She breathes quietly under the sterile sheet, her breath fogging the plastic window they have provided. Her neck is a pale blue from the chlorhexidine. The white line is prepped and my arms are folded, chin down in a wide-based waiting stance I learned in the OR as a student. I breathe, too, to avoid pacing to the door of the ICU room.
Outside the fellow is waiting for another consultant to call him back and see if we should place a central line for plasma exchange. He told me to place the line, let me prep, then decided that we should call them. Now we're waiting, silent. I think about small talk but she's under a sheet and it seems too odd.
It's already been an odd line; I tried a subclavian and missed, which is not unusual, but then felt a pulse under the collarbone, which is, and the monitor started alarming, saying 'v tach' which it says for anything it can't describe. It's a bit like a bad hunting dog that way. But I can't tell and the attempt doesn't feel right so I stop, confirm she didn't have a heart about to stop by talking to her, confirm she has that pulse under her collarbone on both sides, and decide to use ultrasound instead on her neck.
She's a mom with eight kids so she knows hospitals and she knows pain and she's stoic but I wonder what she's thinking. The plasma exchange is for her kidneys; kidneys that are stopping from accumulated bacterial toxin secreted into her from their hideout in her colon. Perhaps made worse by the antibiotics and anti-diarrheal medication she got at the outside hospital.
We wait some more. How stupid, this training system. How preposterous. I can't move until he says so. Six years of medical training and I'm a puppy on a leash to a supervising cricital care fellow who can't decide by himself if he wants to put in a central line or not. He also continued her antibiotics, which we shouldn't have done. And forgot to call nephrology that night. At least he didn't re-start her anti-diarrheal.
The reason not to treat and not to stop the diarrhea comes from the suicidal tendancies of the bacteria. As they die, they release all their toxin, worsening the problem. The diarrhea, as uncomfortable as it is, allows at least some of the toxin to escape.
It's partly my own fault. I'm off my home turf, in theICU, so I'm less likely to actually speak up, but often as a resident you have to choose--do I stick up for this or just shut up and pass on the bad decision? The reason for me to pass on the bad decision is, well, I might be wrong; but that's happening less, and now my thoughts are more likely to be at least substantiated somewhere. The other reason is that even if you are right, some of our teachers are set in their ways, and they may just continue anyway even if you're right. Then you just get yelled at for no benefit.
So I wait. ICUs have their own background music. Chimes, and bells. The alarm for a heart rhythm that will kill in minutes is the same as if a sticker monitoring the patient falls off, so to listen to these alerts is useless. Just let them lull you to sleep.
Finally the OK is given. The line is placed. Dark blood easily filling a syringe in the neck is gratifying, meaning I'm in the right place, not the oh-crap-pull-the-needle-out-and-hold-pressure-and-hope-she-doesn't-stroke-or-bleedout-place. Dressings placed, dated. Line confirmed. Checklists completed. Dressing off. Head of bed up. Now if only we didn't have people getting in our way, we could maybe get some work done.