Hold Your Stick Steady Ya!

I almost said the word yummy

What do you see in this picture? What comes to your mind first? 

I saw veins, plenty of them. I almost said the word yummy. (What did you think? Tsk tsk)

Yesterday night one of my juniors in my resident hall (King Edward VII Hall) barged into my room, demanding that i teach him how to set an IV plug (intravenous catheter). He then related to me of an incident that he witnessed in the wards earlier that day. 

Having just finished his preclinical years (studying basic medical sciences such as anatomy, physiology, pathology, pharmacology etc) and all revved-up to set foot in the wards, he was eager to learn all the basics of being a clinical year medical student. One convenient way was to tag along the houseman in ward and observe what they do. R, a houseman who i know, was going to insert an IV plug when these students came to observe. 

*Clinical year denotes that medical education ceases to be all-lectures. Students will have to attend wards and take on an apprentice role, rotating across departments of different specialties 

Different gauges of IV catheters/cannulae/plugs, just like bullets

Having successfully inserted the plug, R was retracting the needle to check for backflow (blood flowing into the transparent catheter as a sign of successful insertion) when the patient's blood started gushing out in spurts. 

I could see the slight disgust that my junior felt towards R's perceived incompetence as he was describing what happened. I totally did not agree. There were many forces at play, and to blame the poor houseman while negating other possibilities would be plain simple-minded, not to mention unjust.

I really felt disappointed, or even angered at my junior's ignorance. I could understand if that demeaning account came from a layperson. We get misunderstood all the time by the laypeople. But from a medical student? Come on! 

Too often i have seen doctors being wrongly blamed* for untoward incidences that happen to the patients. We do not need more medical students joining the horde to help perpetuate the simple-mindedness. There are many forces at play. There are always physician factor, procedural factor, and patient's factor. But of course the physician is always the most convenient target. 

*Of course i acknowledge that there are instances where doctors clearly were at fault and had to be held accountable. I do not by any means discourage anyone from inquiring into events, but look at it with an open mind, and without emotions. 

Hospital is one scary place, no? 

Almost everyone who has been admitted to a hospital would have experienced that agony of having an IV plug inserted. Every patient hates it. 

Well, it's justifiable that patient harbours ill feeling towards the catheter, and in the same vein, the doctor who inserts it. 

However, believe it or not, we do not like it any better than you do. We feel the pain as well. 

----

I can still easily summon the memory, and the accompanying grief. I was trying in vain to insert an IV plug on a terminally ill patient. She desperately needed one for IV drugs that will lessen her suffering, however she had almost no accessible veins left on her body. 

Little by little, each time she was admitted for treatment, her veins would collapse from repeated insertions of IV plug. Little by little, the veins gave in to repeated trauma and thrombosed, or succumbed to inflammation (thrombophlebitis) which led to thrombosis as well. 

The back of her hands resembled those that came out from a battleground, perhaps surviving shrapnels from an IED. They were so blemished that there wasn't a square inch that was free from scars, or scabs from recent trauma. Her forearms were lined with tramtrack lines, formed by numerous previous IV cannulations, not dissimilar to the stigmata that IV drug abusers inflict upon themselves. 

Each time we got an IV plug successfully inserted, the team of student intern, houseman, and nurses would cheer triumphantly. The patient would thank us profusely, her gratitude overspilling from her jaundiced eyes. 

But the joy would never last long, as we knew that the next battle was impending. 

We were treading a fine line, between replacing the plug too oftenly, and leaving the plug for too long that infection would creep in, while always in full awareness that there might not be another vein the next time we look for it. 

The day finally came. We needed a new IV plug. The old one had been there for too long, and the surrounding area had started showing signs of inflammation. 

I was the student intern to insert a new IV plug. I only had an hour before she would receive her next course of medications.

I was naturally optimistic, being blessed with nimble fingers that were usually able to find a vein and put in a plug when it eluded others. But not this time. Meticulously i spent 5 minutes to coerce a vein to surface, gently tapping on it. It appeared, to my rapture, only to disappear once the bevel of the catheter made its first contact. Unfazed, i was scanning her entire arm for a viable vein. Ah found another one. Baby stay baby, it's gonna take only one second. Then baby went away. 

I stole a glance at my patient, she nodded to me approvingly, and conveyed enormous understanding. I however was reluctant to cause any more pain. After all i was just a student intern. I called my houseman.

She too failed after trying two attempts. There was no one else in the wards that we could ask help from. Only the two of us, and there were truckloads of patients who needed our attention too. I was left to my own device again while she attended to other patients, as the circumstances called for.

I explained to the patient, but before i needed to complete my sentence, she told me not to worry, that it had always been the case. The good veins were getting scarcer, i was told. Take my time, she advised. 

It was already time for her medication, yet we still did not have an access to infuse the medicine. 

While she showed great understanding, each time the bevel penetrated the skin there would be an inevitable, involuntary audible gasp of air, from the pain of punctured skin. I almost wept, guilt hammering at my conscience. 

Backflow*! I advanced the rest of the catheter in. But the blood stagnated in the translucent cannula. Sighs. The vein was too narrow for the catheter to tunnel in, only releasing specks of blood that gave me false hope.

*Newer generations of IV cannulae are made of translucent plastic capable of showing backflow. Backflow refers to blood that enters the cannula and can be seen flowing in just distal to the port, signalling that the tip of the cannula is now inside the vessel

I was nearing emotional breakdown when i finally got it. I inserted the needle between 2 old scars that were spaced less than 2mm apart. I just felt there was a vein, but i could never be certain. It was a leap of faith. Anyway i taped the catheter in place and flushed it with heparinised saline to prevent premature clotting of the plug. Wearily i clapped my nurse's hand which was held in high five. Till another day. She proceeded to administer the elixir of lesser suffering.

That other day never came, as i had finished my one month of student internship. I never found out what happened to my patient, whether she had any more invasive procedure to secure an intravenous access. I didn't have the heart to. 

----

I agree that not every houseman is as good at setting plugs. It's just like sports, some people will be more talented than the others. However, just like any sports, everyone improves with practice. And i can safely assure you that all NUS graduates are well trained in the drills of setting an IV plug, way before they started housemanship.

But it's not only the talent or skill that determines how well the procedure goes. There are many variables which are outside of the doctor's control. 

Entire body twitches in agony

Very often the patient twitches as the needle punctures the skin, and i realise that patients often are not aware of it. As a result of the jerky movement, the doctor loses the vein that was previously secured with finger pressure, thus the vein escapes from the trajectory of the needle. Some even tenses the muscle when the needle goes in!

That, i personally feel, is the biggest cause of repeated IV cannulation. 

At least we weren't born wrinkled right? 

As we age, our skin wrinkles, eye bag sags and breast grows pendulous. That's because our connective tissues all become lax. Similarly the vein becomes less fixed to the surrounding tissue, resulting in excessive mobility. On top of that, ageing changes the consistency of the venous wall, making it less compliant, and less easy to puncture. Therefore, in elderly patients we commonly encounter the phenomenon where veins evades the advancing needle. The doctor has to put in great effort just to outmanoeuvre the slippery vein, usually only succeeding after several attempts. Count yourself lucky if the doctor succeeds within 2 attempts. 

I had a bizarre experience when i was setting a plug on a muscular young man who had nice big succulent veins all over his hands. It seemed really easy and i thought even a novice could have inserted a plug at the first go, but somehow his vein collapsed everytime the catheter went in. No one could explain what happened, much to the patient's dismay. I tried, the houseman tried, the houseman from another team tried, the nurse tried. Eventually one of us succeeded, but i suspected that was more luck than skill. 

(There was no use calling anyone more senior than the houseman, as plug-setting is a fine motor skill which becomes lousy after disuse, and usually no one sets a plug after their housemanship except if you are an anaesthetist. The greatest disservice you can ever bring upon yourself is to insist you get the most senior consultant to insert the plug.) 

So what can we do if we suffer the misfortune of needing an IV plug? 

Calmness and serenity

Stay calm, relax and co-operate with the doctor. If the doctor has to try once more, too bad. Ask the doctor if you had moved unconsciously. Make sure you don't twitch your muscles in pain. Relax and stay calm. Be courteous to the overworked yet underpaid doctor (at least in Singapore). It will make it a pleasant experience for both of you.

If the houseman has tried more than 3 times, it's reasonable for you to ask for a few minutes break and resume later. You can even ask for the houseman to apply some local anaesthetic to numb the area. 

However if you start raising a ruckus, and stresses the poor houseman out, i can assure you he will falter. And it's a bad bad idea as there's almost always no one else in the entire ward to bail you out. 

So, next time if a doctor has to poke you more than once, smile at him, and say hold your stick steady ya!