My palms were sweaty. Wearing the surgical gown seemed hot in the setting of a patient room compared to the North Pole-like temps usually felt in the Operating Room. I imagined how ridiculous I looked as a new R1 (Intern or first year resident) to be wearing mask, gown and gloves at a patient’s bedside. But it was my first time to “solo” a central line placement. I had to find that lumen!! My R2 (essentially the teacher at my County Hospital training facility) had done it in the past while I observed, taught me how and now it was my turn to do it.
Many people think a surgeon’s first operation is an epochal event that a surgeon will fondly recall. To those of us who have lived through General Surgical internship, it is the floor procedures like central lines and chest tubes where you really cut your teeth and gain that gunslinger’s confidence that you can later project into the actual Operating Theatre.
I’d done all the prep steps wrong that evening. I placed the gown over my “short” white coat which would mean I would sweat off extra pounds I couldn’t afford to lose during this most brutal Los Angeles County Internship experience. I’d left the bed at too low a level so my back would take the brunt of the procedural duration. And I’d placed most of my prep materials out of reach.
My R2 was only mildly patient with me and helped to get drapes, scalpel and central line equipment closer to me on a Mayo stand. After prep and drape, I took the needle and approached inferior to the right clavicle and punctured the skin. I kept telling myself to just be the lumen of the subclavian vein, live as the lumen of the subclavian vein. I was aspirating the syringe attached to the needle as I made a pass (or a few) under the clavicle. Bam!! A flash of blood. I hit the lumen. I felt so happy!!! I carefully held the needle in this pay dirt position. Now onto guidewire placement through the needle and then dilation over the wire and eventual central line placement with removal of the guidewire. Easy right? I hit the vein and my R2 always made this next part seem routine, like a wound closure after a huge case… WRONG.
As I removed the syringe from the needle and held the needle in its same position, I was able to get my hands onto the guide wire. The wire comes packaged wrapped in a loose continuous loop. I was so anxious to place it in that I awkwardly fed the wire with the loop above or cranial to the needle instead of with the loop below or caudal to the needle. This is much like your toilet paper. Do you load it with the paper unloading over the top or off the bottom? In the loo, it doesn’t matter as much but with central lines, it can make for an issue.
I used one hand’s fingers to dexterously pass the guidewire into the needle while the other hand was still focused on not moving that needle from its vital position in the lumen. I felt a bit of resistance but then the wire continued to go. I looked up at my R2 as if to say, “I got this!” (before that was a hip phrase) and continued to pass. Suddenly I felt much much more spongy resistance. I looked up again at my R2 and he casually but slightly irritatingly pointed my eyes back in the direction of the patient. All this time I had been focused on a small area at the venipuncture site just under the medial clavicle but this time I looked at the whole of the draped neck area of the patient.
In horror, I visualized a gross deformity in the neck of the patient, with a thin spiny prominence protruding out of the neck region. I immediately realized the wire had gone up as it passed, not down (now does the toilet paper simile make sense?). Crud, what to do? I had a look on my face that it seemed my R2 had seen or had made himself before. He motioned and verbally directed me to back the wire out, in a reticent manner. Remember the patient is awake but draped for these procedures so it’s important to keep calm and project that for the patient’s experience. He made a few somewhat agitated hand motions and I realized he wanted me to re-feed the wire with the loop below the needle so the resultant curve would direct the wire from subclavian downward into the superior vena cava.
I followed suit and the rest of the procedure went flawlessly. Post procedure x-ray showed no pneumothorax and the jugular vein and neck were not harmed by the temporarily errant wire.
Funny the old R2 is now a colleague and we still chuckle when we recount the event and that look on my face about 30 years later. But there are many lessons to be learned. It isn’t just reaching the lumen that counts, although there are many who fail at that first part of the task. This episode taught me to see the procedure or any surgery or any task all the way through. You can’t take downs off in a football game if you want to win and you can’t figuratively sleep through what you feel are the mundane parts of any procedure or operation. Small details like the way the wire comes off the loop matter as much as getting into the lumen. This continual learning from experience improves the outcome of the next procedure. That iteratively helps patients, which is ultimately our prime goal as surgeons.
Ronald A. Navarro, M.D. is the California Regional Orthopaedic Chief with responsibility for orthopaedic clinical care in all southern California Kaiser Permanente. He joined KP as an orthopaedic sports medicine specialist in 1997 after a fellowship in shoulder, arthroscopy and sports medicine at University of Pittsburgh. He is a well published author in shoulder and knee surgery. Dr. Navarro serves on the American Academy of Orthopaedic Surgeons Board of Directors as a Member at Large and is in the California Orthopaedic Association Presidential Line. I declare no conflicts of interest in writing this article.