sonovascpro

I worked there for about 3 months fresh out of nursing school in 2012. I was not new to medicine at the time, justt to nursing. Id been an anesthesia tech for 6 years just before that, and a paramedic for 7 before that in Oakland .CA. So I was no stranger to high intensity, high acuity, understaffed, work challenges. But Parkland was not enjoyable to me. In most ERs 90% of what walks through the doors is not a real emergency, that's expected. But with a volume like parkland has that 90% is a hell of alot of people. It was more than enough prisoners trying to get some time out of the cell, homeless coming in for a meal and time out of the heat, and abusers coming in trying to get meds or an IV. All to often people would come in with paperwork from another ER that they had just been discharged from, and say this is what they said at this place but I want to see what u guys think. I'd walk in and be told I had 8-9 patients but the nurse handing off wouldn't know where most of them were since people just wander there. I'd get descriptions of what they looked like and were wearing, and when they were last seen and where! It was nuts. And they have a dedicated trauma team, so I wouldn't expect to see much trauma action as a traveler. At the time Parkland was being monitored and investigated and inspected by the state and CMS. So that added to the misery daily since inspectors were actually in house everyday. All of this was in 2012, and in the old Parkland building. They have since built a brand new facility with a ton more room so maybe things have improved. I'm not in 20s anymore, so my work habits and needs are vastly different from what they were when i was young. I like my breaks, specialty service pay, clean controlled conditions, and being off on time way to much now. That's why I switched to vascular access!!!! The tests as far as I can recall: meds/math was alot of conversions (Gm>mg>mcg etc,) calculating flow rates with different variables, side effects and interactions of commonly used ER meds (none that u shouldn't already be very familiar with), and i think a few scenarios that asked what med wpuld u anticipate being ordered. The basic ER/trauma was just what it sounds like. Alot of situational questions, some critical thinking/ prioritizing questions, if you have acls and some sort of trauma cert, and some ER experience u shouldn't have any issue with this. EKG was basically like taking the test for ACLS. It was strip recognition followed with what to do next or what to expect next. Everyone I worked with had passed them first shot with no issues, so I'm sure you will do fine. Anyway, good luck with it. You may love it. Like I said I liked the crazy stuff when I was in my 20s, now I like to do a few piccs, do a few IVs and then go home!

A few things about getting into vascular access that may help you or you can do to help yourself out. 1) Most VAT are looking for critical care experience. You will be placing lines on a variety of patients of varying acuity. Most VAT that I have had experience with don't tend to bring on med-surg nurses or out of hospital practice nurses. They tend to draw from a pool of experienced VAT, ICU, or ER nurses. On rare occasion I have seen a very extensively respected and experienced tele nurse be selected. VAT is more than just the skill of using a sono and needle, it requires a lot of medical knowledge, experience, and critical thinking ability to perform safely and effectively. 2) The skills. Obviously you should make certain that your freehand IV skills are top notch, this will help you by being one less thing to learn or be concerned about when you start incorporating the ultrasound. Being that you are in hospice care right now it would likely be difficult for you to regularly get your hands on an ultrasound and vascular training phantom to start learning more about ultrasound guided VAD placement. Finding an instructor led hands on training course is about impossible in most areas. But would be of most benefit to you so that you start off with as much information and guidance as possible to speed your learning and help you avoid learning incorrect techniques, information, and habits. I offer one of these training courses, but it is only available in Texas. Also the nurses that I train tend to be from ER and ICU where an ultrasound is readily available on a daily basis and IV start needs each shift are plentiful for practice. It doesn't do much good to learn something if you wont have the opportunity to use it regularly enough to become proficient. 3) I would say network a bit. There are VAT at most hospitals. Talk to the VAT nurses at these facilities. Also talk to the ER nurses and find out who their staff is for sono IVs. There is always at least one person who taught themselves how to do it. Just be cautious since they likely taught themselves using the internet as a resource, so their techniques and knowledge may not be as accurate as it should be. Those facilities that don't have their own VAT likely contract with an outside agency that provides the service. An outside agency is another option, as most will train you for sono guided VAD placement. They do typically only hire critical care nurses, and often only want experienced VAT nurses since they travel from facility to facility with no "backup" in case of issues, and are strictly profit based operations. They tend to want people who can be up and running quickly to maximize company profits. Don't get discouraged. If you want it you just have to do whatever it takes to get it. I can tell you that VAT RN is by far the best of all RN positions in my experience. Typically pays better, has better hours, cleaner, safer, well respected as a specialty in facility, and you do none of the things that we all hate doing as a nurse. I started in ER, have done cath lab/IR as well. I have tried to go back a couple times just to not lose my skills. But every time I go back I cant believe how much harder I have to work and usually for less money!!! Good luck to you. Feel free to message if you have any other questions.

Not sure which midline kit you are using, or what size (ours are 18 and 20 GA), but It seems that a PICC shouldn't be introduced into a vessel in which a midline already occupies 42% of its lumen. Even a 4fr single lumen PICC is slightly larger than an 18g IV. If this was an ICU patient I'm sure they would have insisted on a PICC with multiple lumens, meaning it would be an even larger 5fr possibly 6fr. In addition you mentioned that the vessel narrowed as you scanned it proximally. That narrowing may account for some of the lack of blood flow issue you mentioned as well. If the patient was as sick as you stated, she was likely hypotensive and hypovolemic as well which would tend to leave her peripheral veins more pliable and prone to collapse under the pressure of suction. It could just be that the vessel wall itself was collapsing onto the catheter lumen opening and occluding the blood return, especially under aspiration pressure. It seems as though your access and placement weren't the issue, it was much more likely patient anatomy and physiology that hindered blood return.

I started with a private contract PICC company that employed 20+ Associate degree nurses, offered on the job training, and virtually every full time PICC RN was making well into the $100Ks. You don't need a higher educational degree to become a PICC nurse, you need a specific skill set and knowledge. Critical care nurses often have the easiest transition (ICU/ER). I started by using ultrasound in the ER for almost all my IV insertions. Eventually I was the go to guy for the entire hospital when nobody could get an IV. From there I went to the private company. My on the job training was shortened significantly by my US IV experience. You will at some point need to decide if you just want to place the lines, or if you want to place and use the lines. If you just want to place look into Vascular Access- Board Certified VA-BC status, if you want to use them after you place them look into CRNI through INS. I like to be done as soon as the line is in, so I am VA-BC. In short look for experience in certain skills, and knowledge related specifically to vascular access and infusion if you want to be a Vascular Access nurse, not degrees.

I don't use needle guides. Never have and never will. PICC insertion involves a lot of "feel" from start to finish. I have always freehanded my PICC needle and my US IVs. This is also why I prefer to reinforce my PICCs by having both the stylet and guidewires in my PICC during advancement. I can feel what is happening with my PICC as it is advancing and adjust accordingly. As far as large or loose skinned patients I stretch the skin from above and below with the pinky finger of each of my hands. My probe hand pinky is resting on the skin anyway, and I hold my needle like I'm throwing a dart so my pinky is pointing down to skin. I have found this to be useful on almost all my insertions, not just large patients. I am also a big fan of cephalics in large patients. The extra tissue in their arms seems to kind of flatten out that sharp curve where the cephalic joins up with the basilic/brachial. Plus the tissue in that area wont be as prone to shifting as you stick. Once again a reinforced PICC will let you feel what your PICC is doing as it approaches this junction. You also asked about white streaks under US. My guess is you are seeing fascia or other connective tissue. Visible nerve bundles tend to follow blood supply. So if you are looking at out of plane blood vessels, you will generally be looking at an out of plane cross section of the nerve bundle too. So in that case it would look more like a large whitish/grey dot in close proximity to the vessel, rather than a streak across your screen.

I would assume that you aren't using 3CG ECG technology for your PICCs? If not then there are a couple of things you can do to check if your PICC is sitting IJ before you break sterile field. 1) flush with a little saline then ask the patient if they heard a strange noise, usually a woosh or bubbling noise. Just don't ask them to listen for it before you do it, or they will hear it every time. 2) The stylet wire and guide wire will both show up under ultrasound as white dots if you scan the IJ. Now this of course breaks sterility of your probe (but you already have access in the arm by this point so you shouldn't need it again anyway), and you will have to pull back your drape and have the patient turn their head away from you. But if your patient says they heard the flush this is a a pretty logical next step to confirm IJ placement. I scan the IJ with my probe in the left hand and my right hand slightly manipulating the PICC to make it move along its length. If its in the IJ you will see the white dot of the wire dancing around in the IJ as you manipulate the PICC. 3) Not sure of your knowledge, training, PICC kit, or experience. But PICCs generally have a natural curve molded into them. On Bard PICCs numbers up at the hub is for R arm insertion, numbers down for left. That's just how their PICC naturally curves. Anyway, may be stuff you already know. I'm lucky to have all 3CG PICC kits only now. But I worked a long time without them too. So this was a really useful assessment before I tore down and called for an xray. Especially when I was traveling for PICCs and was going to leave the facility before an xray was done.

Has anyone here recently gone through the process of writing a CEU program and getting approval either through a state BON or ANA type organization to become a provider? If so can you provide some info on how you started and worked through it? Why you chose _________ as the organization to get your CEU program approved? Did you find out anything along the way or after that would have made your process easier? Do you know of any organizations or individuals who you can pay to either go through or help you go through this process to make it easier? I am looking at developing a single subject training program and would like to be able to offer the program as a CEU program rather than simply a certificate of completion program. If there is company that does this i'd be happy to just pay to get it done. But if not, I'm going to need some info from those who have done it already. So any input would be helpful. Thanks