During my trauma rotation, while I am on call, I am the house surgeon on call for consults. Any other service, resident or discharged patient who needs to speak to a surgeon talks to me first. The other night I got called for a man with a failing kidney transplant whose developed a clot in his left arm after his catheter had been in place for about 6 weeks. He was very sick, needed IV antibiotics and possibly dialysis in the near future. They asked me to come and put in a new central line.
In general, I love procedures. But I am used to putting in lines in the ICU, a fairly controlled environment, with well trained nurses and respiratory therapists and fantastic physician assistants with years and years of experience in the ICU. In contrast, trying to insert a central line on the floor, where no one is nearby by can help you out or even knows what you are doing, where the materials needed for a OR quality sterile draped field are nowhere to be found, is a little bit stressful.
After reviewing the patient’s chart I began to develop the (distorted) sense that this man’s immediate future was in my hands. He needed access. His left arm was clotted. He would need dialysis soon if his kidney continued to fail, so I couldn’t use the future site of his dialysis catheter, the right subclavian. Right Jugular Vein was the only choice left. (ok, there are a few others, but jugular made the most sense.) Getting consent for the procedure (I am going to try and help you, but you could die in the process) was more than just a matter of paperwork. I knew that the chances of me puncturing his carotid artery (the one that goes to the brain), puncturing a lung, or causing so much swelling in his neck that he would have to be intubated were fairly small if I followed the proper guidlines for poking needles into his neck. But nevertheless, What would I do? if I ran into trouble? How quickly could I find a bag valve mask to support respirations? How quickly could I get a portable chest xray to look for a pneumothorax? Could I prevent a large hematoma from develping if I punctured his carotid artery?
I gathered as much stuff as I could, and had to have central supply send up the central line kit as well as needle drivers, scalpels, drapes, etc. I cleaned his neck, standing at the head of the bed looking towards his feet. I draped him with sterile cloths, prepared a sterile mayo stand and emptied all of my supplies onto it. The medical student on call watched intently trying to learn the mysteries of central line insertion. I was not comfortable with the uncontrolled environment (non-ICU) and knew that I wasn’t going to let him do any portion of the procedure, but nevertheless, it was comforting to have him in the room with me. I tried to talk him through the procedure as I went, but i was concentrating too hard on things like making sure I knew where the artery was, making sure I didn’t go too deeply, making sure the guidewire threaded without resistance, trying to keep any air from getting sucked back in through the needle before I had secured the line.
The patient kept complaining that his back hurt and would I please hurry up. All I could think about was why couldn’t he understand that without this line he could die? Can’t he just put up with a little back pain long enough to not distract me from the needles and wires sticking out of his veins that drained the blood from his head to his heart? Can’t you just lay quiet and still and let me finish my job?
The chief of surgery came in and guided me through the last parts of the procedure. It was a small catheter I’d never used before and kept trying to jump out of my hands. With the catheter finally in and flushing properly, all that was left was to sew it to the skin to keep it from coming loose. I tried to provide plenty of numbing medicine, but he kept saying “ouch”. He kept wiggling and moving. Can’t you under stand, I thought to myself, that you could die if I don’t get this catheter secured?
I don’t think he did understand. I don’t think he knew how sick he was. Or maybe he did and he didn’t care. Maybe he was in denial. Maybe he was ready to die. I wrote a quick note in the patient’s chart regarding the successful placement of his new line. Every service and consult that looked through his chart would see that it was me who gave this man access to his antibiotics and to his IV fluids. Thank goodness for the surgeon on call, they would think. What would we have done without her?