The Power of "Thank You"
We all have things at which we excel, and others at which we absolutely stink. The same is true for the variety of tasks that confront surgery residents. For example, my knot tying skills are not what I'd like them to be. I'd love to get my knot tying time down by at least a third. On the other hand, I absolutely rock when it comes to putting in central lines. So while I might be a wee bit behind some of my peers with regard to knot tying abilities, I think I could smoke most of them when it comes to central line placement. That is why the events of the other night were mildly distressing.
For the uninitiated, central lines are big IV lines that range anywhere in size from about the diameter of a pencil to about half of that size. There are six sites where they are commonly placed: Right or Left Femoral, Internal Jugular, or Subclavian veins. Internal medicine doctors at our institution generally access the femoral veins. They are the least scary lines to place in terms of immediate complications. However, since the femoral vein is located in the groin, this anatomic position is the most prone to infection, and therefore is not the site of choice for most surgeons. They therefore usually place subclavian or internal jugular lines which are located in veins just beneath the clavicle or just lateral to the trachea respectively.
Sticking a needle, approximately the length of a coffee stir stick, into someone's neck or chest is not a natural thing to do. The first few times you do it, you half expect your mother to show up and give you a speech about not giving other people ouchies.
As an intern, we are required to do 10 central lines prior to being accredited to do them unsupervised. The surgery lounge has a big chalkboard where a running tally is held for the first few months of the residency year. This is egged on by the senior residents, who of course are eager to have the interns signed off on lines so as not to be the victim of quite as many late night "line supervision calls."
My intern year, I was running neck and neck with another resident for the most number of lines. The prize for being the first to be signed off on lines was a 6-pack of beer, which I naturally found very motivating. He beat me out by a day for that tenth line. I'm still disappointed that someone else won. I don't drink, but my cat would have enjoyed the beer, and would probably have been amusing drunk, but I digress.
My whole point was, central lines are something that I enjoy and that I am good at. I can usually get them in on the first needle stick. This is important because you can kill someone putting a central line in, and the probability of doing so is directly related to the number of times you have to sink a needle several inches long into their body.
Recently I gave a patient a pneumothorax (collapsed lung) putting in a subclavian central line. Because the lung sits right beneath where the vein is that you're aiming for, it is one of the more common complications of central line placement, with an incidence of 2-3%. It was only my second pneumothorax out of the hundreds of central lines that I've placed, so I'm well below the national average so to speak. However, anytime you have a complication, it rattles your confidence a little bit.
Enter Mrs F. into the picture. (as is the case with any medical story, lots of details have been changed so as not to violate confidentiality laws) She has had more central lines than a month has sunsets, and is therefore a "hard stick." Her existing line seemed to be clogged, and it had to come out. That takes away one of your five placement sites, since you don't want to put a new line into an old site. Furthermore, the femoral veins are not desireable places to place a long term line as previously described. That gets Mrs F down to three appropriate sites for line placement. All three remaining sites have scars from previous lines serving as a roadmap for where the underlying vein probably lives.
The problem is, veins don't like participating in human pincushion projects, and eventually scar up and may even clot off entirely. Poor Mrs F. She had to have a central line placed because it is literally her lifeline. A complicated series of events made her GI tract useless, and she therefore is solely dependent on TPN (supplied through her veins) for her nutrition.
Well into this central line attempt, I had failed miserably at line placement in two of the three desirable sites. A dotting of skin puncture wounds provided evidence of my efforts that would have embarrased even the most incompetent of medicine residents. Even when in the vein with the needle, the wire would not thread: evidence of internal venous scarring. It was all very frustrating, and with each needle stick I worried more and more about causing my third career pneumothorax.
Presenting two pneumothoraces at the same week in the weekly Morbidity and Mortality conference would have made me the butt of a few jokes such as "any assasination attempts planned today?" However, the real reason I was worried about giving the patient a pneumothorax was the fact that she had a long anticipated vacation planned for the following day with her daughter. Her being able to go on this vacation was conditional on having a source for nutrition, ie the line I was attempting to place. I was beginning to have visions of her in the hospital the next day with a chest tube bubbling away while her daughter enjoyed the sunny coasts of Florida without her.
With a quick silent prayer to the Lord for better success at the next site and an apology to the patient for the need to continue to play the human pincushion game at yet another location, I proceeded to prep my last available central line site. Thankfully, my syringe feeled with nice venous blood on the first stick. A vampire is the only creature, mythical or actual, that could have felt more joy at the site of blood. Central line in place, I informed Mrs. F that we were done, and that I was sorry that I had to play the human pincushion game so long with her. Then she did something that no patient had after a procedure for quite some time, and that made me want to go somewhere and cry. She said a heart-felt, genuinely appreciative "thank you."
The chest x-ray showed no collapsed lung, the line terminated at just the right place (just an inch above her heart), and she is now somewhere on the highway with her daughter on a brief escape from a life dominated by her myriad medical problems. I also don't have to present two pneumothoraces in one week. However, what meant more to me than all of that, was the fact that she said "Thank You," and conveyed the sense that even were she to miss her flight the next day instead spending the anticipated vacation staring at a hospital ceiling, she still meant it.
Hans
For the uninitiated, central lines are big IV lines that range anywhere in size from about the diameter of a pencil to about half of that size. There are six sites where they are commonly placed: Right or Left Femoral, Internal Jugular, or Subclavian veins. Internal medicine doctors at our institution generally access the femoral veins. They are the least scary lines to place in terms of immediate complications. However, since the femoral vein is located in the groin, this anatomic position is the most prone to infection, and therefore is not the site of choice for most surgeons. They therefore usually place subclavian or internal jugular lines which are located in veins just beneath the clavicle or just lateral to the trachea respectively.
Sticking a needle, approximately the length of a coffee stir stick, into someone's neck or chest is not a natural thing to do. The first few times you do it, you half expect your mother to show up and give you a speech about not giving other people ouchies.
As an intern, we are required to do 10 central lines prior to being accredited to do them unsupervised. The surgery lounge has a big chalkboard where a running tally is held for the first few months of the residency year. This is egged on by the senior residents, who of course are eager to have the interns signed off on lines so as not to be the victim of quite as many late night "line supervision calls."
My intern year, I was running neck and neck with another resident for the most number of lines. The prize for being the first to be signed off on lines was a 6-pack of beer, which I naturally found very motivating. He beat me out by a day for that tenth line. I'm still disappointed that someone else won. I don't drink, but my cat would have enjoyed the beer, and would probably have been amusing drunk, but I digress.
My whole point was, central lines are something that I enjoy and that I am good at. I can usually get them in on the first needle stick. This is important because you can kill someone putting a central line in, and the probability of doing so is directly related to the number of times you have to sink a needle several inches long into their body.
Recently I gave a patient a pneumothorax (collapsed lung) putting in a subclavian central line. Because the lung sits right beneath where the vein is that you're aiming for, it is one of the more common complications of central line placement, with an incidence of 2-3%. It was only my second pneumothorax out of the hundreds of central lines that I've placed, so I'm well below the national average so to speak. However, anytime you have a complication, it rattles your confidence a little bit.
Enter Mrs F. into the picture. (as is the case with any medical story, lots of details have been changed so as not to violate confidentiality laws) She has had more central lines than a month has sunsets, and is therefore a "hard stick." Her existing line seemed to be clogged, and it had to come out. That takes away one of your five placement sites, since you don't want to put a new line into an old site. Furthermore, the femoral veins are not desireable places to place a long term line as previously described. That gets Mrs F down to three appropriate sites for line placement. All three remaining sites have scars from previous lines serving as a roadmap for where the underlying vein probably lives.
The problem is, veins don't like participating in human pincushion projects, and eventually scar up and may even clot off entirely. Poor Mrs F. She had to have a central line placed because it is literally her lifeline. A complicated series of events made her GI tract useless, and she therefore is solely dependent on TPN (supplied through her veins) for her nutrition.
Well into this central line attempt, I had failed miserably at line placement in two of the three desirable sites. A dotting of skin puncture wounds provided evidence of my efforts that would have embarrased even the most incompetent of medicine residents. Even when in the vein with the needle, the wire would not thread: evidence of internal venous scarring. It was all very frustrating, and with each needle stick I worried more and more about causing my third career pneumothorax.
Presenting two pneumothoraces at the same week in the weekly Morbidity and Mortality conference would have made me the butt of a few jokes such as "any assasination attempts planned today?" However, the real reason I was worried about giving the patient a pneumothorax was the fact that she had a long anticipated vacation planned for the following day with her daughter. Her being able to go on this vacation was conditional on having a source for nutrition, ie the line I was attempting to place. I was beginning to have visions of her in the hospital the next day with a chest tube bubbling away while her daughter enjoyed the sunny coasts of Florida without her.
With a quick silent prayer to the Lord for better success at the next site and an apology to the patient for the need to continue to play the human pincushion game at yet another location, I proceeded to prep my last available central line site. Thankfully, my syringe feeled with nice venous blood on the first stick. A vampire is the only creature, mythical or actual, that could have felt more joy at the site of blood. Central line in place, I informed Mrs. F that we were done, and that I was sorry that I had to play the human pincushion game so long with her. Then she did something that no patient had after a procedure for quite some time, and that made me want to go somewhere and cry. She said a heart-felt, genuinely appreciative "thank you."
The chest x-ray showed no collapsed lung, the line terminated at just the right place (just an inch above her heart), and she is now somewhere on the highway with her daughter on a brief escape from a life dominated by her myriad medical problems. I also don't have to present two pneumothoraces in one week. However, what meant more to me than all of that, was the fact that she said "Thank You," and conveyed the sense that even were she to miss her flight the next day instead spending the anticipated vacation staring at a hospital ceiling, she still meant it.
Hans
posted by The Mad Hatter at 2:24 PM
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