so, my pt suddenly developed chest pain, SOB, and extreme dizziness right at the start of shift and I immediately went to my charge to notify her that I'd be calling the MD. I received orders for a stat EKG and troponin level. Unfortunately this pt only had access through a Midline in the subclavian, and due to the patients stage V renal failure, was pitting 4 edema without a vein in site. Per policy we are not allowed to draw blood from midlines. I requested an order for a foot draw, but the draw was unsuccessful.
My charge, in front of everyone at the nurses station, grabbed my patients chart and started to demand that I draw from the midline because according to her it was intact a PICC. I knew that I should not draw from the line as I had been reported by the previous shift NOT to, and I also knew that the line was in fact a midline... But she continued. She raised her voice for all to hear demanding to know why I wouldn't draw and stating over and over that I have an ORDER to draw (which was really the radiologist sign off saying I could "use" the line but never stated I could draw from it.)
I politely told her I was not comfortable with drawing from the line since I had been told not to and that I would need confirmation to draw. She was infuriated. I knew somewhere there had to be more clarification documented so I searched through his/her chart and found the MDs order NOT to draw. I was so proud of myself for doing what I knew was right, but now I fear my charge is reckless and as a new nurse feel out of sorts with everything that happened.
Has anyone else experienced this type of hierarchal bullying? What did you do? Especially as a new nurse I feel like I've lost my leader.
I think your missing the point. You can not draw from a midline. The French is to small and drawing from it causes hemolysis of the sample and makes it useless. Not only that but drawing from too small of a French increases the risk of clot. This patient already had a DVT in the other arm. How is putting the pt at an unnecessary risk beneficial just for the sake of drawing a sample that will be useless?
I believe that you can draw from a midline. it shouldn't be used as the sole source of routine draws- but you can draw from a midline.
If you google "drawing blood from a midline" a bevy of sites will pop up- articles from hospitals, infusion societies, manufacturers of the lines themselves.
I very well may be missing the point-instead of focusing on why you were right and she was wrong- I tried to offer up solutions for better outcomes in the future.
I had suggested that if she were comfortable drawing off the line that she could. She declined and that made me think if she weren't willing to take the chance, why was she willing to let me?
But you also said that it won't work- the sample would be wrecked and in would put your patient at risk for an emboli.
Why would you suggest that she draw from the line if you believed that these risked were involved?
I'm just confused because I did the right thing but it sounds like everyone would have drawn against the order and against hospital policy and that would be ok, no reprimand. What am I missing here because I know I would have gotten screamed at by management and the doc who placed the line and wrote the order not to draw.
Perhaps a call to the physician to inform of the condition and get clarification on the midline access would have helped the situation you were absolutely correct to follow the orders, perhaps the charge nurse could have given you more support by making that call instead of yelling...
I guess there are two issues here so maybe i should just focus on the one thats not policy related because that varies place to place. I'm just concerned for the future relationship between myself and the charge. We really rely on each other on nights and it felt to me like she saw it as a power struggle- as you say- and I was focused in doing what I thought was right.
Sounds like a midline isn't the best choice for this patient. Sounds like they need a central line or a PICC. If the only way labs are able to be obtained is when the pt is in dialysis then something needs to be changed. In a pinch I would have asked to try the midline since there was no other way you would have gotten the sample if lab can't get the pt, nursing staff can't either. Another solution is to have the pt be an MD draw and have the MD do a fem stick for the labs.
This should be discussed with the physician to have a PICC put in the pt or a port that can be accessed at a later time.
I agree and unfortunately calling the specialist at 0100 was not an option so I really relied on the hospitalist's orders and the experience of my charge. When I found the order from the doc that placed the line that stated not to draw an showed it to her... Crickets... Not a word. She looked at it, mumbled "don't draw from it" and said nothing else.
You came to your charge with a problem but didn't have a possible solution. Think of SBAR. This is what I need/old orders say not to use line/patient looks like she's having an MI/perhaps I can call the MD and ask for an order to use the line? Is there anything you can think of that I'm missing?
That's what your charge would have wanted to hear.
We draw from small lines all the time in peds. You do have to be gentle. Sometimes, the sample does hemolyze. And it has to be drawn again. If the patient was truly presenting critical symptoms that needed evaluation, you should address the lack of access at the time you take an order for labs. You can't just not draw the labs. Yes, you do wake up whichever MD at 0100 if you are really concerned that your patient is declining.
I took the order with the suggestion of a foot draw because he had been successful with them in the past. So I had an option. The problem is that the hospitalist, just like me, was obligated to follow the order of the specialist who placed the line and wrote a do not draw order, as well as our policy that does not allow draws from midlines. The Hospitalist wasn't permitting me to draw from the midline, Im not sure if you were understanding that. NO ONE, but my charge, was telling me to draw from the line, a line she wouldn't draw from herself. I'm sorry if it was unclear, but I was being ordered NOT to draw by everyone but my charge. I hope that clarifies things.
002rn05
23 Posts
I think your missing the point. You can not draw from a midline. The French is to small and drawing from it causes hemolysis of the sample and makes it useless. Not only that but drawing from too small of a French increases the risk of clot. This patient already had a DVT in the other arm. How is putting the pt at an unnecessary risk beneficial just for the sake of drawing a sample that will be useless?