Agraphia Medical Tragicomedy


By Step

"Code Sepsis, here now".

Her blood pressure was tanking as a result of a systemic infection, a condition known as sepsis.  Sepsis can kill, and quickly; the most important thing to give is intravenous fluids fast, and plenty of them.  Traditional IV lines are too small - the equivalent of using a garden hose to put out a fire.

A central venous catheter is used instead, where a large bore tube is placed.  Unfortunately few veins in the body - only deep ones - are large enough to support this type of tubing, making central line insertion a potentially very dangerous procedure.  The risks of popping a lung, hitting an artery, or triggering a deadly heart rhythm must be carefully weighed against the benefits.

I remember my first central line - it did not go well.  In fact, it did not go at all.  I knew enough to know that I didn't know anything, and got cold feet before I had the chance to seriously hurt the patient.  Let me be the first to tell you, sticking a huge needle in someone's neck is really intimidating. And these needles are huge.  Think Nicolas Cage in The Rock (great F'in movie) and you've got a rough idea of the size we're talking.  Looking back on it, it was a smart choice.   Plenty of time to learn.  No reason to go cowboy too early.

Back to the present.  When I teach medical students to do procedures, I walk them through every single step of the way, and then have them teach it back to me.  Not just in broad strokes, but the nitty gritty.  Why?  Because if you forget to put on your sterile gown - or you put it on in the wrong order - well, then, you've screwed the pooch just as much as if you missed the vein, haven't you?

So, I started.  Anatomy examined.  Skin disinfected.  Gown on.  Sterile field.  Ultrasound guided.  Vein accessed.  Wire threaded.  Vein dilated.  Line placed.  Sewed in.  Finished.

Total time elapsed - 15 minutes.  Not great, but 45 minutes faster than the last one I did.  Next time I'll be better.

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  1. Ha. Medical students at my school are barely allowed to be in the same room when a central line is being done. Pesky bloodstream infections. We’ll get to infect our patients as interns instead!

  2. I’d talk you through it :)

  3. Agreed, total rock star. Over here in med-school-world I finally did my first ABG. Not as exciting as a central line but progress. I want to do more!

  4. Beep!

    Well done! I especially enjoy the ultrasound guided lines. I find them quite relaxing, more so than the subclavian ones.

    One small thing, though: you can put much more fluid through a peripheral line than a central line. (think short and fat, it’s where it’s at). the reason for the central line in sepsis is:
    – CVP (especially if you like EGDT)
    – pressors (especially if you like EGDT)
    – svO2 (especially if you like EGDT)

  5. Aw, Zac, tell your department to get you a Sonosite U/S. It’s becoming standard of care.

  6. 64. Wow! This can be one particular of the most beneficial blogs We’ve ever arrive across on this subject. Basically Magnificent. I am also a specialist in this topic so I can understand your hard work.

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