Get ‘er done

It was a gorgeous Saturday morning in spring. But it wasn't too happy a morning for Mrs. Ann Urich, who had been suffering from a severe arthritis flare and—courtesy of a few handfuls of NSAIDs—had developed acute tubular necrosis. Her hospital medicine team thought she had a good chance at recovery of renal function, but she would need dialysis for short-term support.

Dr. William Morton was not too happy either. He was covering for an anesthesiology colleague and had hoped to finish early. Then the pager went off: Placement of a dialysis catheter needed. His fellow was off that day. He asked the team if this was really, urgently necessary. The patient is anuric, they replied, and needs to start dialysis now.

James S Newman, MD, FACP Photo courtesy of Dr Newman
James S. Newman, MD, FACP. Photo courtesy of Dr. Newman.

Dr. Morton thought longingly of the old days, when a physician would call for a central line kit, stick it in, and get on with his life. In the current era, nothing was that simple. He did manage to find the patient fairly quickly and solicit her permission. All Mrs. Urich had to say was, “Get ‘er done.” So that's what he thought he'd do.

Hospital policy forbade starting a central line in a non-monitored setting. The ICU was full, but perhaps he could use a room in the PACU for a short time. After a phone call to the PACU attending on that service, he had grudging permission to use one of their beds for an hour to place the line, with monitoring. But there were no PACU staff on a Saturday morning. Dr. Morton pleaded with the medical charge nurse, and eventually they arranged to have Mrs. Urich's floor nurse come along to start the line, though she had never seen one done before.

Next, Dr. Morton called the resident on service and asked if she wanted to start the line. The resident hesitated; she had not completed the central line credentialing exam yet so she could not be of assistance. At any rate, she was on call last night and duty hours required her to go home.

Ensconced in the PACU, Dr. Morton noted there was no ultrasound machine. Thirty minutes later one was found, but it was an older model and Dr. Morton was not quite sure how to use it. Once the ultrasound was working and the patient positioned, she had trouble keeping still. She tried to say something but Dr. Morton hushed her; he was trying to concentrate. He got gowned and gloved, prepped the patient's neck, and draped her head to toe.

Mrs. Urich started to feel claustrophobic under the long drape. Dr. Morton requested a small dose of midazolam to calm her. The nurse broke away and found that her password didn't work on the PACU medication management system. A call went out, and the PACU RN eventually got the midazolam.

The ultrasound machine was humming but there were no probe sheaths on the machine cart, and nobody knew where to get one. Eventually, one was found but it became contaminated in the effort to put it on with sterile technique, so someone ran off to get another. It had now been more than three hours since Dr. Morton got the first page.

He stood in the hallway, taking a mental procedural pause. He reviewed the central line checklist in his mind. He visualized his tasks: Get nice images of the vessels and of the needle and guidewire going into the internal jugular after infiltration with local anesthetic. Prior to dilation of the vessel, transduce the needle to ensure he was seeing venous, not arterial, pressures. Dilate the puncture site over the guidewire using the Seldinger technique. Maybe the catheter would be unable to pass because the skin hole wouldn't be large enough—although it would be big enough to bleed copiously. He focused instead on visualizing a great image of the catheter within the lumen of the right internal jugular vein. The nurse would hopefully be able to store an image, but if not the SAVE button would be only a sterile nose poke away.

He would need a heparin flush, but he was not sure if nephrology would want that or citrate. He then would need a dialysis nurse to mix up the flush and bring it down to PACU. He would also need a chest X-ray. To save time later, he made all the necessary calls, and finally, almost an hour later, reentered the room ready to do what he had meticulously planned out in his mind.

But Mrs. Urich was gone. The nurse was gone. Finally he found them walking back from the bathroom. Mrs. Urich apologized, but as she had been trying to tell him, she had to get up to urinate. He called the team, and they decided to hold off on the line after all. Sometimes you are better off not “getting ‘er done” at all.