This year I get to be one of the 41,000 Americans to develop a Central Line Associated Blood Stream Infection (CLABSI). Since the general population’s chance of getting one of these is .0001%, I feel pretty special. As it turns out, these things are deadly and expensive. Since I’m me, I managed to get the most deadly kind of enterobacter bacteremia, enterobacter cloacae. Like the 42.6% of people die kind (usually CLABSIs only kill 12-25%). This also means it was the expensive kind. Haven’t seen a final bill, but based on past hospitalizations, my insurance company will actually pay out about 89 thousand dollars (average is $16,550) for the ten nights and 12 days I spent in the hospital. While definitely the most serious side effect of the PICC line, it was simply the last in a saga of medical errors and complications associated with the two lines I had.

This warning brought to you by: Kolya

Complication 1: Intraluminal Occlusion

The day after my Intravenous Lecture, my friend dragged me to the ER and they forgot to flush my PICC line with Heparin. Which means it clotted. Which means I was back in the ER 12 hours later and had to have the thing removed due to a intraluminal occlusion (while not as special as my CLABSI, still only 3-9% incidence rate).



Getting a line removed is totally painless, but knowing it was the first time someone did it kinda freaked me out.

Despite what I was promised by the advice line, the ER wouldn’t put in a replacement PICC and told me I’d have to go back through my cardiologist’s office for the replacement, Unfortunately, if I don’t do the saline therapy, I pass out. Which I did, about ten times in two days. When I woke up on day three, the hospital magically had an opening to replace the line that we followed with a three day admission to bring me back to stable. Which was awesome.

This hospitalization brought to you by: Ekat, Whitney, Phil, Brad, Marie, and Kathleen.

Near-Miss-Complications 2 and 3: Possible Clot and Line Movement

After I got the second line life was good - only complication in two months was a clot that resolved pretty quickly (if it was even there). The line also moved 2 inches out of my arm which I didn't realize was a problem. When I eventually ended up in the hospital for the CLABSI, the nurses there freaked out that my home care nurse hadn’t sent me in for an xray to check the line placement. Whoops.

Looks clear to me!

Looks clear to me!

Complication 4: The Healthcare Associated Infection

The six weeks of relative bliss eventually came to an end and I ended up in the ER and left with  a concussion and an infection. Will it get reported as an HAI? Probably not since there were multiple parties involved in the line’s care (me, home nurse, prompt care, primary care), but considering the timing, I’m pretty convinced I got it at the ER.

I live in a studio apartment with six separate forms of hand cleaner. It definitely wasn't me.

As per usual, I ignored my symptoms and went about my business - presenting at XXinHealth with, as fellow speaker Donna Cryer put it, a lovely 102 degree glow. At Datapalooza the next day, I mentioned the fever to a friend who tattled to everyone’s favorite bow-tied doctor - who was finally able to break through my ill guided notions that I might “burn it off." By the time I got to the hospital, I was running a fever of 103.8 and was pretty sure my teeth were going to chatter straight out of my head. All things considered, I didn’t feel that bad – I actually felt a little guilty for getting jumped ahead of the kid who obviously had a stomachache. Granted I was on the verge of septic shock, but you know, whatever.

Complication 5: The Allergies

They admitted me and tried some Vanc for the more common bacteremia. Then my culture started growing something gram negative, so they freaked out and called infectious disease who said the PICC line had to come out. Anyways, once they determined I'm also allergic to penicillin's first cousin, Piper, I was finally started on my stalwart, Cipro, and stopped hallucinating. Which kinda took all the fun out of this whole saga, but I guess it had to end in the interest of, you know, living.



PICC line removal. They called me sweetpea.

Since I had to do twice a day IV antibiotics and my veins love to blow, the hospital had to keep me until they could place a port for home antibiotic therapy. Port placement was an adventure in and of itself - there was an epic yelling match in the OR between the surgeon and the nursing team over patient throughput (took 6.5 hours instead of 1) and whose job it was to make sure I'm not pregnant. Then the anesthesiologist, who was actually a DDS, asked me what grade I'm going into next year. Sparkly blue nail polish actually does take off ten years. Who knew?

Then we had a series of totally minor allergies. First they used sorbaview to cover the port when I asked them not to and ended up with an awesome rash and some blisters; it's been two weeks and they're mostly cleared up, so it's ok. Then I was discharged and the homecare company gave me drugs which, while labeled correctly, were set to incorrect rates; the resultant rash went away in a few hours and I didn't actually puke, so it's cool. Then I was prescribed contraindicated drugs that more than doubled my blood pressure; still, got off totally stroke free, so it's all good.

This hospitalization brought to you by: Ekat, Konstantin, Kathleen, Wen, Ted, Rebecca, Stephanie, Stephanie, Sam, Brad, Marie, Randi, Regina, and Isaac. More experiences from it can be found here. 

What was the point again?

So what’s the point of all of this? The point is that when you’re working with humans there will be mistakes. Most of them won’t kill you. But when you’re working with central lines, they might. See, I’m not immunocompromised and I still spent 12 days in the hospital over an HAI. And that’s a big, big deal. Particularly because it was completely avoidable. Proper hand hygiene is the easiest, cheapest, and most effective way to bring down the number of HAIs. I know that- it imprinted on my brain during grad school and my lean six sigma green belt project was on hand washing. But even I don’t know what nurses can touch with their bare hands after using hand sanitizer, what they need to wear gloves for, and what they need to be sterile for (untouched by human hands). I asked about the observed differences in technique and my nurse told me that variations were due to whether a nurse had a bad experience with a drug before (eg it spilled on them before and they got sticky so they now wear gloves).  Ad hoc variation aside, my most shocking observation is how nurses interacted with pagers/phones. There were many times in which a nurse would be wearing gloves to fix my IV, have their phone ring, pick up the phone, and then go back to what they were doing  without changing gloves or washing their hands. It’s as if the phone was magically excepted from clean and sterile procedures. The "need" to be connected all the time has become ingrained into our culture at the expense of patient safety. As much as I love technology, I'm not a fan of it when it could kill me. So if you learn nothing else - don't text and drive. Or touch central lines. Trust me on this one.

Yesterday TedMed officially began – It’s been great to see and talk crazy tech ideas with Dave Clifford and Rebecca Coelius; learn that Kaiser is so far past faxing orders that they’re into sustainable apples from Ted Eytan; and just hug on Amy Berman and Maggi Cary. Special love to Mark Silverberg for running my interference, Konstantin Karmazin for being completely unflappable, and Ms. Whitney Bowman-Zatzkin – the woman who, despite being Ms. Great Challenges, took the time to run to my side and hug me. Because she’s amazing like that. People of TedMed, you remind me that the heart of life is good and I applaud you for it.

Intravenous Lecture

When you look at the images from last year, the one that stands out is Stephen Petronio’s Intravenous Lecture. Today I had to leave TedMed so I could make it to, literally, my Intravenous Lecture. Yesterday I had a Peripherally Inserted Central Cathater (PICC) line put in so I stop falling over and, today, I had to go learn how to take care of it.

The wires in my chest- you can see the catheter going into my SVC and my loop recorder.

What has not been easy is the administrative side of things, which brings us back to TedMed and three Great Challenges:

Challenge 1: Patient Communication

I had to email or call the cardiology department 15 times to find out about treatment plans or make sure faxes went through.  From here we had insurance authorizations (that got lost), bloodwork (that got lost), infusion referrals (that got lost), PICC line orders (that got lost.) Why did these things get lost? Because they have to be FAXED from location to location.

While I’ve listed out the whole boring process here, don’t read all the stuff in italics, it’s just a long list of interactions. But I think seeing that there is a long list of crazy administrative headaches shows how very broken the communication process is for every single step of getting healthcare.

Ted Med in the Children's Hospital!

TedMed in the Hospital Hallways!

Step One: Get Cardiac Appointment

  • 2/11: Get referred to cardiology by head of cardiology department. AWESOME! 
  • 2/11: Email Nurse
  • 2/18: Have amazing Nurse call you and let you know you can be a patient. 
  • 2/18: Make Appointment for a month out

Step Two: Get Blood Work

  • 3/25: Go to hospital with paper blood work orders.
  • 3/26: Email nurse and say blood work is done
  • 4/2: Call hospital to make sure blood work was done. Find out it was done and entered 3/25.
  • 4/2: Email nurse and ask about results
  • 4/3: Have nurse email you saying you're getting a PICC line. 

Step Three: Get PICC line

  • 4/2: Get told by nurse you’re getting one. Ask if you’re taking Vitamin B12 and if you’re allergic to anything.
  • 4/4: Call hospital about paperwork
  • 4/5: Call insurance about paperwork
  • 4/6: Call hospital about paperwork
  • 4/6: Call insurance about paperwork
  • 4/10: Call nurse about paperwork. Be told to take Vitamin B-12 Supplements as an afterthought (since you called anyway).
  • 4/10: Nurse emails you that paperwork’s been approved and radiology will be calling. Asks about medication allergies for the third time.
  • 4/10: Call radiology and hear paperwork hasn’t been submitted from cardiology
  • 4/11: Call cardiology and ask to resubmit to radiology
  • 4/11: Call radiology and have them say they need insurance approval, despite cardiology having already done it.
  • 4/11: Have radiology call you and schedule PICC insertion
  • 4/16: Get PICC line. They admit you with a diagnosis having to do with your Gallbladder and have lost your insurance information.

Step Four: Get Home Care

  • 4/11: Be told by cardiac nurse that Infusion Company will be contacting you with your infusion information
  • 4/12: Call Infusion Company and be told they haven’t heard of you
  • 4/12: Call cardiology and be told papers have been faxed
  • 4/14: Call Infusion Company and have them say they haven’t heard of you
  • 4/15: Call Nurse and have them say they did fax it, she even talked to the infusion company and the infusion company should be calling you. 
  • 4/15: Call Infusion company. They still say they haven't heard of you. 
  • 4/16: Go to cardiology in person after getting PICC line, have front desk refuse to look up your information since that's what the nurses do
  • 4/16: Call Cardiology nurse have her refax information. Ask if you can have copies of the faxes, be told it’s easier if she handles it. Ask her if you should make a follow up appointment. Have her apologize for not already setting that up.
  • 4/16: Call Infusion Company, get told they have to verify insurance benefits
  • 4/16: Call insurance company
  • 4/16: Infusion Company calls you and tells you have to have an appointment within the next day, even though you have TedMed. Their nurse will call you and come by in the morning, sometime before 2.
  • 4/17: Call Infusion Company and ask when nurse will be coming. Hear that nurse is sick and they don’t know. Say you have doctor friends who can flush the PICC line and they can call you when they have their stuff together. Get told they have their stuff together. Don't yell at the poor lady on the other end of the phone because you know it isn't really her fault. 
  • 4/17: Get called by a nurse. She agrees to give you a 30 minutes heads up. You leave your conference for a couple hours so you can infuse, write this blog, life is good.
IV Process

Today I Learned: Swipe | Saline Push | Swipe | Attach Bag | Swipe | Saline Push | Swipe | Heparin

 

Great Challenge 2: Error Prevention

Even when people did get faxes, their information was wrong: yesterday I was admitted for a PICC line, without insurance for 575.2:  Gallbladder obstruction. The infusion company is dispensing heparin to someone with a 10/30 birthday instead of a 10/3. These are tiny, clerical, errors. Physically they gave the right treatment. So I should just overlook these, right? Wrong.  Say that instead of the wrong number being in my birthday it was in how much heparin they were giving me? A misplaced 3 there is a big issue.  To adventure into magical-what-if-land even further, had the home care people come yesterday maybe I wouldn’t have passed out last night. Maybe if these faxes had gone through I would have done this last week and not gotten another concussion Saturday. I know that’s a really big jump and I probably still would have fallen over, but still, a girl can dream!

Great Challenge 3: Role of the Patient

I asked if I could have copies of all the orders so I know 1. What is going on and 2. Who I need to contact and follow up with and they told me no.  That I shouldn’t have to worry about that and they would handle it because they have better relationships with those people.  Sure, I can request the information through medical records, but by then it’s days old. I want to be copied on communications so I can follow up on them in a timely manner and not end up with a PICC line but nothing to put in it, or, when I finally have something to put in it, waiting for a nurse like I would my cable repair guy - to come by in the morning before 2.

High Fives

High Fives for following up with the system.

So, dear people of TedMed, this is my week. This is my Great Challenge and my intravenous lecture – I can’t wait to hear what yours, metaphorical though it may be, has taught you or reminded you to discuss this week.

PS - Next year's Great Challenge? Medical Waste.

Trash

The trash from one PICC line dressing change/IV start.