Ah, yes. The dreaded IV needle. I call it an “IV needle” because that’s what everyone else calls it. The needle, however, is only a brief part of the transaction—yet it is the cause for all the fear.
These things are really called “IV catheters,” as that’s actually what they are. A catheter is, simply stated, a tube that goes inside the body for medical purposes. In this case, “IV” stands for “intravenous,” meaning “inside the vein.” So, when an IV is necessary, all we’ve gotta do is get a tube in one of your veins. No big deal. Now hold still…
“But I HATE needles!” you say.
This is a common declaration I get from patients as I approach with the IV. To this, I almost always tell them something along the lines of, “Well, that’s great! That means you’re sane. Had you told me you love needles and thrust your arm at me with excitement, I would’ve probably backed away slowly.”
So, yeah, it seems the needle part is the worst, and there’s definitely some misinformation floating around about IV’s, so it’s probably best to go through the process a little bit. Time to bring in a fake patient to help walk everyone through this whole experience. This time, a young woman named Ashley has come in, and her workup here at the ER requires an IV. With the installation of an IV, I can get Ashley’s bloodwork and have access to give her all of the IV medications she needs. But, Ashley, you look a little nervous. What’s up?
“I HATE needles!”
Oh, you missed that part. Sorry. Gotta stick you anyway. This should go without saying, but please hold as still as possible, as wiggling and dancing creates a moving target, so unless you’re a scared child, a confused adult, or someone who has a neuropathic reason why they can’t hold still, please hold still.
“But I don’t want a needle to stay inside my arm! What if it rips up my vein when I bend my arm?”
Ah, okay. Let’s dispel this myth right here and now. I know I said it’s just a catheter, but it takes some visual evidence to really hit the point home. Let’s step away from the clinical setting for a moment, as I just so happened to accidentally leave an IV in my scrubs pocket and then washed the scrubs, so the IV is useless and no longer returnable. And if medical equipment is no longer usable, it’s always a great idea to use it for education.
Without further ado, here’s my basic explanation of an IV catheter:
There ya go. Nothing to be too scared of. As long as we get the IV into a vein, most of the time the rest of the installation goes well, and the needle is only a small part of the process. So, back to you, Ashley. I’m just going to put a tourniquet around your arm to make blood flow in your veins back up a bit to help dilate them to a little larger size (I’m guessing you’re okay with me making my targets a little bigger). I’m going to ask you to open and close your fist to pump a little more blood toward that tourniqueted dead end I’ve created, and now I’m ready to search for a vein.
“But I’m a hard stick!” Ashley announces.
Oh man, if I had a buck for every time I heard this, I’d double my wages, I swear. Usually, when people tell me they’re a hard stick, it’s because they’ve had bad experiences in places other than ER’s. If you want to find the medical personnel who install IV’s the most regularly, go to an ER. We are very well practiced at IV’s, and we get the most challenging patients on a regular basis. The only department I’d say is nearly as seasoned as ER’s at IV’s would be the crews in pre-op departments—the people you see before surgery. They get a constant line of people who need IV’s, and they also have surgeons breathing down their necks about where they prefer the IV’s installed on all their patients. ICU might be in third place, but they’re more seasoned at dealing with bigger tubes and machines. (NOTE: This ranking is all out the window when it comes to kids.)
Do you know what I do if someone tells me they’re a hard stick? I do the same thing I do for every IV start: try my best. The only thing I might change is perhaps I’ll ask where other people usually have good luck starting an IV. This goes for anyone, to be honest. As long as I don’t need to put an IV in a particular spot for a procedure, I’m okay with putting one wherever the patient suggests, as long as there’s actually a vein there. Other than that, if someone says they’re a hard stick, I don’t change a damn thing.
In Ashley’s case, I’m not changing a damn thing. She’s got a good vein right here, below the place where her elbow bends on her non-dominant arm so it shouldn’t kink off when she bends her arm. Perfect. Now, I’m just going to clean her arm here, take the cap off the IV, and…
“Can’t you use a smaller needle?”
Ugh. I get this all the time. There’s a myth going around that we can always use smaller IV’s “if we want.” While it’s true that there are different sizes of needle to choose from, for the most part, the bigger the better. In adults, the two best choices are either a 20-gauge (the pink one like I have in the video) or the larger 18-gauge. (I know the lower number being larger seems opposite, but it’s the same as any other hole-making needle size, much like getting your ears—or whatever—pierced.) Below is a picture of the various IV sizes.
The pink one, the 20-gauge, is what I showed you in the video, and there’s a reason why it was stowed away in my pocket—it’s my go-to size. I find it to be “old faithful,” as it can make it into veins from the hands to the upper arm, stay put and open, and you can use them for anything. I keep 18-gauges (the green one) as my second choice, and I usually install those for traumas or anything that might require faster infusions of fluids or drugs. For major traumas or anything involving larger-scale blood loss, I’ll go with a 16-gauge (the gray one) because you can get a lot of fluid/blood in REALLY fast. 16-gauge is also what they typically use for blood donations, though their needles are little different than IV’s.
By telling you that, I’m certainly not trying to dissuade you from donating blood. Donating blood is essential for survival of people on a daily basis. Ever had a surgery? They had blood on hold for you just in case anything went wrong. Yes, even a basic surgery. So if you think you’ll ever be in a simple position to possibly require blood, please donate—even though they use large needles.
And here’s the truth we all need to hear: THEY ALL HURT NO MATTER WHICH SIZE THEY ARE.
Yes, there’s a slight difference in the way they hurt, but the thing all the needles in the picture above have in common is that none of them are painless. They all suck for a few moments. And that’s the important part: it’s only for a few moments.
So, yes, technically, I could put a tiny little 24-gauge in Ashley (the yellow one—your favorite in the above picture), but what would that do for her? In case you didn’t notice, the smaller the needle, the shorter the hose. And that’s because the smaller the needle, the smaller the person. Honestly, unless I’m absolutely desperate for an IV and the only vein volunteering for the suffering is a tiny little thing in the middle of someone’s finger, I’ll NEVER use a 24-gauge on anyone other than an infant or a newborn. Why? Because that’s what the 24-gauge is made for. Not an adult who just doesn’t like needles.
Even in the case of the newborn, 24-gauges are frustrating. They are tiny little tubes, so they kink off, block off, and come loose so easily when compared with the other sizes. You saw in the video how relatively small the tube on the 20-gauge is. Yet, that’s a reliable size. Anything smaller on an adult is more likely to fail in a shorter amount of time, which means a second (or third or fourth) stick. There are appropriate sizes for each situation. Otherwise, why would anyone get anything other than the smallest needle?
So, Ashley, would you rather have one stick with a larger size, or would you like to have multiple sticks with something that makes you temporarily feel less afraid?
Ashley has agreed to have an adult-sized IV started, but she has decided to look away while I put it in. And that’s absolutely fine. Whatever it takes to keep still for the entire procedure. Thankfully, Ashley does well, as she used some spontaneous breathing techniques to keep herself calm and still during the procedure. I obtain the bloodwork we need and flush the IV with saline, which is what us nurses keep in those syringes seemingly wrapped in cellophane. It’s just saltwater, basically, and it’s meant to keep IV’s clear of blood as well as keep IV drugs separated in the tubing. What’s odd is that some people can taste and/or smell a saline flush through an IV. While there isn’t a cut and dried answer as to why this happens, the clear link is through the blood flow from a vein traveling through the respiratory system, creating a difference in the concentration of sodium in the blood as it moves through cardiorespiratory circulation. All I know is that it’s a benign reaction and I warn everyone about it so they don’t freak out—it’s a harmless side effect.
There we have it. Ashley has a beautiful IV started, it’s secured in a good place in her arm, she’s aware that there’s no needle in her vein, and we’re good to go.
“Wait. Why is the green one in? Isn’t that the 18-gauge? The BIGGER one?”
You shouldn’t have complained so much, my dear. Nurses get to choose the size, after all. You’re fine, though. Enjoy your IV that will be incredibly reliable for you and great for every single bit of testing and infusion. You’re welcome!
This is a good, tough question. There’s the quick answer, and then there’s the longer version/message. Let’s start simple, and then go through the process of ruling out a heart attack.
First and foremost, the only way to know if you are having a heart attack is to be evaluated in an emergency room.
There’s no way around this. If you feel like you’re having a heart attack for any reason, then you need to go to an ER as soon as possible. DO NOT DRIVE YOURSELF. If you truly believe you are having a heart attack, then driving on the road could be more dangerous than driving drunk. If you lose consciousness, then you are now potentially going to kill someone else on the road. Call 911 or have someone else drive if you think you’re having a heart attack, and get to an ER as soon as you can.
What is a Heart Attack?
Simply put, it’s when blood flow to your heart is blocked in at least one place. Your heart is basically the hardest working muscle in your body, and it needs a constant supply of blood to provide it with oxygen to live, electrolytes for proper electrical conduction, and other nitty gritty elements found in your blood that I won’t cover here. If blood supply is cut off to your heart, the muscle starts to die. The larger the supply of blood cut off to your heart, the more likely the heart attack is to be lethal.
A good way to describe a heart attack is to compare it to choking. Let’s say you give a friend of yours named Art a large gumball because you’re feeling nice and generous. And since you’re in such good spirits, you also tell Art the best joke he’s ever heard in his life. Unfortunately, Art starts laughing before he gets a good bite into that gumball and accidentally inhales it. The gumball lodges in Art’s airway between his throat and his lungs, and Art can no longer breathe. Art is choking.
If Art were an artery (he’s named “Art” on purpose—tee-hee) leading back to your heart, you’d be having a heart attack. The gumball would be the clot and Art’s lungs would be the heart tissue not getting oxygen. Get it? Good, because Art is totally going to die if we don’t help him out right away.
Lucky for Art, you know the Heimlich maneuver (now mostly called “abdominal thrusts”), and you get to it fast. A couple of thrusts later, the gumball flies out and Art can breathe again. (If you don’t know what the Heimlich maneuver, sign up for a first aid class right now and learn CPR and basic life-saving skills. Seriously. It’s easy and the world would be a little bit safer if everyone took the time to actually learn these skills. YOU CANNOT LEARN THEM FROM TV SHOWS. ACTORS GIVE TERRIBLE CPR.)
Art thanks you for saving his life, but, remembering that you both gave him the gumball and told him the joke, he decides to spend the rest of the day away from you.
What Art experienced would be a simple version of a major heart attack. If a large artery to your heart gets blocked off completely and suddenly, you are going to have some awful, insufferable symptoms, if not sudden death. Not every heart attack is reversible, unfortunately. Sometimes that gumball gets lodged in there really well and no one is around to perform the Heimlich. It’s sad, but it unfortunately happens.
As for the rest of the types of heart attacks, there is hope and potential treatment. And the only way to capitalize on modern medicine’s ability to help you survive a heart attack is to get yourself evaluated at an ER as soon as possible.
But…What are the Signs and Symptoms of a Heart Attack?
This is where it gets a little muddy. Of course, chest pain is a sign of a heart attack. But there are a lot of different vessels of different sizes around your heart, and depending on which vessel is blocked off, as well as all sorts of other factors of which we aren’t completely aware, everyone can experience different symptoms of a heart attack.
Generally speaking, the larger the vessel being blocked off, the more likely you are to have major symptoms. Or not. Everyone is a bit different, and there are a lot of different ways people experience heart attacks. Some get the classic pressure and pain in the middle of their chest that radiates down their left arm, other people feel like they are having some mild indigestion. Men and women typically present with heart attack symptoms differently, and women’s symptoms are typically more subtle. (Or perhaps men are just more likely to complain about their pain—am I right, ladies? I’m not in this case, though. Just making a joke. This is a heart attack, not the man-flu.)
Considering the fact that there are different types of heart attacks that can present differently in every single person and might vary in their symptoms depending on the person’s sex, the list of possible symptoms of a heart attack kinda look like a frustrating entry from WebMD. (I HATE WebMD, by the way. This will be a future topic. For now, just do us all a favor and do NOT go to WebMD. EVER. Please?) The (incomplete) list is as follows:
Chest pain, pressure, tightness, discomfort, squeezing, or any other way to describe “My chest doesn’t feel normal, and it keeps not feeling normal.”
Pain in any area around or near your chest—arms, neck, back, jaw, stomach—with or without the chest pain
A feeling of being short of breath, whether you are having chest pain or not.
Nausea with or without vomiting
Sweating (usually a cold sweat)
Dizziness or lightheadedness
And all sorts of other things that could be a sign of a heart attack, which you can read in articles here and here.
Doesn’t that list suck? If you spend enough time staring at it, you can totally think, “Oh man, I just coughed once…am I having a heart attack?”
Relax. I’m not here trying to add to the information on the internet that brings people into ER’s unnecessarily. Usually, there is a combination of the symptoms above and they come on rather rapidly. Of course, if you have concerns, then get yourself to an ER as soon as possible. But if you only started having the symptoms after reading the list of symptoms, I’m thinking you’re having anxiety, and I’m sorry I triggered yours. And if you’re prone to anxiety, it’s probably best if you don’t hunt down signs of life-threatening events on the internet. Put the internet down and walk away. And please, avoid WebMD at all cost. In order to cover their tails, they basically say everything could be a sign of death. Including and not limited to a cough. (Yes, I seriously hate WebMD.)
The main thing to keep in mind, if you are seriously concerned about ever having a heart attack, is your risk factors. Age, of course, is a risk factor. The older we get, the more likely it becomes that our bodies will kill us spontaneously. That’s just the hard truth. And yes, genetics seem to play a big role in heart attack risk. If you have any direct family members who have experienced and/or died from a heart attack, that increases your risk of having one considerably. It might seem like poor luck to get genetics like that, but without them you wouldn’t exist, so stop complaining.
The rest of it is really mostly controllable. If you are overweight, eat a terrible diet, and don’t ever exercise, then you are more likely to have a heart attack. Smokers definitely have a higher risk, as do drinkers. If you have other diseases or health problems related to circulation, then your odds of having a heart attack are higher. The most common health problems increasing risk are high cholesterol, high blood pressure, diabetes, lung disease, and so on. In the business, we call these health problems “comorbidities” for a reason.
But chances are, if you’re reading this article and feel fine, you are fine. But maybe, if you’re concerned about your risk of heart attack now, get out there and make a change. You can start by taking a CPR class.
Full disclosure: I have my own risk factors to work on, so I’m not judging in any way.
What will you do to me in the ER to Rule OUt a Heart Attack?
To best describe this, I need a patient.
Poor Art. He’s having a really crappy day. First, some jerk makes him choke on a gumball, and now he’s having chest pain. He thinks it may be anxiety-related, seeing as how he nearly died earlier today, but since his dad died of a heart attack, he’s not taking any chances.
Art is 25 years old, so he’s not high risk. He’s also a fit fellow with no other major medical history. He has no prescribed medications. When he arrives at the ER, he sees that it’s busy. Part of him considers leaving, since he’s pretty sure it’s not a heart attack, but he decides it’s better safe than sorry, plus he got his poor mom to drive him here and she’s too worried to let him go home anyhow. The healthcare professional at triage (the front desk) hears that Art is having some mild to moderate mid-sternal chest pain. Art denies any shortness of breath, any pain radiating anywhere else, or other symptoms. He offers his negative health history but includes the family incidence of a heart attack on his father’s side.
The first thing to do in most ER’s when someone complains of chest pain is to get a basic set of vital signs and an EKG as soon as is feasible for however busy the ER is. But just know that not all chest pain is going to make the staff run around screaming in panic.
This is okay, and it even makes sense. Let’s say there’s a line of people behind Art all waiting to come back. Everyone is line is complaining of chest pain. Some look like Art, but then there’s an elderly lady on oxygen breathing heavily in a wheelchair, unable to walk without losing her breath. There’s also a guy sweating profusely and white as a ghost. Since they’re all complaining about chest pain, I take them back in the order they arrived, right?
Art and the people like him look fine and are acting fine. The woman and the man need to be seen first. In fact, the triage person asks the healthy-looking people to step aside for a moment so they can get the woman and the man who are in high distress back to be seen as soon as possible. This is smart. It doesn’t happen often that people are asked to cut in line, but it does happen. Triage is an art form, and the people working it are some of the hardest working and wisest medical professionals around, and they’re tough as nails—or, at least, they should be, because they are going to get yelled at a lot. In fact, another young man gives the woman doing triage a lot of gruff about being cut in line, as he is having chest pain, too. He is doing well, though. Same as Art. But Art trusts the process and waits for his turn to be seen.
Because it’s an incredibly busy day and the triage person had to take two people back immediately, both of whom were experiencing life-threatening heart attacks, Art has to wait for a bit before being called back for vital signs. He’s still being patient. He knew he was in for a wait walking into an ER. “If I’m waiting, that means I’m doing better than most of the other people here,” Art says to himself. Art is wise, and he’s a good man, making me feel particularly bad about that whole gumball incident.
After about fifteen minutes, Art is called back for vital signs and a second round of triage. His blood pressure, pulse oximetry, pulse rate, respiratory rate, and temperature are taken (If you want some good background info on these, check out my previous post about the monitors), and they are all within normal limits. It’s a good start.
After waiting a little longer, Art is called back again for a 12-lead EKG. This is a great diagnostic tool, and it’s one of the central assessments in diagnosing a heart attack. A 12-lead is basically a picture of a heart’s electrical activity taken from several different angles. If a portion of the heart is in distress, it will change the pathway of electrical conduction, and these changes can be seen on a 12-lead EKG. The 12-lead is a detailed test, far more detailed than basic continuous cardiac monitoring at the bedside when the wires stay on your chest the entire time.
The process of taking a 12-lead is fairly simple. The operator puts your patient information into the machine, and then they place the stickers onto your body for connecting the machine’s wires. This requires chest exposure, just so you know. There are six stickers that have to go on your chest. Two to the left and right of the center of your chest, another sticker below the sticker to the left, and then three more going underneath the left breast area. I am always respectful with women and give them a heads up about the sticker placement. In most cases, bras can stay on. But if the bra is a sports bra or it takes up extra real estate on the chest that would get in the way of proper sticker placement, then it might have to come off. This is rare, but it happens. Just to clarify why, I’ve included a picture of EKG placement stickers here.
And for men, keep in mind that the stickers have to be able to keep in contact with the skin. So…this might require a spontaneous shave. Deal with it, though. This shave might save your life. You’re there to be evaluated for a life-threatening condition, after all. Don’t let some chest hair get in the way.
The four other stickers go on (or near) the four extremities. There are several possible placements, and different people use different sites. Some go with the wrists and the ankles, some go with the shoulders and upper thighs. There is not really a wrong way, as long as these stickers are symmetrically and consistently placed. For those of you cringing about an extremity sticker being placed on an upper thigh, I guess you’ve never done a 12-lead on an amputee.
After the stickers are all carefully arranged, the proper wires are attached to them. Don’t worry, the wires are there to receive electrical activity from your body—you do not get shocked during an EKG. Once all of the wires are attached, the next part is mostly, AHEM, the responsibility of the patient.
I can’t tell you how many times I’ve taken an EKG and asked a patient to be still and silent, and they decide that this is the best time to talk about EVERYTHING ON THEIR MIND.
Don’t be that person. The 12-lead EKG is important as hell. Don’t mess with that test. Be as still as possible and DO NOT TALK during that test. Why? We’re reading electrical signals that are really rather precise. So just do us and modern medicine a favor and stop moving and talking for five, maybe ten, damn seconds.
Art was a great patient. He stayed perfectly still and remained silent during his 12-lead. The lines on the paper were without any of the artifact (wobbly thick lines from movement and other outside factors) that makes reading the damn things far more difficult than necessary. His result was that his heart is in what we call a normal sinus rhythm, which is perfect. This gives all the healthcare personnel around him a great breath of relief, as the charting has become a lot more simple—er, I mean…he’s going to be okay. We’re fairly sure, at least.
This normal 12-lead EKG result just eliminated almost all of the major cardiac events. At the very least, it made the likelihood of Art experiencing a cardiac event that would result in sudden death incredibly minimal. This is great news, but it unfortunately means that Art can wait longer in the waiting room. There are still no beds, and Art’s condition is considered to be stable.
“If I’m waiting, that means I’m doing better than most of the other people here,” Art says to himself once more. And now I love Art to pieces. What an understanding guy.
Finally, after waiting ever so patiently, Art is called back. he gets a room with a tiny, uncomfortable cot. The nurse puts several pieces of equipment on him: a blood pressure cuff on his arm, a pulse oximetry probe on his finger, and five stickers on his chest connected to wires to monitor his heart rhythm in real time. (Once again, for more info on this stuff, read my post on monitors.) The stickers for continuous cardiac monitoring are purely for heart rate and real-time observation of any rhythm changes. The 12-lead is more accurate, but basic cardiac monitoring is still great, as well as essential, in a chest pain patient.
The doc orders some basic medications to give Art for his chest pain (which Art says is a 3/10. If you want some info about the pain scale, I wrote a little something for ya). In most standard sets for treatment of chest pain, a full dose of aspirin (324 milligrams) is given once, and up to three tablets of nitroglycerin are given sublingually (to dissolve under the tongue) five minutes apart to help resolve the chest pain. (Then maybe some Tylenol to help with the headache nitroglycerin gives most people.)
Other medications might be given for different circumstances, but these are two standard medications given to help with chest pain that is otherwise not symptomatic. Medications are a slippery slope that can result in a long, long post (this one is already quite long), so I’ll take a pass this time and promise to do posts about medications sometime in the future. For now, I’ll keep the descriptions to basic procedures.
The next step is everyone’s least favorite: the IV start. (I will definitely cover this in greater detail in the future, don’t worry.) An IV placement in a chest pain patient is standard. If something goes wrong, having an IV placed can be the difference between life and death. With an IV, we can give essential medications immediately. Plus, in the ER at least, when we start an IV we can use that to get your initial blood work. That means only one poke (hopefully) and two tasks accomplished. Hooray, right?
“I…um…I don’t like needles,” says Art.
Bless his soul. Of course he doesn’t like needles. He’s sane. If he looked his nurse in the eye and said “I love needles!” His nurse would consider adding on a psychiatric evaluation. So, yeah, Art’s nurse gets it. But the blood work is essential in ruling out anything potentially life-threatening. So, being a good patient, Art holds still while the nurse (or it could certainly be a medic) starts his IV and gets the initial blood work. Despite hating the entire process, Art does as he’s told and everything goes well. He now has an IV placed and the blood work is going back to the lab.
“So…what are they looking for in the blood?” asks Art. Great question.
I won’t cover all of the different blood tests here, but let’s touch on the main one in terms of ruling out a heart attack causing chest pain in a healthy young man with a normal 12-lead.
Basically, troponin is a type of protein that helps with muscle contraction. It shouldn’t be in your blood in high amounts, and if it is, the likely source is from damage to heart muscle cells. They typically elevate within four hours of heart damage and the persist in the blood for up to 14 days, making them a good indicator of heart distress.
Art’s 12-lead was normal and his troponin level came back as normal, so the doctor feels fairly confident that Art did not have a heart attack. However, considering Art’s family history and the fact that it can take up to four hours for troponin to show up in the blood, the ER doc asks Art to stay for another blood draw for a second troponin level three hours after the first one was taken. Wanting to play it safe, Art agrees.
So, what does Art have to do during this time while he waits? He just has to be patient. And he shouldn’t have anything to eat or drink, just in case he ends up needing an invasive procedure. Since Art knows this, he doesn’t bug the nursing staff to “sneak him something,” as wanting to be snuck food is basically saying you don’t believe or trust the staff at the place you came to for emergent care. (Seriously. No one is actually starving in the ER more than the staff working, so stop asking.)
When the three hours is up, more blood is taken from Art, and then he has to wait another 40 minutes or so for the result. Thankfully, after Art waits patiently, he finds out that the troponin level is still normal. Had Art had more risk factors or had been older, the doc might have suggested he be admitted for further observation, but in this case, the doc is fine with letting Art go home, as long as he makes an appointment to follow-up with a cardiologist. Art is happy to do so, and is discharged home feeling much better.
Some doctors would still insist on Art being admitted for observation. Just listen to your ER doc and discuss a plan with them if you ever find yourself in this situation.
What about after discharge?
After going to the ER for chest pain, definitely see a cardiologist. It doesn’t frankly matter that we ruled out most life-threatening things in that moment—you had an event that you thought was a problem with your heart and the ER sent you home telling you to talk to a heart specialist, SO DO THAT.
I can’t tell you how many times I’ve had patients come in for recurring chest pain, AKA: patients we saw recently for the same thing, and when we ask if they followed up with their cardiologist, they say, “Oh, I thought you guys found that everything was alright, so I decided not to.” NO. We told you that your life wasn’t at risk at that moment. That’s our specialty: EMERGENCIES. You weren’t found to be having an emergency, so you were sent home. Because we don’t actually specialize in hearts, we told you to make an appointment with a heart specialist. Of course we will see you and treat you again, but we will have to start the above process all over from the beginning. And when we discharge you, WILL WILL, ONCE AGAIN, TELL YOU TO MAKE AN APPOINTMENT WITH A CARDIOLOGIST.
Art did make an appointment with a cardiologist. They decided what testing was right for making sure Art’s heart was in great condition. Art and his cardiologist created a health plan together for avoiding any future cardiac problems. Art really is a great, stand-up kinda guy.
I’m happy to explain everything on the bedside monitor screen, but if I tell you, you have to promise me something: Don’t stare at it.
One thing I can’t bear is having a critically ill patient and walking into their room to find the family staring at the monitor like a preschooler when Paw Patrol is on.
“What’s that number? Is that low? Is it bad?”
The questions spill out of their mouths without reserve. They’re stressed. They want to know everything is alright. Or, they want to be prepared for the worst case scenario. They see that monitor as something plugged directly into their loved one’s “live or die button.”
Here’s something I want all of you to know: You need to take your eyes off of the monitors and put them on the person you love. If you’re at the bedside, stay there. You are not at the “monitorside.” We are at the monitorside at the nurses’ station. It’s our job to keep track of the monitor. We are slaves to it, but we are considering an uprising. We mostly hate the monitors, trust me. Of course, they give us vital information (because it shows the vital signs…get it? I’m here all week), so we’ll never have a full-on revolt, but we still hate them nonetheless.
To reiterate, I say “mostly hate” because they are important and we do rely on them. Having said that, they suck. Why? The best way to explain the awful relationship nurses have with monitors is to break down exactly what most of the normal things are on monitors and why they are both good and bad. Of course, they are absolutely mostly good. Like 98% good. But man, that 2%…Grrr…
Anyhow! Moving on!
Let’s start with a scenario—something mild and non-traumatizing. Let’s say we have a healthy young man in his early 20’s who is having chest pain. Eventually, we will find out that he’s perfectly healthy and that his pain is from a muscle strain from recently taking up weightlifting. But, for now, he’s a new patient complaining of chest pain. Obviously, we would have this guy on all of the basic bits of bedside monitoring.
First, Let’s Look at that Blood pressure.
Yes, it’s everyone’s favorite vital sign: blood pressure. Let’s say this patient is a really nice and cooperative person…hell, he’s so cooperative, let’s call him Buddy. Buddy sees me coming toward him with a blood pressure cuff and he actually raises his arm for me to put the cuff on. WHAT A GUY.
I can’t tell you how many people do not do this. Seriously. I know at least 99.9999% of people coming to the ER (excluding kids) have had their damned blood pressure taken before, yet almost all of them go completely limp and refuse to lift their arm to put a blood pressure cuff in place—even when I am in the middle of attempting to wrap the cuff around an arm. I don’t have to knuckle-punch your boob putting a blood pressure cuff on, ladies—why must you force me to?
Anyway, Buddy lifts up his arm and lets me put the blood pressure cuff on beautifully. I take a step back to admire how amazingly positioned that cuff is. Wow. I’m tearing up a little, even. Buddy then relaxes his arm and I press the little button on the monitor to get the blood pressure cuff to inflate. It fills up to 140 mmHg and then Buddy looks at me nervously, saying, “This kinda hurts, Mike.”
That’s when I realize that it would be great to explain to Buddy how taking a blood pressure works.
Why Blood Pressure cuffs Squeeze So hard
Blood pressure is measured in two numbers, both in terms of millimeters of mercury (mmHg), which is just a unit of measurement for pressure. The first thing a blood pressure cuff has to do to measure this is…and this is important…CUT OFF YOUR CIRCULATION. THERE IS NO WAY AROUND THIS. So when you’re having your blood pressure taken and you think, “Wow, this kinda hurts and it’s making my hand numb,” that’s why. The cuff is literally creating a temporary tourniquet to stop blood flow to your arm.
This is also why, when a manual blood pressure is taken by a nurse, they hold a stethoscope against the inside of the bend of your elbow. They are listening to the blood flow in your brachial artery. If they inflate the cuff and can still hear your pulse, they inflate it more. The automatic cuff does something similar in that it listens. In both cases, the listener is sensitive to noise, so please be still and quiet. People love talking through blood pressure readings. Also, if the cuff is “too tight,” people love screaming through blood pressure readings, which only serves to increase the chances of a repeat blood pressure being required, which creates more screaming…and so on and so forth.
Anyway, Buddy is now sitting nice and quiet with his arm relaxed, and the cuff has tightened enough to cut off his circulation. He sits still, despite the discomfort, as I have now properly explained that blood pressures aren’t designed to be comfortable, and he’s okay with that. The machine is now slowly releasing pressure until the monitor first hears Buddy’s circulation return to the artery. As soon as the first noise of circulation happens, the pressure of the cuff is noted in the monitor. In Buddy’s case, 140 mmHg cut off his circulation, and the first sound was heard when the cuff deflated to 121 mmHg, so the top number of his blood pressure will be 121. Great start, Buddy!
Now circulation has returned to Buddy’s arm, but conditions are not ideal for his brachial artery. There’s still a bit of pressure to fight against with the cuff still inflated. In order to hear the pressure of the artery at rest (basically—perhaps “non-stressed” is appropriate here) between beats, the cuff has to release to the point of the blood in the artery no longer being audible. At the moment the sound cuts out again, the bottom number is recorded. In Buddy’s case, the sound drifted away at 82 mmHg. That means that Buddy’s complete blood pressure is 121/82, which is just fine. Great stuff, Buddy! Time to move on and away from blood pressure…
“But what’s that number in parentheses? The 89.” interrupts someone I assume to be Buddy’s girlfriend of two weeks who never bothered to introduce herself to me, even after I introduced myself. “Is that his pulse?”
Ah, yes. The mean arterial pressure. The number that no family member seems to like, even though they have no idea of what it means. This is a simple calculation performed by taking the top number (systolic blood pressure, officially) adding it to twice the bottom number (diastolic blood pressure, officially) and then dividing the result by three. This gives you an estimate of the mean arterial pressure, which is important as it shows the average pressure in a patient’s arteries, which tells us how well blood is being pumped to those vital things called organs. Blood pressure cuffs give us a rough estimate of the mean arterial pressure. The only way to get a true accurate recording is to stick a pressure-sensitive line directly into a patient’s artery, but Buddy isn’t even close to sick enough for such a thing, so we have to rely on his cuff to give us an accurate reading, which is absolutely fine. (For a true calculation of mean arterial pressure, click here.)
I tell Buddy that these readings are great, but I’ve set the cuff to go off every fifteen minutes since he is here for chest pain. I reiterate that when the cuff starts inflating, he needs to hold still until the reading is finished.
“But what about that other number? That one with the squiggly line that says 100. Is that his heart rate? Because I heard 100 is a high heart rate. Aren’t you worried?” chimes in Buddy’s girlfriend. She’s the classic “distrustful of hospitals” visitor. She’s the type who thinks we show up to work just to put people at risk, and she’s starting to bug me. Yes, I realize that I made her up. She might be annoying in her approach and manners, but her questions work for this scenario. But honestly, I don’t know what Buddy sees in her.
I get the “aren’t you worried?” question a ton in the ER. If I worried as often as family members and patients thought I should be worried, my head would explode. I wouldn’t be able to focus. I do worry from time to time, but if I worried as much as everyone else wants me to worry, I wouldn’t be able to function. And do you really want your nurse freaking out? No, you want your nurse in control. I’m in control here, Buddy’s girlfriend!
The number she’s asking about is the measurement of pulse oximetry. It’s read as a percentage, so Buddy’s 100 is the best it will ever get. This reading is being taken from the probe I put on Buddy’s finger. The little red light shines through Buddy’s skin and is able to sense the amount of light absorption in the red blood cells and can differentiate between the hemoglobin (an oxygen-carrying protein on red blood cells) carrying oxygen and the hemoglobin no longer carrying oxygen. From this, it produces a percentage of red blood cells carrying oxygen (Buddy’s is 100! Hooray!—ignore the example picture, as that’s a poor reading), and also, since it is looking at blood passing through arteries at a certain rate, it can determine a pulse rate.
I look at Buddy’s girlfriend after saying this, and she scoffs. “So is the 100 his heart rate or not?” she asks. I take a deep breath, force a smile, and educate his girlfriend who still hasn’t given me her name.
“It’s a percentage. But it can show his heart rate. 100% is great. We are only concerned when it dips below 93%. But if you look up here, this is Buddy’s actual heart rate.”
What I’m pointing to is the squiggly lines that keep dipping up and down in spikes and bumps. This is Buddy’s cardiac monitoring, and it’s showing that his heart is beating at a rate of 76, which is great. The “normal” range is 60-100, but various factors can change what is normal for different people. I’m not going into that here. Buddy is a healthy guy. 76 is great.
The squiggly lines next to the 76 are actually tremendously complicated. For these purposes right now, I’m going to give you a basic idea of what’s going on, because heart rhythms are worth an entire textbook to explain. Just know that we who are monitoring these squiggly lines know exactly what’s going on and it took a lot of blood, sweat, and tears to understand those stupid little lines.
VERY basically, your heart is an electric creature. Every beat is an electrical event. Electricity dictates how well your heart pulls blood in and pushes it out. Your pulse is an electric event. And we measure that electricity. We can measure it so precisely, we can see which part of your heart is stressed (if any) by looking at a squiggly line. Pretty cool, right? Buddy’s heart is in what we call a normal sinus rhythm. This means his heart is beating as it should. This is great. I will cover heart rhythms as best as I can in future posts, so I’m just going to leave things here. Buddy is fine, and the squiggly line is telling us good things. We have good vibes in the room, I’m happy to have explained the monitor to you all, so I’m just going to step out for a minute to check on—
“Hey! But what’s that number in the middle? The one with the other squiggly line that looks weird and says 16…wait…4…wait…35…wait—”
GODDAMNIT! BUDDY’S GIRLFRIEND FOUND THE RESPIRATIONS!
The Stupid Damned Respirations
I take a breath, grind my teeth, and lean against the wall to keep me from falling to the floor kicking and screaming.
Every monitor is equipped with a respiration count, and let me say this loud and clear:
EVERYBODY HATES THIS FEATURE.
A patient’s respiratory rate itself is important, and it’s just the number of breaths a person takes per minute. This can be simply calculated by watching a person breathe for fifteen seconds and then multiplying that number by four, or watching a person breathe for ten seconds and multiplying that number by six, or watching someone breathe for a full minute and writing that down, or just noticing that a person is breathing normally and writing down your favorite estimate appropriate for their age…the POINT IS…NO ONE TRUSTS THE MONITOR FOR THIS NUMBER.
The respiratory rate on the screen is “monitored” by the cardiac monitoring stickers on Buddy’s chest. There are five in total, and their rate of physical movement on a person’s chest determines the respiratory rate on the monitor. Now, think about how comfortable ER carts are to lie on. Add in the amount of time we expect you to stay in one. Now allow for normal fidgety movement…these are all things that cause the respiratory rate alarm to sound. It tries its best to take the rise and fall of the electrodes on a patient’s chest to mean that this is when their chest went up and down…therefore…a breath! But, no. Respiratory rates on monitors are 99% stupid. There, I said it. I can’t think of a single time a respiratory rate alarm went off and I believed it. Why? Because Buddy—healthy Buddy—just shifted in his bed for a bit to find a comfy spot and his respiratory rate alarmed because it sensed he was breathing 90 times per minute. That’s not possible in a grown man without massive effort. So what did I do? I silenced the alarm.
And I silenced the alarm while staring straight at Buddy’s girlfriend. I can do it with my eyes closed, it’s so reflexive.
Now, don’t get me wrong—there are situations during which close monitoring of the respiratory rate is crucial. I’m thinking of a patient being on a ventilator (a machine connected to a tube in a patient’s throat that most people call “life support”), suffering an opioid overdose, having a PCA pump (AKA: morphine button), or someone with sleep apnea. But, in these cases, THEY GET SOMETHING MORE ACCURATE TO MONITOR RESPIRATIONS. Or, they use end-tidal CO2 (I’m not going to explain that here, no way—maybe later, but that’s more advanced stuff). In other words, when monitoring a patient’s respiration rate is vital, no one uses the basic monitor. And honestly, just watching chest rise and fall is more accurate than this part of the monitor.
So, those are the four basic monitor functions. Buddy and his girlfriend both seem satisfied with my descriptions. I also go so far as to assure them that Buddy’s vital signs are also being transmitted to a monitor at the nurses’ station, so either myself or one of the other nurses can respond if something goes wrong—though I don’t expect this to happen in Buddy’s case. His 12-lead EKG (another future entry) and blood work (another several future entries, I’m sure) all look great, so it’s just up to the doc as to whether or not to send Buddy home or keep him for observation (another future entry).
Since the tension has lifted in the room, I feel free to tell Buddy and his girlfriend about how much the monitors bother me as a nurse.
And they do.
Why I Say That the Monitors Bug Me
(FYI: What I’m really talking about in this section is a perspective on a real problem in healthcare called Alarm Fatigue.)
Yes, they are essential. I’d never do without a monitor on most patients. But, damn are they ever ready to alarm. If a nurse is new or if they don’t have the time to tell the monitor about the patient (AKA: program it and set appropriate parameters aside from the default settings), these things can and will alarm about almost everything. A cough can be interpreted as an unstable heart rhythm. Shifting from lying on one side to the other can be interpreted as respiratory arrest. The list goes on and on.
Monitors are designed by companies who don’t want to take the blame for anything being missed in the clinical setting, and understandably so. But, the result is that the nurse (never the doctor—real talk: the vast majority of doctors have no clue how to work a monitor—it’s not their job to know. This is why a doctor will let a monitor alarm blare on and on while they are standing at the bedside—they truly don’t know how to fix it) has to adjust every monitor to accommodate each and every patient. I try, but sometimes how busy I am doesn’t allow me to adjust the monitor settings, so it alarms at every opportunity. This is especially aggravating when I’m drowning in patients. I mean, imagine that you are way over your head in bullshit, everything is beeping in shrill tones because you are way over your head in bullshit and don’t have a moment to fix it. It can make a person nearly go insane.
If every nurse had the time to reprogram the alarm limits on every monitor to accommodate each patient, the world would be a better place.
The world would be an even better place if everyone knew what the numbers on the monitor meant—thus, this article.
And the world would be a perfect place if everyone knew what everything on a monitor meant and promptly forgot about it all so they could pay attention to the person they are there to see.
Really—Don’t Stare at the Monitor
I get it. The monitor is an active thing. Sometimes your loved one isn’t active. Sometimes they are hooked up to everything and they aren’t able to communicate and the only thing making any noise or movement in the room is that goddamned monitor.
Trust me, despite modern technology and all its miracles, there is nothing more important than paying direct attention to the patient—in your case, your loved one. There is no technology that can replace being present. The monitors are our friends, as they are doing their best to watch over everyone when we can’t be in the room, but they aren’t the most important thing in the room by a long shot.
This is why you, as a loved one at the bedside, should not stare at the monitor. Yes, I realize we are in the age of screen-staring, but seriously, this type of screen-staring is especially depressing. You are there to spend time with someone who is sick and needs your company, not to provide a third-string defense against monitor readings. Even though I’ve described the basic things monitors monitor, you are in no way an expert. Hell, even if you were, you should not be watching the monitor. I’ve seen great off-duty ICU nurses at the bedside with sick loved ones and they are still staring at the monitor, even though they know better.
Of course, if the monitor alarms, it’s tough to ignore. I get that. But monitor alarms are just trying their best to replace direct visual assessment—so keep your eyes on your loved one. If an alarm keeps going off and you’re concerned, hit the call light. The nurse may want to change some settings to make everyone’s life a little less noisy.
So, forgive me and my attitude toward monitors. I do my best to program them for each patient individually so they don’t alarm so much, but it doesn’t always work out. I do believe that a basic education for the general public as to what monitors are telling us is in order, and that’s what I hope to have accomplished here. If you have any comments or questions, I’d be happy to hear them. Thank you for reading all of this.
Oh! I almost forgot! Buddy was discharged with a muscle strain. He’s just fine.
…and his “girlfriend” ended up being his mother. That’ll teach me about making assumptions. She must be in her forties, at least—she looks fantastic. She ended up thanking me for my care. We ended on a high note. Goes to show, you never know how these patient/family/nurse interactions will end.
You’re in a lot of pain and you’ve decided to come to the ER. We get you back to a bed, and inevitably part of our assessment is asking you to rate your pain from 0-10. If you’re like many other people, this either confuses you or gives you anxiety. Here are some actual questions I’ve received about the pain scale…
What if I give a number that’s wrong?
(A: There is no right or wrong number. Unless you give a number outside the scale.)
What if I rate it too high and you give me heavy drugs I don’t want?
(A: We can’t give you pain meds you don’t want.)
If I rate it too low will you refuse to give me pain meds?
(A: Your treatment doesn’t rely on the pain scale number, and the doctor will prescribe what he or she thinks is appropriate, regardless of the number you throw out.)
Obviously, the pain scale question creates some anxiety for many. But when you’re asked this question, you need to relax…well, as much as you can. You are in pain, after all.
I’ll admit, the fact that the pain scale trips everyone up is mostly on us. It’s one of those things that healthcare professionals think is easy to manage, but it isn’t. Here’s the simple answer to the “problem” of the pain scale: It’s just a reference. If your chief complaint coming in is pain, then we want to know your starting point so we know how well our interventions have worked. If you rated your pain a 5 and we gave you Tylenol, we want to know if that Tylenol worked. If you rate your pain a 2 an hour later, then we feel confident about our intervention. If you rate it an 8 all of a sudden, we know we need to re-evaluate.
We don’t have some reference sheet with numbers on the pain scale next to the appropriate drugs. The pain scale does NOT dictate what drugs you get. At all.
A ridiculous scenario:
RN: “Hey doc, the patient in room ten says their pain is a 7/10, and I really think they need something to help ease things up. They appear to be in agony.”
Doc: “Well, offer them a warm blanket. That’s all we can do for a 7. Too bad they didn’t say 8—we have all this morphine sitting around…”
See? It’s silly. The doctor will prescribe what they think is appropriate based upon your presentation and assessment, not some arbitrary number. If the number you gave dictated your drugs, then people would only rate their pain either a 2 or a 10, depending on whether or not they wanted narcotics.
Many patients seem to think saying 10 (or more—”It’s a 19!” guarantees eye rolls) guarantees them narcotics, like we’re a fast food joint and they’re ordering a combo meal. Drug seekers are real, and we despise them for taking up time and resources, but don’t worry about being pegged a drug seeker if you aren’t one. Every state has a system to track narcotic prescriptions (in Ohio, we have the OARRS), and the drug seekers’ reports light up like a Christmas tree in Times Square. It’s always fun to walk into a room with a doctor and watch the patient’s face as the doctor says, “You were prescribed ten Percocet yesterday. Where did all of those go?” Usually, the answer is that they lost the prescription or that the drugs “accidentally got flushed down the toilet.” These people are only in the ER to waste everyone’s time, and they are usually easy to pick out.
Of course, it’s okay to say your pain is a 10, if that’s what you’re feeling. For some people, a 10 is labor and delivery. For others, it’s a kidney stone. For someone else, it’s a hangnail.
If you are in pain, just give a number you think is appropriate. More importantly, describe it. We care more about where your pain is on your body, whether or not it’s radiating (traveling) to another place in your body, and the quality of the pain (pressure, stabbing, burning, cramping, etc…). I’ve seen people having massive heart attacks rate their chest pain only a 2. I’ve had patients with broken bones, dislocated joints, acute appendicitis, and all sorts of other situations requiring attention and/or hospitalization rate their pain less than five. I’ve also had patients rate sore throats and minor cuts and scrapes a 10. It’s all relative, and none of it dictates the drugs given. The physician’s assessment dictates the drugs given—as it should be.
So feel free to let loose whatever number you feel is right for you. And you really don’t have to downplay it. Just say what you think it is. We really aren’t going to judge you as long as you aren’t trying to lie. Please don’t lie. And please don’t demand narcotics. We’re in a tough spot with the opioid epidemic in this country, and we’re doing our best, but we’re also being watched closely. (I’ll do a post about pain itself and addressing the opioid crisis in the near future.)
But, if you truly need an accurate pain scale to judge which number to assign your pain, I’ve always liked this one: