有關靜脈導管置入術（Aka打豆）的資訊

看到不少讀者都對靜脈導管有不少的不愉快經歷，不妨了解一下醫護人員的角度，彼此了解大家的處境。

首先我們必須了解的一樣基本概念

「如果可以一針上，無人會想打兩針」

「如果可以一針上，無人會想打兩針」

「如果可以一針上，無人會想打兩針」

好多病人會投訴被打幾針才上，覺得醫生、護士或抽血員手勢不好，訓練不足。其實，有誰不想一針上靜脈，你不能想像一針上靜脈（特別是兒科）的快感有多爽，沒有醫護人員會想瘋狂用針吉病人。

說到訓練，其實所有合資格進行靜脈導管的醫護人員都會在實驗室用假人做過一次又一次的simulation，確保proper aseptic and cannulation technique。但我們都必須明白，假人和真人完全是兩件事，就算你在假人身上是drip神，實際操作時完全不一樣。

以下為一些我們常見遇到的困難或病人不滿的地方

1. 脫水：不少需要靜脈導管的病人都有不同程度的脫水而需要吊鹽水或糖水。例如腸胃出血、腸胃炎痾嘔、感染發燒肺炎等等，這些病人因脫水而令血管不明顯，令打豆難度大增。

*當然有些senior急症室護士或抽血員，無論幾peripherally shutdown都可以搵到條血管去打。但對其他經驗無咁豐富的醫護就不是想像中的易。

2. 非常幼細的血管：平常甚少運動的病人的血管普遍較細和不明顯，增加打豆難度。

3. 痴肥或嚴重水腫：痴肥或有嚴重心臟衰竭或肝腎衰竭而嚴重水腫的病人會令血管非常難找，有時候見不到摸不到只能推算下針。

4. 打豆後成手瘀晒：這是非常常見的副作用，絕大部份的情況下無害，身體會慢慢分解吸收瘀血。但很多病人都覺得是打得不好才會，但其實好多病人特別老人本身有食薄血藥或凝血方面比健康年輕人差而導致瘀血，即使drip神也會有這問題。

5. 醫生護士經驗不足：這跟請fresh grad要有extensive經驗的概念一樣。無人天生就識打豆，經驗只能靠不斷練習去累積，初初打一定會很多改善的地方，這是醫學無奈的地方，你看再多書，在假人身上練再多，都不及對病人的經驗好。

6. 打手背好痛：一般來說會先從遠端血管著手，因為一但不成功仍可以向上找血管打，避免一開始用手臂失敗後用手背的extravasation風險。

見到很多讀者有不愉快的經歷，覺得醫生護士好流，技巧手勢好差。但我想帶出一點的是，打不上的醫護人員的經歷也不會好到那裡去，First go is the best go，每一次的失敗其實都對醫護來說是更大的壓力，如果可以一針上，無人會想打兩針。

講咁多不是為了找藉口為打豆失敗開脫，而是想大家明白

「靜脈導管會失敗是必然會發生的事」

「靜脈導管會失敗是必然會發生的事」

「靜脈導管會失敗是必然會發生的事」

當我們更了解醫護的困難時，或許可以多點同理心去理解和體諒對方，當大家累積足夠經驗後便會成為更好的醫護人員。

#成日會見到病人要求最有經驗的人幫佢打
#永遠都搵drip神打咁其他人點練好手勢呢
#如果可以一針上無人會想打兩針

[解剖學]

繼續「扑頭」系列。點解會有咁多報導，話傷者頭部被襲之後，會大量出血？原因就係因為人嘅頭皮底下有豐富嘅動脈分佈。

人嘅頭皮有五層 (圖一)，由淺入深分別係皮膚 (skin)、結締組織 (connective tissue)、腱膜 (aponeurosis)、疏鬆結締組織 (loose connective tissue) 同埋顱骨膜 (pericranium)。皮膚係好薄嘅最外層，由頭髮保護，亦有好多細小嘅血管同淋巴管；其下嘅結締組織則有豐富嘅神經分佈。腱膜層比較有韌性、係頭皮肌肉嘅附着點，而海綿一般嘅疏鬆結締組織係一個重要嘅夾層，因為細菌同血液可以沿住呢一層擴散出去。而最內嘅顱骨膜，顧名思義，就係顱骨外嘅一層結締組織啦。

供應頭皮嘅動脈位於結締組織同腱膜兩層之間，而且由好多唔同嘅分支供應 (詳見圖二)。呢啲動脈分支互相聚合。當受外力擊中、使頭皮破裂嘅時候，呢啲血管就會撕裂。既然係動脈，其中血液嘅血壓自然比較高，出血嘅情況亦會比較嚴重。仲要注要一點，呢啲動脈嘅血管壁同其上嘅結締組織密不可分，所以雖然血管破裂亦唔識收縮咁滯，使止血更具難度。

如果沖擊再大力小小，使腱膜破裂嘅話，傷口就會難以復合，因為附於其上嘅肌肉 (枕額肌，occipitofrontalis muscle) 會將傷口越拉越開。如果傷口嘅血液或細菌流入疏鬆結締組織層，咁就有機會將佢哋傳至整個頭皮嘅範圍 (前方為眼睛以上、後方為頸部以上)，甚至進入顱內嘅結構 (如腦膜)。

請問你，喺重棍一下下打落人哋個頭上面之前，你知唔知有機會發生以上嘅情況？你知唔知你嘅一棍，可以有幾嚴重嘅後果 (再參考返之前腦硬膜外出血嘅帖子)？

***

[Anatomy]

Another post about attacking the head. Many reports had stated that, after being attacked on the head, people had suffered from massive blood loss. Why is it so? Because under the scalp there is a rich arterial supply.

There are five layers in the human scalp (refer to figure 1), from exterior to interior they are the skin, connective tissue, aponeurosis, loose connective tissue and pericranium (interestingly the initials of these five words form the word SCALP). The skin is a thin layer protected by hair, and is richly supplied by small blood vessels and lymphatic drainage. The connective tissue underneath has abundant nerve supply. The tough aponeurosis acts as the attachment of the occipitofrontalis muscle. The loose connective tissue layer is sponge-like, and is clinically important as it acts as a potential anatomical space to spread blood and microbes into other areas. The innermost pericranium is the connective tissue layer that acts as the external periosteum of the cranium.

Various arteries supply the scalp, and they lie between the connective tissue and aponeurotic layers (refer to figure 2 for details), forming anastomoses. When trauma tears the scalp, these arteries may lacerate - with quite some blood pressure, there will be a considerable blood extravasation. Also worth noting is the firm attachment of the walls of these arteries to the dense connective tissue in which they are embedded, which leads to impaired vasoconstriction and poor effect when carrying out first-aid haemostasis.

If the traumatic force is large enough to break the aponeurosis, the wound cannot heal easily as the occipitofrontalis muscle will tear the wound, making it bigger and bigger. In a more serious condition where blood or pathogens make their way into the loose connective tissue layer, they may spread all through the scalp (bounded anteriorly by the eyes and posteriorly by the neck) or even get into intracranial structures like the meninges, causing secondary and possibly severe complications.

Allow me to ask: before you hit with your stick, do you know there is such a variety of possible consequences and effects? And are you able to evaluate the severity of these consequences after you hit someone (combined with the possibility of having an epidural haematoma, as mentioned in a previous post)?

Figure adapted from Moore KL, Dalley AF, Agur AMR. Clinical Oriented Anatomy, 6th edition. Lippincott Williams & Wilkins, 2010.

《I.V. care》

仲記得啱啱畢業嘅時候
照顧一個病人時會落重心機喺醫生嘅order
覺得搞掂哂醫生開嘅treatment就已經係對病人最好嘅care😎
但有時往往就係因為咁,而少咗細心咁觀察病人,忽略咗最基本嘅nursing care😣
而最常被輕視嘅就係病人嘅IV catheter(俗稱鹽水豆)

一個細細粒嘅鹽水豆可能並不顯眼
但其實佢可以帶嚟唔同嘅併發症,例如感染(Infection), 意外飛脫(Dislodgment), 皮膚損傷（Skin damage), 外滲(Extravasation)等等...🤕
相信好多醫護人員都遇過以上情況, 但其實上述情況全部都可以避免😇

作為一個稱職嘅醫護人員, 一定要好好裝備自己
即使少至IV care都應該好好學習。
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www.3m.com/ivcare
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3M

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