Eff you, you Judas.

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Pet peeve... people who think that just because a person is in the hospital they need IV access. Home fries doesn't need IV access... and it's an easy argument that central access is a hazard in this case.
 
I know that wasn't the point of the post necessarily, but I'm curious: how was the documentation in this case? Solid and you still got chewed out? Or did you maybe not get the chance to document your decision making (patient refused, risk/benefit of central line in patient with endocarditis, etc)?
 
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No central lines just for "IV access". For critically ill patients only or ones who need important IV treatments. None of which applied in this case.

RustedFox was actually nicer than me. I would have documented normal vitals, her refusal of care, and discharged her whether or not she agreed to sign the AMA form.
 
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There was no reason for a central line. From your description, there was no reason for IV access.
Appropriate for the upstairs people to figure out access later if it's needed.
Actually, you did that for them by ordering a PICC.
I'm not sure why anyone complained about this, unless it's some kind of CMG billing shenanigan I'm not picking up on.
 
GeneralVeers said:
No central lines just for "IV access". For critically ill patients only or ones who need important IV treatments. None of which applied in this case.

RustedFox was actually nicer than me. I would have documented normal vitals, her refusal of care, and discharged her whether or not she agreed to sign the AMA form.
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I’d have sent her home too. Normal vitals, normal ECHO? I’d draw some cultures, wait a bit and draw another. Then DC and tell them that we’d call if anything was positive.

Sorry you’re going through this fox. It’s bogus.

This is what you do with that complaint:
 
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I would've discharged her. Would've been a pain to get rid of, but tell her the cultures are pending. If she has endocarditis, someone will call her when the cultures come back positive.

EZ-IO FTW in this case. I'm sure as soon as she got a central line or gets a PICC, she's going to bolt to have easy access to squirt her drug of choice. One could argue that these people should never get central lines or PICC lines unless they have a proven well documented reason for needing them.
 
Had a case like this once. Standard vasculopath / ivdu refusing to be stuck after like 5 attempts. I documented they refused. They flipped out when got upstairs. I said patient refused, and the issue disappeared. We can't assault patients, sorry
 
Clearly, the only solution here, was to have someone that's beyond an expert in IV placement, come down to the ED at this time of crisis, to place the IV. Someone so great, so talented with IV placement, so seasoned and experienced, and the scars to prove it. Someone so revered due to skills so rare and great, they were elevated to bordering on Demigod. The only person with the Jedi-like skills to place this devastatingly important IV, that mere mortals are in-equipped to place, is unquestionably, the hospital CMO.

Consider this express copyright permission for all of you to use these exact words when talking to your CMO.
 
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Birdstrike said:
Clearly, the only solution here, was to have someone that's beyond an expert in IV placement, come down to the ED at this time of crisis, to place the IV. Someone so great, so talented with IV placement, so seasoned and experienced, and the scars to prove it. Someone so revered due to skills so rare and great, they were elevated to bordering on Demigod. The only person with the Jedi-like skills to place this devastatingly important IV, that mere mortals are in-equipped to place, is unquestionably, the hospital CMO.

Consider this express copyright permission for all of you to use these exact words when talking to your CMO.
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Agreed. @RustedFox should partner with the CMO to improve the process the next time a patient's experience isn't optimized. We are a team and the fact that a patient doesn't want to accept any of RF's recommended care shouldn't be a barrier to the patient's receiving "excellent care every time".
 
WilcoWorld said:
Agreed. @RustedFox should partner with the CMO to improve the process the next time a patient's experience isn't optimized. We are a team and the fact that a patient doesn't want to accept any of RF's recommended care shouldn't be a barrier to the patient's receiving "excellent care every time".
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I know you're being facetious, but that is so spot on it actually made me a little angry
 
GonnaBeADoc2222 said:
Why aren't all nurses learning ultrasound iv placement in school?
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We've taught ours, but they seem to just always punt to the resident when they can't get an IV. There are some nurses that when I work with them, I'm guaranteed to need to do an EJ or have me or charge nurse stick the patient to avoid waiting an hour on the IV team. I used to think she sucks at IV's, but I think she does it to keep patient turnover low so she doesn't have new patients all the time.
 
GonnaBeADoc2222 said:
Why aren't all nurses learning ultrasound iv placement in school?
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At some schools, student nurses aren't allowed to touch IV lines and meds, much less put a normal IV in. (yes I agree, its stupid)

Used to be allowed to do this in my old ICU (I'm an RN), got pretty good at it. Switched jobs to ER and went for the ultrasound after letting the doc know I needed to US to put a PIV a patient. The other nurses flipped out because apparently they'd had an adverse event a couple years before I started working there, and the institution put a hard stop to it. Pulled it from the training schedule too.
 
Melchizedek said:
At some schools, student nurses aren't allowed to touch IV lines and meds, much less put a normal IV in. (yes I agree, its stupid)

Used to be allowed to do this in my old ICU (I'm an RN), got pretty good at it. Switched jobs to ER and went for the ultrasound after letting the doc know I needed to US to put a PIV a patient. The other nurses flipped out because apparently they'd had an adverse event a couple years before I started working there, and the institution put a hard stop to it. Pulled it from the training schedule too.
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Wtf else are they learning in nursing school if not how to place IVs and handle medications???
 
GonnaBeADoc2222 said:
Wtf else are they learning in nursing school if not how to place IVs and handle medications???
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My post above might have been ambiguous, they aren’t allowed to touch IV meds

There’s other aspects to bedside nursing but specifically about meds, taught other routes of administration, basic drug interactions to watch for, most common side effects, contraindications, classes of drugs. Nothing terribly specific, except for stuff about insulin (onset, peaks, duration is drilled into our heads)
 
southerndoc said:
We've taught ours, but they seem to just always punt to the resident when they can't get an IV. There are some nurses that when I work with them, I'm guaranteed to need to do an EJ or have me or charge nurse stick the patient to avoid waiting an hour on the IV team. I used to think she sucks at IV's, but I think she does it to keep patient turnover low so she doesn't have new patients all the time.
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Many of ours at the big hospital are trained, some at the smaller/rural sites know how to do it. At the small sites, when they aske to do it, I have them participate as they've expressed interest in learning/doing it without us.
 
It's getting really old, this attitude that the ED is the master and commander of difficult IV access. Either it's an emergency, and the patient gets one by implied consent (sedation or intubation to facilitate critical cares), or the hospital can pay for an ultrasound IV or PICC team to be on 24/7, or it can wait. Bunch of whiny babies upstairs.
 
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Fox800 said:
It's getting really old, this attitude that the ED is the master and commander of difficult IV access. Either it's an emergency, and the patient gets one by implied consent (sedation or intubation to facilitate critical cares), or the hospital can pay for an ultrasound IV or PICC team to be on 24/7, or it can wait. Bunch of whiny babies upstairs.
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No you see the ED docs are physically present in the hospital so if something needs to be done have them do it!!! Also the ED is staffed by CMG who will do anything for the contract.
 
GonnaBeADoc2222 said:
Had a case like this once. Standard vasculopath / ivdu refusing to be stuck after like 5 attempts. I documented they refused. They flipped out when got upstairs. I said patient refused, and the issue disappeared. We can't assault patients, sorry
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But what do you do if someone actually needs access? And they are refusing? Of course you are doing to document it, of course you are going to explain to them why they need it.

I guess at the end of the day if someone says "no", I'm not sure I would admit them....I would send them home. Your EMTALA obligation stops if someone doesn't want the care you wish to provide.
 
Fox800 said:
It's getting really old, this attitude that the ED is the master and commander of difficult IV access. Either it's an emergency, and the patient gets one by implied consent (sedation or intubation to facilitate critical cares), or the hospital can pay for an ultrasound IV or PICC team to be on 24/7, or it can wait. Bunch of whiny babies upstairs.
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Agreed
I wouldn't be surprised at my shop if the hospitalist says "I'll take the patient once he has an IV." I can see that happening
 
GonnaBeADoc2222 said:
Why aren't all nurses learning ultrasound iv placement in school?
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Because they don't learn IV placement in school! They may only start a handful of lines in school and learn how to actually place them on the job. Lots of floor nurses can't do lines by policy (or ability).
 
thegenius said:
But what do you do if someone actually needs access? And they are refusing? Of course you are doing to document it, of course you are going to explain to them why they need it.

I guess at the end of the day if someone says "no", I'm not sure I would admit them....I would send them home. Your EMTALA obligation stops if someone doesn't want the care you wish to provide.
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SQ, IM and PO medications? I managed a no access obese hyperkalemic and septic patient with SQ insulin, PO hydration, and PO antibiotics. Admit and sort it out later.
 
thegenius said:
But what do you do if someone actually needs access? And they are refusing? Of course you are doing to document it, of course you are going to explain to them why they need it.

I guess at the end of the day if someone says "no", I'm not sure I would admit them....I would send them home. Your EMTALA obligation stops if someone doesn't want the care you wish to provide.
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If someone really needs a line and needs to be in the hospital and they are competent, they can refuse. Up until the point that they become so sick that they can’t. These people don’t have a POLST or any signed documentation that says “no IVs”. They are almost uniformly mentally ill and/or substance abusers and will become sick enough that they get vascular access one way or another by implied consent. Are you really gonna let some irrational high person or psych patient dictate what you can and can’t do while you work them up for an emergency medical condition if they really need a line and labs? Sure thing just let them lay there for 8 hours while they dictate the course of treatment.
 
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thegenius said:
Agreed
I wouldn't be surprised at my shop if the hospitalist says "I'll take the patient once he has an IV." I can see that happening
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The hospitalist is credentialed for peripheral venipuncture, as are the inpatient nurses. If no one on the inpatient side is capable of starting a peripheral IV, then the hospital should be closed until those people have had remedial training.
 
Fox800 said:
If someone really needs a line and needs to be in the hospital and they are competent, they can refuse. Up until the point that they become so sick that they can’t. These people don’t have a POLST or any signed documentation that says “no IVs”. They are almost uniformly mentally ill and/or substance abusers and will become sick enough that they get vascular access one way or another by implied consent. Are you really gonna let some irrational high person or psych patient dictate what you can and can’t do while you work them up for an emergency medical condition if they really need a line and labs? Sure thing just let them lay there for 8 hours while they dictate the course of treatment.
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If you can make informed decisions, then the patient will be admitted with IV or discharged/AMAed. I personally wouldn't admit someone like the OP suggested without an IV. I actually would have sent them home, but that's a different thing. The patient will not linger in the ED for hours because "I don't feel good but I don't want to be poked for an IV." I've AMA'ed a STEMI before.

If the patient cannot make informed decisions, and it's an emergency then it's 5-2-1, maybe ketamine, and IV. I just did that the other day. Have no compunction about that at all.

If the patient cannot make informed decisions, and it's NOT an emergency, then I don't know what I would do. Haven't had that problem yet that I'm aware of.

Fox800 said:
The hospitalist is credentialed for peripheral venipuncture, as are the inpatient nurses. If no one on the inpatient side is capable of starting a peripheral IV, then the hospital should be closed until those people have had remedial training.
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I'm just sayin...in reality...the patient says in the ED until they get an IV. At least where I work. But it's been established prior that I think our hospitalists have too much influence. No hospitalist is going to put in an IV. I actually wonder if they are truly credentialed to do an IV. I haven't seen their contract.
 
MechEDoc said:
SQ, IM and PO medications? I managed a no access obese hyperkalemic and septic patient with SQ insulin, PO hydration, and PO antibiotics. Admit and sort it out later.
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Yeah. No.

You pretty much are limiting yourself to floroquinolones, linezolid, metronidazole. The first two I hate. Much less not giving appropriate fluids. You setting up a disaster in a sick pt.
 
Fox800 said:
The hospitalist is credentialed for peripheral venipuncture, as are the inpatient nurses. If no one on the inpatient side is capable of starting a peripheral IV, then the hospital should be closed until those people have had remedial training.
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Punting? Aren't you also credentialed for starting iv's. What you are saying is we cant do it so you do it for me.
 
This thread is a great example of why the suits are winning over the doctors.

@RustedFox posts a story about being chided by admin for providing perfectly reasonable care (sure, you might not have handled it exactly the same way, but there's no malpractice here). What do we do? We jump all over each other criticizing everything from Nursing School curricula to hospitalists to other EM doc's disposition decisions of hypothetical cases.

Divided we fall.
 
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eikenhein said:
Punting? Aren't you also credentialed for starting iv's. What you are saying is we cant do it so you do it for me.
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If a competent patient meets criteria for admission and refuses an IV, they won’t get one - re: battery.

I know this is shocking, but there are patients currently admitted to the hospital without an IV right now.

Obviously this is not ideal or routine, but it does happen once in a blue moon.
 
WilcoWorld said:
This thread is a great example of why the suits are winning over the doctors.

@RustedFox posts a story about being chided by admin for providing personally reasonable care (sure, you might not have handled it exactly the same way, but there's no malpractice here). What do we do? We jump all over each other criticizing everything from Nursing School curricula to hospitalists to other EM doc's disposition decisions of hypothetical cases.

Divided we fall.
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That’s not the reason the field is composed mostly of “doing everything for your patients” plus being contracted has a lot to do with it. So we stand down nurses band together and are able to become executives and they are also winning the general public over.

The exception is ortho they get treated like royalty.
 
When you don't make money for the hospital, and instead often lose money (us) you can be treated like s*** with impunity.
 
Fox800 said:
If a competent patient meets criteria for admission and refuses an IV, they won’t get one - re: battery.

I know this is shocking, but there are patients currently admitted to the hospital without an IV right now.

Obviously this is not ideal or routine, but it does happen once in a blue moon.
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Of course pt can refuse. Read my post earlier. Just pointing out the point of view of the hospitalist or floor nurse. It's not because they cant put in an iv
 
If people refuse IVs I generally discharge them. Not even sure why we argue with these people. If your complaint is "I have endocarditis" but you are eating/drinking, are afebrile with normal vital signs, you probably don't. Even then we are unable to treat you without an IV/labs so that means there is no reason to keep you in hospital. Thanks, and come back when when you change your mind!
 
I would argue that the malpractice gurus argue that patient's don't have to agree with everything to still be taken care of. If they go home AMA, they can still get discharge papers, prescriptions, and more. You want to show that you are trying your best for the patient, even if they don't agree. You don't want to dismiss them.
 
Dr.McNinja said:
I would argue that the malpractice gurus argue that patient's don't have to agree with everything to still be taken care of. If they go home AMA, they can still get discharge papers, prescriptions, and more. You want to show that you are trying your best for the patient, even if they don't agree. You don't want to dismiss them.
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Correct. I always document refusal of care and give them discharge instructions, follow-up and any appropriate prescriptions. This patient RustedFox mentions, probably wouldn't benefit from being in hospital and could be managed outpatient.
 
CMO is definitely a sell out. Every place I've worked where someone complains and gets sent back to me ends up with an, "Okay, I'd have done the same thing" from my department director/chair after a quick email explaining my reasoning.

I'm pretty good at US guided peripheral IVs, but it's a huge time sink in a busy department, and am doing more long 18 gauge IVs in the IJ when I actually need access but not a central line (I'm eagerly awaiting the first complaint when the floor team actually reads my note and realizes what they've got). That needs someone who will cooperate though, and this lady sounds like she'd keep until the morning.

southerndoc said:
We've taught ours, but they seem to just always punt to the resident when they can't get an IV. There are some nurses that when I work with them, I'm guaranteed to need to do an EJ or have me or charge nurse stick the patient to avoid waiting an hour on the IV team. I used to think she sucks at IV's, but I think she does it to keep patient turnover low so she doesn't have new patients all the time.
Click to expand...

I've never worked in an adult ED or community ED where nurses were allowed to do US guided IVs. ICU and PED, sure, but never adults. I had one or two nurses in residency who asked me to do IVs at a disproportionate rate which magically found access when I'd ask them who had tried and how many times and told them which nurses currently working should try before I'd do it. I'm currently grappling with this at my new job, where I want to play nice in the sandbox but don't totally know which nurses are good and which aren't.

eikenhein said:
Punting? Aren't you also credentialed for starting iv's. What you are saying is we cant do it so you do it for me.
Click to expand...

I get what you're saying, but that's not really the case. The patient doesn't need a central line and there are no expectations the patient needs IV access overnight until the PICC/midline team comes in the AM with little chance of decompensation in the meantime. It also isn't needed in the ED. As an anesthesiologist, do you expect the ED to place any central or arterial lines you'd like in the OR before they come to you?
 
Druggernaut said:
CMO is definitely a sell out. Every place I've worked where someone complains and gets sent back to me ends up with an, "Okay, I'd have done the same thing" from my department director/chair after a quick email explaining my reasoning.

I'm pretty good at US guided peripheral IVs, but it's a huge time sink in a busy department, and am doing more long 18 gauge IVs in the IJ when I actually need access but not a central line (I'm eagerly awaiting the first complaint when the floor team actually reads my note and realizes what they've got). That needs someone who will cooperate though, and this lady sounds like she'd keep until the morning.



I've never worked in an adult ED or community ED where nurses were allowed to do US guided IVs. ICU and PED, sure, but never adults. I had one or two nurses in residency who asked me to do IVs at a disproportionate rate which magically found access when I'd ask them who had tried and how many times and told them which nurses currently working should try before I'd do it. I'm currently grappling with this at my new job, where I want to play nice in the sandbox but don't totally know which nurses are good and which aren't.



I get what you're saying, but that's not really the case. The patient doesn't need a central line and there are no expectations the patient needs IV access overnight until the PICC/midline team comes in the AM with little chance of decompensation in the meantime. It also isn't needed in the ED. As an anesthesiologist, do you expect the ED to place any central or arterial lines you'd like in the OR before they come to you?
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You should get your nurses trained on US guided IVs. Free yourself up to do other things.
 
This story is pretty specific RF. Don't get yourself identified.
 
TooMuchResearch said:
You should get your nurses trained on US guided IVs. Free yourself up to do other things.
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That sounds fantastic, but I'm the newest hire and am already staggered on how unreliable the nurses are in our lower acuity area where this is the biggest problem and where I spend the least of my time. I had an NP admitting a patient with no access to the medicine service recently and the resident asked if the ER doctor could get access before they came up despite not being my patient. The nurse told him it wasn't my patient, but maybe if I wasn't busy and was feeling nice I'd do it. Both of these were true that night, so I got an 18 in and sent them up, but I debated if I should've at least insisted the night float resident come down and see how it's done. I showed the NP how to do it with mixed feelings, who has been talking about branching out to solo rural coverage, but then revealed that she's never even placed a central line other than once during a recent cadaver lab. She just watched me do it, by the way, rather than trying herself first.

The house of medicine is on fire.
 
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