Case 1 - Access Denied
You are solo coverage overnight at McCullough Hyde Hospital. You just returned from a code on the floor to an otherwise quiet night to discover a new patient roomed in the resuscitation bay. Ivy Blue is a 58 year old female who arrives from a nursing facility with concern for a fever. Her nurse at the facility called ahead to say that she was going to take a smoke break all night and didn't have any further information anyway because this is her first time meeting the patient. The medics were going to get vitals and an IV but their pizza just arrived so they figured the ED could handle it and they needed to get back to the firehouse. Fortunately, Ivy has been here before so you pull up her chart. She has a history of cerebral palsy, osteogenesis imperfecta, dwarfism, ESRD on dialysis with fistula in the left upper extremity, breast cancer s/p R mastectomy and axillary lymph node dissection, active IVDU, and bilateral AKAs. It looks like she was just discharged without completing her treatment for endocarditis because she refused a PICC line. On exam, she is very ill appearing but alert. She says to the nurse "sometimes I'm a hard stick" between shallow breaths. Vital signs HR 122 and irregular BP 100/56 RR 26 T 38.8 C SpO2 94% on 2L NC Questions Question 1 In the patient with low chance of successful placement of traditional peripheral IV, what is your practice regarding nurse vs physician attempted access? Does this change based on where you're working? Question 2 In general, what access options do you have in your arsenal? What are the relative or hard contraindications to these options for this patient? Question 3 Your nurses have had no success with access after multiple sticks and you used both of your trusty 18G long US IV needles you "borrowed" from UC without any luck. Ivy now has a blood pressure of 90/46 but is still awake and alert and rather cantankerous. You complete your exam and discover that she has profuse diarrhea exploding in the bed, covering her AKA stumps, groin, and abdomen. She has also been injecting drugs into her neck and she has bilateral neck cellulitis. You find further medical records and realize the reason she couldn't receive a PICC line is because she has bilateral subclavian stenosis and DVTs. What are your options for peripheral access? What are your options for central access? Follow up This one is a doozy. No trouble, though. Dr. Ferreri arrives for his shift in a few minutes. You sign it out to him and head home for dinner. Hopefully he figures out how to get access so he can get a pan scan…
Case 2 - PICCture perfect vessels
A few months later, it's a Wacky Wednesday and the grand rounds pizza is laying heavy in your stomach as you muster the strength for your princess shift. You walk in and see a familiar name pop up on the board. It's Ivy Blue. Shudders run down your spine as you remember the access nightmare you had to manage that fateful night in Oxford. How did she get here? What now? Chief complaint - "PICC Problem" Based on your chart review, it seems Dr. Ferreri was able to resuscitate the patient, pan scan her, and admit her for sepsis. She was ultimately discharged AMA again, represented to UC, re-admitted, then sent to Drake for rehab with a PICC line that had miraculously passed through her vasculature. She's here today because her PICC isn't functioning and she is due for a dose of Meropenem and Linezolid. Vital signs HR 88 BP 148/86 RR 14 T 37 C SpO2 97% RA Questions Question 1 What is your general approach to a PICC line that is not functioning? Question 2 What things can cause a PICC line to no longer flush? What should you think about if the PICC can draw but not flush? Question 3 Fortunately, it's a weekday during business hours and the PICC team is in house. You contact them and they can come help but they expect that you make some efforts first. What are the steps you should take before calling the PICC team for help? If you call them, what information is critical to provide them? Follow up The PICC team comes down and assesses Ivy's PICC after your attempts to fix it without any success. They are fortunately able to wire over it and get a new functioning line in place. Phew. Back to Drake…
Case 3 - Praise the EJs
You're back at McCullough Hyde in the middle of a crazy shift. You're a cold brew and two shots of espresso deep, really wishing you were RVU based. Dr. Martella comes in 4 hours from now, for whatever that's worth. Then, there she is again. Ivy Blue shows up on the board. Her name haunts you. You lock eyes and she vomits. Your sphincter tightens. Now what? It looks like her PICC has been removed as she completed that course of antibiotics. She's back to using again. Chief complaint: forearm redness You barely choke down your next gulp of coffee and pop an 8mg Zofran ODT as you open Dr. Ferreri's note from a few months back. Looks like he was able to get an EJ in her by following her track marks. At this point, you are intimately familiar with her disastrous vasculature. If Ferreri can get an EJ in her, then so can you. And it looks like her cellulitis on her neck is gone now. Oh and that "forearm redness" looks like a nasty cellulitis. Is there crepitus? Not super clear… probably needs a CT scan. Vital signs HR 102 BP 188/96 RR 20 T 39 C SpO2 95% RA Questions Question 1 What is your general approach to EJs? Are there certain patients where you would try an EJ before you would try an US IV? Do you need any particular equipment? Question 2 Your first attempt didn't go so well. She has one vessel left in her entire body. The opposite EJ. How do you perform an EJ? Are there any special positioning or equipment considerations to optimize your approach? What's different about this procedure compared to a regular PIV or US IV? Question 3 You successfully get a 20G in her EJ and you're very glad you practiced this skill as an R2 at the head of the bed. Now she needs a CT scan of that arm to see if it's necrotizing… Can you push contrast for a CT scan through an EJ? Are there any special things to note when considering this? Follow up You CT scan her arm and there's gas in the tissue. You start broad spectrum antibiotics and call a helicopter to get her to an operating room and higher level of care. Legend has it, Ivy Blue is still out there somewhere with one less limb for access… waiting to find you on your next shift…