After a series of unfortunate events I wound up being a patient in the ER a few nights ago.  The nurse came in to give me an IV and the paramedic instructor in me became critical.  He wiped the site with an alcohol prep and then felt for the vein afterwards.  Truth be told, he contaminated the site with his finger no less than three times after cleansing the area.  I didn’t let him get away without hearing about it.

“So, you’re one of those guys, eh?”

“What do you mean?” he asked.

“You’re one of those nurses that cleans the site with alcohol and then has to contaminate it two or three times before you actually stick because lord knows it must be incredibly hard to see that great big spongy AC vein you are fishing for,” I knew him so I thought it was safe to give him the business while is was jamming a sharp thing in my arm.  But he knew I was half-way serious.

“Well, you have to feel it, don’t you?  Besides, if you touch it with clean gloves while the alcohol is still wet, the site is still clean.”

“Keep tellin’ yourself that if you want to pal. I hope that gram of rocephin you are about to give me will cover the infection you are causing right now,” I winked at him.

He then tried to make light of it and made a few more excuses about why such practices were necessary.

A few days ago one of my students came to ride along with me for a shift.  He is allowed to perform ALS procedures if I am with him and he was attempting to start an IV.  I watched him closely as he prepared all of his equipment.  Then, just before he was about to stick, he grabbed the index finger of his right hand, twisted the finger off of that glove, and poked the already cleansed site with his bare index finger right before inserting the needle.

“Whoa, there cowboy. Put another glove on that hand, get another alcohol prep, and let’s see you do this right.”

“But, that’s how I was taught,” I could almost hear the comedic sound of a record scratch as the world came to a halt in the back of that ambulance.

After we had dropped off the patient I laid into him, “Just who in the hell taught you how to do that, cause I know it wasn’t me?  And when I get you home I am gonna slap your mama in the mouth because I know that you…did not come…from these loins.”  The obvious reference to ‘Smokey and the Bandit’ fell short on this young student in his early 20’s.

“I learned that from my ride-time in ______________ County.”

“Let me guess, this was some dinosaur paramedic from the 70’s or 80’s?”

“Yeah, how did you know?”

“Because a lot of those guys began their career starting IV’s with their bare hands, and they can’t handle searching for a vein with a glove on.  But you shouldn’t imitate everything you see.  Didn’t that guy tell you not to follow his bad example?”

“No, he said that was the right way to do it.  He makes me do it that way every time.”

Now I was livid, “DID I TEACH YOU TO DO IT THAT WAY?”

“No sir.”

“DO YOU SEE LATEX GLOVE MANUFACTURERS MAKING BOXES OF GLOVES WITH THE INDEX FINGERS MISSING?”

“No sir.”

“DO YOU BELIEVE EVERYTHING YOU HEAR FROM EVERY PRECEPTOR YOU HAVE EVER HAD?”

“No sir.”

“DO YOU WISH TO CONTINUE MAKING ME WANT TO CHOKE YOU?”

I will spare you the rest.  It went on for a while.

These two vignettes are all too common though.  These practices are not taught in any classroom.  They are not advocated by any instructor.  They are simply rituals practiced by providers who think these little bits of nonsense help his or her performance.  Think of a baseball player stepping up to bat.  This player has stepped up to the plate hundreds of times before to perform the exact same complicated skill involving concentration, dexterity, and timing.  Sometimes he is successful.  Sometimes he is not.  But he has his way of preparing for the skill and no one will be allowed to dissuade him from knocking the dirt off of his shoes three times for each foot, licking his fingers twice before rubbing the brim of his cap, and then shaking his hips exactly six times.  Do any of these ridiculous behaviors actually help his performance?  Of course not.  But that doesn’t matter.

It’s the ritual.

However, the ball player probably isn’t causing an infection by pulling on both of his batting gloves between each pitch.  You are.  Do you have to touch an IV site just before you insert the needle?  Is there a certain kind of needle that you like so much that you will take some with you to your part time job so that you can start IV’s there the way you are used to starting them?  Do you find yourself making excuses like “it must be up against a valve” almost daily?

You don’t need rituals.  You need to hone your skills.

I am not immune to this.  When I started practicing by myself in the field I was often very particular about how I wanted things done and in what order.  But then I became a Field Training Officer and I learned that almost every new employee had a different way of doing things even though the same outcome was the result.  I worked for enough different services that used different equipment that I no longer had a preference for one kind of IV needle.  After a while I started teaching and found that all of my instructors did everything differently, but still did it well.

After spending a lot of time training employees with various levels of experience and competency one thing has become painfully clear.  The more someone clings to a certain way of doing a procedure, the more uncertain he or she is in their own skill.

This realization brought me back to an earlier time in my life when I was trying in vain to learn how to play the guitar.  I had practiced diligently, and learned a few songs that I thought were difficult to play.  I wasn’t ready to join a band yet, but I was working myself up to it and daydreaming about it.  Eventually I got to the point where my starter guitar with nylon strings was holding me back.  I started to save money and shop around for a real guitar so that I could continue to improve my skills.  While I was at a party I saw an acquaintance who was an accomplished guitar player and told him about my plans.  He cut me off before I could finish and said, “Hey, wait a minute.  Let’s see this old guitar that is holding you back.”  I brought it to him and he quickly plucked a few strings to make sure it was in tune.  He then proceeded to belt out this outrageous acoustic rendition of Van Halen’s ‘Eruption’ on my ancient hand-me-down guitar.  I had no idea that it could make sounds like that.  When he was finished he inspected the instrument and without looking up he flatly said, “There is nothing wrong with this guitar.  As usual, it is operator error.  Save your money, kid.  Spend it on LESSONS with THIS guitar.”  He then handed my guitar and my ass back to me.

Today, I stand before you completely cured.  I have no rituals.  I have no procedure-induced OCD.  I don’t mind starting an IV on scene, in the back of the truck while it is parked, or in the back of the truck while it is moving.  If it is moving I hardly ever tell my partner to take it easy or pull over.  I could care less what kind of needle I am using as long as it is sharp and I can tell what size it is.  I usually pick an IV site simply by looking, but if I can’t find one I will start to feel around where veins usually exist.  If I find one by feel, I wipe the site with an alcohol prep and then immediately stick the vein with the site still clean and my gloves intact.  In short, I am an experienced provider that needs no mental crutch when performing this skill.  I use whatever is available in a way that makes sense for the particular situation.  I am comfortable using an old starter guitar or a Gibson Epiphone.

What is really surprising to me is that I am constantly finding nurses and paramedics with 20+ years of experience who cling to insanely complex rituals for the most basic procedures.  If you are the kind of provider that does this, your ability to perform this procedure is hanging by a thread.  What if your Medical Director decrees that intubation will be done with a new system?  What if your service switches IV catheters to another brand?  You could be one protocol change or one vendor switch away from poor job performance.  This is no one’s fault but your own, and I am about to hand your guitar back to you and tell you about operator error.

However, unlike my ‘Eruption’ playing life-tutor of the 80’s, I am not going to insult you and walk away.  I am going to tell you how to fix this.  You won’t like it though.  Superstitious creatures of habit usually don’t like change.  But think about this for a minute.  The medical field is the most fluidly dynamic profession of which I am aware.  Who on earth would enter the medical profession and try to fight change with a straight face?  Give up.  Learn something new.  Not tomorrow.  Right now.

Since I am a geek, I will tell you how the geeks do it.  Geeks live for change.  Every month, every week, every day brings new software and hardware and we are clamoring for it.  Any geek will tell you that if you want to hone your skills in a certain area you have to MAKE YOURSELF do it.  For instance, Windows 7 is coming out right now.  Vista is finally getting revamped, and XP is old news.  Across the country geeks everywhere are wiping their hard drives clean, installing Windows 7, and making themselves work in nothing but that environment for a trial period.  Most geeks will do this for a week.  Hard core guys with an interest in the platform will do it for a month.  Why do they do this?  Because someone who is used to change knows that the only way to truly learn how to swim is to jump in the deep end of the river and start moving your legs and arms.  Take a last look at your crutch, toss it aside, and start walking.  Are you sick of the metaphors already?  Good.  Me too.

The only way you are going to get better at starting IVs is if you try to do it differently.  If you still tear three pieces of tape before each IV you start, stop that and try an ops site.  If you hang a bag of normal saline on every run you make whether or not you give fluid, then stop being wasteful and learn to start a saline lock.  If all you ever do is start IVs in the AC then pretend for the next week that your Medical Director has forbidden the AC as a site.  If you start IVs by feel, then for the next month start them by sight.  Everywhere you find yourself performing a ritual, MAKE YOURSELF STOP.  

Gloves are manufactured with the index fingers intact.  Alcohol should be the last thing that touches your patient before a needle.  You are a better provider than you think you are.  You are not too old to learn something new.  And you are not so experienced that you can’t learn a new and better way to do something.  The medical field changes every day and so should you.  If you have been starting IVs or intubating in the exact same way you learned the procedure in school, I can guarantee you are doing it wrong.  Seek change.  Embrace it.  Enjoy it.  Who wants to do the same old thing for the next 20 years?