Consult for IV Start

[nimbus]

IMO there's no reason a smart well trained nurse couldn't do lines and do them well. We have a cardiac surgery NP who does endoscopic vein harvest and endoscopic radial artery harvest better and faster than any of the surgeons.

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[RapidResponseNurse]

The question isn't whether you are allowed by your hospital, the question is how bad of an idea it is. I mean it clearly isn't a good idea, it's just degrees of badness we are arguing over.

I see it as an asset. Do you really think my hospital would have let us do this for years if there where bad outcomes associated with it? Do you really think if I dilated someones carotid and they bled out they would continue to let my rapid team continue to place CVCs? Ultimately my scope will be governed by how safe we are and how good our outcomes are. Here is the thing, if our docs mess up it is just seen by administration as an unfortunate and unavoidable mistake. If we mess up it is seen as a liability and an unjustifiable cost. We do not have the option of being careless, incompetent, or hot headed. I know that every choice I make will reflect on me as well as my team. We have to operate at an exceedingly high level because if we fail one to many times they will strip us of all of our privileges and I will be back to wiping ass on a medsurg for

 

[Mman]

I see it as an asset. Do you really think my hospital would have let us do this for years if there where bad outcomes associated with it? Do you really think if I dilated someones carotid and they bled out they would continue to let my rapid team continue to place CVCs? Ultimately my scope will be governed by how safe we are and how good our outcomes are. Here is the thing, if our docs mess up it is just seen by administration as an unfortunate and unavoidable mistake. If we mess up it is seen as a liability and an unjustifiable cost. We do not have the option of being careless, incompetent, or hot headed. I know that every choice I make will reflect on me as well as my team. We have to operate at an exceedingly high level because if we fail one to many times they will strip us of all of our privileges and I will be back to wiping ass on a medsurg for

I think hospitals can be insanely stupid and care far more about money than quality of care. So I wouldn't justify a hospital's decision on what is actually best for patients. They might just want something done as cheap as possible.

 

[RapidResponseNurse]

I think hospitals can be insanely stupid and care far more about money than quality of care. So I wouldn't justify a hospital's decision on what is actually best for patients. They might just want something done as cheap as possible.

If we are talking about money... Okay doctor messes up and patient dies, family sues the doctor and his malpractice insurance for X dollars. I mess up and patient dies, family sues the facility who allowed an RN to do these things because I am functioning under a predetermined order set put in place by the hospital not the attending in ICU. Seems like the hospital is far safer with only letting docs do it. Plus "Nursing services" are all rolled into a patient's base hospital bill. It doesn't matter if I pass some PO tylenol or start a central line my nursing services are just that, "nursing services." Our whole reason for being able to do the things we can are so in emergent situations patients can receive life saving interventions. If we are slow do I put in a CVC while the docs hang out and do nothing? absolutely not. I am an emergent backup and lifeline not a dedicated provider by any means.

 

[deleted171991]

Cars were initially driven by engineers, then by chauffeurs, then by laypeople, then they drove themselves.

Also, it's called survival of the fittest (most adaptable ones), not of the smartest, for a reason.

 

[RapidResponseNurse]

One quick question? As an intern, resident, or fellow who bills for your services?? I am really curious, seems like facilities must make a killing off of y'all.

Like in my state NPs and CRNAs all bill directly. Why do hospitals even hire CRNAs and NPs to work for the hospital when it seems like there is a massive pool of free labor in the interns, residents, and fellows? Not that I am complaining seeing as how I'm going to be a CRNA. We are affiliated with the University so instead of hiring a few CRNA why not just open up a few more anesthesiology spots and have more docs? What financial sense does it make to pay a CRNA $200k for 4 days a week with very limited call when you could work your residents into the ground for next to nothing? Not talking crap I just see the way y'all are treated and it must be hard.

 

[Planktonmd]

If we are talking about money... Okay doctor messes up and patient dies, family sues the doctor and his malpractice insurance for X dollars. I mess up and patient dies, family sues the facility who allowed an RN to do these things because I am functioning under a predetermined order set put in place by the hospital not the attending in ICU. Seems like the hospital is far safer with only letting docs do it. Plus "Nursing services" are all rolled into a patient's base hospital bill. It doesn't matter if I pass some PO tylenol or start a central line my nursing services are just that, "nursing services." Our whole reason for being able to do the things we can are so in emergent situations patients can receive life saving interventions. If we are slow do I put in a CVC while the docs hang out and do nothing? absolutely not. I am an emergent backup and lifeline not a dedicated provider by any means.

When you put in a central line you usually have an order from a physician who in this case will share the liability for your actions with the hospital who granted you the privileges.
That's how it works and it might be OK if you are as skilled as you stated but that makes you a very exceptional or rare nurse.

 

[deleted171991]

He's a rapid response nurse in a hospital with pretty sick patients. I would expect him to be exceptional.

 

[Mman]

If we are talking about money... Okay doctor messes up and patient dies, family sues the doctor and his malpractice insurance for X dollars. I mess up and patient dies, family sues the facility who allowed an RN to do these things because I am functioning under a predetermined order set put in place by the hospital not the attending in ICU. Seems like the hospital is far safer with only letting docs do it. Plus "Nursing services" are all rolled into a patient's base hospital bill. It doesn't matter if I pass some PO tylenol or start a central line my nursing services are just that, "nursing services." Our whole reason for being able to do the things we can are so in emergent situations patients can receive life saving interventions. If we are slow do I put in a CVC while the docs hang out and do nothing? absolutely not. I am an emergent backup and lifeline not a dedicated provider by any means.

You are missing the entire point. It's cheaper for a hospital to have a nurse around to do something than to have a physician do the same thing assuming the hospital is paying all the salaries.

 

[Mman]

One quick question? As an intern, resident, or fellow who bills for your services?? I am really curious, seems like facilities must make a killing off of y'all.

Like in my state NPs and CRNAs all bill directly. Why do hospitals even hire CRNAs and NPs to work for the hospital when it seems like there is a massive pool of free labor in the interns, residents, and fellows? Not that I am complaining seeing as how I'm going to be a CRNA. We are affiliated with the University so instead of hiring a few CRNA why not just open up a few more anesthesiology spots and have more docs? What financial sense does it make to pay a CRNA $200k for 4 days a week with very limited call when you could work your residents into the ground for next to nothing? Not talking crap I just see the way y'all are treated and it must be hard.

Procedures done by GME physicians (intern, resident, fellows) are billed under the attending physician's codes. Whether that is done by the hospital itself or the physician or a group/department varies by hospital.

NPs and CRNAs can "bill directly" legally, but if they are hospital or group employees they aren't billing anything and somebody else is sending the bill in with their name on it and collecting it instead of them. As an example, if you are a CRNA employed by a hospital, you will never send anybody a bill. The hospital will bill procedures under your name and collect the payments. In exchange, you will get a paycheck.

Why not "open a few more anesthesiology spots"? Because it isn't allowed legally. Additional residency spots have to be applied for and they don't hand them out like candy. So while it is true that for a department a resident is much cheaper labor than a CRNA, they are both limited in number of residents they can have as well as in work hours that they can use them for.

 

[RapidResponseNurse]

When you put in a central line you usually have an order from a physician who in this case will share the liability for your actions with the hospital who granted you the privileges.
That's how it works and it might be OK if you are as skilled as you stated but that makes you a very exceptional and rare nurse.

Thanks for the complement but I would just consider myself average amongst the team I am on. They have been doing this for many more years then me. Quick question, what kind of facility do you work at? Does it have a rapid response team? If it does, is it a real RRT with nurses skilled in invasive procedures, or do they just make an ICU nurse run down to codes on the floor? Here is the difference many places will have "RRT" just because it is mandated to be a magnet facility so they will cut corners by handing an ICU a code pager and calling that RRT. At other facilities with dedicated RRTs those nurses do not take any patients and have to attend mandatory competency tests regularly to keep up their certifications. The beauty of me not taking patients is that when I am just sitting around I can float from ER to ICU to OR and watch MDs, CRNAs, NPs, and PAs perform procedures. If they are non emergent procedures and the provider is nice enough to take the time I can practice my skills under close supervision. This allows us to learn from the best, practice on a regular basis, and be exposed to potential complications on a regular basis.

 

[RapidResponseNurse]

I wish you all who have never been exposed to a dedicated RRT could have us as a tool for you. When our team was started 4 or 5 years ago the older nurses said they came under a lot of fire from the older docs. Now that they have seen how valuable we can be to you, they would not have it any other way. Imagine showing up to a code and you already have access and patient is intubated. Now you can focus all of your medical training on the complex aspects of medicine such as resuscitating this patient, figuring our the H's and T's, and saving the patient's life. All we did was the mindless procedural stuff which frees the physicians up to focus on the medicine. Not to mention I can give you a very detailed focused report so you don't have to deal with a spastic floor nurse.

 

[BLADEMDA]

My hospital has Intensivists and Hospitalists available 24/7 to do what the Rapid Response Nurse does above. I prefer the MD over the RN for these situations.

 

[Planktonmd]

Thanks for the complement but I would just consider myself average amongst the team I am on. They have been doing this for many more years then me. Quick question, what kind of facility do you work at? Does it have a rapid response team? If it does, is it a real RRT with nurses skilled in invasive procedures, or do they just make an ICU nurse run down to codes on the floor? Here is the difference many places will have "RRT" just because it is mandated to be a magnet facility so they will cut corners by handing an ICU a code pager and calling that RRT. At other facilities with dedicated RRTs those nurses do not take any patients and have to attend mandatory competency tests regularly to keep up their certifications. The beauty of me not taking patients is that when I am just sitting around I can float from ER to ICU to OR and watch MDs, CRNAs, NPs, and PAs perform procedures. If they are non emergent procedures and the provider is nice enough to take the time I can practice my skills under close supervision. This allows us to learn from the best, practice on a regular basis, and be exposed to potential complications on a regular basis.

Are you saying you guys show up to codes by yourselves without a physician? Where are all the residents and interns?
If they are standing there or on their way then you are doing procedures based on orders from them and ultimately their attendings, that was my point, as a nurse you don't do invasive lines and procedures without orders.
It's different if you were a nurse practitioner.

 

[RapidResponseNurse]

If you think what I have told you is crazy look up University of Maryland Medical Center "Shock Trauma Go Team." It is based out of Cowley Shock Trauma. They have a flight team that consists of an attending (surgeon or anesthesiologist) and a CRNA that respond to mass casualty situations and perform life saving surgery in the field. It the cream of the crop for sure and my dream job. Its really the reason why I pursue what I am doing.

GO TEAM

The Go-Team responding to a call
As the primary adult trauma resource center for the State of Maryland, the R Adams Cowley Shock Trauma Center's mission is to save lives and reduce the disability of critically ill and injured persons in greater Maryland. The Trauma Center recognizes that there are times when victim entrapment will delay transport to definitive care. In these circumstances, the Trauma Center maintains an advanced resuscitative team capable of responding to the scene of seriously injured patients. This physician-led team complements Maryland's Statewide EMS System by providing critical care and surgical services that are typically considered beyond the scope of prehospital emergency care.

Scene incident commanders may request a GO-TEAM response for patients with suspected life-threatening injuries when extrication times are estimated to exceed one hour.

In situations where preliminary reports suggest that a victim's condition may require the GO-TEAM, but the extent of the rescue operation is unknown, a request can be made to put the Team on alert. The purpose of the alert status is to reduce the Team's response time. In this circumstance, the Team would be assembled but not dispatched until an initial on-scene assessment determines that the Team is needed.

More about the GO-TEAM
When dispatched, the GO-TEAM serves as a specialized component of Maryland's statewide emergency medical system. The Shock Trauma GO-TEAM is composed of an attending physician (anesthesiologist, surgeon, critical care medicine specialist) and a certified registered nurse anesthetist.

Team members undergo a core training curriculum that includes field surgical care, State EMS protocols, scene safety, helicopter safety, hazardous materials awareness, radio communications, incident command, vehicular rescue, emergency vehicle operations and field operations. Additional ongoing training includes:

• Use of self-contained breathing apparatus (SCBA)
• Supporting closed space, trench, and high elevation rescue operations
• Techniques for farm equipment rescue
• Water rescue, including personal water craft operations
• Assisting with law enforcement tactical operations

Any incident commander may request the GO-TEAM through EMRC/SYSCOM, through his/her local fire dispatch board, or by calling Maryland ExpressCare directly at 410-328-1234. A trauma-line consult with the attending trauma surgeon on-call is requested if possible to help prepare the team prior to arrival at the scene. Whenever possible, the Team is composed of personnel located within the Trauma Center. In some circumstances, it is necessary to utilize on-call attending physicians, who respond to the scene directly.

Once on the scene, the GO-TEAM reports to the incident commander for integration into the rescue operation. The GO-TEAM operates under the operational command of the scene incident commander The on-scene trauma attending physician assumes responsibility for medical decisions for patients under the Team's care. The GO-TEAM works closely with on-scene emergency medical and rescue personnel to provide patient care. Once extricated, patient transport is accomplished to the closest appropriate trauma facility as determined by the GO-TEAM attending physician.

The GO-TEAM's Capabilities
These include the following:

• Assess the extent of injury and determine potential consequences that delays in time to definitive care might have on patient outcome. This information is provided to rescue personnel so that they may better plan the pace and type of rescue.
  
  
• Perform advanced airway maneuvers, including surgical cricothyrotomy and mechanical ventilation.
  
  
• Perform chest tube decompression of pneumo-hemothorax.
  
  
• Perform surgical procedures to achieve hemostasis.
  
  
• Administer advanced fluid resuscitation, including blood transfusion.
  
  
• Administer sedative, analgesic and paralytic medications.
  
  
• Initiate invasive and non-invasive vital sign monitoring to include: arterial oxygen saturation, quantitative measurement of expired end-tidal carbon dioxide, measurement of core body temperature, arterial pressure, and central venous pressure.
  
  
• Insert gastric and urinary bladder drainage catheters.
  
  
• Administer vasoactive medications to support blood pressure and maintain organ blood flow.
  
  
• Administer medications and institute measures to reduce brain swelling and lower intracranial pressure.
  
  
• Administer treatments and medications to patients with crush injury in order to reduce the risk of myoglobin-induced acute renal failure.
  
  
• Perform life-saving extremity amputation.
  
  
• Provide advanced medical and triage expertise for mass-casualty incidents, including incidents potentially involving weapons of mass destruction.
  

Source: GO-TEAM - UM Shock Trauma Center | University of Maryland Medical Center http://umm.edu/programs/shock-trauma/professionals/ems/go-team#ixzz3TuPenCkA
University of Maryland Medical Center
Follow us: @UMMC on Twitter | MedCenter on Facebook

 

[Planktonmd]

In many other advanced countries the flight emergency teams always include a physician it's only unusual here in the US

 

[RapidResponseNurse]

Are you saying you guys show up to codes by yourselves without a physician? Where are all the residents and interns?
If they are standing there or on their way then you are doing procedures based on orders from them and ultimately their attendings, that was my point, as a nurse you don't do invasive lines and procedures without orders.
It's different if you were a nurse practitioner.

No absolutely not. We get there sooner because we are activated usually before a patient begins to code by the floors charge nurse when they see the patient going down hill. I have no responsibility other than being available at all times. Ideally myself and the interns get there at the same time, if they are busy with some other emergencies, procedures, or crashing patients in the ICU then I manage them until the doctors arrive. MDs are always the first people they want there when the patient is coding no doubt. Lets be honest though, how many times have the medical team been called but due to other critical situations are not able to respond to the floor immediately. How many times have you got a call from the floor nurse and they say the patient "doesn't look good" and say maybe y'all should "come when you can." Only for you to get there and that patient is practically dead because they did not have the clinical judgement to relay the dire situation the patient was in?

 

[RapidResponseNurse]

If you look at a facility >500-600 beds then it is not to far fetched to believe that you could have multiple de-compensating patients at any given time somewhere in the hospital. Plus I get report about the patients who are "borderline sick" on the floors and make rounds and check on them. You would be surprised how many times I arrive in one of these rooms to find the patient unresponsive and no one has checked on them for hours. Think about it, you have 10 codes/near codes on the floor in a month, 8 out of the 10 the doctors are able to respond immediately and intervene. I am there for the other 2. I am in no way taking over MDs responsibilities. I WANT YOU THERE as the expert to help these patients, I am just there to fill in the holes and keep them alive until you can get there because you where coding, intubating, or intervening on another critical patient. Additionally, say you can spare to send your intern to the situation while you finish up in another room. Assume it is their first week and they have never been in a code situation or ran ACLS it helps to have a seasoned person to help out.

 

[Mman]

I wish you all who have never been exposed to a dedicated RRT could have us as a tool for you.

What makes you think people haven't seen a rapid response team? We have them. And when stuff hits the fan, they call the physician. They are basically there as a resource to the floor nurse if they feel something isn't right.

 

[Mman]

If you look at a facility >500-600 beds then it is not to far fetched to believe that you could have multiple de-compensating patients at any given time somewhere in the hospital.

I think it's also safe to assume more than 1 physician is in house at all times per 500-600 beds.

 

[RapidResponseNurse]

I think it's also safe to assume more than 1 physician is in house at all times per 500-600 beds.

Take my facility for instance, ~500 beds. Internal Med/CC covers ICUs and the floors. That gives you one resident, and one intern for ICU. Then you have one resident and one intern for the floor. 4 doctors for MICU, CVICU, and the floors. CVICU doesnt staff doctors on site at night. SICU has 2 surgery doctors available at all times, and you have anesthesia but they only respond to their specific patients or codes. So when a patient is going down hill the floor will page their floor team first, sometimes they dont respond quickly to the page because they are so burnt out on frivilous things the floors ask them for. So 20 min goes by and they cant get ahold of floor team so they page the Critical Care team. Most of the time critical care will respond quickly, unless of course their patients are trying to die in ICU (pretty common). So say by now 30 minutes has gone by and this patient is about to crap out and no one has responded to the page. So finally patient codes and they pull the code blue. 5 minutes later surgery and anesthesia arrive. Now it has been 55 min before any life saving intervention has been done. All this is bypassed by me responding to a sick patient when the floor team is paged when they first have concerns. Most of the time like 95% I dont have to do any invasive stuff other than basic interventions (O2, breathing treatment, EKG, troponins, nitro, morphine, naloxone, romazacon, atropine, basics) which comes from a standing order set. The other 5% of the time I can intubate, run the code, activate mass transfusion, ect.

 

[RapidResponseNurse]

Remember I work night so there is not a million providers available to us like during days.

 

[Mman]

Remember I work night so there is not a million providers available to us like during days.

I'm still dying at the thought of how understaffed that model is. 2 residents and 2 interns covering 2 ICUs and all the floors with no attending physician in house? Oh vey. Recipe for disaster and certainly not how any hospital should be staffed.

 

[RapidResponseNurse]

What makes you think people haven't seen a rapid response team? We have them. And when stuff hits the fan, they call the physician. They are basically there as a resource to the floor nurse if they feel something isn't right.

Absolutely I always contact the physicians as soon as possible. I want your input as soon as possible, I want you to be there when the patient is crapping out. But would you rather have me waiting around on a phone for someone to answer or delegating the floor nurse to call you while I try to help the patient. Example, patients bradycardic, hypotensive, desating, unresponsive, tready pulse, and pale. Would you rather me wait until I can get ahold of you which may be quick maybe not or just give some atropine and support his respirations until you can come offer expert help.

 

[RapidResponseNurse]

I'm still dying at the thought of how understaffed that model is. 2 residents and 2 interns covering 2 ICUs and all the floors with no attending physician in house? Oh vey. Recipe for disaster and certainly not how any hospital should be staffed.

you always have surgery attending available, Anesthesia attending are available all the time. Thing is surgery and anesthesia only come if they are either already consulted or a code blue is activated. Floor and CC attending can be paged in but usually wont arrive for 30+min.

 

[RapidResponseNurse]

This isnt as complicated as you are making it. >90% of the time MDs are available within a very short time and I always defer to their judgement. I have the skills I do so in the rare times that no one responds I can help the patient before they code. If they do code I am already in the room and can run it until surgery or anesthesia arrive.

Say the patient self extubates while on 100% FiO2 and 15 peep in ICU and our doctors are busy coding in CVICU I can intubate during the time it takes anesthesia to get from the ground floor on the east tower to the 6th floor of the west tower.

If I am successful before they arrive AWESOME, if I am not then as soon as they get there its all theirs. I am there for those rare but all to real situations. I am not a provider, I am a last line safety net

 

[Mman]

you always have surgery attending available, Anesthesia attending are available all the time. Thing is surgery and anesthesia only come if they are either already consulted or a code blue is activated. Floor and CC attending can be paged in but usually wont arrive for 30+min.

I'm still laughing at how understaffed it is. If you don't get it, well you don't get it. I can't help you there. I just know I'd never want to be a patient there and I'd love to be a lawyer nearby. You are telling me there isn't an internist in the building? ICU MD goes home at 5 PM or something? Just craziness.

 

[Mman]

Absolutely I always contact the physicians as soon as possible. I want your input as soon as possible, I want you to be there when the patient is crapping out. But would you rather have me waiting around on a phone for someone to answer or delegating the floor nurse to call you while I try to help the patient. Example, patients bradycardic, hypotensive, desating, unresponsive, tready pulse, and pale. Would you rather me wait until I can get ahold of you which may be quick maybe not or just give some atropine and support his respirations until you can come offer expert help.

I have no idea what point you are trying to make. I'm well aware of what a RRT team is and what it's purpose is.

 

[RapidResponseNurse]

I'm still laughing at how understaffed it is. If you don't get it, well you don't get it. I can't help you there. You are telling me there isn't an internist in the building? ICU MD goes home at 5 PM or something? Just craziness.

I agree I dont know why the ICU attendings go home after they round at the end of day shift. I dont set the policies unfortunately. I didnt realize that most other ICUs staff an attending 24/7. Does a Pulmo/Critical care attending stay on sight 24/7 at your facility?

 

[Mman]

I agree I dont know why the ICU attendings go home after they round at the end of day shift. I dont set the policies unfortunately. I didnt realize that most other ICUs staff an attending 24/7. Does a Pulmo/Critical care attending stay on sight 24/7 at your facility?

I can't count how many physicians we have in house. Every ICU has an in house attending. There are also several hospitalists in house. ED, anesthesia, trauma surgery, OB, etc.

 

[dhb]

You are telling me there isn't an internist in the building? ICU MD goes home at 5 PM or something? Just craziness.

Now i understand why they have a idle RRT

 

[SouthSideSteve]

IMO there's no reason a smart well trained nurse couldn't do lines and do them well. We have a cardiac surgery NP who does endoscopic vein harvest and endoscopic radial artery harvest better and faster than any of the surgeons.

You do realize fellows don't do any endoscopic training (and barely any conduit harvesting). That comparison is ******ed.

Comparing someone who does the same thing everyday to a person who never does it...

That NP is "so much better" because the surgeons are too busy working in the chest to bother harvesting conduit.

 

[nimbus]

You do realize fellows don't do any endoscopic training (and barely any conduit harvesting). That comparison is ******ed.

Comparing someone who does the same thing everyday to a person who never does it...

That NP is "so much better" because

You do realize fellows don't do any endoscopic training (and barely any conduit harvesting). That comparison is ******ed.

Comparing someone who does the same thing everyday to a person who never does it...

That NP is "so much better" because the surgeons are too busy working in the chest to bother harvesting conduit.

the surgeons are too busy working in the chest to bother harvesting conduit.

We don't have any fellows. This particular nurse is the best I've ever seen at what she does. Better than the general and cardiac surgeons that sometimes take her place. The surgeon she assists agrees. She has better training, better experience, better hands in this setting. When she is away on vacation we all miss her because we know the case will take a lot longer than usual.

My point is that the right individual can excel at a particular procedure regardless of their title. I stand by my statement that a nurse can excel at lines. And I know for a fact that many board certified anesthesiologists suck at them. I've seen it with my own eyes. They have allowed their skills to atrophy or they never developed them in the first place.

 

[IveGotTwins]

We don't have any fellows. This particular nurse is the best I've ever seen at what she does. Better than the general and cardiac surgeons that sometimes take her place. The surgeon she assists agrees. She has better training, better experience, better hands in this setting. When she is away on vacation we all miss her because we know the case will take a lot longer than usual.

My point is that the right individual can excel at a particular procedure regardless of their title. I stand by my statement that a nurse can excel at lines. And I know for a fact that many board certified anesthesiologists suck at them. I've seen it with my own eyes. They have allowed their skills to atrophy or they never developed them in the first place.

Who taught her to do these procedures? Probably the ofirmev rep.

 

[SouthSideSteve]

We don't have any fellows. This particular nurse is the best I've ever seen at what she does. Better than the general and cardiac surgeons that sometimes take her place. The surgeon she assists agrees. She has better training, better experience, better hands in this setting. When she is away on vacation we all miss her because we know the case will take a lot longer than usual.

My point is that the right individual can excel at a particular procedure regardless of their title. I stand by my statement that a nurse can excel at lines. And I know for a fact that many board certified anesthesiologists suck at them. I've seen it with my own eyes. They have allowed their skills to atrophy or they never developed them in the first place.

My point with the fellows is that Cardiac surgeons do not learn EVH or even OVH in training, because PAs harvest conduit.


Saying she's good is one thing. Comparing her to people that never do the same procedure is just an asinine statement.

 

[nimbus]

My point with the fellows is that Cardiac surgeons do not learn EVH or even OVH in training, because PAs harvest conduit.


Saying she's good is one thing. Comparing her to people that never do the same procedure is just an asinine statement.

I was comparing her to others who do the exact same procedure....surgeons, PAs, and other NPs.

 

[SouthSideSteve]

I was comparing her to others who do the exact same procedure....surgeons, PAs, and other NPs.

You can teach a janitor to shuck vein, put a CVL in, intubate, or take a LIMA.

Just because someone CAN do something, doesn't mean they SHOULD.

 

[yappy]

I wish you all who have never been exposed to a dedicated RRT could have us as a tool for you. When our team was started 4 or 5 years ago the older nurses said they came under a lot of fire from the older docs. Now that they have seen how valuable we can be to you, they would not have it any other way. Imagine showing up to a code and you already have access and patient is intubated. Now you can focus all of your medical training on the complex aspects of medicine such as resuscitating this patient, figuring our the H's and T's, and saving the patient's life. All we did was the mindless procedural stuff which frees the physicians up to focus on the medicine. Not to mention I can give you a very detailed focused report so you don't have to deal with a spastic floor nurse.

One criticism I have with nursing is how they seem to discourage/limit the duties of other allied healthcare members like paramedics and respiratory therapy. I've seen a progressive ED program in a level 1 get scrapped because of nursing interest when they began to incorporate paramedics in their staffing. The fear was that paramedics would be used to complete nursing duties. A similar logic is used when limiting the function of RT or paramedics on the floor or in special care teams like rapid response. It's really hypocritical to me considering that the training gap between physician and advanced practice nurse is much larger than nurse and paramedic or RT. What gives?

 

[deleted171991]

You can teach a janitor to shuck vein, put a CVL in, intubate, or take a LIMA.

Just because someone CAN do something, doesn't mean they SHOULD.

An entire world of hobbyist auto mechanics would contradict you.

 

[Planktonmd]

Ladies and gentlemen... it is time for all of us to accept that medicine is no longer a sacred profession, and that the art of healing is no longer highly regarded by society as it used to be.
We are now simply vendors of a service that can be provided by others, we now have competitors!

 

[RapidResponseNurse]

One criticism I have with nursing is how they seem to discourage/limit the duties of other allied healthcare members like paramedics and respiratory therapy. I've seen a progressive ED program in a level 1 get scrapped because of nursing interest when they began to incorporate paramedics in their staffing. The fear was that paramedics would be used to complete nursing duties. A similar logic is used when limiting the function of RT or paramedics on the floor or in special care teams like rapid response. It's really hypocritical to me considering that the training gap between physician and advanced practice nurse is much larger than nurse and paramedic or RT. What gives?

I think it just depends what area you work in. When it comes to utilizing other specialties such as paramedics it is true that sometimes in the hospital they are limited. In contrast, flight nursing which one of the most coveted of all nursing specialties almost always has a paramedic and a nurse on their flight team.

 

[DreamLover]

My point with the fellows is that Cardiac surgeons do not learn EVH or even OVH in training, because PAs harvest conduit.


Saying she's good is one thing. Comparing her to people that never do the same procedure is just an asinine statement.

At my hospital, if the Cardiac PA is out sick, the CABG gets rescheduled. No vein harvested, no bypass-like it or not.

Also at my hospital, if I'm carrying the anesthesia charge phone-I'll get calls in the middle of a very busy day for an IV placement on an MICU patient by the MICU nurse who has not even asked the primary team to start another IV or evaluate for CVL placement etc. "Because anesthesia is the best." Flattery gets you nowhere with me in that situation.

The nurses get mad at me too when I tell them to contact the primary team regarding access on their patient. I'm too busy running 4 rooms and the OR board and going to codes/airways, running the PACU etc to go place an IV in that type of situation. I'm all for helping. I'm a benevolent person...but that stuff pisses me off.

 

[deleted171991]

Four rooms AND the board? Ouch!

 

[DreamLover]

Four rooms AND the board? Ouch!

Right? But if you ask some of the CRNAs at my hospital..."They're doing all the work" and I'm just getting paid more. I work my butt off, thus I rest easy at night knowing I earned my money and some!

 

[RapidResponseNurse]

At my hospital, if the Cardiac PA is out sick, the CABG gets rescheduled. No vein harvested, no bypass-like it or not.

Also at my hospital, if I'm carrying the anesthesia charge phone-I'll get calls in the middle of a very busy day for an IV placement on an MICU patient by the MICU nurse who has not even asked the primary team to start another IV or evaluate for CVL placement etc. "Because anesthesia is the best." Flattery gets you nowhere with me in that situation.

The nurses get mad at me too when I tell them to contact the primary team regarding access on their patient. I'm too busy running 4 rooms and the OR board and going to codes/airways, running the PACU etc to go place an IV in that type of situation. I'm all for helping. I'm a benevolent person...but that stuff pisses me off.

Why are nurses calling anesthesia to place a PIV? Can the nurses in your facility not use ultrasound to place lines? In my opinion there is no reason for a nurse to call anesthesia to place PIVs. Honestly they shouldnt even be calling the primary team to place PIVs. Learn how to use a damn ultrasound already!

 

[Mman]

Why are nurses calling anesthesia to place a PIV? Can the nurses in your facility not use ultrasound to place lines? In my opinion there is no reason for a nurse to call anesthesia to place PIVs. Honestly they shouldnt even be calling the primary team to place PIVs. Learn how to use a damn ultrasound already!

No. They should just learn to start IV. Patients have veins and you can get them without ultrasound 99.99% of the time. I think in the last 5 years I've had about 1 patient that we needed an U/S to get a PIV in. And that's out of 10,000+ patients. If you need the U/S, you probably don't know what you are doing. And if they are truly an impossible stick serious consideration needs to be given to a central line instead of a PIV if they will need access for any period of time.

 

[caligas]

Back to the original issue, if the patient is really that hard of a stick and you are a physician who knows how to safely place a central line, you are probably doing everyone a favor by just placing a central line instead of using ultrasound to get a ****ty iv in their fat arm. You can bill for it too or if you are a resident you gain experience.

 

[pgg]

No. They should just learn to start IV. Patients have veins and you can get them without ultrasound 99.99% of the time. I think in the last 5 years I've had about 1 patient that we needed an U/S to get a PIV in. And that's out of 10,000+ patients. If you need the U/S, you probably don't know what you are doing. And if they are truly an impossible stick serious consideration needs to be given to a central line instead of a PIV if they will need access for any period of time.

Today I had a morbidly obese patient having outpatient surgery. I looked at both arms and hands, saw and felt nothing really good. Some tiny spidery veins on the anterior wrist. Thought I felt an intern vein and AC.

I'm sure I could've got an IV in her with an anatomic approach and a couple of fanning passes.

Instead I hit the "on" button on the u/s machine, saw an easy vein, one stick, done. Patient was happy since she usually gets stuck more than once.

If I have any doubt that I can't get an IV in an awake patient in one EASY stick I just use u/s.

 

[Mman]

Today I had a morbidly obese patient having outpatient surgery. I looked at both arms and hands, saw and felt nothing really good. Some tiny spidery veins on the anterior wrist. Thought I felt an intern vein and AC.

I'm sure I could've got an IV in her with an anatomic approach and a couple of fanning passes.

Instead I hit the "on" button on the u/s machine, saw an easy vein, one stick, done. Patient was happy since she usually gets stuck more than once.

If I have any doubt that I can't get an IV in an awake patient in one EASY stick I just use u/s.

I see so many fat patients a day it doesn't even register anymore. I think we do about 2000 gastric bypasses a year in our hospital so we are quite used to the 400+, 500+ and occasionally 700+ lb patients. I can't recall ever having to stick one of them more than twice for an IV. Even if I only get a small 20 or 22 in preop holding, I can almost always easily get a 2nd IV during induction. It's just not that hard. Can PIVs be done with an U/S? Sure. I've done it before and can do it again. It's just almost never needed. I certainly can't dream up a scenario where RNs need to worry about using an U/S to start a PIV. Just get good at starting IVs.

 

[RapidResponseNurse]

patient is severe diabetic, ESRD, +4 pitting edema, AV graft of left arm, obese, and history of IV drug use... Not all that uncommon in MICU. No need for this nurse to place an US PIV in 2 minutes with no risk of major complications.... I'll just have IM or anesthesia come place a central line and risk popping a pneumo and patient getting a chest tube...

Fat doesn't = +4 edema, one limb to stick, and destroyed superficial vasculature. 2-3 inch angiocath in the brachial or basic vein and problem solved in all of 2 minutes. "just get good at starting IVs" how about be skilled with the tools at your disposal, save time and resources, plus save the patient from unneeded pain or risk of complications.