Vent on stupid attendings!

[Annette]

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I tell the ED attending helping another resident place a line that he had contaminated himself and the line. He thought I was joking. To protect the patient (who was already septic), I told the ICU attending that the line was dirty. I got yelled at for not calling the ICU attending to put the line in (bp in the 60's, no peripheral access. Yeah, the patient can wait until you get here . . .) Well, the ICU attending says something smart to the ED attending (no love lost between them) that he put in a dirty line. So I get yelled at again by the ED attending for not talking to him first!

Thank goodness there are less than 240 days left in this hell hole.

 

[Heme/Onc]

I am a fourth year medical student who really knows nothing about the life of a resident but it sounds to me like you were stuck between a rock and a hard place. I am sorry that happened to you.

 

[APACHE3]

Can you post your rotation eval, because this should be good! I hope you weren't counting on honors! 😀

 

[Casey James]

Can you post your rotation eval, because this should be good! I hope you weren't counting on honors! 😀

 

[Annette]

A wonderful update: "We pulled the triple lumen out of her femoral ARTERY, and made her CCO, which should have been done initially." God, he has a way to make it sound like I enjoy torturing puppies!

The patient was DNR- CCA (no intubation, no CPR), but another ED attending (not the dirty line one) convinced the family to intubate the patient while I had been called away to see a crashing patient on the floor.

 

[southerndoc]

A wonderful update: "We pulled the triple lumen out of her femoral ARTERY, and made her CCO, which should have been done initially." God, he has a way to make it sound like I enjoy torturing puppies!

The patient was DNR- CCA (no intubation, no CPR), but another ED attending (not the dirty line one) convinced the family to intubate the patient while I had been called away to see a crashing patient on the floor.

You didn't realize the central line was in her femoral artery until after pulling it out? Or am I confused here?

I once saw a medicine resident cannulate, thread, and suture in a triple lumen central line that I told him was in the carotid artery. Oddly enough, he decided to send a gas when the CVP was measured at 70. I think a CVP of 70 should be clue enough that you're in the wrong vessel.

By the way, weren't you originally trying to match in emergency medicine?

 

[Annette]

I didn't put the line in, a EM resident I trust put it in (yes, I do trust most of the residents in the ED) under ultrasound.

Southern Doc, are you trying to make it sound as if I'm complaining about the ED? I'm not. I'm most upset that I was trying to do the right thing for the patient, and ended up being abused by both attendings.

I did originally want EM, and I expect alot of them. Maybe I'm just expecting too much out of human beings under stressors that I now know I wouldn't tolerate.

 

[Orange Julius]

When I see intelligent people make stupid mistakes, I see it as a warning and not an opportunity to judge. 😉

 

[NinerNiner999]

I didn't put the line in, a EM resident I trust put it in (yes, I do trust most of the residents in the ED) under ultrasound.

Southern Doc, are you trying to make it sound as if I'm complaining about the ED? I'm not. I'm most upset that I was trying to do the right thing for the patient, and ended up being abused by both attendings.

I did originally want EM, and I expect alot of them. Maybe I'm just expecting too much out of human beings under stressors that I now know I wouldn't tolerate.

Not to be the a__hole, but I would think any patient with a pressure of 60 needs a line immediately, dirty or not, and no time should be wasted to break open another kit when pressure needs to be managed. There is always time to put a new line in on on the floor and, if the patient is already septic (and hopefully recieving antibiotics, a short-term line infection should not be overly concerning...

 

[Orange Julius]

Not to be the a__hole, but I would think any patient with a pressure of 60 .

The pressure was 60 because it was in the wrong place. Arterial pressures in a venous line is not what you're looking for. 😉

 

[southerndoc]

Not to be the a__hole, but I would think any patient with a pressure of 60 needs a line immediately, dirty or not, and no time should be wasted to break open another kit when pressure needs to be managed. There is always time to put a new line in on on the floor and, if the patient is already septic (and hopefully recieving antibiotics, a short-term line infection should not be overly concerning...

I agree. I've never heard the surgeons complain about the trauma patient with barely palpable carotids who gets a Cordis with unsterile gloves and enough Betadine just to cover the skin.

Infection is minimized if the line is changed over a wire within 24 hours. Totally eliminated? No, but minimized.

Extremis requires extreme measures to manage. An aseptic line is no good to a patient who has a brain injury from his/her severely mismanaged hypotension.

 

[TommyGunn04]

The pressure was 60 because it was in the wrong place. Arterial pressures in a venous line is not what you're looking for. 😉

Huh? I thought the line was put in BECAUSE the pressure was low (the pressure was recorded by a cuff, not a line). That business about the carotid line and CVP of 70 was a different story. Nice try though 😛 😉

 

[The White Coat Investor]

If I can't feel the pulse, I ain't even gonna pause to betadine the skin. Wiring out a line (or replacing it in a different location later in the ICU under much more stable conditions) may make a little more work for a medicine resident, but it's better than the patient dying because there's no access.

But out of curiosity, anyone ever seen a study indicating minor breaches in sterility while placing a central line lead to an increased rate of line infection? That would be easy to get published. Unfortunately, you'd have to rely on doctors reporting that they screwed up.

 

[njbmd]

Hi there,
One way that I have minimized contamination when inserting lines is to double-glove with two sets of sterile gloves. If I do have a breach in sterility that only involves the glove, I can pull off the top glove and still have a sterile glove underneath. Really saves time in the long run.

njbmd 🙂

 

[Apollyon]

If I can't feel the pulse, I ain't even gonna pause to betadine the skin. Wiring out a line (or replacing it in a different location later in the ICU under much more stable conditions) may make a little more work for a medicine resident, but it's better than the patient dying because there's no access.

But out of curiosity, anyone ever seen a study indicating minor breaches in sterility while placing a central line lead to an increased rate of line infection? That would be easy to get published. Unfortunately, you'd have to rely on doctors reporting that they screwed up.

Wiring across a dirty line makes the next line as dirty - that's why you pull them and start new.

There IS a study done at Duke (which I don't have at hand) that shows full-body cover of the patient, and cap, mask, gown, and gloves DOES reduce infection - that's why we have the "central line imperative" for everyone to gown up and to cover the patient, along with the "biobutton" right over the site as an antiseptic.

 

[southerndoc]

Wiring across a dirty line makes the next line as dirty - that's why you pull them and start new.

The key point is that it absolutely must be done within 24 hours, as during this time there is usually not enough bacteria on the tip to be transmitted to the other central line during the change.

 

[f_w]

I once saw a medicine resident cannulate, thread, and suture in a triple lumen central line that I told him was in the carotid artery. Oddly enough, he decided to send a gas when the CVP was measured at 70. I think a CVP of 70 should be clue enough that you're in the wrong vessel.

How did that story end ? Did VS have to cut down on it or did he just yank it out ?

 

[southerndoc]

Vascular was consulted. They pulled the line out and held pressure for 30 minutes with an OR on standby.

 

[f_w]

I understand hitting 'big red' with your needle if you do your lines without ultrasound, I do not understand how the pulstile flow hitting his sleves could evaded his attention.

 

[edinOH]

Funny thing about bright red blood and pulsatile flow...

The people who usually need lines the quickest are the one's who's bright red blood isn't so bright and who's flow isn't so pulsatile.

If I had a nickle for every time I had to ask myself "Damn, is that arterial?" I could buy about three cokes from the machine out by triage. You know, the one that you can never get to accept your dollar bill.

 

[Apollyon]

Funny thing about bright red blood and pulsatile flow...

The people who usually need lines the quickest are the one's who's bright red blood isn't so bright and who's flow isn't so pulsatile.

If I had a nickel for every time I had to ask myself "Damn, is that arterial?" I could buy about three cokes from the machine out by triage. You know, the one that you can never get to accept your dollar bill.

Which I can speak to from experience, after putting in an U/S guided IC (!) line - pt was quite the vasculopath, attending was manning the U/S probe (poorly), and the blood wasn't pulsing at all, and the M&M wasn't really too painful.

 

[beyond all hope]

Hard to tell sometimes, especially with patients where their venous pressure is almost equal to their arterial pressure. Agreed that sterility and exact placement are not as important for emergency lines.

If you have nonpulsatile flow, and IV fluids flow into the line, than what more else can you do? Document what you've done. Some of our centrals will end up in the artery. I'm sure I've done it already, but I haven't been called on it yet.

We had a central end up in the artery here, which wouldn't have been such a bad deal except for the floor team reamed us in the chart when it was discovered. Point of learning: stay professional on your chart, no matter how upset you are. It doesn't protect you to blame someone else, it just makes the lawyer smell money.

P.S. Love the double glove thing. Do it myself all the time. It also helps when you're stitching: if you've got bloody gloves just toss off the outside pair and your dexterity improves remarkably.

 

[southerndoc]

Hard to tell sometimes, especially with patients where their venous pressure is almost equal to their arterial pressure. Agreed that sterility and exact placement are not as important for emergency lines.

I've never seen a venous pressure equal an arterial pressure.

 

[edinOH]

I've never seen a venous pressure equal an arterial pressure.

I bet they are equal at the funeral home.

 

[southerndoc]

I bet they are equal at the funeral home.

Maybe I should rephrase... in a living person.

(Even those that get CPR do not have a CVP equal to an arterial pressure.)

 

[docB]

I've never seen a venous pressure equal an arterial pressure.

No but in a bad code with a pt who has right heart dysfunction, hypoxia and no A line so you're depending on and unreliable cuff you can question if you're in the red or blue. I had this one bad pulmonary hypertensive frequent flyer in residency. The first time I stuck her and got vigorously pulsatile dark blood back I freaked and pulled the line. Over time and a half dozen other lines on this woman during residency I realized that that's just how she was. I definitely quit pulling the lines.

 

[RuralMedicine]

Hi there,
One way that I have minimized contamination when inserting lines is to double-glove with two sets of sterile gloves. If I do have a breach in sterility that only involves the glove, I can pull off the top glove and still have a sterile glove underneath. Really saves time in the long run.

njbmd 🙂

👍 This has become common practice for me as well. However, if you have no access (and can't get peripheral access---bolusing through a large gauge peripheral IV actually is more successful than a triple lumen (if you love cordis introducers then it evens out) and the patient is in extremis a less that 100% aseptic line is the way to go if it's the best you can. (ie code lines) My preference if the patient is more stable is replace with a new site after 24 hours but a wire change is an option (and here is the one use I think of tip cultures---if the tip is positive then you really need to change the site).

I had a rough morning with an unstable ICU patient who ended up with a mucous plug obstruction of his ET tube. We essentially extubated so I could reintubate. Of course in the chaos of his desaturation event the RT (who doesn't usually work in the ICU but we're a smaller hospital and somehow there wasn't double coverage this morning so she was it) accidentally pulled out his central line. Fortunately we managed to get in a peripheral IV to push drugs for intubation and then I got to put in a new triple lumen (yes using aseptic technique) after successful reintubation. Sadly the nurses gave me a "gold star" because I didn't yell during the crisis. (We're really working on changing the acceptable practice for physician communication at our institution---or at least I'm working on it.)

 

[RuralMedicine]

No but in a bad code with a pt who has right heart dysfunction, hypoxia and no A line so you're depending on and unreliable cuff you can question if you're in the red or blue. I had this one bad pulmonary hypertensive frequent flyer in residency. The first time I stuck her and got vigorously pulsatile dark blood back I freaked and pulled the line. Over time and a half dozen other lines on this woman during residency I realized that that's just how she was. I definitely quit pulling the lines.

If your patient isn't literally trying to die in front of you this is where I find looking at the waveform very helpful. Go ahead pass your wire and then a small catheter (I use the cathether from the catheter over needle in our kits) just DON'T DILATE the vessel. If your waveform looks venous then repass your wire, dilate, and then pass your TLC and success is yours (and the patient's who isn't getting stuck again).

 

[fourthyear]

A dirty line is better than no line at all, but as soon as you have that access and have started to stabalize the patient, get another clean line in another site and pull that out - why make a sick patient more at risk to be sick by leaving the line in even a full 24 hours? And an IJ or subclavian is always better than a femoral anyway - no one needs groin sweat and a foley touching any part of their central line - there's just no way a groin site can be kept as free from contamination as an upper site. Femoral lines are temporary lines for codes or traumas only - then change your site ASAP.

When using ultrasound, make sure to compress the vessel with the probe - a vein will compress, an artery won't. It is pretty easy to stick the carotid under direct visualization if you are thinking it's the IJ - use this compression trick over an over to assure yourself you are really going into the vein, not the artery. And hold your own probe with one hand, the needle with the other - I don't understand why your attending was holding the probe for you - it's a one person procedure.

 

[fourthyear]

"if the patient is already septic (and hopefully recieving antibiotics, a short-term line infection should not be overly concerning...

Sorry, but I have to comment - what an ED way of thinking!!! "a short-term line infection" IS overly concerning - people DIE from this stuff, dude! An already septic patient does need us being careless and giving him any other risk factors to make him more septic. It is important that all lines be put in as sterily as possible, and even if this is done, lines still get infected. Agreed that if you need a line, you need a line, but at least try to do a quick prep (or have someone else at least squirt some betadine over it for you while you put your gloves on) - and if you do put in a dirty line, do the right thing and admit it. The original poster did the right thing to try to get the line changed - too bad the attendings involved had to big of egos to admit there was a breach in sterility and get the line changed.

Hey, by the way, I've never seen an attending participate in line placement at any of the hospitals we work at - it's a resident thing at all our hospitals.

 

[hakksar]

Sorry, but I have to comment - what an ED way of thinking!!! "a short-term line infection" IS overly concerning - people DIE from this stuff, dude! An already septic patient does need us being careless and giving him any other risk factors to make him more septic. It is important that all lines be put in as sterily as possible, and even if this is done, lines still get infected. Agreed that if you need a line, you need a line, but at least try to do a quick prep (or have someone else at least squirt some betadine over it for you while you put your gloves on) - and if you do put in a dirty line, do the right thing and admit it. The original poster did the right thing to try to get the line changed - too bad the attendings involved had to big of egos to admit there was a breach in sterility and get the line changed.

Hey, by the way, I've never seen an attending participate in line placement at any of the hospitals we work at - it's a resident thing at all our hospitals.

While the op did the right thing by trying to protect the patient it seems like she could of been more forceful with the ED attending since she said that he just thought she was joking before she decided to tell the ICU attending. In a perfect world the ICU attending would just note it, politely inform the ED attending, and get the line changed ASAP in a more controlled environment. However, since it clearly is not a perfect world the op should of ensured the ED attending understood that he contaminated the line and only go and tell the ICU attending if the ED attending was still not going to document and report the contaminated line after she ensured he understood.

On another note, the ED way of thinking is not necessarily wrong which is what your post implied. The ED is looking at immediate life threats and although a contaminated central line will definitely complicate an already septic person (especially if another bacterial strain that is not being covered by the antibiotics currently being used for the sepsis is introduced) a patient with a pressure of 60 is definitely in need of a line stat . . . and depending on the clinical picture this may even be sort of a heroic measure. I mean when is the last time you have heard of someone complaining that all the sterile procedures were not completely met with an ED thoracotomy??? The rules are a little different in an uncontrolled environment such as the ED with a patient that is crumping faster than you can snap your fingers.

 

[NinerNiner999]

An already septic patient does need us being careless and giving him any other risk factors to make him more septic.

How does one become "more septic?" Unless you are implying the development of overt multi-organ failure and DIC, which are an evolution of an already evolved septic process. Once you're septic, you're septic - that's what broad-spectrum antibiotics are for. Oh wait - we can't start those either without a line. That being said, the insertion of a "dirty" line (or better phrased "a line placed in less than optimum sterile conditions") will not immediately cause DIC. Careless? I agree that all attemtps at sterile technique should be made. but I'm not going to wait for a gown, glove, sterile drape, and three-way skin preparation while my patient is in shock with a systolic in the 60's - at that point things are bordering on ACLS, not sepsis. I highly doubt that there were any egos involved in not changing the line. It has been clearly stated in this thread that 24 hours is an acceptable window for a line change, especially in the setting of hemodynamic instability.

"More septic".... I'm going to remember this one...

 

[southerndoc]

A dirty line is better than no line at all, but as soon as you have that access and have started to stabalize the patient, get another clean line in another site and pull that out - why make a sick patient more at risk to be sick by leaving the line in even a full 24 hours? And an IJ or subclavian is always better than a femoral anyway - no one needs groin sweat and a foley touching any part of their central line - there's just no way a groin site can be kept as free from contamination as an upper site. Femoral lines are temporary lines for codes or traumas only - then change your site ASAP.

Actually the literature doesn't support that femoral lines have higher complication rates or infection rates. IJ's, although easy to perform, are prone to cause IJ thrombosis. 10% risk of it if left in for >5 days. Even with the most sterile technique, there is a 20% risk of bacteremia if the line is left in for >5 days.

 

[The White Coat Investor]

If your patient isn't literally trying to die in front of you this is where I find looking at the waveform very helpful. Go ahead pass your wire and then a small catheter (I use the cathether from the catheter over needle in our kits) just DON'T DILATE the vessel. If your waveform looks venous then repass your wire, dilate, and then pass your TLC and success is yours (and the patient's who isn't getting stuck again).

That's a damn fine tip

 

[The White Coat Investor]

Sorry, but I have to comment - what an ED way of thinking!!! while you put your gloves on).

Ha ha. Now you're assuming we put on sterile gloves for a crash line. Newsflash...if there's time for sterile gloves there's time for betadine, mask, cap, and drape.

Seriously though, I've discovered there are very few crash lines. I've taken to doing lines completely sterile if there are fewer than 5 people working on the patient and there is a perfusing rhythm.

 

[Annette]

- and if you do put in a dirty line, do the right thing and admit it. The original poster did the right thing to try to get the line changed - too bad the attendings involved had to big of egos to admit there was a breach in sterility and get the line changed.

Thank you for understanding my complaint. I agree, when you need a line, it doesn't matter if it is dirty or not. What I had trouble with was it became an ego issue. The ED attending told me the next day that he thought I had been joking, then started yelling when I told him I hadn't been. Unfortunately, the ICU attending doesn't like or respect this particular ED attending, and the line incident became more ammo between them.

As a medicine resident, I am not allowed to place a line unsupervised by an attending. (Only surgery residents may place lines without supervision). I couldn't get my attending down to the ED in time, so I asked for an ED resident to do the line. The ED resident didn't have a great amount of experience using U/S, so the attending gowned and gloved up to assist.

 

[southerndoc]

As a medicine resident, I am not allowed to place a line unsupervised by an attending. (Only surgery residents may place lines without supervision). I couldn't get my attending down to the ED in time, so I asked for an ED resident to do the line. The ED resident didn't have a great amount of experience using U/S, so the attending gowned and gloved up to assist.

The ED resident didn't have experience with ultrasound? Good grief. How archaic is that? You must be at one of only ten hospitals in the country where the ED residents do not receive ultrasound training.

Would the ED attending not supervise you doing the line? We occasionally allow medicine residents to start lines in the ED. They are supervised either by the ED attending or the senior ED resident.

 

[Annette]

There are alot of "old school" attendings at my institution. They are starting to use U/S more in the ED for lines, and the nephrology people also use U/S routinely. The resident did have some experience, but not a great deal with it.

As far as medicine residents doing lines in the ED, well, there was an incident and the upshot was that the ED attendings will no longer be responsible for non-ED residents (or those not rotating through the department) doing lines. It rarely turns out to be a problem as the medicine residents try to move the critical care patients out as soon as the patient is considered to need ccm. The big trouble will be when the micu/ccu starts to have to board patients in the ED again. Our hospital census hasn't been too overwhelming, but the critical care beds tend to be full all the time now. I am not looking forward to the winter/flu season.

 

[tiene dolor?]

As a medicine resident, I am not allowed to place a line unsupervised by an attending. (Only surgery residents may place lines without supervision).

Are you serious? You can't place a line without an attending observing??

 

[Apollyon]

Are you serious? You can't place a line without an attending observing??

To bill for it, an attending has to "directly observe" a procedure. Some (most) take that relatively seriously, ranging from stepping in during the procedure to being there during the whole process.

 

[tiene dolor?]

To bill for it, an attending has to "directly observe" a procedure. Some (most) take that relatively seriously, ranging from stepping in during the procedure to being there during the whole process.

That assumes of course that the patients are actually able to pay for their care.

 

[Apollyon]

That assumes of course that the patients are actually able to pay for their care.

No it doesn't. Even if the patients can't/don't pay, hospitals that accept MediCare have to follow their rules (even if the pt is not on MediCare).

 

[tiene dolor?]

No it doesn't. Even if the patients can't/don't pay, hospitals that accept MediCare have to follow their rules (even if the pt is not on MediCare).

are you honestly telling me that there is an attending at the bedside when all lines are placed in your hospital? cuz that sure isn't the case at mine.

 

[Apollyon]

are you honestly telling me that there is an attending at the bedside when all lines are placed in your hospital? cuz that sure isn't the case at mine.

Most at least poke their heads in - no one stays from beginning to end (then again, I'm in the ED, so there's an attending 24hrs a day). I know what you are saying, but, even in the units, the fellow observes. I can't speak as to what occurs on the floor.

 

[Annette]

A senior level resident will usually gown and glove up to help an intern place a line. The attending usually comes in when we are about to stick in the big needle and stays until the line is placed. If there is no senior to help out, the attending will usually be there through the whole thing.

As to the reimbursement, the hospital (if for-profit or not for-profit) can deduct the bill for the line as uncompensated care. Also, for liability reasons, the powers that be like to have an attending present. The house service recently was told that their admissions were down, and that that was a problem. Who'd have thought that keeping house patients out of the hospital would be a problem?

 

[beezar]

The key point is that it absolutely must be done within 24 hours, as during this time there is usually not enough bacteria on the tip to be transmitted to the other central line during the change.

Not questioning you, but was wondering if you can provide references pointing to this changing a line less than 24 hour thing.

 

[RuralMedicine]

Most at least poke their heads in - no one stays from beginning to end (then again, I'm in the ED, so there's an attending 24hrs a day). I know what you are saying, but, even in the units, the fellow observes. I can't speak as to what occurs on the floor.

In order to bill you must be present for the "critical portions of a procedure". As an attending I interpret that with a central line as everything from starting local anesthesia to suturing the line in place. Some attendings may interpret this less stringently but I'm not sure they can truly defend themselves out of it. It's pretty much a moot point where I currently am our facility doesn't have residents and I haven't been brave enough yet to let a medical student try a line.

Where I trained I put a ton of lines in without attendings present because they needed to be done (no one billed for those lines however) and very few lines with attendings present. In our program you needed to be credentialed in the procedure before you could perform it independently (but you could be supervised by upper level credentialed residents). I did have a very nice attending (only a few years out of Med-Peds residency) who watched me put a line in at 6pm on a Friday night that we really needed because we had no access and the pt. was too orthopneic to recline below an 80 degree angle and beyond ticked off because the EM resident had stuck him multiple times unsuccessfully for a subclavian (with him sitting bolt upright--probably part of the problem) before calling the admission. (He was swinging at the poor EM resident when I came down to admit). At the time I knew my attending was waiting around because he thought he could get it if I couldn't and I appreciated that. He also was helpful in distracting my patient who was ranting/ gasping about how we were mean because we wouldn't let him eat. [Or was it that we feared he was getting intubated in the next hour or so as his sats were marginal on 50% mask? I suppose it depends on your perspective 😉 ] In the end I got in a femoral he diuresced beautifully with IV Lasix and weaned to NC O2 several hours later. I'm all for IJs or Subclavians but sometimes you can't position the patient in a way that they are safe to put in. He actually was a charming guy once he had diuresced 2L overnight.

 

[fourthyear]

Ha ha. Now you're assuming we put on sterile gloves for a crash line. Newsflash...if there's time for sterile gloves there's time for betadine, mask, cap, and drape.

Seriously though, I've discovered there are very few crash lines. I've taken to doing lines completely sterile if there are fewer than 5 people working on the patient and there is a perfusing rhythm.

It adds about 10 seconds to put the right gloves on. If you put your line in fast/on the first or second stick, you do have time to put sterile gloves on. Even in codes I throw betadine on and put sterile gloves on.

 

[edinOH]

As a medicine resident, I am not allowed to place a line unsupervised by an attending. .

😱

 

[f_w]

Oh, one more thing. Instead of betadine, use the chlorohexidine prep-sticks. They only need 1 pass and dry in a couple of seconds. Squirting some betadine on skin and puncturing immediately thereafter is about as useful as doing the same with saline (heck betadine can even harbor bacteria http://www.cdc.gov/mmwr/preview/mmwrhtml/00001358.htm ).