Four years ago, Florence Witmer was struck with what appeared to be a sudden illness and was rushed by a medical helicopter to the hospital, where she was diagnosed with a flesh-eating disease and immediately underwent an operation.
She had to be cut from one side of her abdomen to the other to remove the infection.
“They thought I was going to die,” she said. “But the good Lord brought me through it.”
The now 79-year-old Penns Creek resident said she has no recollection of it all, but does remember the long road back to recovery, which continues.
In the hospital, a nursing home, and then later at home, she had numerous intravenous catheters inserted to give her the fluids and medicines she needed to get back to health. A tube was regularly inserted into her shoulder by nurses, who then instructed her granddaughter, who has some medical training, on how to do it.
“I hate having them put in,” Witmer said of the necessary but sometimes uncomfortable procedure. “But it got easier.”
After the first few times, she said she realized “I sort of know what I’m going through.”
For those who are facing an IV procedure, Witmer assures “It sounds worse than it really is.”
There can be even more peace of mind knowing that the medical professionals who give the IVs go through extensive training and hands-on, monitored practice before they begin working independently.
Sandra Stahl, RN, BSN, VA-BC, is the vascular access coordinator at Evangelical Community Hospital in Lewisburg. Her inpatient team consists of seven registered nurses who are specialized in the giving if IVs.
“Initially, when we hire somebody in the department, depending on their skill level we would have six weeks to three months of working with someone so that we could watch their technique, palpation skills, and their angle of approach,” she said.
One of the basic pieces of training is learning palpation skills, or “touching a patient’s skin to learn what a vein feels like, the sponginess of it, and to follow it until you can’t follow it anymore,” Stahl said.
The education tools they use for training includes “dummy arms” on which they can practice. Training also includes learning the angle necessary to insert the IV into a vein that is shallow, as opposed to one that is very deep.
“The more you do it, the more skilled you become,” Stahl said.
Nurses cannot administer an IV without a physician’s order, but when those orders do come, Sean Devine, M.D., MBA, associate, pulmonary critical care medicine at Geisinger Medical Center, said they are most commonly used for the giving of antibiotics, chemotherapy, and fluids.
Stahl added that IVs are also used when contrast is needed to enhance pictures on CAT scans or MRIs, as well as for the administering of anesthesia for surgeries.
IVs can be placed peripherally, in the arm, with a shorter needle, or through a longer mid-line catheter. Sometimes a peripherally inserted central catheter (PICC) is necessary and is inserted, Stahl said, in a part of the body that “crosses the border of where the shoulder meets the chest.”
Each patient’s individual need is considered.
The insertion of IVs is one of the most common medical procedures, happening numerous times daily for patients arriving in the emergency department or undergoing outpatient or inpatient procedures.
One day last week, Stahl reported that there were 33 operative cases on their inpatient schedule, not counting all of the outpatient procedures and the 20 to 30 patients receiving IVs, on average, each day in the emergency department.
At Geisinger, Devine said that the numbers each day at Geisinger are at least 50 to 60.
While IVs are very routine and necessary for many patients, there are some conditions that can cause difficulties.
For example, Devine said, “Veins can be difficult to locate because of swelling, and veins that have had multiple IVs placed in the past are more difficult to access.”
Stahl added it is also more difficult to find the ideal “soft and spongy” veins in those with vascular disease or diabetes. Intravenous drug use can also scar the veins and make the IV process much harder.
IVs are also more difficult to insert in elderly people who have had a combination of diseases, such as high cholesterol and cardiovascular disease.
At Evangelical, Stahl said they do have the availability of a peripheral ultrasound machine, which can help to visualize more difficult-to-find veins.
In general, pediatric patients can make the IV process tricky for several reasons, Stahl said. First, their veins are smaller than an adult’s. And second, “They don’t hold still very well,” she laughed, adding, “And you can’t reason with them.”
How to prepare
It is possible to better prepare apprehensive pediatric patients by administering topical medication that can numb the area where the IV needle will be placed. However, because it takes 90 minutes to kick in, Stahl suggested that parents discuss the possibility with a pre-admission nurse or anesthesiologist and plan on bringing the child in a little earlier.
For adult patients, staying hydrated can make it easier for the placement of an IV. But Stahl said sometimes that isn’t possible when a patient is scheduled for surgery and is not allowed to eat or drink anything after midnight the night before the appointment.
Being relaxed is also helpful.
“The more anxious the person is,” Stahl said, “the more difficult it is to be successful with a venal puncture.”
The key is to stay “limp like a cooked noodle,” she said, adding that numbing medication does help to alleviate pain and as a result helps them to relax.
An important job
IVs are utilized every day in patients undergoing everything from routine procedures to life-saving medical interventions.
Those administering IVs have a lot to consider when it comes to the very wide array of individual patient needs.
Once a physician orders the IV, Stahl said they have to consider the goal for the patient, and how long their duration at the hospital will be. They have to be aware of what kind of testing they’ll be undergoing, what kind of medication they are to receive, and what their past medical history is. Knowing a person’s hand dominance and whether they’ve had a stroke or breast cancer affecting a certain side of their body will help them know where to place the IV, as well.
Stahl said her team takes time to explain to each patient who they are, what they’ll be doing, and to ask numerous questions like these. They advise the patient on each step of the procedure – when they’re applying a rubber band on their arm, palpating their skin, looking for a vein, cleaning their skin with alcohol and then with an antibacterial/antimicrobial solution, and when they are administering the numbing medication. They then insert the IV, release the tourniquet, dress the area and then finish securing the IV.
“What we do is more complex than I think people understand,” Stahl said.