My time at the VA intensive care unit has come to a close, and while I am currently enrolled in a class (name: “Medical Imaging and Anatomy,” actual name, “Nate Gives Absolutely No F*cks”), what I’m actually doing is just twiddling my thumbs until it’s time to match on Friday.
If you’ve been paying attention, the Match algorithm actually ran some weeks ago – which means the computer knows who matched and where (and who didn’t). This places the medical student in a fairly unique position: we are Schrödinger’s Med Student. Because no one knows if we have matched, we currently exist in both a matched and unmatched state. Opening the Match will lock us in to one or the other.
Anyway, one of my goals for the VA ICU rotation was to place a central line. A central line, for those of you that are nonmedical, is a very large IV. Instead of putting it into your arm, it usually goes into your neck or chest. The end of the tube that we jam in there sits right at the entrance to your heart – hence the name “central line.”
Central lines are used for a lot of things, but the most common is to give patients medicine to help keep their blood pressure high enough to get blood to all the vital organs. This is pretty useful in shock, when your blood pressure drops and without meds you’d get a bad case of the deathies.
The problem with blood pressure-raising medicines is that they work by tightening the size of your veins and arteries – reducing the diameter so pressure goes up. If you do this through a small vein (like in your arm), that vein will basically close off to nothing and scar shut. Bad.
So we use central lines a lot, especially in the ICU. The procedure is a little bit complicated and carries a pretty real risk of infection or other issues, which primarily means the medical student is to be kept as far away from the procedure as possible, ideally in the next zip code. I will refer to you an image from second year of medical school depicting safe procedural positioning:
As residents and interns place a lot of these over the years (especially in places like the ICU), they get comfortable enough to allow the medical student in the room, then next to the patient, then assisting in the procedure, then maybe – just maybe – to place one themselves.
(Aside: it is a little bit insane that many medical students, at least at my institution, become doctors without ever so much as sniffing a central line – considering that central line placement is a pretty fundamental skill of being a doctor. But this is the world we live in.)
My last week in the ICU, the intern on during the day was an emergency medicine intern with plenty of central lines in her procedure log. One of our sicker patients needed a dialysis catheter placed, which is a horrifyingly large tube. The patient was already intubated and sedated, which meant a lot less moving around. He was a perfect candidate for a medical student-placed line.
However, I have learned, throughout medical school, two tenets above all:
- I am an idiot;
- I shall not get my hopes up.
Med students who fail to learn this have a very difficult time in the latter years of medical school.
“Nate, do you want to do this one?” she asked.
DO I WANT TO PLACE A CENTRA—“sure,” I replied dispassionately, as if placing a central line were as exciting as going to CVS. In reality, placing The First Central Line was hugely exciting, at least in part because it represented the fulfillment of an ancient prophecy. Forecasted by an old ex-girlfriend possessed by divine inspiration/pure unadulterated rage, it said, “One day, you will cause someone a tremendous amount of pain.”
Prophecy notwithstanding, placing a central line also involves bright lights, shiny objects, me stabbing things, and a machine (ultrasound) with a great deal of buttons. It’s the perfect procedure.
We prepped the area, donning sterile gowns and gloves. We covered the patient with blue towels and a drape. Using the ultrasound probe and its many associated buttons, I pointed out the gigantic black circle that indicated the jugular vein – the target for the harpoon of a needle I was using.
(Pictured: me, holding the needle, left. Patient’s neck, depicted metaphorically by Moby Dick, right.)
The first-year critical care fellow hovered near the door. She was a lovely but somewhat nervous person, in the same way that smallpox was a somewhat troubling disease.
“Is the anatomy good? Is it going to be an easy stick? Make sure you use lots of lidocaine. Be careful with the wire! Never lose control of the wire!”
The intern looked at me and rolled her eyes.
Finally, we were ready to start. I grabbed the Spear of Ahab, otherwise known as the needle, and stuck it into the patient’s neck in a highly scientific procedure known as “Ultrasound-Guided Trial and Error.”
I felt pretty good, actually, as I poked my way through to the giant black circle. This part at least was no different than using ultrasound to place a regular IV, something I’ve done probably thirty times.
“LOOK FOR FLASH! DO YOU HAVE FLASH? TELL ME WHEN YOU GET FLASH!” the fellow yelled from the door. Jesus Christ. Making me nervous over here.
The fellow, with her calming and gentle demeanor, was telling me to check the syringe for when blood drew back into the chamber. This tells you that you’ve successfully entered the vein (and not the artery, which would “flash” with bright red blood instead of the darker venous stuff). The carotid artery, which is the Bringer of Life to the brain, sits immediately next to the jugular vein. “Accessing” the carotid instead of the jugular is problematic, in that it carries the risk of inducing a case of death.
I got flash. The good kind. The nurse in the corner, on my signal, hit play on the boom box and the triumphant climax of “2001: A Space Odyssey” flooded the room…
…No, not really.
“I have good flash,” I deadpanned.
I pulled out the stylet from the needle and threaded a metal wire down into the vein. The wire would serve as a kind of scaffold for the rest of the procedure, which included making the tiny hole in the vein into a big hole, in order to accommodate the gigantic catheter I was about to cram into this guy’s neck.
(The patient, by the way, was totally snowed on sedating meds. He didn’t feel a thing. In case, you know, you were worried.)
After the wire was in, the intern and I passed the dilator over the wire and into the vein. Saying we “passed the dilator” is a euphemistic way of saying “we crammed the giant wedge-shaped tube into the patient’s neck using a tremendous amount of force.”
It’s a satisfying feeling.
Once we had dilated, like I said we had turned a small hole into a big hole. This meant that there was an impressive amount of blood flooding from the skin nick (this is normal) until we proceeded to “PASS THE VASCATH,” which again is a euphemism for “cram the giant dialysis catheter into the neck using a twisting motion usually reserved for reinserting corks into wine bottles.”
It’s a tremendously satisfying feeling.
I wrote “PASS THE VASCATH” in all capital letters as that represents the approximate volume of the advice we were receiving from the door.
After that, we were done! We cleaned up, confirmed that we were actually in the right vessel with the buttons machine aka the ultrasound, and finished up. We got a chest x-ray showing that a) the catheter was in the right place and b) I didn’t accidentally stab the guy’s lung in the process. All was well.
I can start residency now.
… That’s how that works. Right?