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Rhonda Wojtas
chest wall hematoma

We started doing PICC lines in Dec 2007. Early on we had a pt the developed a chest wall hematoma 24 hours after the insertion of the PICC line. I believe this happened in late JAnuary. A dye study done at the time the hematome developed showed that the PICC line was patent and in proper postion.

A few weeks later the doctor of the above patient was appoached by for for a PICC line order for a ptaient she had. This patient was in with sepsis related to her gallbaldder. I called on a Friday as the patient was on 3 different antibotics ans was not having surgery until Monday.

 The physician refused to allow me to put a PICC line in. She went on to tell me how the PICC line had cause a chest wall hematoma on her other patient. I explained to her that I really didn't think the PICC line had casued the chest wall hemotoma but that if it had that it was the only incident or issue we had and that we had placed over 100 PICC lines and had not had a problem.

Anyway she went on to accuse me of "brushing it under the carpet". The radiologist called and spoke to the doctor and told her that he too felt the PICC line had not cause the hematoma. He went on to say that IF it had beeb because of the PICC line that it would have happened whether it was a PICC nurse or radiologist.

About 2 weeks ago, the doctor was approached about putting a PICCC line in another patient. The patient was on a dobutamine drip. The doctor wrote "PICC line to be inserted by IR". The order was cancelled a short time later by cardiology becasue the patinet was having a pacemaker placed the next day. The cardiologist did not want to risk an infection the day before the pacer was placed.

Fast forward to today same patient same doctor. But cardiologist orders PICC line. By the time we were able to get to the floor, the prinmary doctor has called and stated the if Cardiology wanted PICC line it was to be placed by radiology. Now this poor man had been stuck poked and proded for over 2 weeks. An it is my understanding from what I have read the Dobutamine with a pH average of 3.5 should not be run in a pheripheral IV.

So the point to my rambling is

1) Does anyone have any documentation of a chest wall bleed 24hours post PICC insertion? Was the bleed thought to be relates to PICC linsertion?

2) How do you deal with such a physician?


Thanks in advance.


Rhonda Wojtas, RN

Subject: *
Mike Brazunas
Wow, what a difficult

Wow, what a difficult doctor.  I have worked with teams over the years that have had individual doctors who made outrageous claims about RN PICCs. 

Earlier this week I was working at a hospital where one doc insists that RN placed PICCs have a much higher incidence of Thrombus.  This is not true according to the data collected at their hospital.   IR and the RN team use the same PICC.  They have tried everything to convince this guy but nothing works. 


I suggested that they challenge him to stand by his erroneous belief.  Tell him that if he really believes that the RN PICCs are dangerous, how can he stand by and let the team continue to place 10 PICCs a day at the hospital?  If he thinks he has identified a serious problem, he should take it to higher levels and work to change the situation for the benefit of all the patients in the hospital.  


To do this he will need DATA and of course he will have none.  Does his false “impression” justify the increased cost of an IR PICC or perhaps even a delayed discharge? 


Hopefully, this can be done calmly and professionally. If the nurse went over his head it would only cause more tension.  If you challenge him (or her in your case) to do something about it if the really believe it, then they must go to higher levels.  


I hope it works out


Michael Brazunas

Clinical Specialist


I have found that only time
I have found that only time and evidence can  change these docs.  Evidence that the PICC team is so good that all the other doc's are using them with good  results, the repeat patients are starting to request them, IR refuses to even take orders for PICC lines because  if we, the PICC team couldn't get it in, they couldn't either.  Over time, these doc's usually come around.  It just takes time which in the short term is very frustrating.
Vasular Nurse
I do not believe PICC can

I do not believe PICC can cause a CHEST WALL Hematoma. By placing a pICC, you did not makie a bruise or incision on the chest. Pts may develop a hemothorax (Very Very raraly), if the stylett is longer than the catheter. I have placed thousands of PICCs basic and MST since 1990in all settings. But never seen a hemothorax or atelctasis from PICC.

The doctor is not going to collect data.  You need to collect data and evidence. Start an outome data collection for PICCs placed by anyone. IR and PICC team. Who placed the PICC, reason for PICC, when the PICC was removed, reason for removal,

complications etc.  Also document diagnosis and risk factors. Patients with met. ca have higher risk for DVT. Risk for bleeding: anticoagulants, low plt.  Risk for infection: Does the pt has bacterimia? Other infections (Chance foe seeding).  

If the doctor continue his behavir / hostlity, you need to go higher up to your nursing department. Ethic committee? I belive that we need to protect ourselves.


Karen Day
Karen Day's picture
does your physician even

does your physician even understand what MST is - maybe they need to observe your procedure and this may help alleviate their misconceptions of how this could happen when we take the precautions we do to place these lines. 

I do agree with the data collection.  You will be able to collect this data to prove your point within your facility, but it most likely won't be data you can publish because you would never get an IRB board to approve it as you would be pitting one department against another within your facility and it could have a negative outcome.  I guess what I am saying, is that physicians won't budge without proof presented to them.  Just collect the data in an unbiased way and present it that way also.  I suspect the data you collect will actually prove that both of your departments (IR and nursing) place these lines with very little complications and in the safest manner - not in a way that would cause a hematoma.  Are there other factors that could have caused this in your patient i.e. chest trauma prior to admittance; cancer, blood coagulopathies?  just a thought. 

I think your physician is being unreasonable and will soon find that your bedside nursing team will place far more picc lines than your IR and will get them placed safe and in a more timely manner.  With the expertise your nursing staff will acquire, IR will no longer place any lines and will depend on you and your judgement.  This physician may also come to depend on you in the future - just be patient.


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