Safer subclavian vein puncture

Correspondence SAFER SUBCLAVIANVEIN PUNCTURE To the Editor:--I enjoyed the letters by Shimotsuma et al 1 and Klofas 2 on subclavian vein puncture. Shimotsuma et al suggest, "Before the puncture, the skin should be pressed down firmly by the left thumb placed beneath the mid-portion of the clavicle." They insert the needle at the caudal margin of this indentation at a point 3 to 4 cm below the mid-portion of the clavicle, aiming for the sternal notch• However, I think that this method has dangers of puncturing one's left thumb (Figure 1A) or of placing the needle point too far toward the back (accidental pneumothorax), because in the latter case, the physician might orient the needle at an angle too close to the vertical precisely to avoid puncturing the left thumb (Figure 1B). On the other hand, Klofas suggests, "With my left index in the suprasternal notch, I begin the puncture about 3 to 4 cm below the mid-clavicle, aiming toward my left index. I place my left thumb on the needle barrel itself about midway from the needle hub to the point" (Figure 2A). However, this method has a danger of placing the needle point toward the upper part of the clavicle or the subclavian artery, if the needle barrel is flexible (Figure 2B). I have personally used, and taught to numerous house staff, a similar technique that I consider to be much better and safer) As in Klofas's method, I place my left index in the suprasternal notch. I make an initial "trial puncture" with a 21-gauge long needle attached to the syringe about 3 to 4 cm below the mid-clavicle, aiming toward my left index. Thereafter, I strike the center of the clavicle with the needle point in a plane parallel to the patient's back (Figure 3A). I then draw out the needle about 0.5 ram. I place my left thumb on the skin above the inserted needle barrel about 2 cm from the needle point to the hub, instead of midway from the needle hub to the point as Klofas suggests, and press downward (on the supine patient's chest) (Figure 3B). I then push the needle in,

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FIGURE 1. In Shimotsuma's method, (A) it is easy to puncture one's left thumb or (B) to place the needle point too far toward the back.

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FIGURE 2. In Klofas's method, (A) the physician's finger presses directly on the needle barrel about midway from the needle hub to the point by the physician's left thumb; (B) when the needle barrel is flexible, there is a danger of piercing the upper part of the clavicle or the subclavian artery. 328

aiming for my left index, and keeping negative pressure with a syringe (Figure 3C). This assures that the needle remains in the plane parallel to the patient's back. It also facilitates passage into the delto-pectoral groove. It is easy to ascertain when the needle enters the vein as blood appears in the syringe. The trial puncture provides a dependable "feel" for the direction to and distance to the subclavian vein. I then withdraw the small needle and repeat the procedure with a needle of the appropriate size for catheterization.

FIGURE 3. (A) The small-bore needle tip strikes the center of the clavicle in a plane parallel to the patient's back. (B) The needle barrel is pressed about 2 cm from the needle point by one's thumb back after being withdrawn about 0.5 ram. (C) The needle point is inserted under the clavicle, keeping negative pressure with a syringe, and the vein is located. Step C is then repeated with a needle of the appropriate size for catheterization.

CORRESPONDENCE

I have used this technique many times over 15 years and have yet to cause accidental pneumothorax or puncture my left thumb. HITOSttl]MAIZUMI,MD

Department of Anesthesiology Sapporo Medical University School of Medicine Sapporo, Japan References 1. Shimotsuma M, Watanabe N, Sakuyama A, et al: Safe subclavian vein puncture: The importance of pressing the skin with the left thumb. Am J Emerg Med 1993;11:561-562 2. Klofas ED: Safer right subclavian vein puncture: The importance of pressing the needle with the left thumb. Am J Emerg Med 1994;12:126 3. Imaizumi H, Ujike Y, Kaneko M: Central vein puncture (11). Intens Crit Care Med (in Japanese). 1990;9:1061-1069

ED SECURITY

To the Editor:--My thanks to Richard M. Zoraster, MD, ~for the opportunity to further address the issue of emergency department security and the best means of attaining it. Dr. Zoraster addresses the problem of merit badge medicine, which I also abhor. Requirements like ACLS, PALSIAPLS, ATLS, base station certification, and ABEM recertification certainly can be and often are cumbersome to physicians. Arguments for such periodic requirements are based on described decrements, over time, in the ability of physicians to carry out tasks considered necessary to practice our profession. Do these requirements slow or reverse this decrement? Do other medical specialties have such merit badges other than Board recertification? Does data prove the value of these certifications? None of the above "merit badges" have to do with physician and staff survival. All of the topics are covered in emergency medicine residencies. This cannot be said of preparation for survival in the violent world of emergency medicine. A number of training institutions are highly secured, such as Henry Ford in Detroit, and many are faced with the recurrent violence and stresses of inner city life in the emergency department (ED) microcosm. This exposure does not teach the resident and future emergency physician how to handle potentially violent individuals and circumstances in settings with less security officers and measures, such as the many community hospitals in this country. It does not teach the resident how to address stressed individuals who, unlike many inner city residents, have not previously had much experience with the disrespect so often shown to ED patients and visitors by ED personnel. The security training required by California Assembly Bill 508 would be best offered during residency. Until this training is part of the required curriculum for emergency medicine residency training and ABEM preparation, I will continue to support the training requirement because physicians can be a primary cause of angry patient and visitor outbursts that result in ED violence. Dr. Zoraster does not address the real issue at hand, which is that ED security is woefully inadequate as evidenced by weaponry found on routine screening and by the assault, battery, and murders that continue to occur in EDs.2-4The shooting of three physicians at L.A. County/USC Medical Center in 1993 prompted changes such that no longer can a person carrying weapons walk unchallenged into the ED. These shootings were instrumental in the passage of the law Dr. Zoraster challenges. Dr. Zoraster mentions that, along with the economic woes of California (particularly L.A. County), has come "substantial numbers of the uninsured" and potential closure of County Clinics and several EDs. Should these closures occur and the numbers of the uninsured and unemployed visiting local EDs greatly increase, so will the stress level of these patients, patient visitors, ED

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personnel, and emergency physicians. Waiting times will increase. Waiting rooms will be more crowded. Tension will be increased. Violent outbursts will be more likely to occur. What is needed is a combination of training in ED violence prevention, adequate security personnel, and appropriate physical security measures. The training requirement of CA AB 508 includes all personnel who regularly staff the ED, including triage nurses, clerks, security personnel, and emergency physicians. Although Dr. Zoraster is clearly frustrated at having his time taken to obtain training he believes is redundant and/or unnecessary, he is now practicing in an increasingly dangerous environment which can only worsen with the clinic closures expected in Los Angeles County. Frankly, it surprises me that there is such resistance to training (or apparent reiteration of previous training in the case of Dr. Zoraster) that is designed to protect the individual being trained and those around him or her. "There is no evidence that practicing emergency physicians are deficient in such knowledge," according to Dr. Zoraster. Such evidence associated with ED security is difficult to find in the literature. Little data from prospective studies are available. Establishing truly prospective studies in this area is highly problematic. Certainly the study of groups experiencing various degrees of security cannot be done within one institution. Training randomly selected personnel and comparing them to an untrained control group has not been done, to my knowledge. Most of the literature on the subject is retrospective in nature, or revolves around telephone surveys, studies on weapons being carried by patients, and "how to" articles, s There is no debate, however, that violence in emergency medicine is widespread and that it seems clear from my extensive review of the subject5 that a significant portion of it can be eliminated by a combination of increased attention to security (including training), stationing security personnel in the ED, reducing the stress of waiting by changing the waiting room design to provide distractions, food, drink, and information on the status of the wait, and preventing uncontrolled access to the ED. 3,6 JOHN S. ANSHtrS,MD

Palomar Medical Center Escondido, CA Pomerado Hospital Poway, CA Section of Emergency Medicine University of California, San Diego References 1. Zoraster R: ED security legislation in California. Am J Emerg Med 1996;14:231 2. Goetz RR, Bloom JD, Chenell SL, Moorehead JC: Weapons possession by patients in a university emergency department. Ann Emerg Med 1991;20:8-10 3. Pane GA, Winiarski AM, Salness KA: Aggression directed toward emergency department staff at a university teaching hospital. Ann Emerg Med 1991 ;20:283-286 4. Special Report. The Los Angeles ER Shootings, Part Ih What hospitals in other parts of the country are doing. Hosp Seeur Saf

Manage 1993; 14:5-8 5. Anshus JS, Boueher D, Hubbell K: Making a Commitment to Security. Emergency Department Practices, Procedures, and Training. Oakland, CA, California Emergency Physicians Medical Group & the California Emergency Nurses Association, 1994

6. Brantley A: Rising Violence in ERs cause hospitals to redesign security. Mod Healthcare 1992;22:44,46

A TOOL FOR THE EMERGENCY MEDICINE EVALUATION OF PSYCHIATRIC PATIENTS

To the Editor:--Psychiatric patients commonly present to emergency departments (EDs) in need of psychiatric hospitalization.