Thursday, May 5, 2011

IV s

I am only getting around to commenting on this old post by Great Z

I honestly thought I was the only anaesthesiologist who was bothered by IV s.

I think I do most things fairly well. Spinals I get first shot most times; epidurals likewise. I can do a wide range of pain clinic procedures quickly and efficiently. Central lines don't usually cause me grief.

But the difficult IV?

I dread them, the patient who comes to OR covered in bandaids from previous attempts, the heavy smoker, the chemo patient, the scared stiff shut down patient and of course the child. Anaesthesiologists, because we do so many, are better at the easy and moderately difficult IV. When it comes to the above patients we are floundering just like everybody else.

My visceral dislike of IV s possibly stems from my internship where I was used as an IV service. This was a little hard on me and the patients as where I did my student internship, the nurses started the IVs so I was learning on the fly as it was. Fortunately early on during a 4 week anaesthetic rotation, one of the anesthesiologist taught me a technique of starting IVs which I use to this day. Early on however I had a patient who had been on IV antibiotics for weeks and had no veins. I asked the resident if she could go on oral antibiotics and he insisted that she needed the IV and suggested I call anaesthesia. I did so and talked to the resident who passed me on to his staffman. "When your staffman comes in and can't start the IV." said the anaesthesiologist, "I will come down and try to start it."

We do have some aces up our sleeves. We know some places where people usually don't look; the palmar surface of the wrist, the medial forearm just below the elbow and of course the feet. I am never shy about using the antecubital vein. I also will use smaller bore gauge needles such as a 22. We have other aces like central lines, IM ketamine and inhalational inductions (which I occasionally do on adults with poor veins). These last two are of course only useful for patients who are going to get a general anyway. Most of us dread the call to the ward for the patient in whom nobody is able to start an IV.

About a year ago, I had a lady for a C/S under spinal. As it turned out she had a mastectomy with an axillary dissection on her right side and of course chemo which screwed up the veins on her left side. I stared at her left arm for a while and couldn't see anything resembling a vein. Using her foot,assuming there were veins there, is of course out as in the event that the OB gets into the pelvic veins, I am going to be transfusing the suction bottle. After thinking, I told the patient that I was going to have to put a central line in her neck. She was quite cooperative and the line went in smoothly under local. I then proceeded with the spinal and she had her baby. At the end of the case I offered to try to put an IV in her foot so that the central line could come out. "Don't bother," said the OB.

For the rest of the day, I got a phone call about every hour from the post-partum ward. "You know we can't have central lines on this ward," the call would go. I would explain that there was no IV access. There was an attempt to transfer her to the General Surgery ward which could take central lines but they weren't comfortable with an obstetric patient. After a while, I told them to sort it out amongst themselves and think about what was good for the patient and not what was in the policy manual. The phone calls stopped and I started waiting for the letters (which never came.)

A couple of years ago I got a call from the pediatric ward. While we have a large Pediatric Centre of Excellence in our city, our hospital for reasons of pride had insisted on keeping a pediatric ward which thankfully they closed about a year ago. "We have a child with bacterial lymphadenitis here," said the nurse,"who needs IV antibiotics and his IV is gone." Okay I don't like being used as an IV service, but I do have some skills in that area, I wasn't that busy, plus in 30 years (including medical school) I had never seen a case of "bacterial lymphadenitis" so I was pretty excited.

I arrived on the pediatric ward to find a happy child playing with his mother. Happy that is until he saw me approaching with the IV tray. Seeing it was going to be struggle, I looked at the child and thought, "he looks awfully healthy to be needing IV antibiotics". So I examined him. Firstly I felt around his neck where the infected lymph nodes were supposed to be and couldn't really feel any. Not even the "shotty" lymph nodes we used to use to justify giving antibiotics to what we knew was a viral infection. I asked what his temperature was and it was normal. I looked in the chart and the white count was normal. I phoned the pediatrician's office. He was not in but I asked his secretary if he could call me back about the patient and left my cell number. He of course never called back.

It was of course quite possible that the child had a dramatic response to the IV antibiotics and the pediatrician just hadn't made rounds yet. It is unfortunately more probably that the child just had a URTI, the pediatrician took pity on the mother, admitted the child and felt he had to have a treatment to justify the admission, something I saw countless times in medical school and internship.

So I empathize with Great Z and all our brother and sister anaesthesiologists who I now know are as stressed out as we are over this issue.


burnttoast said...

Oh, and there was the new infectious disease doc who trained in a C of E where apparently the Anesthesia dept did all the spinal taps !! At least that was the explanation when we got a consult to come to the ER for a spinal tap. Poor guy, had to do them himself, as we just didn't have someone sitting in the lounge waiting to meet this "need". July is always so full of special surprises.
And it wouldn't be so bad doing "consult" IVs if all the good veins hadn't been shot in attempts immediately before the consult was placed.

Bleeding Heart said...

Our emerg docs and internists do their spinal taps with a 20 gauge spinal and then expect just in time service for the inevitable blood patch.
I think I would rather offer a 24/7 spinal tap service.