Friday, January 21, 2011

Number Games

In the world of nursing, there are a lot of numbers that you deal with.

And I'm not just talking about heart rate, temperature, and blood pressure. And I'm especially not going to get into lab values.

No, no, it's all about the equipment.

One day we'll talk about Foley catheters - the ones that go into your bladder - and the meaning behind their numbering system.

Today, we're talking about intravenous lines. IVs, for short, if you weren't sure.

With IVs, numbers are inverse to size. The bigger the number, the smaller the IV catheter. The sizes in common use are 14 gauge to 24 gauge, and like women's clothing, we go in even sizes only. They do get bigger than 14 gauge, but if you get to that point, you're working with older equipment or you're talking about physician-inserted central lines.

Again, central lines are for another day.

Today. IV's.

We often run into people who say, "Oh, I'm a hard stick," which means it's hard to get an IV started. Some of them are right, and some of them are full of shit.

The other day, though, the truly difficult stick was a theme. I think I only started one 20-gauge, which is one size smaller than you should generally be starting on your ER patient.

The 18-gauge should be standard. If you're sick enough to be in an ER, you're sick enough for an 18-gauge. When you give blood, they use a 16-gauge. A 14-gauge requires a hosepipe of a vein. Eighteens, sixteens, and fourteens are really a pleasure to use, whether you're a semi-sadistic ER nurse inflicting pain on your drunk or uncooperative patient... or you've got a trauma or other critical patient that merits the larger sizes.

But I digress.

The other day, I was mostly starting 22's, which should be reserved for kids. Absurd. I even started one in somebody's wrist. Not the back side, but the side right next to the palm of your hand. That's one of the most painful places to start IVs, and as a rule for conscious people, I try to avoid it. I started three there.

But the prize goes to one of our chronic pain patients.

Or one of our doctors, depending on your perspective.

The short version is that the patient had multiple health problems, needed pain medication, and on the off chance that she was admitted to the hospital, the doctor wouldn't settle for an intra-muscular pain medication. He wanted to start a line. We'd tried a few times, and we knew she was a truly difficult IV stick. So I told him the story, and he decided to start an IV in her external jugular vein.

Yes, that's right. Jugular. In the neck.

Don't worry - it wasn't the artery. No squirting blood.

EJs, as we like to call them, are first in line of last resorts for venous access. If you're going to get it, the bigger the better.

On the second try, all we could get on this woman was a 24 gauge.

Yes, a 24.

We try to reserve that for infants. The catheter itself is about a half-inch long. The others we use are 1-1/4 inch long, or longer.

Smallest EJ I've ever seen.

Fortunately, that was at the beginning of the day, and I started off the day with the worst. It did, however, set the tone for the day. I managed to successfully start IVs on most of my other patients, but they were all pretty damn small.

IVs are all about your training, and whether or not you can tap into your natural skill for vein location through your training. Judging by my experience, I fall somewhere in the middle according to both, but I felt ashamed starting so many damn 22-gauges.

It was somewhat redeemed, though, by the fact that the next day, everybody had lovely veins and I started plenty of 18-gauges.

The other side of this is what happens when you get home. My husband can tell you all about that - I palpate his lovely, large, hose-pipe veins all the time, thinking about the 14-gauges I could start in his hands

I could tell you about my veins, too. Where they are, what size IV would fit, but that would be boring.

Suffice it to say that little item on the "You know you're an ER nurse if..." list is true - you examine other people's veins in the checkout line at the grocery...

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