Archives: Call Night

April Intern Year:

***Today we were down in the ER, talking to one of the hospitalists. He gave us the brief run-down on one of his patients who he was admitting, that included the following tidbit:

She is a chronically sick lady who, because of throat cancer ("no reason not to keep smoking!"), has had to have a feeding tube placed through her abdominal wall and into her stomach. See above picture. She is allowed nothing by mouth. We always ask an alcohol history, but with someone who can't swallow, you might think this a moot point. Not so! Patient X mixes oranje juice with vodka and pours it directly into her G-tube. We can take away many things, apparently, but not her ability to get drunk!!


***Last week, I got called down to the ER first thing in the morning to admit a gentleman in respiratory failure who had already been intubated. I was admitting him with one of my favorite Critical Care Attendings, Dr. Lee (alias).

If you've ever been a patient in a hospital or ER, you've probably had a peripheral IV placed. This is where a nurse or doctor pokes a needle into a small vein in either your arms or legs and then puts a small catheter over it that will stay put, so we can give our medicines through it. In the ICU, peripheral IV's often don't cut it. The meds that we use are so heavy-duty that if they come into close contact with the skin, you can end up with serious irritation or burns. Hence, in the Units most patient's require what we call a Central Line. This is essentially a much larger and longer catheter that gets threaded into a much larger and more central vein, so that the meds have more direct access.

There are three veins that we usually put them in (in ascending order of 'makes me nervous' factor):femoral vein (groin), subclavian line (under the clavicle), and the Internal Jugular (the side of the neck). I have put in femoral lines and subclavian lines, but had never done an IJ. All central lines have their risks because these bigger veins run in closer proximity to other vital structures. Like, say, the lungs. It is not entirely rare for a patient to get part of their lung punctured when having a subclavian placed, for example.

So that morning, Dr. Lee said, "Let's put in an IJ. Wanna do it?" "Sure." Inside I'm thinking, "Please, oh, please, do not let me hit the carotid!" The carotid artery--you know, that big pulsating artery in your neck that allows you to feel your pulse--runs right over the jugular.

We gowned up, sterilized the patient, and got our kit out. I felt my landmarks about a million times to make sure I knew exactly where I was aiming (please, please, please no carotid) and then stuck my needle in. The pulse always seems to migrate right when you are sure that you know where you need to hit. Also, the skin on older people's necks is a little leathery, so you have to push with enough force to break the skin, but with enough restraint to avoid running right through things. ;)

I advanced my needle and pulled back on the syringe, waiting for a flashblack of blood to let me know I'd hit gold. It can take a while to find the vein, so I slowly came back and forth looking for my goal.

"I think you need to go closer to the carotid," Dr. Lee said.
"And if I hit it?"
He smiled. "We'll just hold pressure until he stops bleeding.It's happened to me loads of times." Simple Enough. Right.

I took out my needle, repositioned closer to the carotid, and advanced again. Bingo! Gosh, it feels so good to see venous blood return...brisk, but not pulsating in the way it would if you'd hit the artery. From there, I threaded in a wire through the needle that would coarse through the veins creating a path. Then I took a blade to make the skin incision a little bigger. Next, I withdrew the needle over the wire, careful not to let go of the wire and lose it inside the vessel. That would be bad. Next I threaded a plasticky type catheter over the wire, and then removed the wire from within. Lastly, I took a needle and thread and sewed the end of the catheter into the skin. You don't want to risk it slipping out after all that work. And done!

I stepped back, evaluated my handiwork, and exhaled.

"Right now," I thought, "I feel like a doctor."