Friday, November 21, 2008

How to read an X-ray

I had been off of orientation for a month or two in the second MICU I had worked in. Early on in the shift my sepsis patient crashed and needed to be emergently intubated. Everything went smoothly. As the doctors wrapped up, one of the senior nurses on the unit said what I was thinking – “Aren’t you going to put in a central line? This patient needs access.” The doctors were unmoved. They wanted to get back to rounds.

Central lines are IVs with multiple ports which are placed directly into the large veins leading to the heart. They are much more reliable and secure than peripheral IVs, which can become dislodged at any moment. In a code situation it is vital to have good IV access so that any drugs, blood products, or fluids can be administered quickly and effectively. In the MICU where I started you could pretty much take for granted that any patient who had the slightest potential to become unstable would get a central line right away. In this new hospital however, there was a push to minimize their use because of the increased risk of infection that comes with insertion and maintenance of the lines.

Even taking the hospital initiative into account, I was unhappy that the doctors were not taking the need for a central line seriously. With the commotion of the intubation my patient’s blood pressure had gone up, but I had seen this before and was concerned that this would be short lived. If his blood pressure fell too low, he would need pressors. I had been trained never to infuse pressors through peripheral IVs. If the medicines leaked into the surrounding tissues at the IV site, the powerful vasoconstricting effects could cause severe damage to the pateints limb. I watched as my patient’s blood pressure slowly dropped towards dangerous lows. I needed to act now while there was still time.

I went to the doctors as they rounded on other patients. I was rebuffed again. I got lucky and caught the night attending on his way out. He stayed to put the line in. He seemed to take pleasure in refreshing his skills (usually the residents put in the lines under supervision of the fellows). The night attending was expert. Within half an hour of hitting the door, the line was in. The order for a stat chest X-ray was actually executed in short order (sometimes it takes hours for them to show up). An X-ray is necessary because the lines occasionally take a wrong turn and end up near the brain instead of the heart. Proper placement of the central line has to be verified by a physician before the line can be used. My patient’s blood pressure continued to drop.

There was an X-ray viewing room at one end of the unit. I caught an intern and urgently requested her to read the film. As we walked down the hallway towards the viewing room the intern asked me, “Do you know how to read the X-rays for verifying line placement?” Me, agitated, “Nurses don’t do that. The doctors do. Weren’t you trained to do it?” “Well, I was trained…..” Ugh. I abandoned the intern and caught a nurse practitioner. She came to read the film, but the end of the IV was all the way into the patient’s heart. She was not sure if I could use it or not. I circled back to the patient’s room and got lucky and caught the night attending again. The patient was now in need of pressors. The night attending assured me I could use the line as it was. I scrambled to get a bag of Levo mixed (ICU nurses get to do that) as the night attending went back in to the room to pull the line back a couple of centimeters.

I was feeling quite shaken by this point. In the patient’s room with the night attending I expressed my concerns. “I feel very unsafe in my practice.” He seemed to be the only one who understood the urgency of the situation. He responded by teaching me the basics of reading a placement X-ray – “If it is in the heart, you can use it for meds. If it stays there long term it may cause some damage, some erosion, but that is not an urgent thing. You can use it. It is safe."

The Levo was running now and the patient was responding to it. I did not feel very reassured. I did not want to know how to read an X-ray. That was not my job and I would only get myself into trouble if I thought it was. I wanted to be able to rely on the physicians and was not feeling very sure that I could. I reiterated my concerns. “I feel very unsafe here now.” The attending paused for just a moment and looked at me. “I know,” he said, “Imagine how I feel.”


Devadeva Mirel said...
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Jay said...

In healthcare, is it ever acceptable for anyone to push? Doctor, nurse, patient, patient advocate - how can someone get additional attention or consideration without being labeled "trouble-maker," "nuisance" or "kook?" Seriously. What could a patient or patient's family say that wouldn't be insulting but would effectively get the doc's attention even in the midst of a very busy shift? There have been occasions when I've been very worried about a doctor dismissing my concerns. Changing docs isn't always an option. Do you have any suggestions?

dethmama said...

I once had a very symptomatic bradycardia pt. on my unit. Her heart rate would drop into the 30's with dizziness, fainting... I'd run into the room with the atropine.

In spite of all my pleas and hard evidence, the cardiologist waited three days before taking her for pacemaker insertion. I will never understand that.

Leo Levy said...

It may appear that pushing is discouraged and frowned upon in the hospital environment, but the truth is that lots and lots of pushing goes on all of the time. The doctors put pressure on the nurses and the nurses put pressure on the doctors especially. The resistance you feel is against adding any more pressure to the dynamic. If the relationships among the healthcare workers are unhealthy it becomes more difficult to get things done. Some nurses may be unwilling to extend themselves on a patient's behalf (they may be thinking that they know what is really important and will act if necessary) and some nurses may feel some hesitation to put more strain on already tense relationships.
Looking for and connecting with the good in people is what I find works best.

x-ray fluorescence said...

Could you tell me about MICU ?

Leo Levy said...

What would you like to know?

Andy said...

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

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Leo Levy said...

Thanks. I am glad you like it.