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After the Match

After the Match

The Second Most Important EM Procedure

Cook, Thomas MD

doi: 10.1097/01.EEM.0000660476.12584.0a
    ultrasound, IV access

    I did many things for my patients as a medical student in the 1980s that are now the purview of nurses. It was my responsibility to show up before morning rounds and draw blood, label the tubes, fill out the forms, and get them to the lab. Medical students also lined up at the “film room” to check x-rays and have them displayed in the view box for the residents and attendings. We also had to spin our patients' hematocrit and urine, and we were even trusted to do gram stains. (To be honest, we were terrible at this, and most of us ended up with purple and red blotches all over our scrubs and short white coats.)

    The most anxiety-provoking procedure, however, was putting in IVs. It was pretty cruel to have third-year medical students torture patients with multiple sticks. These days, it would be heresy to suggest such a strategy. The volume of complaints landing in the patient liaison's office would cause heads to roll. Fortunately, all of that went away many years ago as health care became more patient-focused. (I am not entirely sure what this means, but I think it is a euphemism for being kind.)

    A funny thing has happened over the past few years, however. The nurses are getting frustrated and telling us once again to put in the IVs. And the patients they are asking for help with are the sickest, with absolutely no intravenous access. If you ask residents to perform an intubation, they run over you on the way to the patient's bedside. But if you ask them to put an IV into a 350-pound, vasculopathic patient whom a nurse has unsuccessfully stuck five times, a sense of doom overcomes them. They know this is going to be awful.

    Of course, you can always put in a central line. Placing central line catheters is what we did for years when we could not get a peripheral IV. Besides, central lines are one of those procedures the ACGME requires us to learn. We even have to log enough of them to complete our training and qualify for the ABEM certification exam.

    Unfortunately, a big problem with this is the CLABSI. Central lines are associated with an estimated 30,000 bloodstream infections each year. (StatPearls. Dec. 22, 2019; And the Centers for Medicare and Medicaid Services monitors hospital infection rates caused by this procedure, denying payment for poorly performing hospitals. In short, putting in a central line solely for intravenous access is highly discouraged.

    So, what do we do?

    Difficult Access

    Of course, the solution is ultrasound. About 10 years ago, there was increasing interest in using bedside ultrasound to place peripheral intravenous catheters, and peer-reviewed journal articles started popping up. At my hospital, we are drowning in patients with difficult IV access while aggressively trying to eliminate CLABSIs. To help with this, we created vascular access teams, or VATs. These teams are composed of nurses armed with ultrasound machines and an array of different catheters that are used to get IV access on tough-stick patients. A quick Google search shows that these teams started forming in just the past few years at many health care institutions.

    The VATs at our hospital became an overnight sensation because nurses were tired of being yelled at by patients who had suffered through multiple unsuccessful sticks. Unfortunately, our VATs are a victim of their success and overwhelmed by the demand for their services. VAT consults can take hours to complete, and the service shuts down in the evening, leaving 24/7 services like the ED to find other solutions.

    We have learned time and time again in emergency medicine that necessity is the mother of invention, and this dilemma is no different. Fortunately, emergency medicine drives a large segment of the point-of-care ultrasound revolution. We cannot wait to get IV access and blood specimens for laboratory analysis in a setting where time is micromanaged to the minute for quality measures (as well as income potential). Delaying appropriate patient care by hours when you need to type blood or get a troponin is not an option. And depending on a VAT serving the entire hospital campus to show up every time you need one is unrealistic. In short, we have to master this skill.

    Airway management is the essential procedural skill emergency physicians must develop during their training. As I have mentioned in past columns, our specialty fought hard for the ability to do this, and we devote an enormous amount of education to being competent in this area. But as a specialty, we all need to recognize that getting peripheral intravenous access with ultrasound guidance is now a critical skill that we need on every shift. My experience is that it is uncommon that appropriately trained emergency physicians cannot acquire IV access on nearly any patient within minutes. It is time for the Emergency Medicine Residency Review Committee to make competency in this procedure a requirement for all residents going forward.

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    Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound ( Friend him, follow him on Twitter@3rdRockUS, and read his past columns at

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