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?
