Saturday, November 04, 2006

I spy ..... an IV!

Every surgeon on the planet has heard some version of these phrases at least a few zillion times:

We can't get an IV; can you come put a central line in this patient (who has been poked like we were playing "Pin the tail on the donkey" with a bunch of 2 year olds)?

This patient's IV has blown for the fourth time today and we can't get another one in! Can you please put in a central line for Dr. X's patient (even though it's 2:36 AM and Dr. X's last patient referral to you was -- surprise! -- a call for a central line in the middle of the night)?

This patient is too large for us to find a peripheral IV site; we need a central line!
And so on. And you know what? These are almost always legitimate calls. In today's world of modern medicine, we are so reliant on IV access that it has become almost an afterthought for most non-medical folks. IV fluids, kill-everything-IV-antibiotics, IV chemotherapy, transfusions, etc. -- all require reliable IV access.

The problem is, some people just flat run out of easy-to-find veins, and then we're stuck (sorry for the pun) with performing a more invasive procedure to provide adequate IV access. And please remember, when a surgeon says "invasive," there is also the implication of "higher risk for complications" that comes along for the ride. There is a middle ground alternative, called a PICC line, which is a peripherally inserted catheter that is passed into the central venous circulation, but in my experience, I tend to get called to place a central line because the PICC nurse has just spent two hours exhausting her options in a patient who has really no visible veins.

For me, the most vexing problem is the patient who does not really "need" central venous access at all --- they don't need longer term IV access, they are not receiving TPN or chemotherapy, etc. --- but they need some form of IV access to get through their hospitalization. And they just don't have any visible place for the nurses to stick them.

Who can solve this problem? Einstein is dead, Stephen Hawking is using his considerable intellectual prowess looking into the origins of the universe, and Aggravated DocSurg (you were wondering how I would get my name in the same sentence as those two, just to throw off Google searches, weren't you) is just too dense to think of anything other than "OK, I'll put in another central line."

Well, let me introduce you to IRIS. In Greek mythology, Iris is the personification of the rainbow, linking the gods to the earth as the gods' messenger. She is said to travel with the speed of the wind, even into the depths of the sea and the underworld. Cool. Kind of like, oh, I don't know, infrared light, maybe?

IRIS also happens to be the acronym for InfraRed Imaging Systems, which makes a neat device for finding subcutaneous vascular structures called the IRIS Vascular Viewer. The portable and apparently easy to use system employs a high intensity infrared LED which penetrates the tissues, is picked up by a detector (an adhesive bandage on the skin), and is converted to a real time image on a monitor. The company's web site has a few good videos showing how the thing works, and this article explains it very well.

This little gizmo apparently costs about $15,000, and each one-time use sensor pad probably costs a few bucks as well --- so it certainly isn't financially a good thing to use for each and every IV. However, as any nurse can tell you, there is never a shortage of patients who are "problem children" when it comes to IV access --- can't find a good vein, or the vein that is cannulated turns out to be a bust, etc., so that by the time the third nurse comes in the room with a handful of needles, the patient runs screaming down the hallway like a teenager in a slasher movie. I suspect that is the situation that would be perfect for IRIS to ride to the rescue -- and save a few bucks in the process. And one of its best features is that, unlike ultrasound, it is very easy to learn how to use -- and its potential is just being explored (see the article). Coming full circle, it could turn out to be a useful tool in central line placement as an alternative to ultrasound.

Of course, since I am an aficionado of Animal House, I also have to say that IRIS, with her swivel-anywhere wheels, looks like a wonderful dancing partner. Now, if I could just get our hospital administrator to liberate a few kilodollars to pay for one of these, I'm sure it would pay off --- in the ED, on the patient floors, in the GI lab and radiology suite, and in the call room, where I can get a bit more sleep.