A day in the life of... Jackie Nicholson
Published: June 15, 2017
All too soon Monday morning is here and as I set off on my journey to work I am thinking about the day ahead.
Much of what I will do, I know about in advance but there are always unexpected things happening, some of which can be challenging. Today I am looking forward to welcoming a new team member and thinking about how to introduce him (gently) to the world of Vascular Access. As a Junior Associate Practitioner his main roles will be clinical support and vascular access device (VAD) surveillance and I have decided to let him observe a typical (if there is such a thing) clinical day.
The first patient on our list needs a Vascath for plasma exchange and we are checking his pre-procedural bloods only to find out that the clotting sample was under-filled which will delay us starting our procedure. We need to start on our next patient while we are waiting for blood results and this is a young man who has had a successful bone marrow transplant and needs his Hickman line removing. Normally we would keep the Hickman line in for a bit longer, however one of the lumens has been ballooning and attempts to unblock this have been unsuccessful.
Due to the amount of time that this lumen has been left without routine flushing, we decide to remove the line rather than repair the line due to the risk of infection in a high risk patient. The patient has been receiving intravenous antibiotics and fluids so his team discuss with him whether he would like a PICC to manage this. He decides to manage without a long term VAD and he is delighted to be line free.
Our next patient is a young woman with a complex history who had a totally implanted port fitted 3 years ago so that she can self-administer IV medication. She has been concerned about some intermittent swelling and skin flushing in her neck area some hours after she has commenced an infusion of glyceryl trinitrate (GTN) for her acute coronary syndrome. I have previously discussed this with interventional radiology and we have booked a linogram to try and ascertain what is happening.
I am puzzling about what is happening and wondering about what the problem could be if there is no obvious problem with the port. Thankfully, the problem is identified quickly as the linogram shows a very small leak of contrast through a very small fracture in the port catheter. We surmise that this part of the catheter has been rubbing against the clavicle and that this may be why the damage has occurred. We are able to show the patient the images and she is relieved that her concerns are valid and that there is a reason for her symptoms. We book her for an elective port insertion for next week so that she can then re-start her treatment.
We have a patient booked for a cuffed renal line removal who does not turn up for his appointment so we have to liaise with the renal nurses to re-book for later in the week. It can be quite challenging to arrange these appointments as the patients are usually having their cuffed line removed as they now have a working fistula or graft. This means that they are dialysing 3 times a week and probably not at the main hospital, so we have to arrange the removal to fit in with the patient’s busy schedule. Our next patient is a regular customer, a lady who has multiple sclerosis and comes to clinic for a Tysabri infusion every few weeks.
Her veins are difficult to find so she comes to us for a cannula to be inserted under ultrasound. It is lovely to catch up with our regular patients. Our next patient has a severe needle phobia and one of the nurse practitioners does a great job placing a PICC quickly whilst our junior associate practitioner chats to the patient and encourages him to take slow deep breaths. He is shaking quite a lot so it is a challenge but we appreciate that he cannot help his anxiety and we offer lots of verbal encouragement. Our last patient of the day is an orthopaedic patient who needs IV Vancomycin so we have tried to get him on our list urgently to avoid administering Vancomycin peripherally.
Thankfully the last procedure of the day goes smoothly (they don’t always) and we re-stock our room for the next day and manage to finish on time. I then go back to my office and try and deal with some of the many items on my to-do list before I leave. I am currently getting ready for the NIVAS conference so there are a few emails to make some arrangements and follow up actions from our last board meeting. I make a point of not taking hospital work home with me and would rather stay a little later to finish something and then leave work behind me.
Thankfully my journey home is straightforward – another busy but fulfilling day.