IV or monitors first?

Started by anbuitachi
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I… Don’t really understand your question. Shouldn’t the patient already have an IV by the time they get into the room?

I suppose if you’re working in whatever parallel universe your job seems to exist in, where are you are expected to mop the floor, cook the surgeon lunch, start the IV, braid the circulators hair, and apply the monitors while making less than minimum wage… then I would start the IV first, since I would want the blood pressure cuff on the opposite side (all other things being equal)
 
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Preop nurse or ed nurse places iv before I even see the patient. OR nurse puts on monitors. But nowadays I like to place the monitors myself because some dopey ones take too long/mess up the pulse ox so I can't get a good reading.

Like you op, I trained in NYC so I know all about placing IVs myself (along with doing half of the hospital's work) and it doesn't work like that anywhere else. We even get hot food cooked by a chef for lunch in the Dr's lounge! This is pretty standard everywhere I looked outside of NYC.
 
dr doze said:
Blood pressure cuff is the first monitor on. Cycle it while placing other monitors. Do things in parallel. Also it is the most likely monitor not to work right off the bat.
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97 out of my last 100 monitor irritations or malfunctions when getting a pt hooked up have been pulse ox related.
 
GassYous said:
Preop nurse or ed nurse places iv before I even see the patient. OR nurse puts on monitors. But nowadays I like to place the monitors myself because some dopey ones take too long/mess up the pulse ox so I can't get a good reading.

Like you op, I trained in NYC so I know all about placing IVs myself (along with doing half of the hospital's work) and it doesn't work like that anywhere else. We even get hot food cooked by a chef for lunch in the Dr's lounge! This is pretty standard everywhere I looked outside of NYC.
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But surely you placed the IV in pre-op, right?
 
GassYous said:
It is amazing how little an nyc nurse can do and still get paid for showing up for work
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It's truly a wonderland for nurses. In ICU fellowship, my PGY2 residents who had finished 4 years of college, 4 yrs of med school, 1 yr of internship, taken step 3 and who were technically licensed physicians at that point......were starting almost every IV, drawing every blood culture, drawing many ABGs, holding pressure on pulled central lines, stocking the line cart, and wheeling patients down to CT like a nursing assistant.
 
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GassYous said:
Preop nurse or ed nurse places iv before I even see the patient. OR nurse puts on monitors. But nowadays I like to place the monitors myself because some dopey ones take too long/mess up the pulse ox so I can't get a good reading.

Like you op, I trained in NYC so I know all about placing IVs myself (along with doing half of the hospital's work) and it doesn't work like that anywhere else. We even get hot food cooked by a chef for lunch in the Dr's lounge! This is pretty standard everywhere I looked outside of NYC.
Click to expand...

Hot food by chef?! Where are you again? I am not in nyc, the best I’ve gotten are some cold sandwiches.
 
vector2 said:
It's truly a wonderland for nurses. In ICU fellowship, my PGY2 residents who had finished 4 years of college, 4 yrs of med school, 1 yr of internship, taken step 3 and who were technically licensed physicians at that point......were starting almost every IV, drawing every blood culture, drawing many ABGs, holding pressure on pulled central lines, stocking the line cart, and wheeling patients down to CT like a nursing assistant.
Click to expand...

But that makes it a wonderland for medical students too.
 
vector2 said:
It's truly a wonderland for nurses. In ICU fellowship, my PGY2 residents who had finished 4 years of college, 4 yrs of med school, 1 yr of internship, taken step 3 and who were technically licensed physicians at that point......were starting almost every IV, drawing every blood culture, drawing many ABGs, holding pressure on pulled central lines, stocking the line cart, and wheeling patients down to CT like a nursing assistant.
Click to expand...
Nice to know the NYC hospital system hasn't changed in 35 years.
 
vector2 said:
It's truly a wonderland for nurses. In ICU fellowship, my PGY2 residents who had finished 4 years of college, 4 yrs of med school, 1 yr of internship, taken step 3 and who were technically licensed physicians at that point......were starting almost every IV, drawing every blood culture, drawing many ABGs, holding pressure on pulled central lines, stocking the line cart, and wheeling patients down to CT like a nursing assistant.
Click to expand...

My first day in the icu, I asked an icu nurse (covering one patient) to draw a time sensitive lab. She told me that I should put it for a scheduled phlebotomy time for the tech but told me she would do it for me because I didn't know their usual practice. She said she was being unusually nice to me since it's my first day. Sorry for asking you to do your job I guess?

It went downhill from there.
 
GassYous said:
My first day in the icu, I asked an icu nurse (covering one patient) to draw a time sensitive lab. She told me that I should put it for a scheduled phlebotomy time for the tech but told me she would do it for me because I didn't know their usual practice. She said she was being unusually nice to me since it's my first day. Sorry for asking you to do your job I guess?

It went downhill from there.
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Ahhhh stop, I'm having ptsd flashbacks
 
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Oh I used to put iv preop in residency. But as an attending we put IVs in OR because they look at turnover time on epic which goes until when the patient goes into the room. So if I do IV in holding it looks bad because it prolongs turnover. I actually prefer to do it in the OR since the position is more optimized and stuff are there.
 
anbuitachi said:
Oh I used to put iv preop in residency. But as an attending we put IVs in OR because they look at turnover time on epic which goes until when the patient goes into the room. So if I do IV in holding it looks bad because it prolongs turnover. I actually prefer to do it in the OR since the position is more optimized and stuff are there.
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They track turnover time… but won’t make pre-op nurses place the IV? Lol…

What about the OR nurses? They can’t hook up monitors while you work on the IV?
 
anbuitachi said:
Oh I used to put iv preop in residency. But as an attending we put IVs in OR because they look at turnover time on epic which goes until when the patient goes into the room. So if I do IV in holding it looks bad because it prolongs turnover. I actually prefer to do it in the OR since the position is more optimized and stuff are there.
Click to expand...

You have the worst job on the planet.
 
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IMGASMD said:
Hot food by chef?! Where are you again? I am not in nyc, the best I’ve gotten are some cold sandwiches.
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In CA, it is common practice to get hot meals free in cafeteria or in Drs' Lounge. Whether the meals are prepared by "Chef"or not is another Q. We also get sushi biweekly prepared by Japanese-looking Chef.
 
GassYous said:
It is amazing how little an nyc nurse can do and still get paid for showing up for work
Click to expand...
I did my intern year in medicine at a NYC hospital. On one of my calls, I was in house overnight in the MICU and it was around 6am. We had a few sick patients but there was one who was looking like he'd inevitably code soon. Anyone who's ever worked in the unit knows the kind of situation I'm talking about. The nurses got some epi out of the code box and started giving it themselves, to keep the patient from coding until their shift was over at 7am. They didn't want to have to deal with all that. I then realized I wasn't in Kansas anymore.
 
anbuitachi said:
Oh I used to put iv preop in residency. But as an attending we put IVs in OR because they look at turnover time on epic which goes until when the patient goes into the room. So if I do IV in holding it looks bad because it prolongs turnover. I actually prefer to do it in the OR since the position is more optimized and stuff are there.
Click to expand...

But the patient should have been in preop way before the surgery started. It takes what, two minutes to open an iv kit and place the iv?

Also I find it very hard to believe that you can't place an iv and talk to the patient before the staff cleans the room, opens the trays and sets up the or table.
 
anbuitachi said:
Huh is this a joke. I remember in residency one year they jacked up the price of food by like 40 percent in the OR cafeteria
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Not a joke

I met the chef when he cut a tri tip steak for me personally on some dr appreciation day. Nice guy
Hospital admin was there scooping food for us and telling us thank you. If you told me that this kind of thing happened when I was in residency I would have called you a liar.
 
Ezekiel2517 said:
I did my intern year in medicine at a NYC hospital. On one of my calls, I was in house overnight in the MICU and it was around 6am. We had a few sick patients but there was one who was looking like he'd inevitably code soon. Anyone who's ever worked in the unit knows the kind of situation I'm talking about. The nurses got some epi out of the code box and started giving it themselves, to keep the patient from coding until their shift was over at 7am. They didn't want to have to deal with all that. I then realized I wasn't in Kansas anymore.
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I literally would not believe that except that a good friend of mine is a resident in New York City. So I totally believe that. Blows my mind.
 
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GassYous said:
But the patient should have been in preop way before the surgery started. It takes what, two minutes to open an iv kit and place the iv?

Also I find it very hard to believe that you can't place an iv and talk to the patient before the staff cleans the room, opens the trays and sets up the or table.
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well we have a lot of stuff to do if working alone so it takes time.
bringing the patient to pacu, hooking up monitors, checking BP, closing the record. (if this is straight forward takes about 5-7 mins total). meanwhile as soon as we leave the room, turnover time starts, but also room is being cleaned and nurses setting up shortly.

Then we need to set up the room (minimal setup maybe 3 minutes).

THen we speak to the patient, get consent, put in note in computer... which takes a while, especially if they DONT speak english which is not infrequent.

If we do IV during that, we'd have to gather teh supplies for the IV, which is annoying and adds more time. Preop is not well designed for IV placement. Since it's mostly just a chair.
 
anbuitachi said:
well we have a lot of stuff to do if working alone so it takes time.
bringing the patient to pacu, hooking up monitors, checking BP, closing the record. (if this is straight forward takes about 5-7 mins total). meanwhile as soon as we leave the room, turnover time starts, but also room is being cleaned and nurses setting up shortly.

Then we need to set up the room (minimal setup maybe 3 minutes).

THen we speak to the patient, get consent, put in note in computer... which takes a while, especially if they DONT speak english which is not infrequent.

If we do IV during that, we'd have to gather teh supplies for the IV, which is annoying and adds more time. Preop is not well designed for IV placement. Since it's mostly just a chair.
Click to expand...

Working alone is more efficient than trying to trust some resident or nurse to do something and checking their work

Your pacu nurses don't hook up the monitors?

You can't set up the room after you see the patient? I can set up a room in the time it takes the or nurse to do sign in and move the patient to the table. That takes around 2-3 minutes and I usually have them intubated and ready to go within 5-6 minutes of in the room.

Why can't you write the note for the next guy during the previous case and sign the previous case chart when you're chilling in the next case? Take literally twenty seconds on epic...

What is your out of room to in the room time? In our outpatient centers it is like ten to fifteen minutes but at the main it is easily 45 minutes to an hour (purposefully so they don't get an addon)

I just find it hard to believe that your preop and pacu nurses don't do their jobs at all but somehow your or nurses are a paradigm of efficiency.
 
GassYous said:
Working alone is more efficient than trying to trust some resident or nurse to do something and checking their work

Your pacu nurses don't hook up the monitors?

You can't set up the room after you see the patient? I can set up a room in the time it takes the or nurse to do sign in and move the patient to the table. That takes around 2-3 minutes and I usually have them intubated and ready to go within 5-6 minutes of in the room.

Why can't you write the note for the next guy during the previous case and sign the previous case chart when you're chilling in the next case? Take literally twenty seconds on epic...

What is your out of room to in the room time? In our outpatient centers it is like ten to fifteen minutes but at the main it is easily 45 minutes to an hour (purposefully so they don't get an addon)

I just find it hard to believe that your preop and pacu nurses don't do their jobs at all but somehow your or nurses are a paradigm of efficiency.
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45-1hr turnover time? Gee, hopefully you are salaried. For me on units, I will get crazy.
 
narcotics999 said:
45-1hr turnover time? Gee, hopefully you are salaried. For me on units, I will get crazy.
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It drives me nuts. It is supposed to be 30 minutes. The good nurses do it in 20-30 but there aren't that many. You should see the excuses I get. "Oh the patient had to pee" Except they went already and have been in preop for 2 hours and you took twenty minutes to bring them back for this thirty minute case?
 
dr doze said:
Blood pressure cuff is the first monitor on. Cycle it while placing other monitors. Do things in parallel. Also it is the most likely monitor not to work right off the bat.
Click to expand...
To make that point to new residents, I describe how to prepare an American breakfast where everything is done at the same time. The blood pressure cuff is the hash browns or home fries, the pulse oximeter is the bacon or sausage and the EKG is the eggs. The laugh but they do it in that sequence after my explanation. All patients come to the OR with an IV.
 
anbuitachi said:
well we have a lot of stuff to do if working alone so it takes time.
bringing the patient to pacu, hooking up monitors, checking BP, closing the record. (if this is straight forward takes about 5-7 mins total). meanwhile as soon as we leave the room, turnover time starts, but also room is being cleaned and nurses setting up shortly.

Then we need to set up the room (minimal setup maybe 3 minutes).

THen we speak to the patient, get consent, put in note in computer... which takes a while, especially if they DONT speak english which is not infrequent.

If we do IV during that, we'd have to gather teh supplies for the IV, which is annoying and adds more time. Preop is not well designed for IV placement. Since it's mostly just a chair.
Click to expand...

Don’t you have IV supplies in the anesthesia cart? Why not make up an IV start kit during the previous case? I almost never start my own IVs, but when I do, I get the stuff from the anesthesia cart because we stock non-safety IVs in there and I don’t have to hunt around the preop area where I’m not familiar with their carts

I also chart review and make a preop note during the preceding case and modify it for accuracy after I put the patient to sleep.

Sadly I usually have time to drop off, preop, block, have lunch and poop during our turnovers.
 
Last edited by a moderator:
anbuitachi said:
well we have a lot of stuff to do if working alone so it takes time.
bringing the patient to pacu, hooking up monitors, checking BP, closing the record. (if this is straight forward takes about 5-7 mins total). meanwhile as soon as we leave the room, turnover time starts, but also room is being cleaned and nurses setting up shortly.

Then we need to set up the room (minimal setup maybe 3 minutes).

THen we speak to the patient, get consent, put in note in computer... which takes a while, especially if they DONT speak english which is not infrequent.

If we do IV during that, we'd have to gather teh supplies for the IV, which is annoying and adds more time. Preop is not well designed for IV placement. Since it's mostly just a chair.
Click to expand...

I can tell you I would probably be the most passive aggressive P.O.S. if I were at your place (more likely would have quit on day 2). You have understaffed or lazy nurses and they have you on a stopwatch for turnover time? No thanks. I would be taking dumps and eating multi-course meals in between every case. Unless they are paying you a million bucks, it’s absolutely disrespectful to be timing you and not giving you appropriate staff. How about the surgeon rolls up his sleeve and puts in the IV?
 
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When I came to nyc it was a shock to me too. I rarely put in preop ivs during residency and pacu nurses hooked up monitors in pacu. They don’t do that in nyc academics. I’m in pp nyc so I still do my own Ivs but nurses hook up the monitors in Pacu. Our hospital is private practice but super inefficient so nobody really cares about turnover time except the surgeons.
 
Simba1711 said:
When I came to nyc it was a shock to me too. I rarely put in preop ivs during residency and pacu nurses hooked up monitors in pacu. They don’t do that in nyc academics. I’m in pp nyc so I still do my own Ivs but nurses hook up the monitors in Pacu. Our hospital is private practice but super inefficient so nobody really cares about turnover time except the surgeons.
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It is amazing. All you have to do is let people go when they are done early and amazingly turnover times are super fast with no bs games. But they give people multiple disincentives for a fast turnover and wonder why turnovers take forever/ first time starts suck.
 
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