A "central line" is a type of intravenous catheter that is inserted into one of the larger veins of the body, typically the superior vena cava, which can be accessed by either the internal jugular vein or, more rarely, the subclavian vein.
A "central line" is also a great cause of fear and trepidation for many med students and junior residents. I recently successfully placed my first central line under with ultrasound guidance and close supervision on an intubated patient. Placement of the line requires inserting a 3-4 inch needle into the neck or chest while avoiding any of the following scenarios:
1) Nicking the carotid artery and watching your patient spurt blood from his neck like a cheap zombie apocalypse flick
2) Puncturing the lung (more likely with a subclavian line) and causing a pneumothorax in which the lung collapses as its surrounding negative pressure space fills with air.
3) Stabbing the heart itself with the long guidewire over which the catheter itself is slid; this is a particularly undesirable possibility as large hunks of raw meat typically do not respond well to poking and prodding. Ask any cow.
4) Failing. In this scenario you can't get your needle in the vein and the patient either dies or (and possibly more dreadfully for many individuals) a more senior medical staff has to save your incompetent derriere.
5) Incurring the wrath of a sickly patient who does not take kindly to being treated as a pin cushion; in this scenario the patient may run the risk of breaking the sterile field by squirming, spitting, swinging fists at your petrified face, or possibly snatching the needle from your trembling hand and attempting to place a central line in YOUR neck.
Sunday, July 1, 2012
Wednesday, June 27, 2012
Polo
New mallet.
Tapped the end so there's no need for a bolt through the side
See
Teip and BBor
Polo
The coveted Joust
Bbor with his new ride
To what end do we save lives?
The end is the same, despite our lofty pontifications and costly interventions. We save lives for the sake of the individual, despite the impact on the herd. We save lives to postpone the tears and nose-blowing of loved ones, despite the knowledge that no tears or hankeys are ever spared. Death is a zero sum game.
We save lives because, for some inexplicable reason, we intrinsically value life- however harsh it may be. We value time. Time on this spinning rock. Yet, ironically, we don't value our own lives enough to quit drinking, quit smoking, quit McDonaldsing, quit winding up in the damned hospital. And we don't value our time on this spinning rock enough to value the spinning rock itself.
The end is the same, despite our lofty pontifications and costly interventions. We save lives for the sake of the individual, despite the impact on the herd. We save lives to postpone the tears and nose-blowing of loved ones, despite the knowledge that no tears or hankeys are ever spared. Death is a zero sum game.
We save lives because, for some inexplicable reason, we intrinsically value life- however harsh it may be. We value time. Time on this spinning rock. Yet, ironically, we don't value our own lives enough to quit drinking, quit smoking, quit McDonaldsing, quit winding up in the damned hospital. And we don't value our time on this spinning rock enough to value the spinning rock itself.
Friday, June 15, 2012
Ode to Veterans Affairs
Beards, beards, and beards galore; welcome to the VA. Missing toes, missing eyes, missing the bus to Battle Creek. COPD, PTSD, straight black coffee; welcome to the VA. Diabetes mellitus, old man who yells at us, abscesses full of pus. Delirium tremens, estranged family makes amends, all vets are old friends, come once you'll come again; welcome to the VA. Cirrhosis, thrombosis, please help us. Tote your guns, smoke for fun, terr'rists go'n run, 'Merica's next to none; welcome to the VA. Yessir, Nossir, thankya Ma'amy, firm shake your handy, spank the nurse's fanny, ain't this life grandy, pass me the brandy; welcome to the VA. Fought in war, decub sore, hate Al Gore. Nicest folk you'll ever meet, missing teeth and missing feet, live in trailers live on the street, laughing joking tender sweet- in terms of patients, you just can't beat...the VA.
Monday, June 4, 2012
"Comfort Care": Euphemism of Euphemisms
Mrs. P went comfort care over the weekend. Died a few hours later. She was puffy, swollen, pumped full of a myriad of unforgiving antibiotics and crystalloid solution, a plastic tube jammed down her throat with dried blood at the corners of her mouth. Unconscious, unable to breathe, unplugged, and now unalive.
Her husband, from whom she was separated, was at the bedside soon after she passed- distraught, he prayed with the clergyman assigned to Mrs. P. He wept openly. A broken marriage and a wife stripped of white cells and stripped of life. Which part was he weeping for?
He found no comfort in comfort care. I find no comfort in comfort care. Here's hoping Mrs. P had some comfort with comfort care.
Her husband, from whom she was separated, was at the bedside soon after she passed- distraught, he prayed with the clergyman assigned to Mrs. P. He wept openly. A broken marriage and a wife stripped of white cells and stripped of life. Which part was he weeping for?
He found no comfort in comfort care. I find no comfort in comfort care. Here's hoping Mrs. P had some comfort with comfort care.
Sunday, May 27, 2012
may your valves be ever infected.
I met Mr. Archer on the 7th floor around 9 AM on a forgettable day in May. He was basking in the morning sun at the window near the end of the hall, staring out onto Mitchell Field below. He reminded me of my grandfather; an aged farmer with gruff hands and a warm smile like morning coffee. Mr. Archer turned as I approached. He smiled and shook my hand the same as he had done the past three mornings. However, I hadn't come this morning to ask more probing questions about contact with cats and cattle, travel to the Southwest, or to check on his fevers- I came to find out how much he knew.
"It's leukemia," he said, with a twinge of grief in his eye. Apparently he knew a lot. "They told me last night." He forced a meek don't-you-worry-bout-me smile. I gently returned the smile through a frown. I had been working Mr. Archer up for possible infectious endocarditis. He had fevers without a clear source and some recent heart surgery, two minor Duke criteria. But he also had a peculiar rash that didn't fit the bill. A skin biopsy of his rash returned the night before- leukemia cutis. Probably from acute myeloid leukemia. Blood cancer.
It was not my place to inform Mr. Archer of his cancer, but I don't deny that I wanted the task. I had liked him instantly. An old-timer with a solid heart, nothing more and nothing less. I had spent time with him. Asked him about his crops and kids. He deserved to hear about his leukemia from someone familiar.
This medical jungle inspires strange desires and peculiar prayers from its inhabitants. As a prime example, I have never wished so badly that a man had endocarditis.
"It's leukemia," he said, with a twinge of grief in his eye. Apparently he knew a lot. "They told me last night." He forced a meek don't-you-worry-bout-me smile. I gently returned the smile through a frown. I had been working Mr. Archer up for possible infectious endocarditis. He had fevers without a clear source and some recent heart surgery, two minor Duke criteria. But he also had a peculiar rash that didn't fit the bill. A skin biopsy of his rash returned the night before- leukemia cutis. Probably from acute myeloid leukemia. Blood cancer.
It was not my place to inform Mr. Archer of his cancer, but I don't deny that I wanted the task. I had liked him instantly. An old-timer with a solid heart, nothing more and nothing less. I had spent time with him. Asked him about his crops and kids. He deserved to hear about his leukemia from someone familiar.
This medical jungle inspires strange desires and peculiar prayers from its inhabitants. As a prime example, I have never wished so badly that a man had endocarditis.
Saturday, May 19, 2012
Malaria Man
ID consults this month. The other day my fellow threw me a new patient- "middle aged HIV+ guy in the Obs unit with 5 days of fever and malaise: go check it out." Needless to say the differential diagnosis for this guy could stretch from here to the Indian subcontinent. I scouted out his records, checking his last CD4 counts and viral loads. Lingering in a healthy range and undetectable, respectively. I reviewed his admit and ED notes- some nausea (an equally nonspecific symptom), fever of 104, maybe a day of upset stomach. Nothing to grasp onto too tightly.
Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.
Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so). Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)
The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example). But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????
I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.
Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.
Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.
Malaria. Best day of med school yet.
Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.
Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so). Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)
The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example). But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????
I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.
Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.
Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.
Malaria. Best day of med school yet.
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