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I have to disagree with you here Chris. If you absolutely have to give a vesicant or extremely irritating drug/IVF without the aid of central access, I would rather see it given through a peripheral IV site. You can see an extravasation/infiltration almost immediately with a peripheral site, but if the same thing happens with a midline, it could take days to see, therefore causing a whole lot more damage.
That is why cytotoxic drugs are given through a peripheral IV site when central access is not an option, with close supervision while checking for blood return at least every hour. They would never give chemo through a midline for this reason, so why would you consider giving any vesicant through one? Someone could lose an arm that way. Then the peripheral IV site is removed and a new one is started for the next dose. And before you tell me that your patients do not have enough veins for that, I will reiterate. A PICC is the best option for that patient. And that is it in a nutshell isn't it. Do the best for your patient. Choose the correct line first. Not everyone needs a PICC, but for those who do, get it done, or don't do it. And make sure the patient or the family knows the difference and has their options laid out before them to make that choice. That is called informed consent, and it is illegal for you to do otherwise.
And by the way, all of you LTC and homecare peoples, just for the record, I am in no way putting down you or your practice. We in healthcare could not get along without you. I just believe that it only takes one person to make a difference, and you can either make that difference or not. I choose to try to make a difference. That goes for ANY practice setting. You homecare and LTC people (and you know who I am typing to) act like people who work in the hospital got it made. Well, we have issues we fight too. They may not be the same issues, but they are issues none the less. And we fight them on a daily basis, so do not for one minute think you are alone.
Heather Nichols RN BSN CRNI
Infusion Services University of Louisville Trauma Institute 530 S. Jackson St. Lou. Ky. 40202 (502)562-3530 >>> "Chris Cavanaugh" <[EMAIL PROTECTED]> 02/06/06 7:28 AM >>> Randy, I have to agree, having also placed midlines in LTC and homecare for
less than 4 weeks of antibiotic therapy or hydration. In LTC and homecare they are used on a daily basis. And yes, I have placed midlines when a PICC is ordered, because the request is "can you get a midline if you can't get the PICC in?" when it does not thread past the shoulder, I do not think US would help me there, but I know a midline is better than a PIV for these already bruised patients. Thanks for your support of alternate care nursing. Chris Cavanaugh, CRNI -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of [EMAIL PROTECTED] Sent: Sunday, February 05, 2006 5:50 PM To: Heather Nichols; [EMAIL PROTECTED]; [EMAIL PROTECTED]; Leigh Bowe-geddes; [EMAIL PROTECTED] Subject: Re: Midlines Well, let me ask how many Midlines you have placed? You seem to have all the knowledge. Having for worked for how long on a Hospital based PICC team with all the advantages that brings gives you an absolute knowledge of Midlines and their capabilities and weaknesses? I think that with all the arguements that have gone on this past week and a half on this list serve that we could figure out that no one has all the answers. Not even the lofty INS Standards are exceptable to everyone. I have placed thousands upon thousands of Midlines in alternative care settings. And never have I had a significant outcome related to Midline catheters. Not one!!! If everyone had the same advanteages that hospital based PICC teams have we would all use PICC's. I am really tired of the the few that have the advantages making us alternative care setting Nurse's look like Nurse's practicing poor care for our Patients. Let me see you convince an administrator that placing a PICC and sending the patient to the hospital for an X-ray is the only way to give an antibiotic for a five day treatment or D5NS because the osmalarity is to high for PIV or Midline placement according to INS Standards. I would love for you to have to deal with not only the administrator about the costs involved but with families that are private pay. I routinely cut my charges for private pay to allow a patient to get a PICC or Midline so that they can afford to have a line placed after a hospital with a PICC team sent the patient back to a nursing facility with no line and 4 weeks worth of antibiotics. If you did not have an x-ray department based in your hospital and your President or CFO continually received ambulance billsof $500.00 for patients that were sent for x-rays let's see how many PICC teams would be based in a hospital setting? Please answer me that one? Do you think that you would still have a job? Do not give us the BS that you always do based on a Standard. It is based on a Standard conceived in a perfect world scenario like hospital based PICC teams. Still feel uppity? Ask your CFO if you would still be placing PICC lines or would your Hospital CFO make you use Midlines even though the Standards say you should use a PICC! And please do not give me the BS that you would rather quit than place Midlines! Please, that is BS!!! Cost of services rule in healthcare! Cost is what every business is dealing with. If you cost more than IR you would not have a job. Period. If you still believe what you are advocating, I can give you the number of hundreds of Administrators, Medical Directors and Directors of Nursing. You can explain to them the need for PICC placement and X-rays vs. Midlines. I know the Standards!! I folow them to the best of my ability. I paid the money for three Ultrasound machines to advance my practice. I give my all to my patients, clients and customers!!!! I take the Standards for what they are Standards. If I ever have to defend myself in a Court of Law I will do my best. But then again after having been in Infusion Therapy and Vascular Access for 16 years I have never had to do that. Even after having placed 10-12000 Midlines over those same years. OK, I am sorry for those of you that do not want to see this kind of e-mail on the list serve. I myself am tired of the bickering. So this will be my last e-mail. I tried once to get off the list serve due to angry e-mails but was unsuccessful. So this is it. Many years on the list serve, many years gaining some valuable knowledge from the members. But, I see an elitetist attitude that I am not comfortable with anymore. I have seen it for many years, but I felt that I got something from the issues. No more. To: Kathy Kokotis, Kathy always loved your enthusiam for Vascular Access mostly agreed with you on everything. Bought my first Ultrasound based on your valued leadership. And you were there when I learned to place my first PICC. Lynn Hadaway: Do not always agree with you. LOL But respect your positions. I have learned much from your emails even if I did not agree with them. To all those Nurses that work in alternative care settings: Continue to provide the best services for your patients regardless of what everyone with rose colored glasses say. You are the front line and the last line for these patients. You are the nurses that deal with all issues in vascular access. You need to keep on fighting for the best in vascular access for your patients. Fighting the CFO's and administrators to get to where the Standards are. Maybe in the future we will not need debates on PICCs vs. Midlines or Ultrasound vs. non-ultrasound placement. I am not sure that day will ever come but if it does I will be happy. I am very sorry to have gone on for so long. I do not normally vent my frustrations in a public setting. But please do me a favor, do not make us lowly alternative care nurse's feel like we are the wicked step children. I am sure that there are more experienced PICC nurses placing lines in alternative care settings than nurses placing lines on hospital based nursing teams. Maybe not. PS: Heather and Leigh Ann: This is not directed solely to you two. It just happened that Heather's e-mail is the one in which I replied. I know you two and like you!!!! Sorry Please Unsubscribe!!! -- Randy Ross R.N., B.S.N. IV Nurse Consultant, President & C.E.O. IV's Etc... LLC Vascular Access & Consulting Ph: 317-541-6463 Fax: 317-894-7709 Email: [EMAIL PROTECTED] Website: www.IVsEtc.com -------------- Original message ---------------------- From: "Heather Nichols" <[EMAIL PROTECTED]> > Ditto. Well said! Kudos! > > Heather Nichols RN BSN CRNI > Infusion Services > University of Louisville Trauma Institute > 530 S. Jackson St. > Lou. Ky. 40202 > (502)562-3530 > > >>> "Leigh Ann Bowe-geddes" <[EMAIL PROTECTED]> 02/04/06 8:39 AM >>> > > While it does occasionally happen that a fibrin sheath completely > covers a line and causes retrograde flow of the solution, I have seen > chemical phlebitis be a more common cause of retrograde flow when the > line is a midline. There are very few medications that can safely be > administered via midline without causing phlebitis. The inflammation can > cause the path of least resistance (or the only available path) to be > retrograde. Make sure that you are choosing wisely when placing a > midline. Like you, Nancy, we have essentially stopped placing midlines. > It is too rare in our circumstances that the infusate is appropriate. > Another important point may be to stop placing dual lumen midlines. The > blood flow at the point of tip termination is not adequate to properly > dilute two different medications, particularly if these meds are not > compatible with one another. > Leigh Ann > > Leigh Ann Bowe-Geddes, RN, CRNI > IV Therapy Specialist > Infusion Services Department > University of Louisville Hospital > Louisville, KY > 502-562-3530 > > >>> <[EMAIL PROTECTED]> 02/03/06 9:36 PM >>> > > Nancy, > It happens occasionally to me also. But, it can also happen with PICC > lines. > The catheter is has developed a fibrin sheath. The sheath completely > covers the catheter. The fluid runs through the catheter and into the > sheath and with no where to go it comes back down the cathter. At least > this is my deduction from many years of experiencing this phenomenon. I > use to think it was me or my technique, then maybe the catheter. But, I > have found that it can happen to any nurse and any brand of cathter. > With PICCs and Midlines. > > A study would be great but, I could not perform the study due to lack > of resources. My lines are placed mainly in the external settings and > can not afford to send the resident to IR for a Dye study. But, I > believe that this is what is occuring with your catheters as well. I > now use the Groshong 4Fr single PICC but, previously used the V-Cath as > well and both cathteters can have this happen. I can tell you that when > you take the line out nothing will be on the catheter. And after > inserting another catheter some patients will continue to develope these > sheaths. Some do not. Without a study of the patients labs, > medications, and previos history I am afraid an answer is not > forthcoming as to what patient will or will not develop these sheaths. > > > I have ask many experts and catheter reps and no one seems to have the > answers. Actually most think it is the fault of the inserting nurse and > their technique. I believe it is with the patient and their > physiology. > > Just my two cents. > Randy > > -- > Randy Ross R.N., B.S.N. > IV Nurse Consultant, > President & C.E.O. > IV's Etc... LLC > Vascular Access > & Consulting > Ph: 317-541-6463 > Fax: 317-894-7709 > Email: [EMAIL PROTECTED] > Website: www.IVsEtc.com > > -------------- Original message ---------------------- > From: "Nancy Sullivan" <[EMAIL PROTECTED]> > > Here goes some question about Midline. > > My hospital IV team (that I am on) has stopped putting in midlines > because we > > were experiencing leaking at the insertion site. > > Is any one else experiencing this problem. > > Also, Do you place them in the ac or upper arm? > > Do you use MST and or ultrasound to place a midline? > > Where is the tip if you use the upper arm? > > We use Bard 4fr groshong ad 5fr dual per q cath midlines, that is > if we happen > > to put one in. > > Thanks > > Nancy > > > > > > > > --------------------------------- > > Brings words and photos together (easily) with > > PhotoMail - it's free and works with Yahoo! Mail. > > > > > > > > ----------------------------------------------------- > Confidentiality Disclaimer This message, including any attachments, is > confidential, intended only for the named recipient(s) and may contain > information that is privileged or exempt from disclosure under > applicable law, including PHI (Protected Health Information) covered > under the Health Insurance Portability and Accountability Act (HIPAA) of > 1996. If you are not the intended recipient(s), you are notified that > the dissemination, distribution, or copying of this message is strictly > prohibited. If you receive this message in error, or are not the named > recipient(s), please notify the sender or contact the University of > Louisville Health Care I.S. helpdesk at 502.562.3637 to report an > inadvertently received message. > ----------------------------------------------------- > > > ----------------------------------------------------- > Confidentiality Disclaimer > > This message, including any attachments, is confidential and intended > only for the named recipient(s) and may contain information that is > privileged or exempt from disclosure under applicable law, including > PHI (Protected Health Information) covered under the Health Insurance > Portability and Accountability Act (HIPAA) of 1996. 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