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Are IVs scut work?

2016-10-26T17:04:59+00:00

Is there educational value to teaching and learning how to place peripheral IVs? Not the exciting central lines, IOs, or ultrasound guided IVs. I am talking about straight forward and routine peripheral IVs. 

Or is this scut work? Can there be any educational value to scut work?

It is easy in a hectic ED to get lost in the sheer amount of work that has to get done during a patient’s visit. Labs need to be drawn, EKGs must be performed, radiology images have to be obtained. Not to mention the all important medical decision making processes. These tasks depend upon many people to make happen. In addition to the physician, there’s the nurse, phlebotomist, EKG tech, xray tech, lab tech…  so many techs!

Peripheral IV placement

I personally feel that learning how to place and master peripheral IVs is a critical skill for an EM physician. We all know about the ABCs… and C stands for circulation, and obtaining IV access is an important part of addressing circulation. The peripheral IV is a core component of our work. We have all been in codes where access isn’t obtained, and the IO fails to hit the mark. No one should die without having an IV first. 

CT Transport

Another example of “scut work” that I value is the transport of critically ill patients to CT. Why?  Because of the importance of learning how difficult it can be to obtain multiple CT scans on critical patients. Imagine the intoxicated and abusive ED patient who comes with multiple traumatic injuries. We order CTs and expect results to appear in PACS immediately. But how often do you go with the patient and observe how difficult it is to subdue the patient and get them onto the (very narrow) CT table? Or think about the times a critical patient has gone to CT, only to crash without having a physician present? I have gone many times with these types of patients and can attest that it is not an easy job to have difficult patient comply with testing while they are altered. It adds perspective when determining what and how to order exams.

Final thoughts

I am not saying we need to be super heroes and accomplish all these tasks alone. That’s not realistic, nor a good use of time. However, I do feel that there is value in learning. The ED is our domain, and we should have mastery over all that occurs within it.

What do you think?

Is there value in tasks such as IV placement, accompanying difficult patients to CT, knowing how to obtain an EKG, and other “non-physician” tasks?

 

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
  • You have to crawl before you can walk!
    As a current student I think that scut work or not, if you don’t know the basics then how are you supposed to master the really complicated stuff?

  • Agree with above. “Scut work” does have a learning points, if you are willing to accept them. I do not feel the tasks mentioned above are “scut work,” however. Regarding peripheral IVs, we definitely need to be able to do this. In my shop, we continuously have recently graduated nurses coming through. It is becoming increasingly obvious that these new nurses do not have the needed skills to place tough peripheral IVs. Some of them have never placed an IV (that is another rant for later).

    Also, pitching in with these non-physician tasks shows something about you. As a ED physician, if you have not learned by now, you need to know, nurses and techs can either make our job easier or hell. We are a team in the ED. Creating an atmosphere of teamwork makes our jobs easier and improves efficiency/throughput. Plus, who doesn’t like it when the nurses say “Thank God” when they see you starting a shift?

  • It is important to know how others on the “team” do their job. IV’s is a must know for the physician. As pts weights are increasing, IV’s are getting tougher. Physicians are being asked more and more to place these. Personally, I enjoy using the US for PIV insertion.
    The ED is a different beast all together. We work in a fish bowl, continuous direct contact with nurses, techs, med students, residents, for the duration of your shift. Being a leader, is being in the trenches with the troops, not barking out orders. A couple of quotes:

    A leader is one who knows the way, goes the way, and shows the way.

    You cannot be a leader, and ask other people to follow you, unless you know how to follow, too.

    Basically, this may be scut, but worth its weight in gold. Sometimes just helping a tech clean a patient, clean a stretcher, makes life so much better.

    Great Post Nikita.

    Salim

  • Great discussion! 2 other advantages for residents taking sick patients to CT:

    1) For the borderline cases, it really makes the resident think about the case. How quickly do we need the CT? Do they need to go right now or can they wait for transport, etc? How safe is it for the patient to go without a doc?
    and probably more importantly:
    2) EM residents don’t get a lot of independence. Thankfully our training environment is much safer than many others and there are always attendings around. But being the only doc in radiology with the sick patient is a good blend of being alone with a sick patient and having your supervising attending (fairly) close by if you really need them

  • Agree with Salim. One of the “domains” at our med school around which the curriculum is based is Interprofessionalism (IPL). To that end, each clerkship has a set of items students have to do during the clerkship (called their Passport). On my Passport, to meet the IPL criteria, students have to assist with triage, perform an EKG with a tech, spend 1 hour with the point desk person, start IVs, NGTs, give nebs with RT, etc. Over the course of the month, they see a lot of the non-doctor side of the job…and they understand much better what others’ roles are.

    • This passport concept is really cool, and a great way of showing the med students that providing quality healthcare to our patients is a multifold process.. ie you need clerks to schedule those appointments and to understand that less than 24 hr appointment doesn’t mean that its ok to give it next month. What a great way also for the med students to realize that EVERYONE working in the hospital has something to teach you… not just the residents and attendings.

    • I really like this passport idea….

  • I think this is a good point (along with others above), in that you need to have some familiarity with every step, in case you need to do it yourself and so you can empathize with people on your team.

    With that said, if you distill down what it means to be an emergency physician, the essential element is the ability to make critical decisions based on limited information. These other tasks are fine, however, the decision making ability is the thing that should receive the overwhelming majority of the training experience. If routinely taking patients to CT or doing IV’s/blood draws, this compromises the ability to see a high volume of patients and have a meaningful discussion about them with attendings and senior residents.

  • The most crucial piece of an emergency department that is safe, functional, a good learning environment is the Emergency Physician’s mind. EPs need time to think and process cases, so minimizing additional tasks that should be performed by other staff members should be a departmental priority and policy.

    That being said, the Emergent/Urgent lines and pushing patients to CT is totally expected, the rare lines that are just not getting done are acceptable if a super-busy ED. As well, getting set of bloods in lab prior to signing out really helps your colleagues (do unto others…). If you are doing these things consistently, your administrators need to know so they can fix it.

  • Niki,
    Have to disagree with my former resident. Sure we need to know how to place an IV but using residents to pick up the “slack” for others in the ER is not the solution. It’s using residents in a primarily service capacity rather than in the role they were meant. While this is (sadly) the norm in the US it is not so else where and I think that this “philosophy” actually detracts from your educations.

    Second, IO’s are the LIFE SAVING access of choice in ALL patients. They are easy to do and can be done almost anywhere by anyone…that’s why the miltary trains their people to do this. Also, it is a mcuh better way of getting easy and reliable access than an IV.

    Last point, is same as the first. Experiencing taking a pt to CT is important and helpful, but residents should NEVER be used to do other people work. They have their won dedicated function in the ER, to learn, and using them to do other peoples work, rather than staffing an ER or hospital appropriately, is not the solution.

    • Thanks for your comments Mike! Sometimes I wonder how much my opinions are a product of my environment! 🙂
      But your thoughts are always a breath of fresh air!

  • I agree with all that has been said. I don’t find transporting critically ill patients to CT. I agree with Seth- I think it’s a great opportunity to have some independence to do a critical intervention while still being close to a safety net.

    I also agree about IV starts- it is an important skill to have and you should help out- especially with those that are difficult sticks. The one caveat is that you have make sure that starting IVs don’t become an expected task for a resident. I didn’t have an issue with this in my training but I have heard stories far and wide of places where it was expected for the resident to start IVs. This is far from the norm but I think that it needs to be said.

    While it is nice for you to start IV when things are busy, as a resident your focus needs to be on learning. Is starting IVs an essential skill? Absolutely! However, starting routine IVs shouldn’t take time away from education and seeing more patients when it can be delegated to someone else.

    We are seeing so many more patients today we did 10 years ago. The one constant in every ED is that the providers are the rate limiting step. If we take providers away from seeing patients to routinely start IVs then you can grind a department to a halt. While “moving the meat” should not be a mantra for a new trainee, we also owe it to our patients to make sure that they are seen in a timely manner.

  • Thank you for this great article. I am a current third year med student and former ED paramedic with 5 years of working experience prior to medical school.
    While working as a paramedic I would often assist EM Residents, Attendings and PAs in establishing external jugular vein IV access. They often missed, even in patients with what I would call ‘good’ EJs. Fundamental technique errors were the rule and not the exception. These included errors in holding the IV catheter appropriately, pulling the patient’s skin taut, and advancing the angiocath at the appropriate time. However, by virtue of the fact that we were resorting to EJ access, the argument could be made that these patients fell into the ‘difficult stick’ category, and attribute the EJ access failure to that. Still, the consensus among the nurses and paramedics was that it was ironic that the physicians and PAs did the EJs on the patients when most of us would not trust them to start peripheral IVs on us.
    I wouldn’t endorse mandating quotas of IV placements for EM Residents. But I do think that IV practice needs to be emphasized and we should encourage EM residents to practice PIVs in the ED whenever they can spare the time.

    • Thanks, Marco, for your insights as a medical student and ex-paramedic. Yes, becoming an expert in peripheral IV’s is a key skill to master for EM residents, but the gray area is whether they should be expected to be consistently doing this procedure on a daily basis on shift. Thanks for your comments.

  • I’m an ER tech, and I’m a little offended by the fact that everything we do is lumped under the category of “scut work” here. Your jobs aren’t easy, I know, but neither are ours. Sure we do all the nasty cleaning not even the nurses want to do, but we’re more than glorified janitors. We spend a hell of a lot more time with the patients and their families than you MDs do. We’re the one who has to grab an EKG on the critical patients who come in regardless of how labored their breathing or severe their muscle tremors are. We’re the ones who have to explain why we’re putting defibrillator pads on them when they’re going up to the ICU, and the onus is on us to treat the frightened, wide-eyed patients on BiPAP gently enough to diffuse some of their fear when we go in to take vitals or perform other “housekeeping” duties.

    I appreciate the spirit of this article, and I do think it’d give you docs a lot better idea of the whole picture of ED care if you were to learn some of these skills. However, my experience in the ED I work at is that the attendings don’t even know our names, and 90% of the time won’t even grace us with a “thank you” every time we hand off an EKG. I hope it is different in your respective work environments. We know you’re busy, but there’s something to be said for treating everyone like an equal human being. That goes for the patients who you spend the majority of your time diagnosing and treating from behind the partition, and for the techs who run around taking care of the “scut work” for you. If learning IVs, EKGs, or radiology tech-related work would help you do all this, I sincerely hope you all go out and get scutty ASAP.

    In addition to working as a tech, I’m applying to medical school this May. I look up to the attending docs I work with immensely despite all this, and I’m sure some of your techs do as well. Please keep this in mind next time one of them hands you an EKG.

    • Hi zeroeznonez: Sorry to hear that you were offended by the comments. The main question of this blog post was whether doing these procedures, which are traditionally done by other qualified healthcare providers, should be incorporated more into the workflow for the practicing and in-training emergency physician. Thanks for your comments and best of luck in your medical school application process.

    • thanks for the thoughtful response. the one bit of technical knowledge I can contribute is that once in a while we get patients who can’t stop moving, whether it’s because of an altered mental status or tremors or labored breathing. Often these EKGs will have a ton of artifact in the baseline, and/or appear to be axis deviations. Most of the physicians will understand that the artifact makes it hard to discern anything but major abnormalities, but some will ask for a repeat EKG. 90% of the time we won’t get a better reading the second time around, unless the patient has been sedated or something. I’m no expert but I wonder if a) having a doc perform a repeat EKG would improve the success rate (of obtaining a workable baseline) just by virtue of his more extensive medical/anatomical training and clinical experience, or b) having a sense of what kind of movement is generating the artifact helps with the interpretation. It wouldn’t be worth the time in every case, sure, but for the crashing, diaphoretic, and altered mental status run that comes in, I imagine having an accurate EKG could significantly impact the diagnosis/treatment plan.

    • Interesting Q about artifacts on EKG. Here’s the trick that several of our nurses and tech’s use with great success:

      http://academiclifeinem.blogspot.com/2011/10/trick-of-trade-quieting-shaky-ekg_11.html

      Don’t think having a physician will make the tracings any better.