WhiteCoat

This Isn’t Football, Ma’am

If you’ve ever tried to insert an intravenous line before, you know how difficult of a task it can be with a child. Adults usually have thinner skin and most of the time have (not always) less fat on their arms. Infants and toddlers have lots of pudge on their arms and seeing a good vein is usually difficult and often impossible. The nurses who are really good at starting IV lines – the ones that everyone in the hospital calls in a pinch – have their little tricks for getting IVs in place.

Often the veterans know that you can’t always go by sight. Sometimes veins are deep enough below the skin that you can’t see them, but you can feel them. When the hospital staff ties the tourniquet around your arm and starts prodding you with their fingertips, they’re seeing if they can feel any of the veins. Almost like the way a safecracker feels for the tumblers in the safe to drop when turning the dial.

When the veins are especially difficult, one trick that many providers use is to remove the fingertip of of the index finger of one of the rubber gloves, put a little betadine (disinfectant) on the exposed finger tip, and use that finger to palpate for a vein.

A mother who worked as a phlebotomist at another hospital (and who was badmouthing that hospital to our staff) brought her young child in for evaluation of a high fever. The doctor working that night ordered some blood tests and some IV fluid. One of our best nurses pulled the finger off the tip of the glove, put a little Betadine on her fingertip, and began palpating the pudgy kid’s arm. Immediately, the mother whipped out her cell phone and started texting someone.

No one thought much about it until the child’s grandmother called the emergency department and said she received a text message that the nurse was performing an “illegal procedure” by pulling the fingertip off of the glove.

Fifteen yards, repeat first down.

The nurse was trying to avoid poking your kid a couple dozen times before having to insert an intraosseous line. Next time, we’ll keep the fingers on the gloves. No problem.

Sometimes we just can’t win.

22 Responses to “This Isn’t Football, Ma’am”

  1. DreamingTree says:

    Ummmm…the nurse is putting herself at risk more so than the patient. I bet that woman’s co-workers just LOVE her.

  2. Aaron says:

    I’m sensing a new niche product that could be totally be mainstream in 5 years.

    • WhiteCoat says:

      They already make infrared lights that can “view” veins on a patient’s arm.
      Unfortunately, despite the product literature, they don’t work well with a lot of subcutaneous fat.
      Oh, and their cost ranges from $10,000-25,000

  3. Anonymous says:

    Why didn’t the nurse explain what she was doing before starting? Just sayin’ seems like it would have diffused the situation before it even started and you probably would have gotten an “oh, ok”.

    • DensityDuck says:

      “Defuse”, not “diffuse”. HUKED UN FUNNIX WERKED FER YU!

    • JustADoc says:

      Explaining the minutiae of exactly why a professional does something the way they do it can take an enormous amount of time.
      If the mother had a concern, she could have voiced it and I am sure the nurse would have been happy to explain why she was doing it and why the risk to her child was higher with the fingertip of the glove intact than with it removed.

      • Katherine says:

        I was coming to say “Jeez, why didn’t the mother just ask what she was doing?”

        As a patient, I figure as long as you tell me what you’re doing to me along the lines of “I’m putting in an IV line” I don’t need to know the details of *how* most of the time, and if I do, I’ll ask.

      • Matt says:

        “Explaining the minutiae of exactly why a professional does something the way they do it can take an enormous amount of time.”

        That’s one thing physicians have lost in not billing by the hour or using some other mechanism that values their experience and their time. There’s no disincentive to not trusting that you’ve hired a professional to handle a professional service. Your time is, at the end of the day, what you’re truly offering to the public. That time’s value depends on your skill and experience, but it’s your time that you’re selling.

  4. ndenunz says:

    Was the grandmother a cop? Maybe she was a JCAHO surveyor.

  5. MiniMedic says:

    Multiple thoughts on this one:

    1.) She was using a cell phone in the ED. Correct me if I’m wrong, but isn’t this one of your pet peeves, WC?

    2.) Anon, with all due respect, this woman would probably respond “Well, you should be good enough to find it WITH the glove on,” since she is a high-and-mightly phleb and knows all things regarding veins. *sarcasm*

    True medical professionals should be able to figure out what other medical professionals are doing and why, if their head isn’t lodged up their distal colonic opening. I’ve watched doctors and nurses do their thing, and I don’t question them or how they do it, even if it’s a tad bit different from what I do.

    3.) I do not permit anyone who hasn’t been doing my job longer than I have to tell me how to do it without a sound argument.

    4.)You also should not argue with anyone holding a pointy object that has an intended destination of your body. It’s called “retribution.” Hell, I’ve offered to help them. (“You might want the left arm…I’ve got good veins right…there!)

    Sorry if this got a little long…

    • WhiteCoat says:

      Cell phones are one of the big three – along with “ER” and baby talk.
      Fortunately (or unfortunately) I wasn’t there for this interaction – the nurse just told me about it the next day. I would have just told the mother that she needed to leave the room with the cell phone.
      The rest of your comments are right on.

  6. Novathecat says:

    Back in the days of yore, we always felt for veins bare fingered with a little alcohol to enhance the touch. Folks today are such weenies.

  7. My hat is off, nonetheless, to this nurse and all nurses who are able to find that miniscule vein during crunch time. IV sets are designed for minimal exposure at best. This mother must be one heck of a pleasure to have around.

  8. whitecap nurse says:

    I love that the mom was eager to rat out the nurse to someone else but happy to let her proceed with what the mom thought was an unsafe IV start on her own child.

  9. Curious says:

    So, WC, was what the nurse did truly against the law – “illegal,” as the mother believed, or was it merely an unorthodox trick to find the kid’s vein without turning the kid into a pincushion?

    Or both?

    • Fyrdoc says:

      There is nothing “illegal” about it. BSI (body substance isolation) is generally for the protection of the worker, not the patient. Having started in EMS when AIDS was known as GRID (gay related immune disorder) and gloves were not routine outside of surgery, I still start IVs without them. If the nurses are calling for my help, it is a tough stick and the gloves do deaden the touch. Would this make OSHA or JCAHO happy? No. Does it put the patient at risk? No. I still prep the skin with alcohol immediately before venipuncture (and do not touch after that) just the same as I would if gloved. Remember the gloves used for IVs are NOT sterile. They are as likely to be contaminated as my finger!

    • WhiteCoat says:

      Fyrdoc is right – gloves are more for the protection of the healthcare worker.
      The technique isn’t so unorthodox, though. Many people do it.
      The whole scenario just shows what happens when medical care gets micromanaged. You want to go “by the book,” (when the book is often written by those who practice little or no medicine) you’ll end up with more procedures, more cost (charges are per IV stick and intraosseous needles aren’t cheap), and more complications in the system as a whole.

  10. paul says:

    this person is a phlebotomist? really?

  11. SeaSpray says:

    The woman sounds like a real *gem*. Badmouthing her co-workers and then if truly concerned ..texting her mother? Instead of questioning the nurse in front of her? Sounds like a negative and annoying person and not to be trusted.

    That being said ..I have had lab techs and nurses on occasion remove a glove..find the vein and then stick the needle in. I didn’t speak up because I felt awkward, but the last time I did while at my pcp’s office. I politely asked her if she should use an alcohol pad since she touched it. She apologized and used one. Who knows where her fingers were before. And if in a hospital ..it’s well known that hospital acquired infections occur.

    This was some years back, but the head of infection control had informed a bunch of us that if OSHA came in and saw that gloves weren’t being used in a situation that was remote, but possible for blood contamination they could fine the hospital 10,000 on the spot. But ..that is for the protection of the staff as Frydoc said.

    I never thought of the gloves as not being sterile, but I can see that is the case. Sometimes they just pop out and have to get pushed back in.

    So ..then it doesn’t matter if med staff touches the area prior to inserting a needle? Infection won’t be introduced? I didn’t have to be concerned? I thought if bacteria was at the injection site ..that it could then be introduced to the body ..being pushed in by the needle. ??

    I will relax then. :)

    It’s amazing how pudgy babies are in their extremities and their little no neck bodies ..so CUTE! :)

  12. T White says:

    “Sometimes we just can’t win.”

    I don’t even think we can get a tie these days.

  13. Christine says:

    I was a phleb for several years, and although the official rules prohibited the removal of fingertips on gloves, we all did it on occasion.

    I can’t believe a phleb would rat out another like that.

    Also, a lot of people don’t realize that alcohol wipes are antiseptic, not antibacterial. So the site for a blood draw really isn’t sterile unless something stronger is used (like iodine or chlorohexadine).

  14. TireDoc says:

    This simple case just underscores the adversarial relationship that exists between patients and caregivers today. The litigious nature of our society has actually backfired and created patients who are absolved of all responsibility and reasonable behavior towards their care. This more often than not results in poor decision-making on the part of the patient when interacting with us! I would never want to agitate someone who is about to stick me or my child with a needle!

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