10 September 2010

Friday Flashback - 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.

Originally posted 31 August 2007


  1. We once had a septic patient who was on a few pressors. Infectious disease wanted his current central line out like, yesterday. It was a Sunday night some other terrible time for this to happen. A surgery resident came and pulled the old line and put a new one in. Surgeon left all gloating about how it was a piece of cake, took no time, and anyone could have done it, why'd he have to be called? About 30 seconds later the patient was SOB and had breath sounds in only one lung. We paged the surgeon back. He called us back and the first thing he said was, "I just hate getting paged to the floor I was just on putting in a central line, should I bring a chest tube tray, or do you already have one in the room?" It's already there, come on up doc.

  2. Please be so kind as to not link to a private blog. It's frustrating to we peasants who have not been invited to the party.

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  4. Sharon- This is a "flashback" post. It was originally written awhile ago. When the post was first written, 10/10 was a public blog that anyone could read. He stopped blogging awhile ago and I'm guessing locked it just to prevent people from spamming the comments. He no longer blogs.

  5. Shadowfax,

    Have to ask -was not the pneumo "Rick's"? He was the one struggling, and probably jabbed hard and frequent. Too bad no CXR before your line attempt.

    If the patient is not in extremis, I make it routine to order an xray after someone elses line attempt prior to mine. Helps determine paternity so to speak...


  6. I usually take a peek with the US probe to look for pneumo now--my impression is sensitivity exceeds CXR, but don't kow the data. Anyone know?

  7. For all the doctors out there? Hell, I'm "only" a paramedic and I was saying out loud "He punctured the lung... He punctured the lung" right up until I read that indeed, you pnctured the lung - didn't even take a doc to see that one coming.

    Good story, though!

  8. they say if you haven't caused a ptx you haven't done enough central lines. i guess you've done enough central lines.


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