January 20, 2010

• This is Spinal Tap

  Am I keeping to my once a week posting, or have I already broken my resolution?

  In either case, it has been a busy busy week. I have been fortunate enough to perform two lumbar punctures on patients and it wasnt anywhere near as scary as I thought it would be. I find that happens a lot in residency…I spent all medical school getting all psyched up about one thing or another that I thought would happen when I became a real doctor, and then it actually happens and it turns out not to be anything I can’t handle.

  But I digress. My very first lumbar puncture ever was on a elderly (surprise surprise) gentleman who was pretty much comatose by the time he came in. The ED doc had stopped by the workstation to talk with the attending and asked if there were any residents around who wanted to do a procedure. As part of residency, we have to do X number of procedures like paracentesis (draining belly fluid), lumbar punctures (spinal taps) and ABG (drawing blood from arteries) to ensure that we are capable to provide any kind of care at any time as part of the diagnostic workup. So off I went to do the procedure with the ED doc providing a watchful eye and a guiding voice as I did my very first solo spinal tap.

  The gentleman was rolled on his side and placed with knees to chin, balled up in the fetal position as tight as the nurse could make him. This helps curve the spine and presents the maximum surface area available for me to slip a needle in between. This is good because the last thing you want to do is miss the spinal fluid and accidently stab the spinal cord. Then after feeling for the anatomical landmarks, the spot was marked and confirmed by the ED doc and I numbed the area and in I went. I’m told by friends who have had it done that it is a fairly painful procedure but this gentleman didnt even flinch, which told me just how sick he was. Fortune smiled upon me however and I got it on my very first try…a gentle popping sensation and sound as I passed through the vertebral colum, and when I withdrew the trocar (guideline inside the hollow needle) a clear fluid came dripping out. I collected in into 4 small vials and then sent them off for studies to find out if he had an infection in his spine.

  Now quite often interns will cause a “traumatic tap”. This means that they dont find the right space on the first try and the first vial will have a high degree of red blood cells, and thus be pretty much useless to the lab. High degree is 60rbc or higher. COnversely, there is also a “champagne tap” wherein no rbc’s are seen, and the csf (cerebro-spinal fluid) collected is clear like champagne. It is also called that because if you actually achieve fewer than 10rbc’s, or a totally clear tap, the attending who supervised you is supposed to buy you a bottle of champagne. So my very first one had 22rbcs in the field…too high for free alcohol, but a pretty respectable number for a first try by a rookie.

  ….

  About three days later, I have an 80 year old woman with severe dementia who initially came in with a pneumonia, but has altered mental status a little more severe than could be explained by her dementia alone. So infectious disease specialist is consulted and recommends a lumbar puncture to rule out meningitis (inflammation of the spinal cord). No ED doc around this time to help, and my resident has clinic. She offers to find a third year to supervise me, but reassures me that, “you have already done one, you will be fine” The third year who is there to supervise has only done one in his three years of residency.

  Let’s pause there for a moment, shall we. The person supervising me during this procedure will have less experience than me by the end of the procedure. Ah, residency.

  Carrying on. Unlike my first patient who was knocked out 6 ways from sunday, my current lady is demented, angry, fidgety, and has a mouth like a sailor. It takes 2 nurses to hold her in position and this time I am doing the whole procedure from memory, with minimal input from the supervising resident. (which I am okay with, i just didnt want to be alone to do this) I found the landmarks on my own, I cleaned and draped the patient and even had to use my “doctor voice” to quiet the lady down because all her moving only prolonged the pain and procedure for the both of us.

  Unfortunately, the first attempt, I missed the landmark completely, placing the needle about 1inch too high…whether because of the difficult behavior of the patient or my own inexperience is anyones guess.

  Rallying to the fight however, I knew my mistake, and just like in showbizness, you never let them smell the fear. I simply told the patient that I had to do the procedure again and she would have to stay still this time. I then re-anesthetized the same area 1 inch lower, and set back to work…and a short time later was rewarded with spinal fluid. I had guessed my mistake correctly and adjusted myself accordingly with no one other than myself (and the resident) the wiser. And for all that the rbc’s in tube 1 was only 61, with the patient not suffering a post-lumbar puncture headached that commonly occurs after traumatic taps.

  So while my second attempt did not warrant a bottle of champagne, I still celebrated with a glass of beer for a job well done. One of the procedures that had frightened me so much in medical school, the thought of putting a needle into someones spine, had succesfully been done by me twice in one week on an easy and a difficult patient and both times I had achieved success.

  Looks like I’m starting to get the hang of this whole doctorin’ thing after all

  • 1:09 am
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