16 July 2007

First Pass


She was, my patient conceded, "a bit overweight." In medical terminology, she was morbidly obese. She weighed about 280 pounds, and her BMI was somewhere over 50, seeing as she stood only five foot two. In more vivid verbiage, she might have been described as resembling nothing so much as a bowling ball, a round body with spindly legs and arms jutting out at improbable angles.

Her complaint was "headache" and her temperature was 102.8 degrees Fahrenheit. She was on multiple immunosuppressants, including steroids, for a mixed connective-tissue disorder. There was no apparent explanation for her fever -- no urinary tract infection, no cough or runny nose. As I gently flexed her neck forward, she winced.

And I winced.

Because there was just no option -- she needed a spinal tap to assess for meningitis. And with a body type like hers, the likelihood was that it would be a flog. I could see where this was going to end up -- a half hour of torturing this nice lady trying to get the tap myself; a call to interventional radiology and the obligate half-hour delay in the call-back; enduring the open scorn (best case) or scathing abuse (worst case) of the radiologist who was called in the middle of the night to do the procedure under x-ray guidance. There was seven hours left to go in my shift, I reflected, and I would be lucky if I could get the disposition accomplished before then.

So, first off, I got set up to give it the obligate college try. Lie her on her right side and set up the table as usual, as if this is anything other than going through the motions. I set up the test tubes, neatly in a row, as if there is a chance they will soon be filled with glistening CSF. I go through my usual pre-procedure patter, trying to put her at ease and trying to get myself to believe that this is just like any other tap I will do this week.

Sitting on my little stool, face to face with the small of her back, I could not find a single anatomic landmark to guide me. The spinous processes were buried under a thick layer of fat and not at all palpable. The iliac crest at the top of the hip-bone was similarly obscured. For that matter, I couldn't even positively identify the midline! The nurse and the patient's husband watched me, their expressions full of a simple confidence that I would quickly put this to rest. How little they know, I thought. I was careful to give her a healthy dose of numbing medicine and premedicated her for the procedure with dilaudid, figuring I was about to be causing her some pain. I made my best estimate of the locations and angles I would try, placed the needle against her clean skin and closed my eyes before sliding the needle in by feel alone. I waited for the sudden, hard resistance that would indicate I had just rammed the needle into bone. But it didn't come. Bemused, I pulled the stylet back and peered into the hub of the needle. Crystal clear fluid briskly welled up and began to drip out.

My jaw was hanging open behind my surgical mask, but my eyes and voice hid my astonishment as I said "We're in," in my most professional tone and began to collect the fluid. The nurse cooed, "There, that wasn't so bad, was it?" And the patient replied, "I didn't feel a thing. Is it always that easy?"

Easy? Yeah, that's the word for it: easy. Well, as far as they know...

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The icing on the cake came an hour later:
WBC: 0
RBC: 0

17 comments:

  1. When I was a resident in the VA, we had a code come into the ER with the same body habitus. I was the senior resident and nobody else wanted to get vascular access, so I was tagged to go for the femoral line. Like you I got it on the first try and everyone around the code broke out laughing. Sheer dumb luck.

    Well written, by the way. Were the drinks on you that night?

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  2. Nice job, doc.

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  3. Nice job! My morbidly obese LP story involves getting CSF only after calling the OR for the extra long (5 inch spinal needle) and hubbing it.

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  4. branson -- good point. I've used them, too. I (and you, I am sure) have done LPs on bigger patients, but what made this patient blog-worthy was the serendipity of getting in right off.

    Cheers,

    SF

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  6. Rob...were the drinks on him? 0/0 man...where I come from that's called a champagne tap and someone owes YOU the drinks! And from the description he gives, he's owed a LOT of drinks.

    BTW, Meat:

    Ever tried US to locate landmarks? Works pretty nicely. Practice a couple times on someone whose landmarks you can palpate, to get an idea of what images you're looking for. If I can't palpate 'em, I go for US every time before a blind stick. Not a guarantee, but much better than sheer luck.

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  7. Wanted to point out what I see hibgia beat me to: the ER where I once worked as a tech had a strict policy. If the patient was morbidly obese (or even heavily overweight + unable to see landmarks), the LP had to be US-guided.

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  8. Well done. There's nothing I hate more than flogging around with an LP needle on a no-landmark-having obese person.

    I sometimes use the butt crack as a reference point for "middle" but beyond that, it's often impossible to tell much else.

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  9. Er.. I've flogged off mine to the interventional radiologist ;)

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  10. Are you sure she got the dilaudid you ordered? Nurse K and her ilk might have "wasted" it...

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  11. A clean tap. Good job.

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  12. Wowie. Lots of great stuff.

    One, no, I have never used u/s for landmarks for LPs, but we have just hired a doc out of an u/s fellowship and I intend to look into it now! I had actually never thought of it!

    Two, Keagirl, you remind me of the 3rd year urology rotation I did when the senior urology resident sat us all down and earnestly, with an utterly straight face, explained to us that "Urine is the champagne of body fluids." He was not amused when I explained to him about the champagne tap, or when I asked him whether you could smell the fruity bouquet of urine like you could a good brut champagne.
    No, I did not get honors in that rotation!

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  13. Champagne tap! (or maybe...melted butter, considering the source....)

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  14. Johnny the G.U.7/20/2007 12:58 PM

    "Two, Keagirl, you remind me of the 3rd year urology rotation I did when the senior urology resident sat us all down and earnestly, with an utterly straight face, explained to us that "Urine is the champagne of body fluids."

    Of course, the above resident was not our friend "The Independent Urologist" who was only a "junior" resident on the service at the time (and who probably would have had a much better sense of humor).

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  15. They are taking away our SC & IJ lines and leaving us with femoral sticks alone due to some rogue medics that would bypass the AC (which protocol said we were supposed to make 3 peripheral attempts or spend 2 min total on sticks; while using the ETT for meds, before moving to CVP. I always disliked fems because most of the people ARE obese. Can you give some guidance on landmarks and techniques for obese people. THANKS!

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  16. BTW, we use 14-16g angios with a syringe on the end, not a full kit. Maybe you can go through the process you would with the "big needle". THANKS! PS We have very long transports.

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