Heard on the Wards...

[iish]

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I was on the wards today and heard an IM resident really upset that the ED had admitted a patient to his service for IV abx, but had failed to send him to the floor with IV access. This then spiraled into himself, another resident, and 2 med students talking about how stupid people in the ED were. I entirely agree that it is poor form for the ED to admit a patient for IV abx without IV access. When I hear people talk about things like this, I always make sure to see who the resident was that did this. In this case I quickly looked up the patient to see which resident had seen them and then realized that the resident was one of the IM PY3 senior residents. Not one to let this nonsense go unnoticed, I interrupted their BS ranting and told them that it was one of their own that made this grave mistake and that we ED folks would never send someone to the floor without IV access except for the few that may historically require a PICC, but even those only after a solid effort. For some reason I felt compelled to share this story. Pointing this out to them for some reason made my day (I don't know what that says about my day)

 

[QuackaDO]

Strong work! What was their reaction to your discovery?

 

[RustedFox]

Oh, if I only had a nickel....

I still hear it occasionally... that damn DoctorRustedFox admitted this guy and didn't check to see that he had a history of Factor Eleventeen and THAT'S why his coumadin was subtherapeutic and he could have just switched him to Zzarelto and just sent him home!

(Nevermind the fever to 103.3 with no source. LOLZ.)

 

[Spinach Dip]

So, these four individuals were incapable of starting an IV themselves because.....

 

[WilcoWorld]

I was on the wards today and heard an IM resident really upset that the ED had admitted a patient to his service for IV abx, but had failed to send him to the floor with IV access. This then spiraled into himself, another resident, and 2 med students talking about how stupid people in the ED were. I entirely agree that it is poor form for the ED to admit a patient for IV abx without IV access. When I hear people talk about things like this, I always make sure to see who the resident was that did this. In this case I quickly looked up the patient to see which resident had seen them and then realized that the resident was one of the IM PY3 senior residents. Not one to let this nonsense go unnoticed, I interrupted their BS ranting and told them that it was one of their own that made this grave mistake and that we ED folks would never send someone to the floor without IV access except for the few that may historically require a PICC, but even those only after a solid effort. For some reason I felt compelled to share this story. Pointing this out to them for some reason made my day (I don't know what that says about my day)

So…what did they say?

I'm guessing it was something along the lines of "Geez, we've misjudged Emergency Medicine Physicians. They really are a swell bunch of intelligent, contentious and hardworking guys and gals who universally have our patients' interests in mind."

Right?

But seriously, good on ya for calling them on this. I've never admitted someone for IV ABX without administering the first dose in the ED.

 

[WilcoWorld]

(Nevermind the fever to 103.3 with no source. LOLZ.)

How did you fail to figure that out?! The discharge summary clearly proved it to be a "Febrile illness - resolved".

 

[dotcb]

After we obtain US IV access for a patient, they've been admitted and boarding in the ED for 6 hours, their IV blows. The IM team approaches me to ask if we can obtain US-guided IV access on the patient (again). I have to remind them that IV access is a skill necessary in care of the hospitalized patient and that we've moved on to care for new emergency patients...

 

[GeneralVeers]

So…what did they say?

I'm guessing it was something along the lines of "Geez, we've misjudged Emergency Medicine Physicians. They really are a swell bunch of intelligent, contentious and hardworking guys and gals who universally have our patients' interests in mind."

I quite agree with them. We are a contentious bunch, aren't we? I'm always up for a good argument.

 

[gman33]

Anyone who sends you work will get trashed from time to time.
In your future job you will have to work with the same docs over and over.
You can fight and bitch, or try to learn their preferences and work together.
If you can make their life easier, maybe they won't try to block your next weak admission.

 

[WilcoWorld]

I quite agree with them. We are a contentious bunch, aren't we? I'm always up for a good argument.

I should be more conscientious when posting my contentions...

 

[VA Hopeful Dr]

Do keep in mind that the most practiced skill of the medical resident is bitching.


PS: My wife is a medical resident, don't tell her I said that or she'll kill me 🙂

 

[MSmentor018]

nice work on clearing that up. if you don't stop that kind of stuff early it'll spiral out of control

you try not to send people up without access but it happens from time to time. when's the last time you seen an IM resident place a PIV? exactly, they have the RN's do it (the RN already knows to place an iv for abx), or picc team or even the PICU/NICU nurse might float down to help. it just requires a click on the computer orders then it's time for lecture and lunch. worse comes to worse an EJ or god forbid a central line just for abx. sounds like an sense of new generation entitlement...but then I've been doing this a while. If I have time I started placing 1.88 in PIV in the IJ for those really hard pts just for situations like this to help out the IM service, which in turns helps me when I ask them to admit something crappy. you gotta help each other out but the respect on both sides has to be there.

we have an academic center with residents and private services. I don't know how many of you guys have that too but if the residents don't take them, that's fine I call the private service. let's face it, in the real world no one's working for free. usually an admission=money, simple as that. admission for iv abx w good insurance...that's easy money. and with 3-4 days admission, cut and paste computerized charting....that's like printing your own money. it doesn't matter to residents but their attendings sure feel it

 

[gman33]

The SMART EM podcast just discussed an article last month on how many patient have PIVs that never get used.
Something like 40% if I remember correctly.
Patients that need IV medications currently should always have access before they leave the ED.
The rest, not so much.
If the inpatient team decides to start IV therapy, it should be their responsibility to get access.

 

[MSmentor018]

The SMART EM podcast just discussed an article last month on how many patient have PIVs that never get used.
Something like 40% if I remember correctly.
Patients that need IV medications currently should always have access before they leave the ED.
The rest, not so much.
If the inpatient team decides to start IV therapy, it should be their responsibility to get access.

my smart em podcast locked up on my phone. does that PIV use include getting daily blood draws or just med administration?

 

[Bostonredsox]

nice work on clearing that up. if you don't stop that kind of stuff early it'll spiral out of control

you try not to send people up without access but it happens from time to time. when's the last time you seen an IM resident place a PIV? exactly, they have the RN's do it (the RN already knows to place an iv for abx), or picc team or even the PICU/NICU nurse might float down to help. it just requires a click on the computer orders then it's time for lecture and lunch. worse comes to worse an EJ or god forbid a central line just for abx. sounds like an sense of new generation entitlement...but then I've been doing this a while. If I have time I started placing 1.88 in PIV in the IJ for those really hard pts just for situations like this to help out the IM service, which in turns helps me when I ask them to admit something crappy. you gotta help each other out but the respect on both sides has to be there.

we have an academic center with residents and private services. I don't know how many of you guys have that too but if the residents don't take them, that's fine I call the private service. let's face it, in the real world no one's working for free. usually an admission=money, simple as that. admission for iv abx w good insurance...that's easy money. and with 3-4 days admission, cut and paste computerized charting....that's like printing your own money. it doesn't matter to residents but their attendings sure feel it

You have a massive misconception of what life is as a medicine resident at a community hospital. There are no "lectures and lunches" here. All of my roommates from med school are EM residents and they all know I work more hours then they ever dreamed of in their worst nightmares on their longest rotations. Community shop medicine residents are workhorses.

There are no picc nurses here. There are no consult Iv services. And I have been called to the Ed to put many lines in patients the old time Ed doc couldn't manage to get access on because he's too old and crusty to take 5 minutes to learn how to use his brand new ultrasound. I've put more lines in through 2 and a half years of residency then both of the two brand new EM attendings we just got (both just finished EM residency) almost more than their cumulative total. Not all medicine residents and hospitalists wear bow ties, carry clipboards and ask you stupid questions about checking complement levels and whether you checked their cortisol before calling for admission.

It's amazing to me the conception Ed docs and surgeons have of medicine residents and hospitalists when their exposure is limited to academia. In community medicine we are everything. Ed says there's an admit in T2, she's sick, not sure from what but pressures in the 70s so I gave a liter and some zosyn, All yours my shifts over. There are ****ty doctors on both sides, don't generalize against the profession.

 

[gman33]

my smart em podcast locked up on my phone. does that PIV use include getting daily blood draws or just med administration?

Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warburton D. Half of All Peripheral
Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain
With No Gain? Ann Emerg Med. 2013 Apr 23. doi😛ii: S0196-0644(13)00200-X.

10.1016/j.annemergmed.2013.02.022.

Haven't read the article. My impression was that they were talking about any use.

 

[MSmentor018]

You have a massive misconception of what life is as a medicine resident at a community hospital. There are no "lectures and lunches" here. All of my roommates from med school are EM residents and they all know I work more hours then they ever dreamed of in their worst nightmares on their longest rotations. Community shop medicine residents are workhorses.

There are no picc nurses here. There are no consult Iv services. And I have been called to the Ed pt put many lines in patients the old time Ed doc couldn't manage to get access on because he's too old and crusty to take 5 minutes to learn how to use his brand new ultrasound. I've put more lines in through 2 and a half years of residency then both of the two brand new EM attendings we just got (both just finished EM residency) almost more than their cumulative total. Not all medicine residents and hospitalists wear bow ties, carry clipboards and ask you stupid questions about checking complement levels and whether you checked their cortisol before calling for admission.

It's amazing to me the conception Ed docs and surgeons have of medicine residents and hospitalists when their exposure is limited to academia. In community medicine we are everything. Ed says there's an admit in T2, she's sick, not sure from what but pressures in the 70s so I gave a liter and some zosyn, All yours my shifts over. There are ****ty doctors on both sides, don't generalize against the profession.

you're right the lunch/learn thing is academic only (I should have mentioned that) and hospitalist work a ton more hrs than EM. it's all part of the job. academia is well academia. but in the comm mine has a chef that comes in every thur 11-1 for the hosp staff that can get in line. otherwise it's staffed with the usual breakfast time and lunch stuff. everything is consulted out to subspecialist, including critical care service made up of NP/PA's for central line access. the hospitalist purely admits to be the H&P machine. even for the podiatrist. the other comm place i was at would call the ER to send a RN up to do the hard IV"s. i m sure there's something that's been done and authorized by the nursing staff before calling you to do a central line

its funny you said about going to the ED for the gray headed EM docs. part of my contract is flying around the country teaching the older EM guys this new invention called the ultrasound. standard of care is changing and those crusty guys gotta change with it. i went to a place that would just drill I/O's then send'em up to you. sorry you're getting dumped on, that's an incredible amount of lines. i had w 14's in I'd leave them alone but if the gomer's getting pressures then they should be putting the line in. if they're that sick, call them on it. if its just abx administration, let it go

 

[Groove]

Always poor form to admit without IV access. It just looks bad all around with potential for badness (code blue in the elevator?) so the accepting service complaining are warranted IMO. If my nurses can't get it, I'm reticent to dilate and throw a triple lumen in a patient who simply needs access. I'll either US a long (1.8-2.0'') PIV to a deep brachial or just get creative. I put an art cath in a ladies IJ just other day for this reason. If they want to re-wire, dilate and upgrade to a triple, go for it, but at least they got access.