31 August 2007

The Trifecta

10/10 muses on how Pride goeth before the fall, relating an embarrassing story about how the gods of medicine will bring you down for excessive cockiness. I too have paid that karmic debt, and since he started the confessional, I might as well carry on...

This was way back in residency. In fact, this occurred during the last few weeks before graduation. God damn, but I was at the top of my skills then. I could put in a central line* faster than taking a piss. I could intubate with my eyes closed. Chest tubes were such common events that I let medical students do them. I fancied myself the best at doing procedures in our entire residency program -- and not entirely without cause. I had gone the three years of doing central lines on a daily basis without ever causing a single pneumothorax**. People sought me out to do the difficult procedures. One attending wrote on my evaluation, "Dr Shadowfax is almost as good as he thinks he is."

So one day the ER was almost empty. I sat around shooting the shit with Rick***, a close friend and the chief resident in our program. He was working the acute room, and I was supposed to be supervising the interns, who were all surfing the internet. A sick old man came in by ambulance and Rick went to take care of him, so I tagged along. The patient was an emaciated fellow, semi-conscious**** and in respiratory distress. So we put him on oxygen, a breathing treatment, EKG, and Rick got the guy prepped for a central line. I leaned back against the counter, sipped my coffee and watched.

Now Rick was no slouch himself at procedures. I don't want to disparage him here. But I could not resist the temptation, nay, the sacred obligation, to issue a running commentary on Rick's technique as he attempted to put in the central line. Which is to say that I taunted him. Mercilessly. Creatively. Persistently. And the more I taunted him, the more apparent it became that Rick was just not going to be able to get that line in. Maybe it was my distracting him, or maybe it was just that the thin old man's chest heaving up and down made it really difficult to get the line in. Either way, after an extended and particularly eloquent riff on how he couldn't find his way to . . . well, I'll leave it at that rather than get too obscene . . . Rick slammed down his needle in the tray and said in irritation, "OK smart-ass, you give it a try!"

I made a big show of getting my tray ready while the radiology techs took a chest x-ray. I made sure to dispense plenty of advice to Rick about how best to line up the needles and scalpels and other elementary, condescending details. Rick just glared at me. I said, "Step aside, sonny, and I'll show you how it's done." I stepped up to the neck, found my landmarks, and in 30 seconds, the line was in. I pulled my gloves off with a flourish, and told Rick that if he had any further questions I would be happy to arrange a tutorial. Rick still just glared at me.

As I began to stride masterfully out of the room, we both noticed that the patient wasn't doing so well. His respirations were much more labored, his pulse was up, and his oxygen level was down. All of a sudden, the levity was gone and we were back to work, with a really sick patient. Of course all the docs out there know what happened, so I'll skip to the punchline: a repeat chest x-ray showed a pneumothorax. Rick suddenly had the biggest shit-eating grin on his face as he showed me the picture. "Well, doctor, you had better do something about that, hadn't you?" he said. So, faced with the deteriorating respiratory status of what was now *my* patient, I intubated him, sedated him, and put in a chest tube to relieve the pneumothorax. That is the trifecta: central line followed by intubation and chest tube.

And all the while, I had to endure Rick's insightful commentary.


*Central Line: a procedure where you shove a needle into the neck, usually into the jugular vein, and thread a catheter into or near the right atrium of the heart. Reserved for the sickest patients or those with no other veins to access.

** Pneumothorax: a rare but known complication of central line insertion in which the needle goes too far into the neck and punctures the apex of the lung. This causes the affected lung to collapse, worsens breathing (duh) and requires insertion of a chest tube -- a tube into the chest -- which re-expands the collapsed lung.

*** We're still friends, surprisingly.

**** Obligatory disclaimer: the patient was really out of it. Even I am not so unprofessional as to talk smack about another doc in front of a patient or family.


  1. Heck, Rick probably gave the patient the pneumo with all his unsuccessful attempts. That seems more likely to me, anyway.

  2. Oops, I see that he got an X-ray right before you started your procedure. Still could have happened that way though. The PTX might not have had time to become apparent yet.

  3. Ah that bitch Karman she'll get you every time.

  4. Fortunately, a chest tube treats its own complications.

  5. That's actually a rather funny story for something becoming incrediblyy f****d up really fast - I don't care who you are.... :-)

  6. U Rock! Hey thanks again for the note before I headed south of the border. Went okay except I was out of breath the entire time. Came back and my bp was 240/120. Internist sent me to cardiologist -did nuclear scans, echo and stress test no problems. Nobody can figure out what my breathing issue is. Oh well.
    Thanks again for the note. The blog is still awesome - as usual!
    The wannabe doc's here are all still huge fans!
    Write On!

  7. As you know, it's unfortunately all true. The ER gods are merciless.

    1. If you've never had an iatrogenic PTX, then you haven't done enough central lines.

    2. If you've never missed an appy, then you haven't taken care of enough patients with belly pain.


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