Difficult access: Would you go for EJ or pedal?

[Murse901, MSN, RN]

This post is part vent and part truly asking for any info on evidence-based practice. It is going to be lengthy, and I apologize for that.

Background: I'm a fairly new RN, but have been an LPN since 2006 and also worked EMS for 3 years. I'm new to the ED, but not new to emergency situations.

So, last night I have a little old lady that comes in for severe dehydration. She's AOx4, but extremely weak, hoorifice voice, and just looks bad overall and very dry. Sinus tachy on the monitor (110ish, not too bad), elevated BP. The MD sees the pt before I do (he's pretty fast on his initial assessment), and orders everything under the sun except for fluids.

Still, I'm pretty sure he's going to order fluids at some point, so I'm going to want a pretty good access, even if we're not bolusing it in because of her small size. Check her AC's first - nothing. Check hands, she's got some tiny baby spider veins that probably wouldn't even get a 24 in - no good. See a decent-looking vein near the shoulder, but it blows on me. A similar vein in the other arm blows.

MD is not opposed to an EJ and is very good and very fast. Her EJ's don't look awesome, but they are there and will easily accept an 18. I ask the MD if he will do an EJ. He tells me to find a vein and set him up for it (not a verbal order, just a "look and see what we got" kind of deal).

I put the pt in position to look for the EJ. Charge nurse walks in and asks me what I'm doing. I give her a brief report on the situation and I tell her that I'm looking for an EJ and MD will stick. Charge nurse asks me what her feet look like. I tell her that I haven't looked. Charge nurse takes the pt out of position for the EJ and starts looking at her feet. She has some veins that will probably take a 22 there, but they don't look great. I tell her, "I'm not really comfortable doing that". She says, "We'll have to get an MD order for it" (meaning, she thought I wasn't comfortable doing it without the order). I said, "No, I mean I'm not really comfortable with those veins. They look like they'll probably blow, and circulation isn't going to be that great in the feet anyway. MD says he doesn't mind doing an EJ".

She pretty much dismisses my concerns, tells me that she wants to avoid an EJ if possible, and gets the order for the foot stick, and she gets a 22 in the left foot. It actually holds, she draws labs from it, and it flushes well without blowing.

Fine. As long as we have access and got the labs, I'm cool with it.

Lab calls. Labs hemolyzed. I attempt to redraw labs from the foot. No go. No return. It still flushes well, but no return. Look for additional access to redraw the labs. Obviously, she has nothing. She had nothing before, she isn't getting fluids, and she has nothing now.

Charge nurse calls RT to do an arterial stick. Pause for a moment. Okay, you're uncomfortable with EJ access, but you don't mind doing an arterial stick on a dehydrated little old lady just to redraw labs. Okay, then. Continue.

RT gets arterial access at a painful expense to the pt. Labs sent. Some of the labs hemolyzed (the ones at the end of our stick, because the artery was clotting off).

At this point, pt has been in the ED for nearly an hour and a half with only half the labs processed and a 22g in the foot for access. If this patient needs a lot of fluids or needs blood, this foot access is NOT going to cut it. Sidenote: MD ordered a T&C, so he's feeling that she may need blood. Not sure yet.

I tell the charge nurse, "We don't really have time to play around with this. Let's get an EJ. MD already said he'd do it". Charge nurse tells me no. Repeats that she wants to avoid EJ access. She's going to redraw from the foot IV.

I'm hands-off at this point. It's at the end of my shift, I have one other critical patient I'm working on admitting as well as two other non-urgent patients. Charge nurse seems to feel like she has a handle on the situation and she already has report, so I'm letting her have at it. I admit my other critical patient, come back downstairs and give change-of-shift report to another nurse who is taking over my patients.

When I get back, I'm past the end of my shift. Little old lady is getting a liter of fluid and a Levaquin piggyback running into her foot. Not sure what happened after that as I just went home.

*takes a deep breath*

So, let's review the case. MD could have and would have obtained EJ access for me within less than 30 minutes. Unlikely that labs will hemolyze on an 18g EJ as you have excellent access and not using a tourniquet. Instead, we get a 22g foot access in 90 minutes. Labs severely delayed due to lengthy access time and hemolyzation of blood. Pt needs arterial stick d/t hemolyzation. Art stick hemolyzes. If the patient needs blood, she will need to be stuck again anyway.

Is there any evidence that an EJ is more dangerous than foot access? I understand that there is a risk of hitting the IJ, but this is an experienced emergency MD doing the procedure. Even with that risk, is it not more acceptable to get EJ access when anticipating blood/fluids rather than foot access? What would you have done?

[Altra, BSN, RN]

The decision point for me would have been whether or not the patient was hypotensive or trending in that direction. If not, the 22# in the foot would probably have been OK in the short-term. Many ER nurses avoid/forget about using a pump to infuse fluids -- we're so used to bolusing by gravity.

But the culture of your facility also determines how this is going to play out. What happens when your patient arrives on the floor with an EJ? Do your med-surg units even accept patients with EJs? Is the receiving nurse going to be on the phone to IV team as fast as she can, demanding different access or a PICC? If the patient is acutely hypotensive then access is a priority RIGHT NOW. If not ... then let's think about not only the ER course of treatment but beyond that to admission as well to advocate for the patient.

At my facility I can insert an EJ. Your policies may vary.

I agree that this was not the best management of your patient. I have encountered nurses with a never-ask-an-MD-to-do-anything-unless-absolutely-necessary mindset -- your charge nurse may be one of these. I have also experienced an ER RN saying "EJs should be saved for life-threatening situations"

Maybe there was some different verbage you cold have used with your charge nurse that would have set better boundaries.

[ckh23, BSN, RN]

I don't know off hand if there is any evidence, but I'm thinking EJ instead of foot, especially if the MD is ready to place one. It may be fine for now, but an IV in the foot is more easily disloged than an EJ. Also if the patient goes hypotensive or becomes septic down the road the body is going to shunt blood away from the extremities. I would rather have something EJ so I know meds/fluids given will hit central circulation quicker than the foot. As another poster mentioned about sending the patient to IR for a PICC or the MD dropping a central line? If they are anticipating this patient getting blood they are going to need more access. If the patient ends up in the unit neither the foot or an EJ is going to fly for the only access.

[Murse901, MSN, RN]

The decision point for me would have been whether or not the patient was hypotensive or trending in that direction. If not, the 22# in the foot would probably have been OK in the short-term. Many ER nurses avoid/forget about using a pump to infuse fluids -- we're so used to bolusing by gravity.

You bring up some excellent points. Our Med/Surg floor will accept a patient with an EJ. They give us funny looks when we bring them up with an EJ, but there is no policy against them accessing it. RN's at my facility cannot place EJ's, but we can access them without any special protocol or order in place.

We always bolus with a pump at 999. No gravity unless it's a code/potential code situation.

My thought process was long term, not just ED, although I understand that some ED nurses do not consider long-term. I was thinking more in terms of #1) patient will need to be stuck again if she needs blood (22g not a good access for blood), #2) those frail foot veins are going to blow if fluid is infusing too fast, and she will need to be stuck again.

Also if the patient goes hypotensive or becomes septic down the road the body is going to shunt blood away from the extremities.

Good point. At this point, new access will have to be obtained. In this case, either EJ or central line. This is going to delay care, when the patient could have already had good access in place.

[Medic/Nurse, BSN, RN]

EJ.

I do not know why that site seems so objectionable to so many. It is a peripheral vein. Period.

I think you had the right idea and it appears that the charge nurse may have had some "knowledge deficit" or some other "issue". She likely treated you poorly because she took issue with you being comfortable doing something she did not - just thinking. After all she was the charge nurse and you were well --- not. And how better to show you who she was than to get prickly over what amounts to NO REAL ISSUE. Insecure folks get threatened by the strangest things. Just a thought. Those type of "interactions" that you had to endure, all while the patient was delayed in getting what she clearly needed make me very tired.

I am against pedal and even dorsal hands for volume - if you infiltrate (pump) there are so many itty, bitty nerves in those spots that do not like to be compressed by wayward fluids and such and will protest damage with functional impairment.

In 18 years of being responsible for IV access I have never had a major problem with an EJ site. Quick, generally accessible even on "large" folks and not easily "disturbed".

I would not have been setting up a MD for an EJ look, though I'd have gotten a central line kit out for him/her.

I was spoiled in flight work - my own central access or my favorite for immediate access - a well placed and prepped EZ-IO (though not really the best choice in the situation you describe).

EZ-IO link: http://www.vidacare.com/EZ-IO/Index.aspx

You were right from the beginning. Never stop advocating for the best, expedient care that a patient requires. Knowledge is power - share it. Sounds like this would be an excellent teaching case and example to open a dialogue (and possibly prompt a policy review) at your facility - talk to your education department. Good work.

Practice SAFE!

:angel:

[A&OxNone, MSN, RN]

Agreen with the post above. What about an IO? Even though it doesn't fix your immediate problem of getting blood, you can at least start some fluids and try to get the veins plumped up a little while you are looking..

They put IO access in my ER on difficult sticks. They say it's better to have some access than NONE, and sticking with a butterfly is a lot easier that finding a good vein to thread a catheter.

We also would do EJ sticks before pedial, though

[netglow, ASN, RN]

I agree with you OP. And with Altra about some nurses looking foolish as possible to avoid utilizing an MD. That LOL is going to loose that site ASAP, and gonna get a EJ anyhoo. And, ABX in the foot of a LOL is kind of not a good idea - she's got a great chance of getting a non-healing area down there courtesy of the local ED.

[TraceyRN_CEN]

In my ED, we put in EJ's all the time. I have numerous patients who actually say 'you are going to have to put in my neck" because they have experienced multiple unsuccessful sticks. I have only been an ER nurse for 3+ years, but in that time, I have never used a pedal vein for access.

I don't understand why your charge nurse preferred the pedal to the EJ. IMO, you were on the right track.

[crb613, BSN, RN]

EJ.. we (nurses) put them in all the time, or as someone else suggested a central line. Don't know what her problem was, but if she is not comfortable with doing EJ's she needs to step aside..... I just don't have time for that.

[murphyle, BSN, RN]

We would've put in an EJ or an IO, no question. (RNs have long been able to do EJs in our department; however, new policy states that one of the MDs has to check you off on the procedure before you can do it on your own.) Per hospital policy, "non-traditional" PIVs (basically feet and mammaries) have to come out within 24h of placement; they're only meant to be used for emergency access when you don't have the staff or facility resources for a PICC or a central line. EJs, on the other hand, can stay in just like any other PIV. IOs also have to be out within 24h, but it's a central access in a non-collapsible space; you can use the IO to get her properly fluid resuscitated and hopefully "fill the tank" for a better shot at PIV access elsewhere.

We have a few techs who are really, really good at pedal sticks; if one of them tells me they can get a foot line, I'll let them try it. Otherwise, I'll take the EJ every time.

[Emergency RN]

IMHO, I don't think that it was the clinical aspects of one access versus another that was at issue here, but more so sub rosa ego and hubris on the part of the charge RN. I too, would have gone with the most productive and expedient access.

[mmutk, BSN, RN, EMT-I]

Our ER went through a spell where we I-O'd everything that looked bad! Now we generally just have the MD or charge nurse do an EJ if needed. I don't mind sticking a leg or upper arm or chest wall if I can see a vein but it better look like it can at least handle a 20g in my book.... or EJ here we come.