I can stick a jugular or femoral with the best of them, even do intra-osseous hydration, but this is out of my experience.”
“You’ve got great hands. I’ve watched you. You can do this. You’ve watched one. Now it’s time to do one. Next week you can teach the interns.” Gavin smiled and winked. “Come on, I’ll talk you through it,” he went on in a raspy whisper.
Beck hesitated. If the central venous line wasn’t inserted properly it could puncture the lung or the subclavian artery, which could cause hemorrhaging. Did he want to risk it for experience?
“Look, I’ve got five or six other guys chomping at the bit to do this. I’m offering it to you. It’s your call.”
Beck’s first inclination was to let the intern or resident do the procedure, but the adventurous part of him, the part Gavin had just challenged, thought, Why not?
All Gavin had to do was look at Jan and on cue she went right to work gathering the supplies.
“And I’ll give you my best nurse to assist. Hell, she could perform a subclavian in her sleep. She’ll anticipate your every need, and I’m here as back up if you run into a problem.”
Gavin was offering a once-in-a-lifetime chance. He decided to take it. Beck nodded and walked toward the gurney. He looked at the semi-conscious patient. The last thing he wanted to do was make matters worse for the guy, but Gavin believed in him and any experience here at Mercy Hospital was a bonus and could save a life in the field.
With the patient’s neck in a cervical collar, the jugular approach was definitely out, which left the subclavian route, a procedure he was much less familiar with. His brain jumped to hyper-speed, running through the procedure he’d never actually performed himself but had observed frontline doctors and Gavin do.
Recalling how his advanced medic courses had made training even more challenging by first having the medics run a mile, dive under low shelters and start IVs in near darkness while holding the fluid bags with their teeth, he figured this couldn’t be much more difficult. The jugular lines he’d trained on, though on sedated goats, had to be performed in equally chaotic circumstances while being timed with a stopwatch. And in the field the only way to check if you’d made it into the right vein was to lower the IV bag and check for backflow.
It would be a huge risk, but Gavin believed in his skills, and life was all about taking chances if you wanted to grow.
All things considered, the controlled atmosphere and bright lighting, with Gavin’s back-up and Jan’s assistance, this procedure should be far less complicated. Still, his confidence wavered and he took a deep breath to steady his hands. He used the only technique that ever got him through battles: tune out the rest of the world—focus on the patient, one procedure, and one chance at success.
OK. He was ready.
Beck cut open the patient’s shirt and exposed the area he’d be working on. He washed his hands while January tilted the head of the bed slightly toward the floor to make sure the central veins were filled.
While he gowned up and put on gloves, Jan used the antimicrobial wash to cleanse the skin.
Jan also wore sterile gloves and she handed him the local anesthetic in a syringe with a small needle. He’d concentrate deep at the middle third of the clavicle to find the vein for cannulation, so he started superficially injecting the anesthetic there and worked outward along the entire length of the bone. Gavin nodded his approval.
Without having to ask, Jan handed him a longer needle and he injected a second round of medicine deeper into the flesh to ensure a pain-free procedure. Drawing on strict training, with each injection he aspirated to make sure he hadn’t punctured the vein.
She handed him the guidewire and Gavin helped him check both the stiff and floppy ends while waiting for the anesthetic to numb the skin. He spoke quietly into Beck’s ear, telling him the next step of the procedure.
Beck reached for the scalpel Jan provided and used it to nick the skin just enough to make sure the cannula would fit. He firmly palpated for the pulse, then used the introducer attached to a syringe and guided it carefully into the deep part of the clavicle, aiming toward the sternal notch.
He encountered resistance. The last thing he wanted was to run into trouble with an audience. He lifted his gaze toward his attending doctor.
Gavin spoke up. “Walk the introducer down just a bit.” Beck complied. “That’s it,” Gavin said.
He followed Gavin’s instruction until he had passed the blockage and could easily advance the introducer again. Steady suction on the attached syringe revealed a flush of blood when he entered the vein. He deftly removed the syringe from the introducer, feeling a bit like a circus juggler. Gavin had gloved up and reached in to help him handle the exchange. Beck used his thumb to prevent back-flush of blood from the introducer entrance.
Again, as though reading his mind, Jan was right there, handing him the guide wire to insert into the introducer. He took great care to make sure the wire didn’t uncurl past the sterile field. Gavin hovered, ready to jump in if anything went wrong, and held a portion of the wire that threatened to touch outside the field.
Once satisfied he was in the right place, after checking the markers on the guide wire and leaving just a bit protruding from the insertion site, Beck glanced at Gavin, who nodded his approval.
“Looks right,” Gavin said.
Beck removed the introducer over the guide wire. Jan handed him the cannula, already having removed the plastic end-stop, and he inserted it over the guide wire until it was level with the skin. Once confident all was well, and getting a nod of approval from Gavin, he removed the guide wire and left the cannula in place. He passed the withdrawn wire to Jan, who was waiting to receive it. In the field, he’d had to do everything in the procedures himself, and having her assistance was a luxury he greatly appreciated.
Jan had flushed the connecting line with saline and her steady hand reached toward his to attach it snugly to the cannula. A quick flash came to mind of the famous Michelangelo painting of The Hand of God where fingers almost touched. January was the only other person who knew about his passion for art. Hell, they’d discovered art together.
He quickly refocussed when she handed off the line and he connected it. When she passed him the needle and sutures, he took another breath, glad to see something that was easy for him to perform. He dutifully stitched the cannula in place flush to the skin through two separate holes in small plastic wings.
He let out his breath, not having been aware he’d been holding it, and allowed himself a mental pat on the back at a job well done. He passed a subtle smile January’s way. She nodded her approval.
While he disposed of the extra suture and the needle, Jan cleaned and swabbed the skin and applied a small dressing.
Shortly after that the portable X-ray technician came to take a quick radiograph of the chest. They stepped outside and Gavin slapped him on the back.
“That was smooth,” Gavin said. “Just like a pro. Have you ever thought about becoming a doctor?”
Beck laughed. “Never.” He grinned but quickly stopped when he noticed the dagger looks from a couple of interns. He shifted and glanced at Jan down the hall, disposing of the equipment and trash. “She was a huge help.”
Gavin grabbed his arm and pulled him closer. “The nurses here at Mercy are exceptional, and Jan is one of our best.” He glanced with a mischievous twinkle in his eyes at Carmen. “Whatever you do, don’t let her know I said that.”
Beck chuckled and nodded. “Not a chance.”
Gavin barreled toward the obviously unhappy interns. “Follow me to my office.” They did what they were told.
Five minutes later the X-ray revealed that the subclavian line was in the right atrium instead of the superior vena cava. Beck had advanced it too far. Once again, under Gavin’s tutelage, they went back to the patient, snipped the sutures and withdrew