Saturday, May 06, 2006

Walk the Line (Placement)

Courtesy of ClinicalCases

Of the many and varied annoyances we endure on call, the CXR for line-placement at odd hours is becoming more common. When a surgeon or internist places a catheter in a large vein, there are some potential complications that should be excluded with a radiograph of the area. These problems include a pneumothorax, hematoma, and aberrant course of the line. All well and good. However, some of our clinicians have gotten into the habit of placing the line, and then telling the nurse to get Radiology to "OK the line" as they walk out the door.

Now, I can exclude the complications outlined above, although if I'm working from home at 3AM, I don't have high-res monitors at my disposal, and I can't really confirm that there isn't a tiny pneumo. But even a Sony Jumbotron would not tell me if the line is "OK", in other words usable. That is a clinical determination. If there was good return of blood through the line at the time it was placed, then it should be usable from a hemodynamic (plumbing) standpoint. For this reason, I am now placing the following sentence in the impression of each and every study I read for line placement:

Function of the line cannot be evaluated radiographically. This must be determined by the presence or absence of blood flow at the time of insertion.

Now, the question becomes: is the clinician who placed the line responsible for looking at the post-procedure radiograph? I posted this question on AuntMinnie, and while there was some debate, the majority felt that yes, the clinician IS responsible. He/she placed the line, and will collect the fees for doing so. Line placement has known possible complications, and the clinicians are perfectly able to see these on the radiograph. Are we selling our birthright if we ask them to look themselves? I don't think so. Dr. "Sofa King" posted this on the AuntMinnie thread:

Part of the procedure for line placement in confirmation of positioning and excluding the presence of a pneumothorax. If you have not done this the procedure is not over. If you cannot do this you should not be performing the procedure. If you cant see the cathether traversing up the neck, you shouldn't be performing the procedure.

The ONLY purpose of these rediculous follow-up xrays for placement of anything in a patient is to spread or turn over liability. Don't kid yourself that it is for anything else.

That said, we are not asking them to interpret an xray. Like a stethescope and ultrasound (both of which most of these guys have in their offices) the xray is just another tool of the procedure. Don't think that the idea that you won't let these guys read things in the hospital will stop them from taking anything from you when they want. They have xrays in their office and they can easily take a one week course in anything and get credentialled.

Couldn't have said it better myself. We'll see how much trouble my little canned statement causes. For me, that is.

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