Hospitalized patients need an IV, period.
I respectfully disagree. If you said "most to nearly all hospitalized patients would likely benefit from having an IV in place" I'd be more inclined to go with you on that. However, there are few "always" (implied in your statement) or "no[ne]" in medicine. When "rules of thumb" and "guidelines" become dogma it is generally not a good thing. Evidence and individual clinical scenarios quite frequently do not bear dogma out. Medicine, fortunately, though frustratingly, is a moving target. Becoming entrenched in one way of thought is the enemy of individual growth and can, on occasion, unnecessarily complicate or compromise a patient's care.[/COLOR]
If you are finding ways to "work around" not having one, due either to parental reticence or nursing refusal to do their jobs, you are placing your patient at risk and you know it.
I know no such thing. How am I placing patients at risk? In this scenario given: the baby is in the hospital for clinical observation and parenteral antibiotics. The baby is still in the hospital receiving parenteral antibiotics being clinically monitored. You infer that I have a low index of suspicion for the potentiality of clinical deterioration in the setting. In fact, quite the opposite. I am well aware, having seen it, that even a routine rule out sepsis baby can precipitously tank. Do you think an IV will magically prevent this? The cases in which I have seen this all had IVs in place. You're hoping that an IV will allow you more rapid access for resuscitation? Okay, I buy that. But, these kids, who hopefully are caught quickly (even the routine ones need to be watched like hawks), get transferred to the PICU it even if they have an IV, they get arterial monitoring lines and usually a CVL (99% of the time placed by the pediatric intensivist/pediatrician). Acute fluid resuscitation would be the priority and if a PIV or CVL can be placed rapidly enough an IO can. The previous placement of an IV, isn't likely to have played a large role one way or the other. Going back earlier to the point where I would have been discussing the options of replacing an IV or going down the IM route with the nurse and parents (it wouldn't do IM only for the nurse's wishes; the parents would have to be requesting it as well) I would treat it like any other situation in which to obtain "informed consent". Indications (continued antibiotic administration), anticipated benefits (possibly less painful), anticipated risks (possibly more painful, risk of clinical deterioration and need for rapid infusion fluids which might require an IO in an emergency), alternatives (place an IV). etc. Just the discussion may bring the parents/nurse around to wanting an IV. But what if they don't? Are you going to call CPS, FAP, the parent's command (for the military folk) just to get the IV when there is a reasonable alternative (based on the dogma that "all patients in the hospital need an IV, period")? As your career progresses you are going to be faced with patients and families who are going to question what you want to do and why you want to do it. It is physician arrogance to think that they will never be right and the physician's judgment will never be wrong. Sometimes a suspicious family member has saved a patient's life in the face of an incorrect doctor. Sometimes it has just spared a patient pain by forcing consideration of alternatives.
And for the occasional clinically stable (i.e. expected to go home in 48 hours) baby who noone, not even the NICU nurses, can get a peripheral IV, are you going to call the surgeon for a cutdown? My guess would be that the surgeon would be reticent. [/COLOR]
Suppose the patient actually *is* septic (an uncommon scenario in "rule out sepsis", I know), do you really want to be trying to get that line as the infant clinically decompensates? I spend enough time with the Pediatric Surgeons to know how well that works out.
I addressed this above.[/COLOR]
Basically, you are treating a routine admission like a routine admission, which I know is common. But these kids are admitted precisely because there is a small but real risk that they can go bad any second. Not keeping a line placed is grossly irresponsible, and something that isn't tolerated in the surgical fields where I have been.
I will reiterate that regardless of whether the child has an IV for antibiotics or is getting them IM, they need to be monitored very closely. It should never be taken for granted that they are just a "routine" rule out sepsis case. I think we both agree that to be cavalier in the situation is folly. But by finding a different way to do the right thing is not being cavalier. Not keeping the line in is not "grossly irresponsible" in the right clinical circumstance. There might be a slight (at most [again, in the right clinical circumstance]) increase in risk, but one that is well within the range of acceptable limits if the parents are informed and agree. I'm not a surgeon, so I don't know what is "not tolerated" in the surgical realm. But surgeons are often best at managing surgical and mixed surgical/medical problems (in peds, ex. NEC, HPS), not routine medical problems that rarely directly interface with their area of expertise. This may affect your frame of reference, though I'm always appreciative of the frame of reference their surgical colleagues bring to the table.[/COLOR]
Also, for the life of me, I cannot understand why anyone would order something they consider unnecessary.
I'm not quite sure what you meant by this, but I'll address it in the way that I think it was meant. People order procedures, tests, interventions, monitors, IVs quite frequently that they consider beneficial but aren't quite sure if they are "necessary". I'm sure you're quite acquainted with surgeons being asked to do a test/procedure at the behest of an internist or pediatrician who thought it was the right thing to do, but the surgeon did not. Sometimes we do things just to "ward off evil spirits" knowing that there's no science or evidence behind it. I agree, that few people truly order something they consider unnecessary, but we order things all time that may not be truly needed.[/COLOR]