So I'm doing a hospital admission on a 78 year old man the other day with bad COPD and chronic systolic heart failure. As I'm doing my history and physical the nurse pulls out a vein light. I was amazed but not surprised that such a technology existed. Every year that passes, hospitalized patients seem to get sicker and sicker.
As our elderly march ungracefully towards their delayed and unexpected death, the quality of their heart, lungs, kidneys and yes, even their veins seem to deteriorate exponentially. It's just not that easy these days to get stable IV access in hospitalized patients.
Not a day goes by where I'm not being called by a floor nurse to tell me they can't find any veins or the patient's IV access is unstable, or they need a central line. I've been working as a hospitalist at Happy's hospital for seven years and these calls are always some of the most frustrating, especially when they come from my partner's patients. But this is the first time I have ever heard of the vein light.
Why not use a vein light, I say. A few years back, the Site Rite was introduced to assist doctors with central venous lines. This is an ultrasound assistive device the physician can use to directly visualize the patient's jugular vein. I tried it three for four times several years ago and gave up. I found it difficult to manipulate while trying to place the catheter and I haven't used it since, mostly because I only put in subclavian lines.
If doctors can have ultrasound guidance for the central lines, why shouldn't nurses have a vein light to find their patient's vein as well. If it keeps the nurse from calling me at all hours of the day or night to tell me they can't find a vein or can't get IV access, I say get one for every nurse in the hospital.
IV access in the hospital is one of the most basic (and important) parts of the patient experience. It can also be one of the most frustrating for doctors and nurses alike when stable IV access becomes a problem. One of my biggest pet peeves as a hospitalist is having a partner of mine check out to me an unstable patient with nothing more than a 22 gauge for IV access.
I also hate it when the physician assistant or nurse practitioner in small town America sends me a septic patient with hypotension on dopamine administered through a 38 gauge butterfly IV as they role into the ICU. If you are going to to work in the emergency department you have to be able to stabilize the patient appropriately. If that was your mother you shipped away by ambulance, you would expect them to have a central line or large-bore IV access at the least. Anything less is inexcusable.
What is a large bore IV? It is an IV with an 18 gauge or larger lumen. The smaller the number the larger the lumen. You want large lumens for IV access in unstable patients so you can administer fluids, medications and blood products very quickly.
Why do you need intravenous access in the hospital? If you're sick enough to be in the hospital, you are sick enough to require IV access. If you should crash and burn in the middle of the night and you have no IV access, you're going to wish you hadn't demanded the nurse remove your IV. IV access is a basic safety measure in the hospital. If you code, the nurses must have a way to administer your epinephrine.
I think every nurse in the hospital should be given a vein light as a patient safety initiative to guarantee IV access. Unfortunately, I know that is not feasible. Why? Because this vein light, nothing more than a glorified stud finder, costs almost $500. That is amazing. Would you pay $500 for a stud finder in the name of patient comfort? I can assure you that you won't find a vein light in Egypt. And you wont find vein lights in the future of American medicine as hospitals struggle to survive under the weight of a bankrupt Medicare National Bank.
What is the order of hierarchy when it comes to establishing IV access in the hospital?
- The Emergency Room Nurse. Most patients get admitted through Happy's ER or through a small town hospital ER. It's the ER nurses job to establish adequate IV access. Frequently, I am asked to admit unstable patients with 32 gauge IVs placed by the triage nurse, covering for Susy who's on lunch break. A 32 gauge IV does not constitute stable IV access for a hospitalized patient. Instead, all ED nurses should be trained in placing double lumen peripheral IVs. I asked an ED nurse why all nurses don't place them. It seems like this combination 18+20 guage IV would solve a lot of the IV access problems I encounter in the hospital and it could save many patients from getting PICC line complications. I was told that these IVs intimidate a lot of nurses. Interesting to say the least. By the way, I didn't see any vein lights floating around in the ER. Maybe it's time to introduce them. This original Happy crude medical ecard helps explain.
"Securing stable IV access is our mission here in the ER. How YOU choose to defined stable is YOUR problem"
- The Floor Nurse. If the patient is admitted from the ER, they should already have adequate IV access established by the time they hit the floor. If the patient comes from a small town ER or hospital they should already have adequate IV access as well. Often times, however, they don't. These hospitals aren't splurging on $500 vein lights, I can assure you of that. Sometimes the patient arrives as a direct admit from the doctor's clinic at which point they won't have any IV access at all . Some floor nurses are better than others. In fact some floor nurses are a lot better than others. I'm sure many nurses would agree. I know a few nurses who never miss. They are the go-to-guys and gals when it comes to needing IV access. If a floor nurse can't get an IV and they've tried "multiple times", I'm glad they now have a $500
stud findervein light to help them.
- The ICU Nurse. Once the floor nurse has exhausted his or her skills and the vein light has failed them, the next person to call is the ICU nurse. ICU nurses can get IV access 90% of the time a floor nurse fails. Most of the time, adequate IV access can be achieved by these nurses who specialize in taking care of really bad protoplasm. Sometimes they even resort to placing external jugular lines
- The Flight Nurse. If the ICU nurse can't get the peripheral IV access, and the jugular fails, even after they've tried the vein light, it's time to call in the flight nurse. These are the trauma nurses who fly around in helicopters and stabilize field traumas. These are the folks who can stick just about any vein with a pulse. But you have to get lucky. Often they aren't in house. If they are, they can solve the problem 90% of the time an ICU nurse fails. I'm not sure many flight nurses carry around the vein light though. Something tells me it would be a badge of weakness for them.
- The Nurse Anesthetist. Happy's hospital has 24 hour access to anesthesia services. However, the one person in house is often off doing a trauma case or putting in an epidural on a pregnant lady to earn their keep. Occasionally, when all routes for peripheral IV access have been exhausted, I must write an order to "consult Anesthesiology" to place a peripheral IV. Once the emergency room nurse, floor nurse, ICU nurse and flight nurse have exhausted their capabilities, I can usually count on these folks to get the job done at 3 am. I'm pretty sure the vein light is not a part of their hospital issued arsenal. Something tells me the scrub nurses would laugh them out of the building. If the nurse anesthetist can't get peripheral IV access, even with their $500 vein light, there isn't a soul in the world that's gonna get it at 3 am.
- PICC Line Nurse. My experience as a hospitalist is that patients need IV access 24 hours a day, not just Monday through Friday from 8 am- 5pm and Saturdays until noon. That's why PICC Lines must be available 24 hours a day, if necessary. I'm just glad they are.
- Hospitalist. I'm lucky # 7 on the road to IV access. If all roads have been exhausted, it's time to place a central line. For me, that means a subclavian approach (under your clavicle/collar bone). I've done hundreds of them. In seven years I've given two patients a pneumothorax. That's pretty dang good. My record from start to finish is twelve minutes. I like using the quadruple lumen catheters for extra access. I never place anything with less than three lumens. Some of Happy's partners don't do central lines. Some only place jugular lines. It's really a matter of preference. My preference is the subclavian approach. That's what I'm comfortable with. I don't use ultrasound guidance mostly because I rarely have a problem obtaining access. And if I do, it's time for someone else to try. Who might that be?
- Intensivist, Pulmonologist, Trauma Surgeon, Anesthesiologist, Interventional Radiology. It's a head to head competition on who gets to try next. It depends on what time of day it is, what hospital I'm at, where the patient is , and who's following the patient. It comes down to an issue of urgency and convenience. Who's the easist doctor to reach. What happens if none of these doctors can get IV access?
- Jesus. If you are a patient and you have exhausted options one through eight and the nurses with their fancy vein lights and the doctors with their fancy ultrasound machines and the trauma surgeons with their fearless nothing can stop me now attitude can't get IV access, it's time to call Jesus.
Here's a video demonstration on how to find a difficult vein using a $6,000 vein locator. These things are crazy. The patient won't know even know what hit them.
"I've blown more veins in my life than you've... Never mind."
Jim Valvano, RN - "Don't give up. Don't ever give up on your IV start."
Winston Churchill, RN - "Never, never, never give up on an IV start."
Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.