POTD: Shot through the heart, and you're to blame, darlin' you give (MIDLINES) a bad name

Have you ever been walking over to get the ultrasound machine for the 3rd US-guided PIV and hit yourself in the head saying “why don’t I just do a midline? I know they’re going to need pressors anyway…”. If this hasn’t happened to you yet, it will! And when it’s come to that point where you’re reaching for that central line, consider that it might be quicker, easier, and better for the patient to do a midline. If nothing else, we’ve all been asked by an inpatient team to please place a midline (sometimes indicated, other times from our perspective maybe not - but that's a point for later).

I used to get annoyed feeling like I wasn’t getting my central line experience in residency. However, when I think about it from a patient perspective, and all the benefits of a midline, I’m now very happy to do them and in the cases in which a trialysis (now dialysis) or triple lumen aren’t truly required, I opt for a double lumen midline instead. BUT… we need to ensure we place them properly or we could get in big trouble!

Here are a few good things about midlines:

• If you can put in an ultrasound-guided peripheral IV and you are familiar with seldinger technique, you can place a midline

• They’re pretty quick

• They’re not technically a central line (but they can become one if you’re not careful! More on this later…)

• They have lower infection risk than central lines

• They have longer dwell-time than PIVs and CVCs

• They’re more comfortable for your patient

• You should of course get verbal consent, but technically in our hospital, written consent is not required for midline placement (of course if your attending wants you to get written consent, you should, it’s never a bad idea)

• You don’t need a confirmatory xray

How to place a midline:

I’m not going to go into great detail here, as the setup is exceedingly similar to CVC placement, but I do want to highlight some important differences and some tricks.

1. Verbally consent your patient and explain what to expect

2. Gather supplies - midline kit, sterile probe cover, 2 hep-locks (blue cap things at the end of IV connection tubing), chlorhexidine, extra sterile flushes if needed, sterile gown, sterile gloves, ultrasound, roll of tape, mayo stand with chucks/towel

3. Locate the vessel of interest with ultrasound and take a clip or image for documentation purposes

4. Open your kit and drop extra pieces in a sterile manner onto your sterile field

5. One of the things included in this kit is a paper tape measurer - you may have wondered before “why is this silly piece of paper here?” well, here’s why… midlines are intended to have the catheter tip end in the axilla NOT cavo-atrial junction (where the SVC and RA meet). If a midline doesn’t terminate at the appropriate spot and instead goes into the heart, you’ve now inserted a central line without the patient’s consent (YIKES!)

6. Sterile prep the insertion site 

7. Sterile dress yourself (and yes! This should be done under full sterile practice!)

8. Prep your kit - I recommend putting 1 heplock on the primary lumen and the 2nd on one of the sterile flushes. I also recommend setting out all your pieces in the order that you will perform the steps in a clear manner so you can do it efficiently. NOW, using the measurement you got from that paper tape measure, you must TRIM THE CATHETER (louder for the people in the back!... TRIM ITTTTTTT!!!) to the length of the termination in the axilla using the cute little guillotine device provided. You may have to do it a couple times because there is a wire to cut too. 

9. Administer lidocaine

10. Using seldinger technique and under ultrasound guidance, proceed with the steps ending in catheter insertion, ensure guidewire removal, ensure it pulls back with good blood return and easy flushing

11. Properly dispose of sharps

12. Keep for yourself or gift the cute pink and white candy stripe masks :) 

13. pro-tip: with sharpie, write the date of insertion - it's kind of like signing a work of art. You are the *Michelangelo of Midlines* (feel free to throw that around at your next party)

Here is a photo of the contents of a kit + extra things you’ll need. The little guillotine guy is the blue thing that looks vaguely like a chip clip in the middle.

TLDR: Midlines are great, easy, effective and better tolerated. They are also illegal central lines unless you properly trim them to have catheter termination at the axilla.

Happy trimming my fellow Midline Michelangelos!

Kat

POTD: Endurance Medicine

It’s that time of year…the flowers are in bloom, my favorite trees with the flowers right on the trunks and branches, birds are singing, Spring is springing and people are running ridiculous lengths all for a free banana (which is really like a $120 banana if you count the registration fee).

As it turns out, I am one of those ding dongs taking part in the madness this year for the first time. And as an underprepared, pregnant person who knew better than to run but did it anyway and may have a tinge of rhabdo, I think this POTD deserves some attention and brings up some of the big concerns with endurance running (or cycling, or any other long duration workout). 

For those working event medicine at these events coming up, please pay special attention! I saw far too many bodies on the side of the route this weekend - seemingly young and probably otherwise healthy. Thanks to Matt Friedman who suggested this and provided some good graphics which I’ll attach here.

Let’s go about this stepwise…

You are a fellow runner in the Brooklyn Half Marathon and you come upon a participant who is lying on their back in the grass just off to the side of the course without anyone around them. You approach and what do you do? You all are trained in BLS (and even ACLS!) so you know what to do - “Hey! Are you okay? Can you hear me?”

Are they responsive? If the answer is NO, you know what to do. Check for pulses and if not present, initiate ACLS. If the answer is YES, this is actually a bit more complicated, but let’s simplify it into 3 categories based on temperature (ideally rectal but use what is provided to you in the field): hypOthermia (unlikely this time of year), normothermia, and hypERthermia. 

Hypothermia seems unlikely in this scenario, and my colleagues have taught on this in prior months, so for the sake of keeping it topical to this endurance running season, we will keep it to the latter two categories and their associated algorithms. 

Normothermia

Defined (by this resource) as a core temperature of 95-104˚F. Firstly, place the patient in a supine position with the legs raised above the heart. Next, assess their mental status - can they tell you what happened? Why did they collapse? How do they feel now? Any medical problems or medications?

Assess their fluid status - did they collapse 2/2 dehydration? Are they vomiting? Thirsty? Sweating? Flushed? Poor skin turgor? Sunken eyes? Hypotension? Tachycardia? If they seem okay other than being dehydrated, make moves to properly hydrate them in a safe area, in the shade and in an observed setting for a while to ensure their safety prior to discharge (they should probably not continue the race). 

If they are altered, you’re on a different pathway. What’s one of the first things we do in patients with AMS? ABCDE and F! For fingerstick - check that BGM, they may just need a snickers. If this is normal and they are altered, make moves to get them to the medical tent and likely transport to the hospital. They may have something more serious than simple dehydration and overexertion like electrolyte derangement, of which the most common in these races is hyponatremia.

Hyponatremia

Your patient is normothermic, but altered with a normal BGM. They look sick, they are vomiting, they may have some edema and you notice crystalized salty sweat stains all over them…consider hyponatremia.

In some setups in the field, you may have access to an EPOC or point of care electrolyte test. If you do, use it! If they have normal sodium 130-135, consider just giving them oral salt. Crack open that raw can of Campbell’s Chicken Noodle Soup and have them go to town on it (people actually do this intentionally in long races - yuck!). Restrict their water intake. If they tolerate this, check the sodium, vitals and mental status again in 30 minutes. If they don’t, then it’s time to level up!

This seems wild to me, having never even given this in the actual in-hospital setting, but you should consider a bolus of 100cc 3% NS (hypertonic saline). Remember that most people we see in the ED with hyponatremia have been chronically like that, these athletes were presumably not altered or hyponatremic prior to that starting gun going off (albeit a little cooky to run so far) - the point is, we can reasonably assume that this is a case of very ACUTE hyponatremia and so it makes sense to have a lower threshold to give them that corrective bolus. Monitor them closely - did this make a difference? Or did they get worse? Consider re-dosing and transporting to the hospital.

Hyperthermia 

Hyperthermia is defined as a rectal temperature >104˚F and comes in 2 sort of flavors or intensities: heat exhaustion or heat stroke. What’s the difference? Mental Status.

You can be hyperthermic without AMS, and as you may have guessed, heat stroke (hence AMS) is considered more serious than heat exhaustion. The extreme temperatures cause nervous system dysfunction and that needs fixin’ and QUICK!

Begin rapid cooling using whatever you have in the field - ice bath, evaporative cooling with misting and fans, cooled IV fluids.

If the patient cools to a normal human temperature compatible with life but remains altered, consider the other things already mentioned - hypoglycemia, hyponatremia and treat as needed.

Cardiac Arrest 

In the case of cardiac arrest 2/2 exertion, initiate ACLS as you would in the typical patient. Time is myocardium and brain and all those other things your professors told you. Consider that the aforementioned etiologies may be contributing and consider how they might alter your approach, but don’t delay chest compressions and other ACLS protocols trying to chase something else.

Welp, I hope you learned something and feel prepared to help the underprepared runners (and even those who’ve been training for months and have done this before!) in the coming weeks as they run silly distances on their silly little legs. I have to say it was very a cool experience to run with 22,000 other people on the streets of Brooklyn and see everyone cheering each other on and congrats to the many Maimo peeps who ran it on Sunday! We can do hard things!

POTD: A Couple ED Hacks

For today’s POTD, I wanted to share a couple hacks I’ve collected from others over my residency that may make Mondays a bit more manageable. 

#1 Stockinette (and yes, I too thought there was a “g” in there) Arm Sling

Have you ever been working a busy Peds ED shift and come across a young’n with an injury requiring a sling? You walk around looking for a tiny human sized sling for the 3 year old and feel like it’s an issue that we don’t have anything small enough. Spoiler alert: the real issue is that no 2 year old is going to keep their arm still BUT you should still do your best to at least try and properly immobilize/sling them.

Thanks to Eric Lee who taught me this, we can actually fashion a tiny human sized sling using stockinette!

Just cut a long piece of stockinette of width that will be tight enough around the little arm to give it a good hugging feeling. The length should be about 2.5-3 length of the entire arm (shoulder to hand). Once you’ve measured this, cut a slit into one side of the stockinette that extends a little less than half the length of the tube. Simply place the child’s arm inside the stockinette tube with the cut side towards the head and this will nestle just below the axilla, wrap the cut part around the child’s trapezius area where you will tie a knot at the nape of the neck or just on the unaffected shoulder area which connects the part with the arm inside. 

See this website for another way to macgyver a teeny sling - this one seemingly provides better immobilization: https://www.chp.edu/our-services/plastic-surgery/resources/brachial-plexus

Bonus: this is adorable - especially on babies ❤ 

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#2 Fluorescein Eye Drops

Imagine being a patient coming into the ED with excruciating eye pain and being told that someone is going to stick a piece of paper into your already searing eyeball and then look at it with a fancy named lamp that turns out is actually just a black light. 

There are a couple ways to effectively and less painfully deliver the fluorescein dye needed for a Wood’s lamp exam.

First, you can simply use the tetracaine drops and drop them onto the fluorescein strip and let that liquid fall into the patient’s eye. This can sometimes be challenging given that they often have a hard time keeping their eyelids open and you’ll need both your hands to use this technique.

Second, you can use tetracaine and simply place the fluorescein strip directly into the eye just under the bottom eyelid. This works too but again, it may be sensitive and there is a chance there is a foreign body hiding under that lid that may be more irritated by the paper you placed there.

Lastly (and this is my personal favorite), grab a 3 or 5ml syringe, a flush and a fluorescein strip. Open the empty syringe and remove the plunger. Take off the cap from the flush and place it on the empty, plunger-less syringe. Rip off the end of the fluorescein strip containing the dye and place it in the cylinder of the empty syringe. Squirt 1-2cc of the flush into the empty syringe. You’ll notice the fluid will become fluorescent yellow. Replace the plunger (you’ll have to flip it over and remove the cap on the other side in order to advance it) and voila! You now have fluorescein eye drops! I like this because it also allows you to use it again in the case that you need to repeat your exam and is generally less uncomfortable than putting a piece of paper in someone’s eye.

I hope these simple hacks aid you on your quest to conquer Peds and Fasttrack! Let me know if you have any other ED hacks you think are worth sharing, I know we all get inventive and it’s fun to hear what people have found works well!