Clinical tips for intern year

[deleted144744]

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[telenurse]

Tips to expect from typical night calls (at least the things I typically call for)
If a nurse calls for low BP...she should tell you the baseline, and if pt has CHF, any recent narcs, etc, before you bolus, BP meds
If a nurse calls for HTN...she should tell you baseline, if pt has HA, other symptoms, is pt a renal pt etc, BP meds

Fever greater than 100.8 (or whatever the parameter was), any procedures/surgeries, infections, recent cultures in past 24 hours, any antibiotics, has pt been coughing & deep breathing, any diaphoresis, any recent xrays, any trends with fever(does pt always spike temp at night)...

Low urine output...nurse should have vital signs, latest BUN/Cr, hx of CHF, WBC count, infectious process, recent procedures, lactic acid (if done), what's I/O been past 24-48, has pt had any diuretics

N/V, nurse should have Bowel sounds, narc usage, fever, recent surgeries, etc.

Diarrhea, bowel sounds, recent antibiotic usage, smell color consistency of stools (most floor nurses can dx cdiff by smell)

Constipation, should never be a night cover call...unless pt has reached the point of bowel obstruction

If a nurse calls you because a pt c/o of "worst headache of life" she better have recent vital signs, and a good neuro assessment or she isn't worth her salt.

If a nurses calls for dyspnea, crackles and wheezes to both lungs, decreasing pulse ox, tachypnea, in a pt with CHF and an infection, and increasing BP from baseline, and states the pt might "need some lasix and sounds wetter than she did an hour ago". This is an EMERGENCY getting ready to happen, Dependent on spO2 I sometimes bypass calling the intern and go straight to the rapid response team.

Unfortunately not all nurses will provide the info needed, so you will have to ask...also remember in the months of January and July, graduate nurses arrive fresh from taking their boards and will remember to call the MD, but forget all the necessary info.

I'm not going to tell you what to do in these situations...that's out of my scope of practice.
But I have no problem telling you what to expect out of the nurse.

 

[OB1🤙]

In other news, Telenurse lives in a magic fantasy world in a gingerbread house, and rides to work on a flying unicorn.

If this was Opposite Day, her post would be right on.

(Telenurse- you're clearly awesome at what you do. I wishwishwish so hard our nurses would do these things. But they don't. Like, ever. And the sad part is, they don't care that they don't do them. But that's a story for another thread.)

/Hijack

 

[telenurse]

In other news, Telenurse lives in a magic fantasy world in a gingerbread house, and rides to work on a flying unicorn.

If this was Opposite Day, her post would be right on.

(Telenurse- you're clearly awesome at what you do. I wishwishwish so hard our nurses would do these things. But they don't. Like, ever. And the sad part is, they don't care that they don't do them. But that's a story for another thread.)

/Hijack

You know...I took that list from a sheet of "things to know about your pt before you call the doctor" that I hand out to all graduate nurses I orient...Sigh...it should be standard practice

 

[telenurse]

Actually...it's a running joke about me and the new interns and "doc, I think she needs a little lasix..."
For some reason I just seem to always get the pt sounds a little crackly, so I get concerned and I call the new intern...whose upper level is busy doing something like transcutaneously pacing a 3rd degree AVBlocker, and the next thing we know we have a full blown case of flash pulmonary edema...you know, 120mg lasix IVP, nitro gtt, maybe some lopressor IVP for the underlying afib c RVR, continous BIPAP STAT, STAT serial ABG's, CXR's, narrowly avoiding getting tubed and bagged. And it's me and the intern...
It's only happened about 3 times in the past year...but a different intern each time...I gotta bad bad rep with asking for lasix...

 

[Winged Scapula]

In other news, Telenurse lives in a magic fantasy world in a gingerbread house, and rides to work on a flying unicorn.

If this was Opposite Day, her post would be right on.

(Telenurse- you're clearly awesome at what you do. I wishwishwish so hard our nurses would do these things. But they don't. Like, ever. And the sad part is, they don't care that they don't do them. But that's a story for another thread.)

/Hijack

Telenurse...you're one in a million. Get back on that unicorn and fly back to your gingerbread house where nurses actually care and have all the information you suggest.

I have found it fun, if not effective, to just be silent when a typical nurse calls me with one of the presenting symptoms and no other information. She waits for me to ask for the information (which I have learned she won't have anyway, so why should I bother asking for it)...and then when I am silent, she wonders if I have fallen asleep or am "still there". When I respond that I am indeed, "still there", she will then ask "what do want to do?" To which I respond, "I'd like a little more information about the patient, how about the rest of the vital signs, the history (especially if its a patient I am cross covering for my partner), etc.

Its a little game I play, but I'm usually on the losing end unfortunately.

 

[Winged Scapula]

Just a comment to the OP:

IMHO, its a bad idea to let patients go without IV access, in most cases. An emergency is not when you want to be trying to get one. The 20 year old s/p appy? Yeah, they can probably go a few hours without an IC if they are eating and drinking well, taking oral meds and look to be going home soon. But the elderly male in for pneumonia? All you need is a nice arrythmia to see that HE needs an IV, even if he's taking everything PO.

But even more importantly, do not put stuff off until the morning if the problem happens on your shift. Your fellow residents will not appreciate it. It was not clear if you meant putting off IV placement until an IV team gets there in the am, or until the service team gets in. Either way, probably not a good idea to do this on a regular basis. I do agree the EJ is woefully underused.

And a 250 ml bolus will get you laughed off the surgical floors; so make sure, as with most things in life, you are "titrating" your interventions to the patients. A little old lady in CHF might do fine with 250 ml; your post-op patient or pancreatic fistula will need much much more fluid in most cases.

 

[group_theory]

Hypertension: Check with a manual cuff. What does the patient’s bp usually run? If BP meds are due, give them early and recheck it soon. If no BP meds, give Clonidine 0.1-0.2 mg PO or Hydralazine 25mg PO. (DO NOT GIVE IV beta-blockers unless the patient is on a monitor)

Just to add, in Hypertensive EMERGENCY, avoid sublingual nifedipine as it may precipitate an uncontrol drop in blood pressure. The same with IV hydralazine. It can result in prolong, severe, uncontrolled hypotension.

Here is a good review of the various antihypertensive meds, their benefits and their side effects, that can be used during a hypertensive emergency or urgency.

Varon J, Marik PE. The diagnosis and management of hypertensive crises. Chest. 2001 Jan;119(1):316.

 

[carrigallen]

Things to add:

Hypotension:
begin by STOPPING antihypertensives (think iatrogenic causes first)
If sepsis is suspected, give 1L-2L boluses
calls for hypotension warrant physical exam, note in chart.

Fever:
Consider C-diff diarrhea as well - order a cdiff set.

IV Access:
Consider that stable patients do not always need IV access.

Hypertension: Unless a patient is unstable or has signs of end-organ ischemia, blood pressures can be treated with PO meds. Give PO meds time to work.

Electrolyte repletion: be careful in renal disease.

Nausea and vomiting: If no IV access, compazine 10 mg IM or 25 PR.

Shortness of breath: Confirm pulse ox pleth is real.

Asthma exac: Can also give 2 g Mag if refractory to iv steroids. Avoid bronchospastic drugs (ie beta blockers)
III. PE: If older pt, start contrast dye nephropathy prophylaxis with Mucomyst 600 PO x4, IVFs.

MI: Avoid femoral sticks (need site intact for cath)

Altered mental status: Check U/A, med list - most common cause of confusion is iatrogenic or UTI.
Old agitated patient: Seroquel 12.5 or 25 mg qHS.
Old combative patient: Haldol 5-10 mg IV or IM
Young combative patient: Geodon 10-20 IV or IM.

 

[buckley]

Thanks guys! This is a great thread
Telenurse...wow....I wish I end up working with nurses like you. I once "caught" a nurse doctoring her vital signs chart. It was so obvious she just made up values. Her heart rate of the patient was always in the 80s and all are ECG tracings revealed sinus bradycardia. Harumph.

 

[Winged Scapula]

I actually agree with you...but its an unpopular opinion, especially amongst those who have never seen, as you and I have, the stable patient suddenly and horribly crash and not have IV access.

Admittedly I've done it...but its dangerous and unless you know how to put in a quick central line, I don't recommend it.

 

[fab4fan]

I actually agree with you...but its an unpopular opinion, especially amongst those who have never seen, as you and I have, the stable patient suddenly and horribly crash and not have IV access.

Admittedly I've done it...but its dangerous and unless you know how to put in a quick central line, I don't recommend it.

In my head, I can just hear the speechifying from IC nurses about "unnecessary IV's being a pathway to infection, blah, blah, blah..."

WARNING: I am in a really dark mood when it comes to hospitals and hospital BS right now. Just so you know.

 

[Winged Scapula]

In my head, I can just hear the speechifying from IC nurses about "unnecessary IV's being a pathway to infection, blah, blah, blah..."

IC, just like JCAHO - getting in the way, from their ivory tower, of taking care of patients.

Next time a patient without an "unnecessary IV" codes, let's call IC down to start the chest compressions.

 

[Geri_Gal]

Old combative patient: Haldol 5-10 mg IV or IM

That is a lot of Haldol. Even old combative patients do well by "start low, go slow". For agitation, 0.5mg IM/PO can do the trick. 1-2mg IM, repeated PRN for the full on combative elderly folks with Super Strength. IV Haldol has been associated with Q-T prolongation/Torsades more so than IM or PO. In fact the FDA has not approved Haldol IV for agitation due to this. (IV Haldol is still used a lot though, and the risk of Torsades is low)

 

[deleted109597]

Did anyone else stop reading the instant that they learned this information came from a senior radiology resident?

Also, lack of an IV usually means a stat central line consult in my hospital. It is generally a pain. That and "We don't want to stick him for labs anymore".

 

[telenurse]

In my head, I can just hear the speechifying from IC nurses about "unnecessary IV's being a pathway to infection, blah, blah, blah..."

WARNING: I am in a really dark mood when it comes to hospitals and hospital BS right now. Just so you know.

Oh god...it's actually policy in post open hearts to d/c IV access if it hasn't been used for 48 hours...but the hospital policy states IV's can be left in for up to 92 hours+ if charted healthy by an RN & the dressing is changed. So I walk a fine line...if very healthy, use some chloraprep make it a sterile dressing change and document carefully.

If any pt seems to be going downhill, even slightly, even not my pt and I just jump in to help out. One of the first things I try to do is find out IV access and size. If it's bad, or 22-24g, or only one IV and pt looks bad, I put in a 20g or 18g stat.

 

[fab4fan]

IC, just like JCAHO - getting in the way, from their ivory tower, of taking care of patients.

Next time a patient without an "unnecessary IV" codes, let's call IC down to start the chest compressions.

When JCAHO visits, the hospital might as well just start playing the "Darth Vader" theme music over the hospital PA system.

 

[Winged Scapula]

Did anyone else stop reading the instant that they learned this information came from a senior radiology resident?

Good pickup...I didn't notice that. Certainly adds a different flavor to the advice.

Also, lack of an IV usually means a stat central line consult in my hospital. It is generally a pain. That and "We don't want to stick him for labs anymore".

Exactly. Patients who crump without an IV almost always get a stat central line...especially if you're calling me. Protect the patients from surgeons and keep a peripheral in please!

 

[Doowai]

Things to add:

Hypotension:
begin by STOPPING antihypertensives (think iatrogenic causes first)
If sepsis is suspected, give 1L-2L boluses
calls for hypotension warrant physical exam, note in chart.

.

I should be an intern in a few months. SO I am asking - does everyone agree with this? What about rebound hypertension? I would want to know from the nurse what their trend had been over the past few days, week.

During night call I think I would would make sure blood pressure cuff was right size-and palpate femoral and carotid pulses since they have to be above 80 and 60 mm Hg respectively to be palpable.. I would look for signs of shock : inadequate tissue perfusion, altered mental status etc.

Would anyone put the patient in trenedelenbergs?

 

[buckley]

I'm afraid I agree that not every inpatient needs an IV access...Yes, I cite infection, and also unnecessary costs. But I come from a charity hospital where patients can't afford IV catheters and antibiotics. Still, Id like to think that if I was a patient, I'd hate to have a needle stuck to me unnecessarily. The only sudden-sudden-need-IV-access-situations I can think of are massive MI, PTE, seizure (worse come to worse, stick the diaz rectally). All others I think have adequate time to develop and should be noted on monitoring that the trend is not going well...As an intern, when we admit patients for procedures, we only put the cath in at midnight when their NPO starts. If you're the procedure intern...hahaha...it's an assembly line of IV insertions.
Still for the sudden sudden IV insertion cases, we've learned to use all extremities. I know concerns for PTE and DM, but if you're worried enough to tourniquet the foot, I think it would warrant it in court. That vein in front of the medial malleolus is a pretty easy site. I have no US training so I have no idea if this is sound advice for practicing there.

 

[buckley]

And although I have never taken the time to read up on it, I am sure there is substantial diurnal variation in BP.

Yep...circadian BP rhythms are fact. But with antihypertensive meds, this can go haywire.

 

[telenurse]

More times than not, symptomatic hypotension prompts me to do a full septic workup, plus at least an EKG. I always fluid challenge them. I give thought to a stim test, depending on sick they are. Trendelenburg is, at least to me, a nursing intervention and I don't waste my time with it. It doesn't do anything to address the cause, it only makes you feel better about the number. It will also interfere with your ability to assess the results of your fluid bolus.

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Yep, if I have a doc on the way for symptomatic hypotension, the pt's already in trendelenburg...and extra bags of NS are spiked are ready to go wide open at the word...

 

[Winged Scapula]

I'm afraid I agree that not every inpatient needs an IV access...Yes, I cite infection, and also unnecessary costs. But I come from a charity hospital where patients can't afford IV catheters and antibiotics. Still, Id like to think that if I was a patient, I'd hate to have a needle stuck to me unnecessarily.

That's about the worst excuse ever. Patients generally don't want any interventions and are not knowledgeable enough to know what's necessary and what isn't.

Besides, the point here is that an IV is not unnecessary. In the US, patients don't pay for supplies; although I suppose in the abstract you can say we all pay for them, but I don't not put an IV in a patient because I'm worried they can't pay for it. In the grand scheme of things, a couple of dollars doesn't matter when you have a hospital bill of thousands and thousands of dollars.

The only sudden-sudden-need-IV-access-situations I can think of are massive MI, PTE, seizure (worse come to worse, stick the diaz rectally). All others I think have adequate time to develop and should be noted on monitoring that the trend is not going well

Obviously you've never had a non-monitored patient go south without warning. In the US, patients are either in the ICU, telemetry (where they are monitored) or the floors where vitals are checked usually every 4 -8 hrs. It is not uncommon for a disaster to happen in these patients who have not seen a health care worker in some time.

Still for the sudden sudden IV insertion cases, we've learned to use all extremities. I know concerns for PTE and DM, but if you're worried enough to tourniquet the foot, I think it would warrant it in court. That vein in front of the medial malleolus is a pretty easy site. I have no US training so I have no idea if this is sound advice for practicing there.

The foot is an option, for temporary usage, although most nurses freak out when you try it and of course, the patient cannot ambulate with it in. In the patient who is vasoconstricted and fat (typical US patient), its not easy access.

I do agree that situations which warrant a stat IV access are not common, but I would venture that even non-stat, but urgent (ie, rapid A Fib) situations are still not the time you want to be dealing with placing an IV in a patient. Having been called to more than 1 code in a patient whom the primary team said didn't need an IV, I'll remain cautious and have one in my patients until they walk out the door (and that is my rule...do not DC the IV literally until the patient is packed and ready to walk out the door. I've seen trouble start upon the discharge process.)

 

[Blade28]

Having been called to more than 1 code in a patient whom the primary team said didn't need an IV, I'll remain cautious and have one in my patients until they walk out the door (and that is my rule...do not DC the IV literally until the patient is packed and ready to walk out the door. I've seen trouble start upon the discharge process.)

This is so true. I've been burned before when either the intern or cross-cover has ordered "D/C PIV" the afternoon/evening before the day of discharge, figuring that the patient was halfway out the door anyway. Of course, it's inevitable that in some of these patients, an IV will be required that same night - or the next morning.

So the "D/C PIV" order goes along with the "Pt may go home now" order, in my book.

 

[Winged Scapula]

This is so true. I've been burned before when either the intern or cross-cover has ordered "D/C PIV" the afternoon/evening before the day of discharge, figuring that the patient was halfway out the door anyway. Of course, it's inevitable that in some of these patients, an IV will be required that same night - or the next morning.

So the "D/C PIV" order goes along with the "Pt may go home now" order, in my book.

I learned this practice the hard way on CTS.

It was not unusual for a routine post-op CABG to develop rapid AFib on day of planned discharge and an ebullient intern or nurse would have already removed the IV in anticipation of such.

 

[buckley]

That's about the worst excuse ever. Patients generally don't want any interventions and are not knowledgeable enough to know what's necessary and what isn't.

Ummm..actually, being the patient who happens to be a doctor, I was trying to point out that if I was admitted for a procedure, I would hate to have that IV stuck in me when I know there is no indication for it.

Besides, the point here is that an IV is not unnecessary. In the US, patients don't pay for supplies; although I suppose in the abstract you can say we all pay for them, but I don't not put an IV in a patient because I'm worried they can't pay for it. In the grand scheme of things, a couple of dollars doesn't matter when you have a hospital bill of thousands and thousands of dollars.

I think this is where we don't see eye-to-eye, and I'm not saying you are wrong, ok? It's just that in my view, an IV line is an intervention, which clearly should have an indication. And I do not think that just being in the hospital is an indication for that. If the patient is not on NPO and has no IV meds, I would not put in that catheter.

Obviously you've never had a non-monitored patient go south without warning. In the US, patients are either in the ICU, telemetry (where they are monitored) or the floors where vitals are checked usually every 4 -8 hrs. It is not uncommon for a disaster to happen in these patients who have not seen a health care worker in some time.

wow...you just sent shivers down my spine. i trained in a charity hospital all my life and we check vitals q1 in the ICU, q1 for toxic patients in the floors, q4 for "stable" patients. now i understand why you guys are so paranoid to have that iv line in...The iv line is not the problem, q4 monitoring in the ICU? Either you have a very very low threshold for ICU admission, or you're really courting disaster. Where I come from, if a patient is well enough to be on q4 monitoring, he doesn't belong in the ICU....One thing that bothers me is, why? US hospitals are so well-staffed. I mean, you guys even have phlebotomists, social workers, receptionists, etc. And I was under the impression that many hospitals there are not lacking in terms of cardiac monitors and pulse ox's. That's actually a big reason why I want to train there.

 

[BlackSails]

wow...you just sent shivers down my spine. i trained in a charity hospital all my life and we check vitals q1 in the ICU, q1 for toxic patients in the floors, q4 for "stable" patients. now i understand why you guys are so paranoid to have that iv line in...The iv line is not the problem, q4 monitoring in the ICU? Either you have a very very low threshold for ICU admission, or you're really courting disaster. Where I come from, if a patient is well enough to be on q4 monitoring, he doesn't belong in the ICU....One thing that bothers me is, why? US hospitals are so well-staffed. I mean, you guys even have phlebotomists, social workers, receptionists, etc. And I was under the impression that many hospitals there are not lacking in terms of cardiac monitors and pulse ox's. That's actually a big reason why I want to train there.

Read her post again. Patients on the floors have Q4-Q8 vital checks, not ICU patients.

 

[fab4fan]

Obviously you've never had a non-monitored patient go south without warning. In the US, patients are either in the ICU, telemetry (where they are monitored) or the floors where vitals are checked usually every 4 -8 hrs. It is not uncommon for a disaster to happen in these patients who have not seen a health care worker in some time.

Agreed. We check our post-ops frequently, though they're not on a monitor. I have had some go bad, and when they go bad, they go bad fast, or so it seems. Thank heaven each had an IV line.

 

[oudoc08]

What about those patients who are in the hospital for no other reason than waiting on placement. I remember having several of those on my 3rd yr medicine clerkship. The ones who wander the floors in their street clothes, and go smoke q1h.
They're in the hospital, and while they may have chronic medical issues that could theoretically cause them to go south (who doesn't?), they're not being acutely treated for anything, just being babysat. However, they're still getting occ. VS, routine meds, etc.

When assessing risk/benefit of IV access in these folks, I can't see that 1/100,000 chance of them keeling over as a random everyday event, would outweigh the infection, cost, etc. risks of having IV access. Not to mention, it's not unheard of for some of these folks to wander off from the smoking area with a handy little IV drug port.

 

[oudoc08]

Have you done your clinicals yet? I have a lot of these patients. 1/100,000 is an absolute joke. These people go South at the drop of a hat. People who are waiting for placement need placement for a reason.

Quite no reason to be rude. Of course I've done my clinicals. I threw that stat out there facetiously. I wasn't referring to the patient awaiting nursing home placement for osteo, or something along those lines, moreso to social placement or arrangements. The pt's who we skipped rounding on nearly every morning. "Mr. X, oh yeah, our resident dude who we're trying to figure out how to get his PPI & Abx paid for since his H. pylori came back positive."

Seriously, I had more than a few on my rotations, waiting on ways to get their charity cases paid for, how to get them their meds paid for, etc. For liability reasons, and to prevent bouncebacks, my uppers didn't want to send these people out w/o a way to ensure their continued care. These issues sometimes added 1 or 2 days, or as much as a week, to resolve.

Others were psych placement issues. Does every psych patient in the hospital need an IV, in your opinion? They could keel just as easy, or easier as someone else, but I didn't see many on the lockdown wandering around w/ IV's. (And they were taking as many(or more) PO or IM meds than some of the medicine pts, which could result in clinical instability, (respiratory/CNS depression, etc.)

I didn't and still don't believe (nor did my residents or my attendings) that many of these people need repeat changes of an IV heplock simply because they're having an extended stay due to social and financial reasons. Risk/benefit and common sense like anything else.

Along those same lines, maybe we should keep IV's in every nursing home patient. They certainly have the capacity to tank. Or every assisted living patient, or every alcoholic, or every person w/ heart disease, eczema or whatever...

Sorry, now I'm being sarcastic. I simply believe in treating each person as an individual, and I've always taken a dim view of "monkey medicine", that is, everybody gets this or that, just because, or because of a remote chance. CYA is one thing, allowing it to cause you to blanket treat patients is another, IMHO.

I was simply asking for reasons or other cases why you or anyone else in this forum, who thinks that every patient in the hospital needs a line from door-to-door, might give me a reason so that in the future, I might have a different view.

 

[buckley]

Read her post again. Patients on the floors have Q4-Q8 vital checks, not ICU patients.

Oh i see. That's a relief. But if you do read the post again, for someone who is not familiar with your set up, it can be interpreted as I did. But I am glad to be wrong.
So if patients are monitored---how come you still have nonmonitored patients? (which was the explanation why patients are suddenly going south). I'll accept the sudden MI...but then again in a patient with no prior history or risk factor, that's not very common now right? And even then, unless it's really massive, the IV line is not such a big issue for me.

 

[fab4fan]

Wow, where I'm from case management would be all over these pts. trying to get them out the door. The last people trying to figure out how to get the pts. their meds/whatever would be the docs. They're busy taking care of more urgent issues.

 

[oudoc08]

You should probably graduate before you take a "dim view" of anything in-house. Cover the wards for a few months, and deal with the "stable" patient who starts crashing with no IV, then tell me about how I'm just practicing CYA.

I was a paramedic for over 7 years before med school, been involved in EMS since 1994, but thanks for that unnecessary condescension, anyway. I'm not going to knock the fact that you've only been a doc for less than a year (per WS), because I respect what you've learned in your short career and enjoy learning from others experiences. You should do the same. I've taken care of thousands of patients, saw plenty of monkey medicine, plenty of CYA, and while yes, I agree, practicing defensive medicine is at times a necessary evil, there are also times, when I've seen people get particularly lazy about it, and use it to cover their insecurities. This is evidenced by the differences in practice between old attendings all the way down to new interns.

The "O2, IV, Monitor for all" syndrome. Anyone familiar w/ prehospital medicine will know what I'm talking about. It's typically the newbies who aren't sure which patients need something, so they blanket treat, using strict adherence to protocols as a security blanket to hide their lack of experience, forgetting that no patient is textbook, and that deviation from established standards is often necessary using not only medical knowledge but also accumulated clinical acumen to formulate the most appropriate treatment for any one individual person.

Fine. If something is without risk, go ahead. However, IV access, while routine and fairly safe, is most certainly not without risk. Besides potential hazards to any procedure, there are cost issues as well as patient discomfort. If you're immune to those, then fine, but I'm not. I'm willing to weigh the fact that any unneccesary procedure which causes one of my patients discomfort, is a variable which will be weighed into my decision to treat or not to treat. I can stick a tube in any orifice, but do I need to? You ever had a foley?

And you seem to be offended at being questioned by a medical student. Why is that?
I've seen attendings act the same way towards being challenged by a resident. Does that make you wrong?
Absolutely not. Let's have a rational discussion and drop the attitude. It's supposed to be what this forum is about, not getting all defensive.

 

[Winged Scapula]

Oh i see. That's a relief. But if you do read the post again, for someone who is not familiar with your set up, it can be interpreted as I did. But I am glad to be wrong.
So if patients are monitored---how come you still have nonmonitored patients? (which was the explanation why patients are suddenly going south).

The US hospital typically has 3 levels of care:

1) intensive/"unit"
2) "step-down"/telemetry/intermediate care
3) floor/ward

The first two are generally interpreted to be either unstable and in need of continuous monitoring or "stably unstable" and in need of frequent monitoring (ie, q2).

The last group are interpreted to be stable. They do not need continuous monitoring or even q2 monitoring. As a matter of fact, an easy way to piss off nursing, abuse their resources and get paged a lot, is to request q2 vitals on a floor patient. If they are that sick, then they need to be moved to the ICU or intermediate care unit.

A patient in the first two categories who becomes stable enough should be moved out as quickly as possible. One, it is a heck of lot cheaper to be on the floor than it is in the unit and two, you can get very sick in the unit from the indigenous flora.

Obviously when we move patients to the floor, we are making the statement that they are stable and hoping/presuming that they will stay that way. If I could predict which patient was going to crump on me everytime, I'd be a lottery winner and laughing at all of you guys here. Being facetious but my point is that the majority of hospitalized patients are not monitored because we have determined them to be stable, within normal range and not likely to have a disease process that will result in the need for frequent monitoring.

However, as we all know, we are physicians, not fortune tellers. Sometimes its the failure to recognize impending doom, sometimes its part of the master plan of the patient's favorite deity.

]quote]I'll accept the sudden MI...but then again in a patient with no prior history or risk factor, that's not very common now right? [/quote]

You'll have to remember, I'm a surgeon and I spend my time taking care of surgical patients. Most of them are elderly, many of them are vasculopaths whom, even without a prior history of MI, definitely have a risk factor for it, and many of them are your random, routine post-op MI/PE/bleed/CVA/whatever

I'm not taking about your social work admit for the homeless 22 yo. I'm talking about the morbidly obese 26 yo s/p lap gastric bypass that develops sudden SOB on the floor awaiting discharge; the post-op CABG who goes into AFib; the "routine" lap chole who gets severe PONV and can't tolerate any PO, etc.

And even then, unless it's really massive, the IV line is not such a big issue for me.

And that would be your perogative, but I'd venture even a weensy little heart attack patient probably needs an IV.

 

[Winged Scapula]

Others were psych placement issues. Does every psych patient in the hospital need an IV, in your opinion? They could keel just as easy, or easier as someone else, but I didn't see many on the lockdown wandering around w/ IV's. (And they were taking as many(or more) PO or IM meds than some of the medicine pts, which could result in clinical instability, (respiratory/CNS depression, etc.)

Fortunately, I've rarely had to venture onto the psych wards and its usually for a "wound" check which the psych people were too scared to take the dressing off and assess before calling surgery to look at the scratches on some patient's wrists which didn't even penetrate skin.

I think you have to look at where Tired and I are coming from. We are surgeons and we deal with sick patients. Even our healthy patients can get very sick, very rapidly. Lord knows that when Tired and his colleagues are finished operating, their patient's Hct has probably fallen 10 points, so they better darn well have an IV.

I have no idea what the incidence of psych patients having medical instability is, but like Tired, I'd venture its awfully low because the minute a psych patient needs medical or surgical care that patient is rapidly transferred out of the psych unit.

But I'd be doubtful that they are "just as likely to keel" as our patients are. The fact of the matter is that post-operative MIs, CVAs, PEs, and even simple dehydration are extremely common in many, many patients. Tired has only been a physician for a few months and yet he can attest to the fact (as our nursing colleagues have above) that these patients can and do go south quickly and sometimes without warning.

I didn't and still don't believe (nor did my residents or my attendings) that many of these people need repeat changes of an IV heplock simply because they're having an extended stay due to social and financial reasons. Risk/benefit and common sense like anything else.

No one is advocating that but honestly, I don't see patients staying days or weeks on end for placement/social/financial issues, so I've never had to deal with that. Obviously you have to use your brain a bit...the morbidly obese patient who needs placement after surgery? Sorry, but they get an IV...they're too hard to get in the first place, and these patients are walking time bombs. When you've seen a 26 yo die in front of your eyes after a gastric bypass, it scares you, believe me.

So there is a time and place for everything and for every decision. Our point is that the advice given to the OP about leaving IVs out is not necessarily good advice. It may be great advice for the stable young otherwise healthy psych patient awaiting placement. It is terrible advice in the situation I've described above and for many others I've witnessed.

Along those same lines, maybe we should keep IV's in every nursing home patient. They certainly have the capacity to tank. Or every assisted living patient, or every alcoholic, or every person w/ heart disease, eczema or whatever...

Sorry, now I'm being sarcastic. I simply believe in treating each person as an individual, and I've always taken a dim view of "monkey medicine", that is, everybody gets this or that, just because, or because of a remote chance. CYA is one thing, allowing it to cause you to blanket treat patients is another, IMHO.

I've always been a minimalist, believe me. I was roundly chastized during residency for not wanting to do a lot of things. But experience has taught me that in the patient population I took care of, IV access is almost always necessary. This is not a CYA matter but based on knowledge and experience.

YMMV.

 

[oudoc08]

Then your uppers are serious p****** who need to man up and handle their issues. I know this happens once in a while, but it sounds like an endemic issue wherever you are in school. Sorry that this accounted for so many of your patients; it is a waste of educational time.

People with no money or insurance? In a university hospital? The hell you say.

I would also be fascinated to know what kind of insurance fraud you are pulling to get the hospital paid for these non-services.

Insurance??? Muhahahahaha! Charity if it's approved. Otherwise, they bill, but eventually it's probably getting written-off. Can't squeeze blood from a turnip. And we grow a lotta turnips here in OK.

We could always do it this way.

[youtube]http://youtube.com/watch?v=NJXOcVv_z70[/youtube]

 

[oudoc08]

Thanks Winged for your reply. I see where you guys are coming from, and respect your views.
I also am pretty minimalistic, but fairly aggressive with the necessary things. If somebody's blood pressure is tanking, there's no 250cc from me (unless they're a CHF'r whose hearts about to quit). They're getting the big guns. Same w/ bad hypotension, SOB, chest pain, and any other bad juju. No "hmm. Let's see... Do I give this MI 1 or 2 mg of MS. Let me go look it up". On the flip, I'm not hitting every sore knee that walks in with films, joint sticks, labs, and a scope, either. Iatrogenic problems are IMO one of the larger causes of the problems we have to deal with on a day to day basis, and while I'm very aggressive with the sick patients, I'm absolutely NOT that guy that when the attending asks why I ordered something, I'm like " Uhhh. I don't know.. Uhh.. that's the way I've always done it. "

Which usually turns into a chew session about money, complications, etc. about unnecessary "that's the way we've always done it" type of issues.

 

[oudoc08]

Wow, where I'm from case management would be all over these pts. trying to get them out the door. The last people trying to figure out how to get the pts. their meds/whatever would be the docs. They're busy taking care of more urgent issues.

That's the way it is at my institution. The docs didn't tend to the placement issues when it involved social or financial reasons alone. That was the case mgrs job. But, it just always seemed like there was some issue. Like "Place A won't take them because they're too sick, and Place B won't take them because they're not sick enough, well I guess they'll just stay here until something changes".

Used to amaze me to no end. One other reason was transportation. Perhaps a family member was supposed to pick up a patient for discharge. But they never showed up. Guess who stayed another night while they tried to to find another ride for grandma.

I personally offered to front the cab fare for one guy (<$10), but my team said it wasn't my worry, and that it'd be taken care of. Guess who had to round on the guy the next morning. I'd of rather lost the 10 bucks and gotten 15 more minutes of sleep.

 

[oldbearprofessor]

I would go one step further than what Dr. Cox wrote above, and say that there every patient in the hospital must have some form of vascular access.

I do hope they don't have you covering the well-baby nursery?

I now return you to your discussion of adult patients.....I just couldn't resist.

 

[Winged Scapula]

I do hope they don't have you covering the well-baby nursery?

Central lines for all of those little ruggers!

 

[oldbearprofessor]

Central lines for all of those little ruggers!

Femoral line I hope. Double lumen please. The moms will love you for it - we can give them a bit of pheonobarb IV and everyone sleeps at night in the nursery...

 

[Winged Scapula]

Femoral line I hope. Double lumen please. The moms will love you for it - we can give them a bit of pheonobarb IV and everyone sleeps at night in the nursery...

Femoral lines are for the weak and lazy.

Subclavians for them all!

(actually one of the most fun cases I did as an intern was placing a femoral line in a ultrapreemie...I couldn't believe how small the vessel was when I peered over the top of my loupes).

 

[Blade28]

Femoral lines are for the weak and lazy.

And yet during codes, G Surg is the one that gets called to place femoral CVLs.

(actually one of the most fun cases I did as an intern was placing a femoral line in a ultrapreemie...I couldn't believe how small the vessel was when I peered over the top of my loupes).

Think that's small? Try doing a bronchial artery/vein anastomosis with 9-0 Prolene IN A 300 GRAM RAT!

 

[Winged Scapula]

And yet during codes, G Surg is the one that gets called to place femoral CVLs.

Its trying to place one when the patient's body is moving all over the bed with each chest compression that requires the skill of a general surgeon!

Think that's small? Try doing a bronchial artery/vein anastomosis with 9-0 Prolene IN A 300 GRAM RAT!

Ok you win!

 

[Blade28]

Ok you win!

 

[tkim]

Neat, I was a CNA and ER tech for six years before I was a doctor. Sad that you would try to use your limited technical experience as an ambulance driver to imply that you have some kind of clinical experience to make judgements on this issue. Your classmates may buy into your "I have real world experience" line, but since I've been there too, I know that it's a lot of bluster.

Another ambulance driver here with twelve years in before med school. Yep - we blustered through a lot of field calls. Yep, blustered through intubations, IV starts, defibs, drug pushes, field deliveries.

I would have to say that between a CNA, ER tech, and paramedic "ambulance driver" the jobs with the least amount of technical skill are the first two.

Paramedic training requires at least a year of full-time didactics and hospital and field rotations. This is on top of completing the initial BLS course. Where I trained, we were required to have ACLS, PALS, and a watered-down version of ATLS - PHTLS.

Your remark about 'doing a couple of months on wards' is well-taken. Certainly anyone who hasn't 'walked the walk' on the wards has little to say about it. Kind of like how a former ER tech who's never done a street call shouldn't dismiss a job he's never done. But that's just one former ambulance driver's opinion about a former CNA/ER tech.

 

[buckley]

And that would be your perogative, but I'd venture even a weensy little heart attack patient probably needs an IV.

Agree...but not so much that you actually don't have time to put that in should it happen out of the blue...
But your points are received and do have merits. I still wont want that catheter in without an explanation should I become your patient

 

[deleted109597]

Guess who had to round on the guy the next morning. I'd of rather lost the 10 bucks and gotten 15 more minutes of sleep.

Damn. For 15 minutes of sleep to be lost it has to be an ICU patient. A placement patient gets a three liner.

PT s c/o
AFVSS
Placement pending
-Dr.Mcninja

 

[deleted109597]

I still wont want that catheter in without an explanation should I become your patient

Intermittent needle therapy should suffice. If you aren't sick enough to receive IV meds, you aren't sick enough to be on a med/surg floor. At least, that's my opinion. Unfortunately, for every family that can't do wound changes it is different.

 

[oudoc08]

Another ambulance driver here with twelve years in before med school. Yep - we blustered through a lot of field calls. Yep, blustered through intubations, IV starts, defibs, drug pushes, field deliveries.

I would have to say that between a CNA, ER tech, and paramedic "ambulance driver" the jobs with the least amount of technical skill are the first two.

Paramedic training requires at least a year of full-time didactics and hospital and field rotations. This is on top of completing the initial BLS course. Where I trained, we were required to have ACLS, PALS, and a watered-down version of ATLS - PHTLS.

Your remark about 'doing a couple of months on wards' is well-taken. Certainly anyone who hasn't 'walked the walk' on the wards has little to say about it. Kind of like how a former ER tech who's never done a street call shouldn't dismiss a job he's never done. But that's just one former ambulance driver's opinion about a former CNA/ER tech.

Tired, your ignorance doesn't help your argument.

I spent two years and over 1200 clinical hours to become a paramedic. ACLS, BLS, PALS, PHTLS (We didn't do ATLS).

A CNA is a 1-2 week course. An ER tech is on the job training . (I was the latter, never the former.)

And "ambulance driver" doesn't rile me up anymore. Try again.