Multiple Critical Patients During Single Coverage

[RoyBasch]

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I am a relatively young attending, and like many of you the majority of my night shift is single coverage. Every few months it seems I have a single coverage night shift that has a category five **** storm hit with multiple critical patients arriving within 60-120 minutes of each other. Each patient requiring intubation, ventillation, multiple medications, +/- central line (they always have difficult vascular access), and moment to moment fluctuations in status requiring frequent reassessment. Objectively this is a difficult situation; but I'm wondering if some of you guys have some "master level" moves for making it more manageable.

I have attempted to call in the hospitalists and intensevists (home call) to come to the ER so they can continue to manage one case while I manage the other, but they simply refuse to come in and say they won't come in to manage a patient I am capable of managing.

I have also attempted unsuccessfully putting the ER on diversion but EMS comes anyways saying "patient is too critical to make it to the next ER."

I do try to write admission orders quickly to move the patient up to the ICU but I don't feel that good about a patient going upstairs to the ICU not maximally stabilized without another physician or provider directly accepting the handoff where they can continue to resuscitate the patient.

 

[d2305]

I would think that a facility with an ICU would have more than single coverage. Do you have any PA/NP?

 

[WilcoWorld]

This doesn't address the real issues, but if you're really strapped consider delaying the fastidiously placed neck line. An IO or a crash fem line are both appropriate temporizing measures as long as you get them swapped out once the dust settles.

 

[deleted547339]

What kind of lines are you putting in? Having RN places PICCs or midlines could help. Also, doing blind subclavian or fem is faster than dealing with the US. But it sounds like your ER needs better staffing.

 

[Angry Birds]

I am a relatively young attending, and like many of you the majority of my night shift is single coverage. Every few months it seems I have a single coverage night shift that has a category five **** storm hit with multiple critical patients arriving within 60-120 minutes of each other. Each patient requiring intubation, ventillation, multiple medications, +/- central line (they always have difficult vascular access), and moment to moment fluctuations in status requiring frequent reassessment. Objectively this is a difficult situation; but I'm wondering if some of you guys have some "master level" moves for making it more manageable.

I have attempted to call in the hospitalists and intensevists (home call) to come to the ER so they can continue to manage one case while I manage the other, but they simply refuse to come in and say they won't come in to manage a patient I am capable of managing.

I have also attempted unsuccessfully putting the ER on diversion but EMS comes anyways saying "patient is too critical to make it to the next ER."

I do try to write admission orders quickly to move the patient up to the ICU but I don't feel that good about a patient going upstairs to the ICU not maximally stabilized without another physician or provider directly accepting the handoff where they can continue to resuscitate the patient.

If you really have such a chaotic situation frequently--ever few months--then, here are the possibilities I can think of:

1) The problem might be you. I find that Category 5 **** storms happen to the crappy attendings who can't move the meat. They let patients pile up because of holding on to them too long. Then, when the crashing patient hits the door, this makes **** hit the fan. The key is to move the meat so that when the crashing patient arrives you have the resources to focus on that patient and that patient alone. Using the **** analogy: think of each patient as a turd. You have to keep taking the turds out. Otherwise, the turds pile up, and then they become a big stinking pile of turds. Then, when the crashing turd comes in, the **** hits the fan, since it has nowhere else to go.

2) The problem might be me. I might just be recoiling at your situation since I don't work at such a busy shop as you. In fact, I specifically left an ER gig because I was getting burnt out from how busy it was. I could handle it, and moved the meat, but it burned me out, and I would come home a completely drained shell of a person. So, I left and picked a place with much lower volume, and I love it. Only once at my new place have I had two crashing patients at the same time, and I managed it by prioritizing ABC's and being efficient.

3) The problem might be your hospital. This is likely what it is. If this happens regularly, ask yourself: why the **** am I still working here? Your shop is likely understaffed if you routinely feel like this.

Lastly, I'll reinforce what I said above by saying that I'd die before begging the hospitalist or ICU doctor to help me out, or even an ER colleague who is off duty. That's embarrassing. And if it's really not your fault, then it's still your fault, since you shouldn't work at a place that puts you in that situation. You might as well ask the patients if any of them have seen Scrubs or Grey's Anatomy, and if so, to put on a steth and help you out.

 

[TooMuchResearch]

This doesn't address the real issues, but if you're really strapped consider delaying the fastidiously placed neck line. An IO or a crash fem line are both appropriate temporizing measures as long as you get them swapped out once the dust settles.

And the ICU or accepting facility can typically handle that task.

 

[BoardingDoc]

+/- central line (they always have difficult vascular access)

If you're putting in a CVL just because of difficult vascular access and not because they need it for some other reason, you should be putting in an US guided peripheral line. If you don't know how to do one/aren't good at them, start practicing them on your shifts when you're not as busy.
If that fails/blows repeatedly/whatever: put a long 18g into their IJ. Or drill an IO. Either way, I can think of very few cases where one or all of these alternatives wouldn't work at least until things calmed down.

Also, just because the patient is on pressors doesn't mean that they immediately need a CVL. If you've got a working PIV and you're running levo, that's fine. Put the CVL in later, or if you're absolutely getting murdered, explain it to the hospitalist and have them get the PICC team to come in and do it in the ED or upstairs.

 

[RoyBasch]

put a long 18g into their IJ. Or drill an IO. Either way, I can think of very few cases where one or all of these alternatives wouldn't work at least until things calmed down.

Also, just because the patient is on pressors doesn't mean that they immediately need a CVL. If you've got a working PIV and you're running levo, that's fine. Put the CVL in later, or if you're absolutely getting murdered, explain it to the hospitalist and have them get the PICC team to come in and do it in the ED or upstairs.

These are the two solutions I opted for ultimately. "Easy IJ" in patient with no other access after a few attempts at peripheral US guided line. And then in another patient with good PIVs ran pressors through them and requested a stat PICC when the team arrived in the morning.

 

[Angry Birds]

If you're putting in a CVL just because of difficult vascular access and not because they need it for some other reason, you should be putting in an US guided peripheral line. If you don't know how to do one/aren't good at them, start practicing them on your shifts when you're not as busy.

Pretty soon your nurses will start sucking at putting in peripheral IV's and come to you asking, "do you think you can try with ultrasound?"

 

[Hercules]

I would think that a facility with an ICU would have more than single coverage. Do you have any PA/NP?

Not at night. I’m in a 60k ED with 3 ICUs. We drop down to solo doc coverage with no PAs from 3a-8a and single doc coverage with a PA from 12a-12p.


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[shoal007]

That's plain stupid (one doc overnight with 60k pt) . My shop is 35k and coverage overnight md and app. ****show on my overnight shifts happen once every couple months at most

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[Hercules]

That's plain stupid (one doc overnight with 60k pt) . My shop is 35k and coverage overnight md and app. ****show on my overnight shifts happen once every couple months at most

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To each their own. We determine our own staffing and coverage, and we’re very happy. Our volume drops off after about 3A to only about 2pph so it works for us. So far the pain of the solo time has been vastly outweighed by having less of our hours as night shifts because nights suck no matter how you slice it.

By the same logic we do 3 tens on the weekends instead of our 4 eights on weekdays. We all vastly prefer short 8 hr shifts but having the extra weekend shifts off every month is worth it to us.

That’s the great thing about determining your own coverage. You decide what’s important.


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[BoardingDoc]

Pretty soon your nurses will start sucking at putting in peripheral IV's and come to you asking, "do you think you can try with ultrasound?"

Overblown fear and a poor reason to avoid learning a new skill IMHO. I've only had nurses ask me to do US guided lines a handful of times where I felt it wasn't warranted. In those cases I simply ask how many times they tried, and how many times the second nurse tried. If they are going through proper steps, help them out. If they aren't, tell them to do their job. I have no problem with either scenario.

 

[GeneralVeers]

Don't waste your time with central lines if your ED is clogged. I rarely do them anymore at all. Multiple critical patients? Quickly assess, get an IO line, write your fluids, pressors, meds and orders, and move on to the next one. Honestly the time it would take me to asses, get an IO, and write orders is about 2 minutes. Nurses can be implementing your orders while you move on to the next patient. As soon as I have enough labs to admit, I put the admit order in for the ICU, and have the secretary page the ICU attending.

 

[Angry Birds]

Overblown fear and a poor reason to avoid learning a new skill IMHO. I've only had nurses ask me to do US guided lines a handful of times where I felt it wasn't warranted. In those cases I simply ask how many times they tried, and how many times the second nurse tried. If they are going through proper steps, help them out. If they aren't, tell them to do their job. I have no problem with either scenario.

I am a recent grad, so u/s guided IV's were a part of our training. Admittedly, this skill has atrophied, since I don't use it. I think it's a very time-consuming process--despite what its advocates claim. Getting the u/s machine, wiping everything down, plugging things in, etc., average time is probably 20 minutes from the time you think about this to the time you put the u/s machine back. Twenty minutes is a long time.

I'd rather pop an EJ in. Or, the easy IJ.

Don't waste your time with central lines if your ED is clogged. I rarely do them anymore at all. Multiple critical patients? Quickly assess, get an IO line, write your fluids, pressors, meds and orders, and move on to the next one. Honestly the time it would take me to asses, get an IO, and write orders is about 2 minutes. Nurses can be implementing your orders while you move on to the next patient. As soon as I have enough labs to admit, I put the admit order in for the ICU, and have the secretary page the ICU attending.

I don't agree with this either. I've never had good results with an IO. I just don't think it suffices with regard to a crashing patient. Maybe a temporizing measure--and even then, I'll ask the EMT to place it while I work on a real line. A central line in a crashing patient is a game-changer in my opinion. Maybe just my experience. Shrug.

I don't do IO's or u/s-guided peripheral IV's. I use EJ's, easy IJ's, and central lines. (I guess everyone has their own preferences.)

 

[GeneralVeers]

I am a recent grad, so u/s guided IV's were a part of our training. Admittedly, this skill has atrophied, since I don't use it. I think it's a very time-consuming process--despite what its advocates claim. Getting the u/s machine, wiping everything down, plugging things in, etc., average time is probably 20 minutes from the time you think about this to the time you put the u/s machine back. Twenty minutes is a long time.

I'd rather pop an EJ in. Or, the easy IJ.



I don't agree with this either. I've never had good results with an IO. I just don't think it suffices with regard to a crashing patient. Maybe a temporizing measure--and even then, I'll ask the EMT to place it while I work on a real line. A central line in a crashing patient is a game-changer in my opinion. Maybe just my experience. Shrug.

I don't do IO's or u/s-guided peripheral IV's. I use EJ's, easy IJ's, and central lines. (I guess everyone has their own preferences.)

You are correct. It is temporizing. The OP's dilemma was what to do with multiple crashing or critical patients. My answer is IO to get things rolling and move on. If I'm busy, single coverage, and the nurses are able to get two decent peripheral lines, I leave the central line up to the ICU the next morning.

 

[TheComebacKid]

I am a recent grad, so u/s guided IV's were a part of our training. Admittedly, this skill has atrophied, since I don't use it. I think it's a very time-consuming process--despite what its advocates claim. Getting the u/s machine, wiping everything down, plugging things in, etc., average time is probably 20 minutes from the time you think about this to the time you put the u/s machine back. Twenty minutes is a long time.

I'd rather pop an EJ in. Or, the easy IJ.

I've never done an easy IJ so forgive me, but essentially it's still an ultrasound guided procedure, right? if that's the case, how do you save any time? seems like it would take just as long as doing a peripheral US guided IV.

 

[GeneralVeers]

I've never done an easy IJ so forgive me, but essentially it's still an ultrasound guided procedure, right? if that's the case, how do you save any time? seems like it would take just as long as doing a peripheral US guided IV.

Actually it's way faster. The IJ is always visible on US. I can do one in < 5 minutes. However I work in an area of the country where no one has a neck, so it makes IO an easier option.

 

[The White Coat Investor]

I am a relatively young attending, and like many of you the majority of my night shift is single coverage. Every few months it seems I have a single coverage night shift that has a category five **** storm hit with multiple critical patients arriving within 60-120 minutes of each other. Each patient requiring intubation, ventillation, multiple medications, +/- central line (they always have difficult vascular access), and moment to moment fluctuations in status requiring frequent reassessment. Objectively this is a difficult situation; but I'm wondering if some of you guys have some "master level" moves for making it more manageable.

I have attempted to call in the hospitalists and intensevists (home call) to come to the ER so they can continue to manage one case while I manage the other, but they simply refuse to come in and say they won't come in to manage a patient I am capable of managing.

I have also attempted unsuccessfully putting the ER on diversion but EMS comes anyways saying "patient is too critical to make it to the next ER."

I do try to write admission orders quickly to move the patient up to the ICU but I don't feel that good about a patient going upstairs to the ICU not maximally stabilized without another physician or provider directly accepting the handoff where they can continue to resuscitate the patient.

Time to increase coverage. If that isn't in your power, change jobs before you kill someone or get sued.

You can put the central lines off to the intensivist. If they complain about you giving levophed through a peripheral, tell them to come in and do it when you call next time.

 

[emergentmd]

That's plain stupid (one doc overnight with 60k pt) . My shop is 35k and coverage overnight md and app. ****show on my overnight shifts happen once every couple months at most

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Not unusual or dangerous. I have worked at many 50K+ ER all with ICUs and they all had single coverage a part of the nights. Maybe a midlevel floating around but they really don't help with crashing patients.

We have all been through this, and if you are a good EM doc should be able to handle this. I had this recent day with single coverage at night all come in about 15 min.

1. Flash pulmonary edema, hypoxic, prob will crash soon - Pan Lab/Xray intubate (5 min Physically in room)
2. Unresponsive 2 yr old without a clear cause carried in by parents - Labs, CT head, IV fluids (5 min in room)
3. CPR in progress with return of circulation with a Igel tube in - Changed out Tube, Central line/cooling catheter, pan labs/CXR (15 min in room)
4. Seizure in Status. - Pan labs, intubated (5 min in room)

#1,3,4 admitted to ICU after labs back. #2 workup neg, appeared well, admitted for Obs. had all of these patients admitted in about 1 hr.

Truthfully crashing patients are much easier than patients that are sick and I have no clue what is going on. These crashing pts are pan labs/xray, stabilize, admit.

 

[emergentmd]

I've never done an easy IJ so forgive me, but essentially it's still an ultrasound guided procedure, right? if that's the case, how do you save any time? seems like it would take just as long as doing a peripheral US guided IV.

I do femoral lines. 10 min in and out. I am sure some hates them, but I am there to stabilize and they can change it out or put in a PICC upstairs.

 

[southerndoc]

10 minutes? Am I missing something? I can put an IJ in <5 and a femoral in <2.

 

[gamerEMdoc]

I got you beat. I can put in an IO in 10 seconds and don't have to be sterile. 🙂

 

[Birdstrike]

I am a relatively young attending, and like many of you the majority of my night shift is single coverage. Every few months it seems I have a single coverage night shift that has a category five **** storm hit with multiple critical patients arriving within 60-120 minutes of each other. Each patient requiring intubation, ventillation, multiple medications, +/- central line (they always have difficult vascular access), and moment to moment fluctuations in status requiring frequent reassessment. Objectively this is a difficult situation; but I'm wondering if some of you guys have some "master level" moves for making it more manageable.

I have attempted to call in the hospitalists and intensevists (home call) to come to the ER so they can continue to manage one case while I manage the other, but they simply refuse to come in and say they won't come in to manage a patient I am capable of managing.

I have also attempted unsuccessfully putting the ER on diversion but EMS comes anyways saying "patient is too critical to make it to the next ER."

I do try to write admission orders quickly to move the patient up to the ICU but I don't feel that good about a patient going upstairs to the ICU not maximally stabilized without another physician or provider directly accepting the handoff where they can continue to resuscitate the patient.

If this is happening occasionally, then my response is, "Welcome to Emergency Medicine." If it's every shift, to the extent that the acuity and volume are to severe to handle by one competent doctor, then your department simply may just need to extend your double coverage. But in general, you should be able to handle two critical patients simultaneously, most nights. If it's 5 dying patients, simultaneously, every night, then you need more coverage.

And you said in your own words, that you are new. So don't worry, you'll get better at this. It takes time, and there's still a lot of learning to do the first few years after residency. But having single covered busy EDs at night, countless times, I think I can honestly say that solo covering an ED at night, is one of the toughest things anyone in medicine has to do. Very few human beings, and most physicians for that matter, have what it takes to even sign up for this, let alone do it well, or at all. So give yourself some credit where credit is due, which as physicians (especially EM physicians) we rarely do. You're a total bada$s. This is the stuff heroes are made of.

 

[d2305]

It sounded like there was no one in the ICU to admit the Pt.

 

[gamerEMdoc]

It sounded like there was no one in the ICU to admit the Pt.

Also check your hospital medical staff bylaws. Typically a consultant can not refuse to come to the ED if consulted. If gou ask nicely and say “could you come in and help me” they are going to say no. But if you say “im consulting you, i need you to come see this patient in the Ed” and they refuse, then often times that’s a terminal offense. And if the patient is unstable and they are refusing to help, this goes beyond hospital bylaws and is an EMTALA violation. I wouldnt be abusing this, obviously, but if you need the consultants help and its to the detriment of patient care when they refuse, Id report them to admin.

 

[Arcan57]

OP, I’m going to summarize what I took away from your post:
1) You occasionally have a temporarily high volume of critical patients at times when you’re the only doctor.
2) You feel overwhelmed by these surges.
3) You’re attempts to change #1 (by limiting patient volume or getting another doc) when on shift are not successful.

Since you say this is only happening every 3rd month of so, I’d say it doesn’t seem like staffing is the problem.

It does seem like you haven’t internalized a sense of competence in managing multiple critical patients simultaneously. This is a problem that needs to be addressed in a proactive fashion. Failure to do so results in becoming “that doc” and loss of nursing confidence.

The good news:
1) This is a learnable skill.
2) This may have nothing to do with your knowledge base or skill set.

The other posts give good advice. They’re also all ways of dealing with one of the most common problems we face in dealing with multiple critical patients: our own expectations.

We are trained in and the leaders of our field perpetuate the idea that we are master resuscitationists. Listen to any of the EM critical care podcasts and you’ll get the idea that any critical patient requires constant bedside attention and that stepping away for even a minute is sentencing the patient to death. Does this approach lead to an intellectually cleaner look to the ED care? Absolutely. Does it lead to significantly improved patient outcomes in the absence of a system built around providing critical care? Who knows?

Letting go of the expectation that you have to be constantly at bedside in order to provide quality care to the patient will go a long way towards destressing during these situations. Hit the must do actions - restore or maintain oxygenation, ventilation, and perfusion. Identify if a consultant is needed to perform a procedure you can’t (STEMI, herniating ICH, ruptured AAA, etc) and if so make the call immediately. Get things started on the next patient then come back and reassess if your interventions have been done and what their effects have been on the patient. Does supervising the nurses drawing blood, changing patient into gown, transferring patient to travel monitor, and putting in the life saving foley really require your time?

TLDR; don’t freak out, you can handle it if you compartmentalize care into the critical actions

 

[turkeyjerky]

10 minutes? Am I missing something? I can put an IJ in <5 and a femoral in <2.

Either you're a Jedi or you're getting some help that not all of us can count on. I'd say you're times are achievable once a patient is draped and equipment is set up, but I typically have to do that myself, and this is by far the most time consuming aspect

Arcan's and Emergent's posts are spot on. Most critical patients don't really require nearly as much bedside time as we typically give them. You don't need to be in the room watching RT set up Bipap. You don't need to stand bedside waiting for rads to come shoot the cxr on the trauma. Obviously most of the time you will be under usual conditions, but if there's someone else to see then you leave the bedside.

I definitely would not expect anyone else to come in to assume management of typical critical patients in the ER. However, you can definitely move not completely optimized patients up the the ICU, and at that point the CC doc might just have to come in.

 

[RoyBasch]

Thank you everybody for your replies. I think the two most useful takeaways are:

-placing fewer CVCs (I only did one that night, but probably coulda gotten away with a 2nd easy IJ and placed none). The procedure itself is fast, but its the finding the US, prepping, draping, etc. That is much slower than actually canulating the vein and placing the line. This is something I really need to be phasing out of my community practice except in select--and very infrequent--situations.

Although I still have resident's place them frequently at my teaching facility as I think it's good for their training. Most residents want/need procedures and there is lots of coverage to see other patients while they are in the procedure.

-Just spending less time at the bedside, even in critical patients the time it takes for actions to be implemented and the patient to respond (i.e. RN starts blood/fluid, it goes in, labs/radiology drawn/done and resulted etc.) is a longer interval than I think and I can afford to be away from the bedside longer than I think while waiting for status changes as a result of actions.

 

[southerndoc]

Also check your hospital medical staff bylaws. Typically a consultant can not refuse to come to the ED if consulted. If gou ask nicely and say “could you come in and help me” they are going to say no. But if you say “im consulting you, i need you to come see this patient in the Ed” and they refuse, then often times that’s a terminal offense. And if the patient is unstable and they are refusing to help, this goes beyond hospital bylaws and is an EMTALA violation. I wouldnt be abusing this, obviously, but if you need the consultants help and its to the detriment of patient care when they refuse, Id report them to admin.

It doesn't matter if they are stable or not, if you request a consult and the consulted doesn't see the patient, it's an EMTALA violation.

"Stable" by CMS standards is not stable by EM standards. A patient with a distal radius fracture that is not reduced is certainly not unstable by our view as their vital signs are normal, they're not in distress, etc. However, CMS considers this a medical emergency and their condition has not been stabilized. Stabilized in the eyes of CMS means treated. Stable appy that goes home on antibiotics instead of to the OR? Not definitively treated (despite recent literature); therefore, EMTALA violation. Admit an esophageal food obstruction overnight instead of having GI see patient immediately and they suffer a complication? EMTALA violation. "Worst headache of life" that doesn't get a CT? EMTALA violation.

Seriously, you'd be amazed at what is considered stabilizing treatment by CMS. Attend one of their EMTALA conferences and it'll change the way you practice.

 

[BAM!]

I would think that a facility with an ICU would have more than single coverage. Do you have any PA/NP?

you think wrong!

 

[BAM!]

10 minutes? Am I missing something? I can put an IJ in <5 and a femoral in <2.

You know you're supposed to use sterile technique, right?

 

[BAM!]

Are a lot of you placing Easy IJ's? What kind of success is everyone having?

This is the first I've heard of the Easy IJ. I've always thought about putting a short 18ga "peripheral catheter" into the IJ but never did because I thought it would kink or I'd get into trouble somehow.

 

[Angry Birds]

I've never done an easy IJ so forgive me, but essentially it's still an ultrasound guided procedure, right? if that's the case, how do you save any time? seems like it would take just as long as doing a peripheral US guided IV.

GeneralVeers answered this question for me (although I hate IO's):

Actually it's way faster. The IJ is always visible on US. I can do one in < 5 minutes. However I work in an area of the country where no one has a neck, so it makes IO an easier option.

But yeah, I agree that the easy IJ is way easier and faster than getting a peripheral IV due to the much larger target.

10 minutes? Am I missing something? I can put an IJ in <5 and a femoral in <2.

Yeah, so I think you're perceiving time differently. There is absolutely no way that you can put a femoral line in <2 minutes. At least not how I count the time (which is the correct way to think about the issue). I start the clock the moment the thought/decision is made to do an action and I stop the clock at the time that the last step of that process is completed (and the next action is performed). So, unless you are a genie, there is no way that a femoral line is in place two minutes after you think of putting it in. In fact, I don't even have a table and a femoral line kit brought to me in two minutes. If you actually count the minutes, it usually takes 10 minutes to even start the procedure, let alone finish it.

Even the mechanical procedure itself, no way you are doing it in <2 minutes. I just don't believe it. It takes longer than that to do a peripheral IV, let alone a central line. I'm not doubting that you are fast. I just think you're perceiving time incorrectly. Like when you tell your buddy, "I'll be there in 2 minutes" but you're really there in 10 minutes....

Either you're a Jedi or you're getting some help that not all of us can count on. I'd say you're times are achievable once a patient is draped and equipment is set up, but I typically have to do that myself, and this is by far the most time consuming aspect

Exactly.

Arcan's and Emergent's posts are spot on. Most critical patients don't really require nearly as much bedside time as we typically give them. You don't need to be in the room watching RT set up Bipap. You don't need to stand bedside waiting for rads to come shoot the cxr on the trauma. Obviously most of the time you will be under usual conditions, but if there's someone else to see then you leave the bedside.

I definitely would not expect anyone else to come in to assume management of typical critical patients in the ER. However, you can definitely move not completely optimized patients up the the ICU, and at that point the CC doc might just have to come in.

Very good points!

Thank you everybody for your replies. I think the two most useful takeaways are:

-placing fewer CVCs (I only did one that night, but probably coulda gotten away with a 2nd easy IJ and placed none). The procedure itself is fast, but its the finding the US, prepping, draping, etc. That is much slower than actually canulating the vein and placing the line. This is something I really need to be phasing out of my community practice except in select--and very infrequent--situations.

You might consider not putting in a CVC now and then, but for the most part, CVC's can be game changers in my opinion. But, you could delay putting one in while taking care of your other sick/crashing patient.

I'm all about bang for my buck. I feel like CVC's are time consuming but the benefits are great. Meanwhile, I find u/s guided peripheral IV's time consuming and not as good, in which case you might as well put in an easy IJ. And IO's are mighty quick, but I find them to be too crappy to rely on.

 

[southerndoc]

You know you're supposed to use sterile technique, right?

The 2 minutes is with sterile technique. Seriously, it doesn't take that long to throw in a line. Granted, the ultrasound, kit, etc. are at the bedside when I do one. I tell the nurse and everything appears within about 2-3 minutes. One of the pluses of working at a great department.

If I'm doing a femoral line (unless it's an Icy-Cath or Vas-Cath), then they get Chlorhexadine and sterile gloves. +/- drape. Femoral lines are crash lines for me -- usually for cardiac arrest patients or trauma patients (Cordis). Although even with trauma, usually I put in a subclavian Cordis and it's not always under the most sterile conditions.

 

[emergentmd]

I would love to see anyone do a 2 Min central line under sterile conditions even in the most optimal condition. Even at 5 min, its pushing it.

Drape/prep - 1 min
Access Fem V - 30 sec
Guidewire/dilator - 1min
insert central line and flush - 1 min
Suture in place - 1 min.

 

[Angry Birds]

I would love to see anyone do a 2 Min central line under sterile conditions even in the most optimal condition. Even at 5 min, its pushing it.

Drape/prep - 1 min
Access Fem V - 30 sec
Guidewire/dilator - 1min
insert central line and flush - 1 min
Suture in place - 1 min.

Seriously. I want it timed and videotaped, and then put in Guinness if it really can be done in 2 minutes.

And, you didn't even list off getting a table, the tray, gloves, flushes, gowning, yelling at a nurse, etc. etc.

 

[southerndoc]

Seriously. I want it timed and videotaped, and then put in Guinness if it really can be done in 2 minutes.

And, you didn't even list off getting a table, the tray, gloves, flushes, gowning, yelling at a nurse, etc. etc.

Perhaps you should work at a place where the nurses set everything up. It doesn't take a minute to drape a patient? It doesn't take a minute to insert a guidewire, incise, and dilate. We use STAT-Locks instead of suturing.

 

[deleted547339]

Perhaps you should work at a place where the nurses set everything up. It doesn't take a minute to drape a patient? It doesn't take a minute to insert a guidewire, incise, and dilate. We use STAT-Locks instead of suturing.

I’m on AngryBirds side. I’m sure you’re quick, but most people think they are quicker than they are. I supervise residents who spend 30 mins doing a procedure and think it takes 10-15. Again, not saying that you’re not exceptionally fast, but I’d be shocked if it objectively took substantially under 5 mins, even if set up for you.

 

[GeneralVeers]

An US-guided IJ takes me 30 minutes from setup to dressing placement. Even a crash femoral takes me 10 minutes including setup.

I wish I had the line skills of some of you!

 

[BoardingDoc]

Perhaps you should work at a place where the nurses set everything up. It doesn't take a minute to drape a patient? It doesn't take a minute to insert a guidewire, incise, and dilate. We use STAT-Locks instead of suturing.

Set a timer next time you do an IJ and let us know what the clock says. I'm sure you're fast. I'd be very surprised if you're as fast as you think you are. Gown, gloves, kit setup, draping, us probe cover, needle, wire, dilate, line, suture... In 5 minutes?

 

[Angry Birds]

Set a timer next time you do an IJ and let us know what the clock says. I'm sure you're fast. I'd be very surprised if you're as fast as you think you are. Gown, gloves, kit setup, draping, us probe cover, needle, wire, dilate, line, suture... In 5 minutes?

I agree. And start the clock like I said: the moment you make the decision to place a line.

 

[southerndoc]

I agree. And start the clock like I said: the moment you make the decision to place a line.

I will time it next time. I don't factor in getting the equipment. I don't do that, the nurse does. I will time it from the time I walk into the room to start it.

We have a nurse practitioner that puts in lines that is even quicker than I am. I swear you blink and she has a line in place.

 

[Psai]

I’m on AngryBirds side. I’m sure you’re quick, but most people think they are quicker than they are. I supervise residents who spend 30 mins doing a procedure and think it takes 10-15. Again, not saying that you’re not exceptionally fast, but I’d be shocked if it objectively took substantially under 5 mins, even if set up for you.

Every surgical resident ever will tell me that their operation will be 2 or 3 hours and invariably it's twice as long.

 

[emergentmd]

I will time it next time. I don't factor in getting the equipment. I don't do that, the nurse does. I will time it from the time I walk into the room to start it.

We have a nurse practitioner that puts in lines that is even quicker than I am. I swear you blink and she has a line in place.

I will give you full nursing support, and start the time when you place the first drop of betadine. Stop when you secure the line. Do it in 2 min, tape it for me, and I will be always beholden to you.

I think 5 min is the fastest I could do in a crash pt if everything goes extremely well.

 

[Janders]

I put a full sterile line in <2min once...

Got called to the ICU for an urgent femoral CVL [overnight, no intensivist or gen surg available]. There was a surgical PA who had seen a couple, but wasn't signed off to do it solo. So I asked them to set up everything for me, and I'd come up in 10 minutes.

10 minutes pass, I bolt upstairs. I walk in the room-- patient draped, prepped, sedated, PA is standing there fully gowned/gloved, has my gown and gloves ready to go and even helps me get dressed. The CVL kit is even unpackaged and laid out in order, and the CVL proper is flushed with saline already! I felt like a surgeon in the OR. Needle to vein, wire to needle, nick skin, dilate, slide line over wire and pull wire out. Flushed the brown port. PA says "thanks a ton, I can suture it in and put the dressing on."

I walk downstairs whistling dixie, easiest procedure EVER.

Back to my usual environment where I'm trying to find a trashcan lid to use as a table to balance my kit on while screaming for someone to bring me a sterile flush since I dropped mine somewhere under a panus.

 

[Cinclus]

Back to my usual environment where I'm trying to find a trashcan lid to use as a table to balance my kit on while screaming for someone to bring me a sterile flush since I dropped mine somewhere under a panus.

This describes almost every central line I've ever done. I usually use the soiled linens bin as my "table," and I often manage to drop things through the tiny part of the adhesive circle on the drape that is not fully adhered to the patient.

 

[GeneralVeers]

This describes almost every central line I've ever done. I usually use the soiled linens bin as my "table," and I often manage to drop things through the tiny part of the adhesive circle on the drape that is not fully adhered to the patient.

For me The challenge is finding the sterile probe cover. It is never in the same spot and 50% of the time I end up using a sterile glove with non-sterile US gel stretched over the probe and hope it is sterile enough that the patient doesn't get an infection.

If I worked in a place where everything was set up and draped so I could stealth in and place a line in 5 min I would do a lot more of them. Sadly I never have worked at a place with that experience so I avoid lines like the plague

 

[anbuitachi]

I put a full sterile line in <2min once...

Got called to the ICU for an urgent femoral CVL [overnight, no intensivist or gen surg available]. There was a surgical PA who had seen a couple, but wasn't signed off to do it solo. So I asked them to set up everything for me, and I'd come up in 10 minutes.

10 minutes pass, I bolt upstairs. I walk in the room-- patient draped, prepped, sedated, PA is standing there fully gowned/gloved, has my gown and gloves ready to go and even helps me get dressed. The CVL kit is even unpackaged and laid out in order, and the CVL proper is flushed with saline already! I felt like a surgeon in the OR. Needle to vein, wire to needle, nick skin, dilate, slide line over wire and pull wire out. Flushed the brown port. PA says "thanks a ton, I can suture it in and put the dressing on."

I walk downstairs whistling dixie, easiest procedure EVER.

Back to my usual environment where I'm trying to find a trashcan lid to use as a table to balance my kit on while screaming for someone to bring me a sterile flush since I dropped mine somewhere under a panus.

I mean it really depends on what you consider a full sterile line. Technically you only did part of the process.
All these people saying they did it in <2 min sterile is either skipping parts or not doing it correctly. How long did you wash your hands for? Hand washing alone is supposed to take ~30-40 seconds. You also have to wait for prep to dry. And this doesn't apply for emergencies obviously, but if just for difficult IV access, aren't you supposed to get consent/explain the procedure , risk, benefit, etc for central lines?? Not sure how it works in the ED.
Also if you are using 3ml Chlorapreps to prep, you are supposed to wait 30+ seconds before draping! If you use larger chloraprep, you have to wait longer.

And it's pretty crazy how an ICU can be run by just a PA at night who can't even do central line.

 

[southerndoc]

<2 min was for a crash femoral line (I usually use the drape, but I don't gown). <5 mins was for an ultrasound guided IJ.

Don't get me wrong here, I've had my fair share of bad lines. A recent one took about 30 minutes to get because she was so dry, the IJ was flat, and it was overlying the carotid. Had to have the patient almost at a 90 degree head stand while humming to distend the IJ enough to even get it.