06 September 2008

Cannulas and catheters

If you arrive in hospital unwell Dr Grumble would bet ten pence to a bath bun that a cannula would be inserted into one of your veins. If you were a actually ill you might find a catheter plunged into your bladder as well. It is something of an assault. On his post take ward round Dr Grumble will ask why the patient has been subjected to these assaults. These days he is lucky if there is a doctor present who was around when the patient was admitted. You have to rely on notes. Quite often there is no note recording these interventions. You can't go back in history and check how Dr Grumble would have done it in his day but Dr Grumble's firm recollection is that whenever he put in urinary catheters he made a note dutifully describing the indication and even the aseptic technique. But now he often finds nothing. He cannot complain to the doctor (or would it have been a nurse?) concerned because there is no name. No nothing. It is unacceptable. As clinical governance has become the focus of management basic clinical practice is deteriorating. It is interesting to consider why this might be. Are the doctors of today not as diligent as the doctors of yesteryear? Is Dr Grumble's memory faulty? Was Dr G the only doctor in his day who bothered to make notes? Was Dr Grumble better trained or more closely supervised?

Of course Dr G cannot answer many of these questions with certainty. Plainly the calibre of today's junior doctor cannot be much different from yesterday's. You might expect training to be better. We now have colonies of plastic pelvises for students to practise on. But wait. Dr G never had a plastic penis to practise on. He was taught as a student by a junior doctor on a real patient. That focuses the mind. And when he learned he was taught to write full notes including the indication for the procedure. He has continued that way ever since.

Dr Grumble wonders if it is the teachers fault. We now teach on disembodied torsos. We focus on the practical elements. There's no reassuring interaction with the patient. There is no patient. There is no indication. There are no notes. Dr Grumble helps at these teaching sessions. It must be his fault.

Anyway the BBC has rumbled our rotten practices when it comes to Venflons though every jobbing consultant in the kingdom must be aware of this issue. In some ways the problem with urinary catheters is worse. You can read the article here.


Garth Marenghi said...

there is no problem with fitting cannulae that are not used, as long as once it is realised that they are not going to be needed they are removed,

however lots of patients come into AE with an unknown diagnosis and it is not known on admission whether the cannula will be needed,

the risk of going too far the other way is that when people are not sure of a diagnosis and the patient 'appears' stable, a cannula will not be put in,

when these patients become unstable and decompensate the lack of IV access will not be beneficial,

the better solution is to encourage better nursing and checking to make sure that once a diagnosis is made and a patient does not definitely need the access, it is removed

Dr Grumble said...

I do agree that when a patient arrives things can be so uncertain that IV access is desirable. We have all seen the the infarct with pain in the wrists. The main problem is not that they are put in and never used but that they were not taken out.

Anonymous said...

"The main problem is not that they are put in and never used but that they were not taken out"

That happens much less o. Infact the opposite sometimes happens. Jobsworth nurses take out cannulas day and night at the 72hour mark regardless of whether there is anyone around who is available to put another in, nor whether the person actually has veins.

As for A&E, as an A&E guy myself the whole practice really narks me. Because I know damned well that half my patients don't need a cannula, but the ward will not accept without. The ward nurses often seem to equivicate 'oral medication' with 'able to go home with medication'.

Dr Grumble said...

The ward really has no right to insist on treatments that are not necessary - common though that may be. How can that problem be addressed?