Monday, May 19, 2008

The Thin Red IV Line

Small minds take pride in small things, but small things sometimes make a big difference....

The Thin Red IV Line

The year was late 2005. The patient was an obese pregnant lady all set to deliver her first baby in UM. The attending doctor was a trainee obstetrician who moved with an air of agility. The four of us then medical students were entrusted with the task of setting an intravenous line for the first-time mother. We tried and failed, re-tried and failed again….and again.

It was impossible, we thought. The lady was just too fat and chubby and uncooperative. We gave up, approach the trainee obstetrician and related our woeful malady to her. She mumbled something inaudible, prepared a tray and moved with haste towards the patient. She applied the tourniquet, made a few swabs on the skin and with one simple prick, secure an intravenous line in a large vein somewhat proportionate to the patient herself. She cleaned up her trash as she was getting to leave, remarked that it wasn’t that difficult after all.

I was left impressed and wowed over. It was a surreal moment, one that made me all too keen and enthusiastic to acquire the skill and art of setting an iv line where others have failed and given up.

Housemanship and Procedures and Obsession Over Heroism
As medical students progressed in medical school, it is very much a norm to discuss and ponder over the choices for our housemanship training or internship.

Most people would want to apply back to their hometowns for reasons that are obvious. Family and loved ones and longtime animal friends are still the things that matter the most in life.

The more ambitious and decided ones would already have an institution of their choice to provide training in the discipline that they were interested in. A small lot prefer to stay back in teaching hospitals and universities either because they believe they’ll receive more sound training and teaching or because they intend to pursue a career in academic medicine.

Then there are those whose primary aim is to secure skills and hands-on training. These medical graduates might voluntarity transplant themselves to Sabah believing that they get to do more and see more. It is widely believed that hosue officers in Sabah more practical training in bedside procedures and surgical inteventions. True enough, house officers in Sabah get more opportunity to do much more than their counterparts in West Malaysia. Most house officers in Sabah who have completed their rotations would be pretty skilled in chest tubes, internal jugular catheters and endotracheal intubation. Those who have graduated to become medical officers in the district hospitals are performing Caesarrean sections, appendicectomies and minor orthopaedic procedures on a daily basis.

I have had my share of brazen, whimsical medical procedures and my fair share of failures and complications as well. Even so, nothing beats the insertion of an intravenous (iv) line.

Young doctors have an inherent obsession over clinical procedures and clinical skills. There are a number or reasons for this phenomenon.

Most doctors are by nature kiasu and of type A personality. Each wants to outdo the other in studies and clinical skills and career advancement. The state of Sabah’s healthcare provides a fertile ground for fledgling doctors to learn and polish their diagnostic and therapeutic bedside procedures.

Perhaps it is because the seniors and predecessors of these medical graduates once boasted about their audacious exploits in the course of their training in Sabah and encourage these new doctors to follow their pathway into Sabah likewise. Some of their claims are plausible and true, like house officers being accorded a chance to perform pericardiocentesis. Some are totally preposterous altogether. A senior medical officer once claimed that he performed a partial gastrectomy all by himself as a house officer in a patient with perforated stomach ulcer. These tall tales might have an inch of possibility or it’s simply a case of misery in need of company. If a doctor made a foolish mistake and ends up trapped in Sabah, one might as well con and drag many others into whatever predicament one is in.

Television series play a role too, I suppose. Medical dramas like House, ER and that lame Hong Kong ER-wannabe have a tendency to depict doctors performing daring and gallant interventions with supernatural impressive results. Such miraculous total turnarounds are of course rarely seen in reality or more often than not, at painfully slow speed and usually with significant residual physical impairment. Nevertheless, it leaves a lasting albeit erroneous impression upon the medical students or aspiring doctors.

More recently, the Public Services Department (JPA) started an attachment program for potential government scholars in medicine. The high-achieving potential JPA scholars are made to rotate around the hospital departments over a period of two weeks to observe the daily life and work of doctors in government service. Instead of observing the struggling house officers rushing about in their daily duties of taking orders and carrying out menial tasks, these pristine minds are made to observe among others, complex surgical procedures and valiant resuscitative efforts. They just might end up going back desiring to be the super surgeon or emergency physician they have just observed in action without knowing that the long term ultimate outcome is not necessarily sweet and beautiful.

In short, medical students and later medical graduates are exposed to a basketful of wrong ideas of clinical medicine. Instead of improving their skills of history taking and recognition of ominous clinical signs, they are aspiring to insert their first chest tube and perform their first lumbar puncture. Instead of reading pharmacology and mastering very basic procedures like blood taking and intravenous cannulation, they are studying syndromes and dreaming of intubating their first patient and be called a hero thereafter. They are in fact jumping the gun in the midst of their obsession over risky clinical procedures and epic interventions without mastering basic skills.

It is akin to a baby attempting to eat walnuts when they have yet to wean off breastfeeding.

The Belittled IV Line
Personally, I feel that one of the most important clinical skills a house officer must acquire is the setting of an iv line. The principles behind intravenous cannulation form the basis of many other complex and skill-demanding clinical procedures.

IV lines are lifesaving, much more so than a costly internal jugular catheter. Patients have died unnecessarily because the attending doctors did not secure adequate intravenous access for drugs, fluids and blood products. In the same vein and no pun intended, critically ill patients on the brink of death have been successfully resuscitated because functioning iv lines of adequate caliber were set in place.

IV lines permits continuous treatment especially in patients requiring regular doses of antibiotics or cancer chemotherapy. Patients with difficult iv access often receive irregular and insufficient doses resulting in the development of bacterial resistance and failure of treatment.

Almost every patient that is admitted in the hospital has an indwelling iv line. It is a symbol of both captivity and liberation. The removal of an iv line usually implies an improving patient planned for discharge very very soon.

The ubiquity of the all-important iv line is also the reason of its being underappreciated, at least in Sabah – I think.

In many developed countries like the United Kingdom, blood taking and intravenous cannulation are done by specialized ‘phlebotomists’. In Peninsular Malaysia, in probably almost every hospital, the job of securing a proper intravenous access falls upon the doctors, and almost always the house officer. In Sabah, the task of setting intravenous lines is entrusted to the nurses and the justification for this is that our doctors are seemingly just too busy and overworked.

Strictly speaking, staff nurses are not trained or accredited to set iv lines, despite the fact that the more senior ones tend to do a much better job at intravenous cannulation than many doctors. I have nothing against nurses inserting iv lines for patients. It’s just that the ward nurses are overworked in their own right. In addition, the house officers are not learning this essential clinical procedure.

I find it peculiar and embarrassing that some house officers trained in Sabah are so skilled in setting catheters in almost every part of the human body but appear pretty useless when it comes to setting a simple iv line.

Size Matters
When someone else’s work is thrust upon us, it is natural for any human to search for an easy way out or to do the bare minimum just to get it over with. It is not in the nurses’ official job description to set iv lines, so there is no reason why they should go the distance to ensure that the patient’s iv access is the right choice, right size for the right procedure. In their rush to complete their endless clinical duties and needless paperwork, nurses have discovered that the smaller iv lines are much easier to set and require less time.

As a result, we have patients going for major surgeries with a minute iv line that is barely running. How in the world is anyone able to transfuse blood at an adequate rate if the patient suddenly bleeds uncontrollably in the middle of an operation?

The pampered house officers meanwhile have become complacent, taking for granted that they are under no obligation to set iv lines throughout their tenure in Sabah. In fact, it seems that the house officers in general want to have nothing to do with anything related to iv lines. They may examine the patient and detect that vague cardiac murmur but will not realize that the patient’s iv line is blocked, swollen, infected or simply inappropriate.

Sad and scary stories about iv lines are abundant and outrageous.

When patients deteriorate out of a sudden in the wards, doctors suddenly realize that the patient does not have sufficient intravenous access for drugs and fluids. I have had my fair share of scare under these circumstances.

The Recalcitrant House Officers
While the house officers are obsessed and fixated about fancy procedures, I am preoccupied with securing iv lines, if that is not already obvious by now. In addition, I believe that all house officers should be competent in the skill of setting iv lines before graduating to more ‘glamorous’ procedures like bone marrow biopsies.

My conscience is clear in the sense that I have spent hours by the side of patients trying to secure iv lines for their surgeries the next morning or for that all-important medication. Personally, I find great satisfaction being able to attain an iv line in patients where others too have tried but unsuccessfully. It is not groundbreaking open heart surgery but nevertheless an achievement in its own sort.

Small minds take pride in small things, but small things sometimes make a big difference to simple folks.

I have tried to convince the house officers to take the initiative of setting iv lines without waiting for and prodding the nurses to do so. Admittedly, I have not been very successful. Manners and diplomacy do not work with everyone, some doctors need to be chided and admonished fervently before they will get out of the not-my-job mentality into the I’m-doing-it-for-the-patient way of thinking.

In the meantime, I am getting impatient and furious when patients turn up with inadequate iv lines due to the apathy and couldn’t-care-less attitude of the house officers.

Perhaps I should start behaving like the medical officer I vowed to myself I would never become….


sl said...

Wow... you can get so upset by small iv lines? Oh dear. Next time, take a deep breath ok?

Anonymous said...

yes, take a deep breath, and let it rip!

Anonymous said...

Seems that everytime a newly graduated doctor think of going to the east to start his/her career...they would always say Sabah...I want to go Sabah...Sabah is nice...Sabah this, Sabah that...What about Sarawak ? its larger, with bigger problems, and lots of local bumi's cut off from the services of modern medicine. Dont want to stir anything, but im a Sarawakian, and i feel irked everytime i hear that from my. i go WHATS WRONG WITH SARAWAK ?. haha...just a thought..:P

ken said...

ya itu la.. semua urang mo pi sabah.. in the end sia yg mo bikin houseman terpaksa kana buang pi the way, ko kerja di hosp mana ni product of the system? inda lama lagi sia mo graduate ni.. tulung2 ah nanti? hehe