I know the obvious answer is of course not. Nursing and medicine are two distinct professions. Even though nurses and physicians closely interact with each other, and have a few areas of overlapping responsibilities, they function in two distinct specialties, with their own evidence based practice guidelines.

Ok, but what if in an area of practice, such as infusion therapy, there are standards of practice for nursing and  none  in medicine (at least, nothing I can find)? We all know that doctors insert peripheral IVs as would a registered nurse. A registered nurse inserting a peripheral IV would be expected to follow the Infusion Nursing Standards of Practice, but what about the doctor? What standards of practice would the doctor be held up to?

There is an unfortunate case (one of several) where a doctor started a 20 g peripheral IV using the antecubital fossa in a critical ill patient. The patient coded and only with the antecubital PIV in place, resuscitation began including vasopressor drips, which was infused by an RN. The resuscitation efforts continued and the doctor inserted a central line, only after the antecubital PIV site became swollen. The upside to this case, the patient was transferred to the ICU where she eventually stabilized and survived. The downside, the patient ended up with an extravasation in her left antecubital fossa and now living with scars, chronic pain and limited left arm movement.

I am hoping that if the RN was inserting the PIV, the RN would have known to avoid areas of flexion such as wrist and antecubital fossa. It is a standard of practice for infusion nursing, standard 37, 1. H. Site Selection should avoid areas of flexion. My nursing colleagues especially those in the ED have always said, we always start IV’s in the antecubital area. To which I would always reply, “please don’t and avoid putting it there!”. I have written about this in my blog, click here, which to date continues to be the number 1 read post here. Many patients offer their antecubital fossa when a nurse is about to start an IV, I still say, “just say no”!

Many thoughts have crossed my mind about this case. Considering the doctor already knew and wrote on the notes that the patient is critical, and may need ICU care for vasopressors, why did the doctor start a PIV instead of a central line?  Could the RN have intervened,  demanded a central line instead and prevented the extravasation?  Why did the RN start the vasopressor drip via a PIV knowing that hospital policy states to only give via a central line? Were their actions justified so they can save the patient’s life? Why start an IV in the antecubital fossa, when it is an area of flexion? Should doctors who start IVs be held up to the  infusion nursing standard of practice? Who is liable, the doctor who started the antecubital PIV or the RN who started the vasopressor drip?

What are your thoughts?