Friday, April 08, 2005

No Problem!

"Size 7 1/2 gloves please. "
My critical care fellow stood beside me, providing back-up. My intern had declined to perform the procedure.
Looking at Mr. B now, I can't blame her. He's morbidly obese, over 300 lbs. I wonder how someone can allow themselve to get like this. Worse of all, he practically had no neck. So much for looking for the apex of the sternocleidomastoid.
We'll need the site-rite.
I guided the 'poor man's ultrasound' probe to his right neck. There! Didn't seem that difficult to find his internal jugular. Compressible? Check. That's not his carotid (good thing).
I scrubbed and gowned up. The patient, already intubated and on a vent, was unaware of my presence and what I was going to do to him (his next-of-kin, of course, had consented).
After infiltrating the skin with lidocaine (not necessary, really, since he was out. But habits die hard), I took the 3 1/2 inch gigantoid needle, and stuck it into his neck at a 45 degree angle. First go, no aspirate. Partial withdraw and aimed more laterally and went in again, while pulling on the plunger of the syringe. No blood. Repeated 3rd, 4th time (why oh why did I volunteer to insert a central line into the biggest patient we had in the ICU?). On my fifth try... about 2 inches in (I was starting to worry about popping his lung)... flashback! Nice aspirate of dark, venous blood. Removed the syringe and confirmed it wasn't the carotid (it wasn't squirting into my face). Quickly inserted the guidewire, then made a cut with the blade, and then the dilator. Finally, shoved in the dialysis Mahurkar line as far in as it would go. Put 2 stitches in, and I was done.
Good work, my fellow said.
No problem, I lied.
But when I removed my sterile gown and gloves, I notice I am covered in sweat, and my hands were trembling. No problem.
I realize too why I had been so nervous. I had inserted many lines before, but never in a guy this big. Also, this was the very room that had that patient who died of complications of a line placement just 2 years before; I saw my fellow then insert a line and caused a catastrophic tension pneumothorax. By the time the chest tube went in, it was all over.


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