometimes within 24 hours of a double mastectomy with JP drains hanging out of her. It kills me to refuse these women IV pain meds when they are in agony because insurance won't pay for longer hospitalizations, so they have to have po pain meds.

I've discharged pt's home with dobhoff tube feeds, I don't know how the pt was supposed to guarantee the tube didn't migrate. I've discharged pt's home with CHEST TUBES (having brain spasm, can't remember the name of the valve, BLADE28 probably knows).

If these pt's are well enough to go HOME by US standards, imagine how sick the pt's are that are staying on the general med-surg wards.

In the US, nurses insert IV's, NG/enteral tubes, foleys, rectal tubes, with certification nurses can insert PICC's, pull venous and arterial sheaths from cardiac caths and various other procedures. Nurses also routinely auscultate lung and heart sounds, which I understand they don't in the UK.

Heimlich valve is the chest tube you're talking about.

Realistically, keeping a patient in the hospital simply for dobhoff tube feeds or a JP drain that isn't quite ready to come out yet is a huge expense when visiting RNs or the patient and their family can learn how to do it. Patient who have peritoneal dialysis do it at home on a regular basis, patients with stomas manage those at home...JP drain management or Heimlich mgmt is not that complicated.

But regarding IV access...it is better to have it. There have been a few patients that I have reluctantly given the ok for "no IV", but I have been burnt on it before as well. The last thing you want is a delay in blood infusion or fluid bolus for a patient with a sudden change in their status.

 

[chimichanga]

smq123 - unfortunately, that experience (the ignorance about anything not white bread Americana) seems to be common where you are at...even in the relatively urban environments.

I never ceased to be amazed when our nursing staff would call me on our Hispanic patients (admittedly few in white bread Hershey) and bungle their names.

I was a pt in Mexico, and they never once got my name right...


How dare they 🙄

 

[Blade28]

Heimlich valve is the chest tube you're talking about.

Beat me to it! 🙂

 

[telenurse]

Thanks Smurfette.

 

[dpmd]

Women are discharged home sometimes within 24 hours of a double mastectomy with JP drains hanging out of her. It kills me to refuse these women IV pain meds when they are in agony because insurance won't pay for longer hospitalizations, so they have to have po pain meds.

The insurance company typically not covering a longer admission is no reason for someone to have inadequate pain control. Uncontrolled pain is an appropriate reason for continued hospitalization. I have ordered various combinations of medications for people whose post op pain was more difficult to control than usual (in people who actually appear to be in pain, not the druggie with normal vitals who refuses to try anything but IV dilaudid-they can go F*ck themselves). What drives me crazy is when I round on a patient we are planning on discharging and discover they have been in terrible pain all night but no one was notified (patient didn't tell anyone, or nurse didn't call). I then get to scramble all day trying to get them an oral regimen that will work (I refuse to discharge a patient in severe pain), when a simple change before the pain had ramped up all night might have done the trick.

 

[telenurse]

The insurance company typically not covering a longer admission is no reason for someone to have inadequate pain control. Uncontrolled pain is an appropriate reason for continued hospitalization. I have ordered various combinations of medications for people whose post op pain was more difficult to control than usual (in people who actually appear to be in pain, not the druggie with normal vitals who refuses to try anything but IV dilaudid-they can go F*ck themselves). What drives me crazy is when I round on a patient we are planning on discharging and discover they have been in terrible pain all night but no one was notified (patient didn't tell anyone, or nurse didn't call). I then get to scramble all day trying to get them an oral regimen that will work (I refuse to discharge a patient in severe pain), when a simple change before the pain had ramped up all night might have done the trick.

It's an ongoing fight with one of the services here...I hate floating to that floor. It's a private practice surgeon with priviledges at my hospital...and his pt's don't get crap for pain...if they're lucky they may get 1-2 mg morphine q4 prn IV x2. Otherwise it's all vicodin and darvocet, sometimes po toradol. He won't even give norco, because it's supposedly nonformulary...but I know for a fact our pharmacy stocks it because we use it on CABG pt's so they get the benefits of more hydrocodone without having to limit them to only 8 tabs of vicodin a day due to the tylenol content. I truly do NOT like this surgeon, and hope Karma kicks him where it counts and limits him to 1 mg of morphine every 4 hours.

 

[dpmd]

I hate docs who won't appropriately manage pain. Think for a second: if you usually give 2mg morphine q 2hrs to someone who had a lap chole, what on earth makes you think that is going to work for the guy you just did an ex lap on ? These are the same people who will take a person off a PCA that they have been maxing out on at a 30mg per 4hr limit, and switch them over to vicodin when they start taking orals. It only takes a minute to look at the equianalgesic chart and figure out a reasonable oral regimen.

 

[ramonaquimby]

what's this about
"CT at night if creatinine is normal, V/Q in daytime"

tell me more! 🙂

 

[I heart EM]

what's this about
"CT at night if creatinine is normal, V/Q in daytime"

tell me more! 🙂

He means good friggin luck getting a senior radiologist out of bed to get the V/Q on that likely PE. You're getting a CTPE with the Rad OD, guidelines be damned.

 

[Strength&Speed]

If I had my way, every patient would get an IJ on admission. Sick of getting called for "we can't get labs" and "his IV is blown, do you mind if we don't put one back in?"

im glad you dont have your way. Central access in every patient. line sepsis up the ying yang, plus costs of culturing, etc. etc...


oops, sorry for hijacking it again...I didn't realize the thread had devolved into whether or not to place an IV/immigrant payment problems/how often we check vitals/and EMT vs. CNA battle. Not exactly helpful tips for the incoming intern.

 

[Green912]

Central lines= not a benign procedure!

Went to a full arrest in the ICU during night float. Cause of arrest...Subclavian LINE CHANGE OUT. Yep, not even a new line but changing one out that came from the ED. Guy (relatively stable UBI Bleed) ended up dying after a 40 minute resuscitation. Anything can happen.

 

[Blade28]

Went to a full arrest in the ICU during night float. Cause of arrest...Subclavian LINE CHANGE OUT. Yep, not even a new line but changing one out that came from the ED. Guy (relatively stable UBI Bleed) ended up dying after a 40 minute resuscitation. Anything can happen.

What was the etiology of the arrest? Aspiration from being in Trendelenburg?

 

[BlondeDocteur]

My hospital has a special: the "DR to ER" special. Roughly 95% of the patients in our neighborhood are from the Dominican Republic and practically all of them tell sick relatives that they can hop a $300 flight up to New York and roll right in to the Columbia-Presbyterian ER for some free goodies. Discharging them can be difficult to say the least.

That being said, I actually really enjoy the weird dynamic at our hospital-- it's half a community hospital for a very disadvantaged immigrant population, and half a big tertiary academic referral center. I've gotten to take care of interesting patients with odd conditions from each (neurocystocercosis, bizarre tumors, etc).

And I vastly prefer the poor patients in need of care to any others. First off, they need it, cause god damn they have some ****ty lives; take any kind of social history here and it leaves you stunned. And secondly, because they don't read WebMD.