Monday, 11 June 2007

Slowly... slowly...

One of our patients, James, is a heroin addict with H.I.V. and he’s in hospital with an abcess infection that’s spread to his blood stream (septicaemia).

He is as sick as a dog. He has a fever of 41°C (106°F) and as the infection courses through his veins, it causes him to shake (rigors) and, quite understandably, he feels awful. Over the weekend we were treating him with powerful antibiotics given straight into his blood stream via a drip. Like I mentioned, this guy injects smack and over the years that he’d been shooting up, he’s knackered all of his veins and this morning we finally ran out of veins that we could use to put the drip up.

He needed a central line.

A central line is a plastic tube going into one of the large (jugular) vein in the neck. Inserting a central line into a person involves (not to put too fine a point on it) lying your patient down, turning their head away from you and then stabbing them in the neck with a metal spike roughly the length of a child’s forearm. It’s one of the things that really highlights the sky-high levels of trust that our patients give us as doctors.

As you can imagine, there are lots of thing that can go wrong with central lines so we try to avoid put them lines into patients unless it’s absolutely necessary. Because not many patients have them, junior doctors like me don’t get to put them in very often. So when Dr Fletcher, our consultant, asked us which one of us wanted to put the central line into James, I jumped up and down with my hand in the air and shouted, “Pick Me! Pick Me! Pick Me!”

So I got to do a central line… on a H.I.V. positive drug addict with who was having rigors. My mother always used to say that you should be careful what you wish for.

I haven’t put in a central line for several months so, after I’d explained the risks and benefits to James and he’d agreed to let me do it, I asked one of the anaesthetists to help me do it an a master-and-apprentice fashion.

Now, I’m no psychic, but I reckon that if there was a mind-reader watching me put a the central line into James’ neck, he or she would have possibly overheard something along the lines of this:

Me: OK, I’ve got to absolutely spot on with this. This guy is covered with sweat and he keeps shaking, I can so see this going horribly wrong if I make the slightest error. Slow and steady is the way forward.

James: I feel like shit. It’s like my whole body’s on fire. I want to puke but this doctor won’t let me. He’s a nice enough bloke, but I just wish he’d get on with it so that nurse can give me my medicine and I can start feeling better.

Me: So, I’ve got my gown, mask and sterile gloves on, I’ve got my sterile field set, all the equipment is ready, I’ve cleaned his neck with iodine, OK I’m ready to go.

James: I’m so going to spew if this guy doesn’t stop playing with that machine and start doing something and why does he have that stupid looking gown on? I know I've got H.I.V. but surely this is a bit O.T.T. - he looks like someone from a bad sci-fi film.

Me: The local anaesthetic’s in now. I’ve got the ultrasound machine ready so I can see the needle-tip, it’s time for the big needle

James: Whoa! What the hell is that!?! He wasn’t kidding when he said it was a big needle that’s the biggest needle I’ve ever seen in my life! And I’ve seen a hell of a lot of needles!

Me (out loud): “OK Sir, now it’s REALLY important that you keep REALLY still for this bit.”

James: Too right I’m keeping really still. That thing is like an offensive weapon and I can see your hands shaking. The end of that needle is moving all over the place. I’m just going to close my eyes and pray.

Me: OK, success, I’ve got the needle in the right place, now I’ve got to pass the guidewire down into the jugular vein.

James: …thy will be done on Earth as it is in Heaven…

Me: Slowly… slowly… OK, it’s in now I need the dilator.

James: …though I walk through the shadow of death, I shall fear no evil…

Me: That the hard bit done, now I’ll pass the actual central line over the guidewire, then all I’ll have to do is stitch it into position and it’s all done.

James: I feel sick again.

Me: All done! That was actually not too difficult and not even very messy. Well done me!


Ally said...

O.o Oh god!! Never thought this things actually exist. And a jugular punctre, damn that's freaky.

surly girl said...

ag. i had to call an ambulance this afternoon for a boy who fell off his bike on the way home from school (and who landed hard on his head) and that was enough to make my knees go all funny. 'nuff respect to you, mr junior doctor, sir.