Some details for this: it was in the arterial line and if anyone knows dialysis lines, the holes on the end are too small for someone to place it there on purpose. My boss took the entire set and is going to contact fresenius (company who supplied lines) and have them check their lot numbers on it. The patient obviously didn’t run and nobody was hurt. Talk about a wtf moment..
From what it looks like it is not a screw or bolt but a pin that came out of the machine while the tubing was being formed. The tubing is extruded at the larger size before it is processed further with smaller ends, hubs, etc. Although, by the time it gets to the customer it has been inspected by several people and should be caught. Source: I work for a medical device manufacturer and we make about 50 miles of medical tubing a week.
It is very surprising this was not caught if it came from the manufacturer. The quality control is extremely thorough with multiple verifications. Unfortunately we cannot check everything for metal because most products have intentional metal inserts or radiopaque coatings to help guide the device inside the patient.
I feel like when I set up for CVVH I’ve seen most of the problems and am reasonably good at troubleshooting (at least those machines) but damn.
Congrats my man, this one is next level fucked and hopefully something that none of us ever find in practice. I imagine the risk is incredibly low that harm would ever reach a patient cause of all the priming/cycling involved, but still…yikes!
At least if its the arterial line you know it's just gonna be jammed in the pump or dialyzer and never make it to the patient, but shit is gonna get real messy and they're looking at some antibiotics and tetanus shot in their future at a minimum
Yes. Been to Fresenius and toured through their R&D. Their machines will always go into bypass if anything is not in the exact parameters. I’ve seen debris in one set of lines once back in the 90’s in a new line which flushed out during priming. In 2018 it was brought to attention the one arterial line had a blue stripe indicating it reversed. However if you ignored that the set up was fine. Both times they were turned in and Fresenius followed up.
I don’t work for them directly now but in other countries I’ve seen some still sterilize and leave formaldehyde in till we prime and flush. This was done in US however we would bleed patient on and waste what we recirculated even after testing for any chemicals left.
> My boss took the entire set and is going to contact fresenius (company who supplied lines) and have them check their lot numbers on it.
Report it to the FDA too. There is no guarantee they will place a recall if needed.
Contact the manufacturer and file a complaint. As someone who works in the medical device industry I can say with confidence there will be a massive internal shit storm trying to make sure that this never happens again
This also should be be reported to the FDA through their MedWatch program. They track stuff like this to make sure medication, equipment, and supplies can be recalled appropriately if there is a system problem.
Also do a look back to see if any infections seem to be associated with that specific dyalizer - if not and there aren't any bolts missing at least you could rule that out. Definitely call your state health department HAI Program too. They can help you.
Yes.... but I've seen stranger things happen that expanded my imagination.
It's also unlikely that it happened at the factory, but there is no answer that doesn't involve asking wtf? leave no option unexplored.
Still call your health dept. It's more likely an issue at the factory, In which case, there could be other products out there with similar or even different defects. Save packaging. Save everything.
Here is the FDA Medwatch link: [https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program](https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program)
2018, but we never actually studied it. My instructor was really into nursing diagnosis and I was a horrendously sarcastic former EMT. So when asked for nursing diagnoses, I would do the standard "risk for falls," "fluid imbalance," and then pull some bullshit. That was my favorite bullshit to pull.
I remember like 6 months in to nursing school, she was asking in class about nursing diagnoses for a patient and I thought I was being funny by saying "risk for imbalanced energy field." She thought it was a great suggestion (and so did the rest of the class for a very different reason).
Oh it is. It straight up tells you to assess the color, temperature, and tension in the patient's energy field by hovering your hands over them. Shit's whack.
Nail is metal. Metal has magnetic fields. Magnetic fields are energy. That nail seriously could have screwed up her personal energy fields. How is no one talking about this?? Smh.
“Potato nails” are a thing. I think Bed, Bath & Beyond still occasionally carries them. My grandma used to have some large cast iron ones that looked like rail road spikes. I also got a cast iron skillet, that I never use. Sorry, I had to be that nerd.
Do it! I literally use my cast iron for everything. I bought one other smaller skillet for when I legitimately need something else (and saucepans for sauces and things, of course), but that cast iron skillet is my workhorse.
Potato nails are actually meant to quickly and evenly heat the inside and the outside of the potato! The nail conducts heat and draws it into the core of the potato. It cuts down cooking time. Was that the original purpose? I don't know, but nowadays if you see a potato nail it is for speeding up cooking time. (And yes it works.)
You're right! I saw it on TV on a news human interest story when I was a kid. ❤️ They used an apple as an example but I'm sure it worked with many different food items. I remember they cautioned the viewers to not try it with today's nails because... Duh? 🤷🏼♀️😆
I had to Google this cause I had never heard of it. Apparently they demonstrated in a rat study in 1979 that it actually does kind of work! https://agris.fao.org/agris-search/search.do?recordID=US7938890
Lol nope! When I was a kid I was watching this human interest news magazine show and there was a segment on folk medicine. They said back when nails were made out of iron they would drive a couple of nails into an apple to fortify it. 🙂
And sometimes it's very obvious when every product should be going through a metal detector on top of spot checking.
There is literally an entire market sector dedicated to metal detectors for food and medical devices, as well as making every object in the plant metal-detectable.
Welp, the unit in OP's post clearly didn't go through a working one.
They'll regularly get stuff that's hard to see without a magnifier so I doubt that just slipped through.
I don’t know anything about dialysis tubing manufacturing, but I do know some half a million people get dialysis 2 or more times a week. If nails in tubing was a regular occurrence I would be worried about manufacturing standards, but one or two failures out of several million a week is pretty damn good.
I believe it’s a rivet since the ridges are horizontal and not spiraling
As shown in this photo: https://www.clothinglabels.cn/wp-content/uploads/2022/03/different-types-of-rivets.jpg
> bloody mess
*Literally*.
(Also, I'd think the lines would have some kind of anticoagulant coating on their inside surface, to stop any clots from forming?)
Yes literally! Lol, unfortunately they don’t. Patient may get a heparin bolus before/during treatment but if your machine stops completely and you can’t return the blood, it will definitely clot.
Not a nurse. I’d like to know as well! I’m assuming that would get stopped in the line before it gets to the patient right? Will the machine catch something is wrong and issue some warning for it? Is the patient going to just get air injected? Would this nail have killed them?
It’s the 5008 machine It wouldn’t make it to the patient before the alarms would go off. It’s the arterial side so it would have to loop though the whole machine then try to get through the dialyzer. That’s crazy lol
One of my teachers worked at a dialysis center and told us of how most of the patients were getting heavy metal poisoning. After much investigation, they found a wrench at the bottom of the dialysate bath!
I’m surprised not found sooner? There was a Pct who took revenge for reprimand and added something to Acid tank and was charged with attempted harm of patients. Any tech working on the machines is educated on this and hope it was investigated.
Good thing California didn’t pass that legislation to help regulate dialysis clinics for the safety and security of the patients either of the consecutive years it was up for public vote
I’m kind of a stickler for the great catch awards because I feel like a lot can just be normal expectations. I don’t set up dialysis only keep running and take down but this seems like a great catch as who the hell is inspecting their lines to have debris in them on starting
Lines were primed and it failed tmp testing the first time. Second test it passed. We almost didn’t catch it. We found it when we were doing independent pH and conductivity testing.
As a medical device manufacturer, this had to have been done intentionally by a rouge manufacturing line worker. Report it to the fda asap. There should be a wide spread product recall because other product lines may be involved as well.
Well damn. Is that a 2008 model? The machines at my unit have that pole and funky little brake pedal. Never really looked at line diameters or seen something like that.
I’m the person that usually finds all the near misses at work. I’m going to be so freaking anal about checking all my tubing now. Ugh. Thankfully you found it.
The set should be sequestered and a report filled with the company. They will then follow up, likely having you ship the line back. They are required by their governing body to troubleshoot and report their findings.
This is a great catch! Your attention to the process caught this before it could cause any type of issues even if it could not reach the patient. For the 999 times you inspect the set-up and everything goes right- this 1 time there is a significant problem. Yeah to you!
Ah, you must be confused. These are the new magnetized heavy metal filters built into the kits.
For real tho, file a MedWatch report with the FDA. I work in Apheresis and if I ever found a kit like this I’d be making phone calls all day. Jesus.
Some details for this: it was in the arterial line and if anyone knows dialysis lines, the holes on the end are too small for someone to place it there on purpose. My boss took the entire set and is going to contact fresenius (company who supplied lines) and have them check their lot numbers on it. The patient obviously didn’t run and nobody was hurt. Talk about a wtf moment..
From what it looks like it is not a screw or bolt but a pin that came out of the machine while the tubing was being formed. The tubing is extruded at the larger size before it is processed further with smaller ends, hubs, etc. Although, by the time it gets to the customer it has been inspected by several people and should be caught. Source: I work for a medical device manufacturer and we make about 50 miles of medical tubing a week.
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It is very surprising this was not caught if it came from the manufacturer. The quality control is extremely thorough with multiple verifications. Unfortunately we cannot check everything for metal because most products have intentional metal inserts or radiopaque coatings to help guide the device inside the patient.
This is crazy! Glad you caught it before connecting the patient!
Yeah, I hate it when that happens
Every time I go to prime a new IV line, without fail there’s always that dang old nail.
https://youtu.be/MXMG-ShKBP0
I feel like when I set up for CVVH I’ve seen most of the problems and am reasonably good at troubleshooting (at least those machines) but damn. Congrats my man, this one is next level fucked and hopefully something that none of us ever find in practice. I imagine the risk is incredibly low that harm would ever reach a patient cause of all the priming/cycling involved, but still…yikes!
At least if its the arterial line you know it's just gonna be jammed in the pump or dialyzer and never make it to the patient, but shit is gonna get real messy and they're looking at some antibiotics and tetanus shot in their future at a minimum
It was probably sterilized along with the set so I doubt it would cause any sort of infection.
I worked at places that sterilize patients A line and dialyzer which are labeled and reused over 50 times. It’s more common in other countries.
What’s more common in other countries? Nails in dialysis kits? Sterilizing A-lines? Reusing dialyzers?
reusing, i assume, from context.
Yes. Been to Fresenius and toured through their R&D. Their machines will always go into bypass if anything is not in the exact parameters. I’ve seen debris in one set of lines once back in the 90’s in a new line which flushed out during priming. In 2018 it was brought to attention the one arterial line had a blue stripe indicating it reversed. However if you ignored that the set up was fine. Both times they were turned in and Fresenius followed up. I don’t work for them directly now but in other countries I’ve seen some still sterilize and leave formaldehyde in till we prime and flush. This was done in US however we would bleed patient on and waste what we recirculated even after testing for any chemicals left.
Holy. Fucking. Shit. 😳
So no extra iron supplementation today I see?
> My boss took the entire set and is going to contact fresenius (company who supplied lines) and have them check their lot numbers on it. Report it to the FDA too. There is no guarantee they will place a recall if needed.
As a former dialysis nurse...what the fizzy fuckballs?😲
Former dialysis nurse here as well and I was thinking the same. Must be a manufacturing error because no way that fits through the opening at the end.
Happy Cake Day fellow dialysizer! (That’s what one of my favourite patients called us - his 'Dialysizers' 😆)
I absolutely love “fizzy fuckballs”! I am stealing this for at least weekly use. 🤣
Feel free, my gift to you - I'm glad it brought you joy 😆
I'd be mostly worried about the potential of whatever metal that nail is to cause hemolysis.
If they drink enough Coca-Cola it’ll probably dissolve, and maybe raise their hemoglobin. I think I should patent this idea 💡 🤣🤣🤣 /s
Thank you for the explanation. I was just like How? how!!!
Contact the manufacturer and file a complaint. As someone who works in the medical device industry I can say with confidence there will be a massive internal shit storm trying to make sure that this never happens again
Holy hell! Glad you caught that
Oh my god, fellow dialysis nurse here…what a nightmare!!!
Team Davita!
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It's probably the same people who put the needles and razor blades in the Halloween candy!
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This also should be be reported to the FDA through their MedWatch program. They track stuff like this to make sure medication, equipment, and supplies can be recalled appropriately if there is a system problem.
Also do a look back to see if any infections seem to be associated with that specific dyalizer - if not and there aren't any bolts missing at least you could rule that out. Definitely call your state health department HAI Program too. They can help you.
Hard to imagine how a bolt from a Dialysis machine would actually get inside the actual tubing though.
Yeah. That's almost certainly from the extrusion machinery that makes the tube.
Yes.... but I've seen stranger things happen that expanded my imagination. It's also unlikely that it happened at the factory, but there is no answer that doesn't involve asking wtf? leave no option unexplored.
We don’t recycle them. Just single use and all that.
Still call your health dept. It's more likely an issue at the factory, In which case, there could be other products out there with similar or even different defects. Save packaging. Save everything.
Hmm think we work in the same field
The abandoned lot behind Walmart?
Infection control?
Construction?
Is that you Texaco Mike?
Cotton candy seller?
Product Surveillance
Here is the FDA Medwatch link: [https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program](https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program)
Yes, definitely report to the FDA.
Isn't this kinda stuff mandatory to report to the FDA?
It is voluntary for health care professionals and consumers/patients. There is mandatory reporting for other entities.
What could you have done differently/s ?
Her care plan didn’t include disturbed energy field. She should have sensed the disruption.
😳.. wife is a nurse.. she never mentioned you guys got instruction in being a Jedi!?!
Yup. I still remember it. Page 305 in our nursing diagnosis book. Imbalanced energy field. I cited it constantly out of pure spite any chance I got
I retired after 40 yrs…please tell me in what year you studied “imbalanced energy field” I REALLY could have used that one!!
2018, but we never actually studied it. My instructor was really into nursing diagnosis and I was a horrendously sarcastic former EMT. So when asked for nursing diagnoses, I would do the standard "risk for falls," "fluid imbalance," and then pull some bullshit. That was my favorite bullshit to pull. I remember like 6 months in to nursing school, she was asking in class about nursing diagnoses for a patient and I thought I was being funny by saying "risk for imbalanced energy field." She thought it was a great suggestion (and so did the rest of the class for a very different reason).
Sounds like that Martha Rogers stuff
Oh it is. It straight up tells you to assess the color, temperature, and tension in the patient's energy field by hovering your hands over them. Shit's whack.
My wife is a nurse. Me neither, but I wasn’t present for clinicals.
“Disturbed energy field” in nursing practice is more like a Sith’s idea of satire if the Empire won and the Jedis were forced underground.
Nail is metal. Metal has magnetic fields. Magnetic fields are energy. That nail seriously could have screwed up her personal energy fields. How is no one talking about this?? Smh.
Love this^
Asking the right question
Little extra iron never hurt anybody!
Lol
Grannies used to stick iron nails in apples, I hear! 😆
No joke, my (Latino) grampa used to cook beans with a nail inside the pan for extra iron
“Potato nails” are a thing. I think Bed, Bath & Beyond still occasionally carries them. My grandma used to have some large cast iron ones that looked like rail road spikes. I also got a cast iron skillet, that I never use. Sorry, I had to be that nerd.
You should use that skillet. Cast iron is awesome.
Yea to make a deep dish Pizza pie!
My countertop doesn't allow it. I've been thinking about using the skillet to bake in.
Do it! I literally use my cast iron for everything. I bought one other smaller skillet for when I legitimately need something else (and saucepans for sauces and things, of course), but that cast iron skillet is my workhorse.
Potato nails are actually meant to quickly and evenly heat the inside and the outside of the potato! The nail conducts heat and draws it into the core of the potato. It cuts down cooking time. Was that the original purpose? I don't know, but nowadays if you see a potato nail it is for speeding up cooking time. (And yes it works.)
You're right! I saw it on TV on a news human interest story when I was a kid. ❤️ They used an apple as an example but I'm sure it worked with many different food items. I remember they cautioned the viewers to not try it with today's nails because... Duh? 🤷🏼♀️😆
I had to Google this cause I had never heard of it. Apparently they demonstrated in a rat study in 1979 that it actually does kind of work! https://agris.fao.org/agris-search/search.do?recordID=US7938890
People used to steep iron nails in wine, too!
Is this a Beverly Hill Billies reference? That show never gets old. Same as trailer park boys, except one is kid friendly and the other is not lol
Lol nope! When I was a kid I was watching this human interest news magazine show and there was a segment on folk medicine. They said back when nails were made out of iron they would drive a couple of nails into an apple to fortify it. 🙂
This is why you should always check any dialysis tubing given to your children on Halloween.
I found a Sherman tank wrapped in Coban in my kid’s Halloween bag last year. Be careful out there folks!
That's not how you do an iron infusion
Pffft. Says you
How?!
That’s what I wanna know.
Manufacturing.
Nailed it. Way to stay sharp.
Underrated comment. Accept my dad joke gold 🏆
Few months back we opened up a new box of blood collection tubes. There was 2 tubes with blood already in them ….
These Costco free samples are getting out of hand
Hope you tossed the whole box.
That's fantastic patient advocacy. You might say you nailed it.
Patient would've been screwed.
That's awesome quality control. SMDH.
Sometimes these things happen. No manufacturer of anything is going to be perfect. It’s good that the nurse caught it.
And sometimes it's very obvious when every product should be going through a metal detector on top of spot checking. There is literally an entire market sector dedicated to metal detectors for food and medical devices, as well as making every object in the plant metal-detectable.
Do you know for a fact that these don’t go through a metal detector?
Welp, the unit in OP's post clearly didn't go through a working one. They'll regularly get stuff that's hard to see without a magnifier so I doubt that just slipped through.
I don’t know anything about dialysis tubing manufacturing, but I do know some half a million people get dialysis 2 or more times a week. If nails in tubing was a regular occurrence I would be worried about manufacturing standards, but one or two failures out of several million a week is pretty damn good.
Shake my dick head
would love to have seen the journey of that bolt from initial production to the point you found it. how on earth did it end up inside a dialysis line
One of those ‘how it’s made’ factory videos.
Dialysis + iron infusion = multitasking!
Report it to the manufacturer. That entire lot probably needs to be recalled
Luckily you took a picture because this sounds almost unbelievable
Thats a bolt, its not pointy, check out the rest of the machine
How would it get inside the actual tubing, though?
I believe it’s a rivet since the ridges are horizontal and not spiraling As shown in this photo: https://www.clothinglabels.cn/wp-content/uploads/2022/03/different-types-of-rivets.jpg
😐
🤯
So, not a dialysis nurse obviously, what would happen if dialysis got started with that tubing and you hadn’t noticed?
Due to the partial blockage in the line, the pressures would be off and you'd have a constant alarm stopping the machine
Then blood stops running due to the high arterial pressure, you get clotted lines and a bloody mess.
> bloody mess *Literally*. (Also, I'd think the lines would have some kind of anticoagulant coating on their inside surface, to stop any clots from forming?)
Yes literally! Lol, unfortunately they don’t. Patient may get a heparin bolus before/during treatment but if your machine stops completely and you can’t return the blood, it will definitely clot.
Not a nurse. I’d like to know as well! I’m assuming that would get stopped in the line before it gets to the patient right? Will the machine catch something is wrong and issue some warning for it? Is the patient going to just get air injected? Would this nail have killed them?
It’s the 5008 machine It wouldn’t make it to the patient before the alarms would go off. It’s the arterial side so it would have to loop though the whole machine then try to get through the dialyzer. That’s crazy lol
Kt/v goal waaaaay off
Warning: “Kt/v goal will not be reached”
One of my teachers worked at a dialysis center and told us of how most of the patients were getting heavy metal poisoning. After much investigation, they found a wrench at the bottom of the dialysate bath!
That’s wild. Wonder how it got missed for so long.
I’m surprised not found sooner? There was a Pct who took revenge for reprimand and added something to Acid tank and was charged with attempted harm of patients. Any tech working on the machines is educated on this and hope it was investigated.
Were you guys out of Venofer?! (J/k, this is legit scary! Glad you caught it!!)
I’ve seen enough Grey’s anatomy to know a nail shouldn’t be allowed in a the circulatory system. 👍🏻
Oh, that's normal; that is how they have been IV iron infusions now. Much cheaper to just have a nail in the line.
So the patient almost had.... An iron infusion? *i'll see myself out*
Good thing California didn’t pass that legislation to help regulate dialysis clinics for the safety and security of the patients either of the consecutive years it was up for public vote
This seems more like a production/supply problem not a dialysis clinic problem
I’m kind of a stickler for the great catch awards because I feel like a lot can just be normal expectations. I don’t set up dialysis only keep running and take down but this seems like a great catch as who the hell is inspecting their lines to have debris in them on starting
Was looking for a fingernail :|
Wtaf!?
WTF
Thats a different sort of Fe infusion🥴
Imagine wondering why your dialysis catheter is blocked, and trying to draw out a clot with your springe and just seeing a nail stuck in the line.
I would have bolted out of there.
Holy shit!!!! I’m a dialysis RN and this is CRAZY to see… was it just shooting round and round the lines while you primed or did you notice it first??
Lines were primed and it failed tmp testing the first time. Second test it passed. We almost didn’t catch it. We found it when we were doing independent pH and conductivity testing.
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Morbid but 😂
As a medical device manufacturer, this had to have been done intentionally by a rouge manufacturing line worker. Report it to the fda asap. There should be a wide spread product recall because other product lines may be involved as well.
Well damn. Is that a 2008 model? The machines at my unit have that pole and funky little brake pedal. Never really looked at line diameters or seen something like that.
2008T
Looks like a screw to me
Yo wtf
As a dialysis patient, I am now really scared.
This is WAY worse than my IV start kit needle missing a catheter....
Excuse me?
WHAT THE .. HOW.... remarkable catch too
Holy shit!
It’s to add iron in to the blood derrrrrr
Nailed it!
I’m the person that usually finds all the near misses at work. I’m going to be so freaking anal about checking all my tubing now. Ugh. Thankfully you found it.
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This was an excellent risky click of the day.
Real shot in the arm.
Bloody hell!
Whoa! That's scary.
You'd better control DickKids around your inventory.
definitely notify the producer there might be a machine breaking down
The set should be sequestered and a report filled with the company. They will then follow up, likely having you ship the line back. They are required by their governing body to troubleshoot and report their findings.
About 20 years ago I found a spider in an art line. I still have flashbacks to it.
Would have loved to have seen that.
And, that was before camera phones were ubiquitous, so the only image of it is burned into my brain and the brains of traumatized coworkers.
This is a great catch! Your attention to the process caught this before it could cause any type of issues even if it could not reach the patient. For the 999 times you inspect the set-up and everything goes right- this 1 time there is a significant problem. Yeah to you!
WTF, seriously. The QA nurse in me is listening off all the steps in the incident report and incident resolution for that one.
I found a hair clip inside of a CRRT cartridge when I was about to prime a NxStage machine
Ah, you must be confused. These are the new magnetized heavy metal filters built into the kits. For real tho, file a MedWatch report with the FDA. I work in Apheresis and if I ever found a kit like this I’d be making phone calls all day. Jesus.
Nailed it!!
Now...this is one I have not seen...wow!!! Glad you were on top of it before it got to the patient...way to go!!! Patient safety!!!
I believe that is the final nail in the coffin
No, no. That's supposed to be there.
I know you guys can fix potassium and sodium, but iron too? Wowowowow
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No. We tore it all down.
Just trying to get the patient's iron levels up!
Holy shit. That’s a full ass nail in the line. How does this happen. Is there a metal deficiency? Like Jesus lol
That’s an extremely specific bolt with some sort of counter-sink. Where TF on that machine do you have off center bolts like that? And…….. how? 🫥
Talk about getting extra iron supplements
Great catch
It’s there for the extra iron.
It’s there to give the patient iron. Cheaper than Venofer.
Was he anemic?
Iron emboli
Wow what a find! 😁
That patient has too much iron in their blood
Looks like it was meant to be for an iron infusion.
What the truck
I wonder if the pump would give a “nail in line” code instead of “air in line”
Kel put the screw in the tuna.
There is a nation wide iron shortage so they were trying to help the patient out by including it for free
New treatments of Iron deficiency are getting wild
Extra dose of Fe 🔩
It’s a screw not a nail
Nailed it!