For the last 4-5 days, I have had an unstable patient I have been working my ass off to keep alive. 15 different problems, the top three of which were acute respiratory failure requiring mechanical ventilation, shock believed to be septic (infectious) in origin requiring pressors, and acute renal failure on the short road to dialysis. In short, this guy came in with multi-organ failure. 

And the very first day he came in, he also was having atrial fibrillation and a minor heart attack, meaning I was rushing around trying to put in a central line to give him the pressors, checking blood gases and labs every hours giving this person ridiculous amounts of my attention. And from that first day he looked like he improved a little. Still seriously gravely sick, but not at death’s door. At best, in death’s driveway.

I got in touch with his family, and found out he was DNR (do not resucitate) on day 1. Yesterday, on my day off, the covering doctor called the sister and gave her the daily update about his steadily failing kidneys and inability to get off the respirator, telling her basically she might want to consider coming in as his condition was looking worse by the day.

She responded that she couldnt as she lived out of state, and told us in accordance with his wishes to withdraw care, initiate comfort measures only and let him die with dignity. She made only one request.

“Before you extubate him, could you please give him a hug so he doesnt die alone?”

…

I could use a hug myself.

My “Family Voice” has been getting a lot of practice these days.

The “Family Voice” is something that I think all doctors subconsciously develop somewhere along the way during residency. It’s the tone, the inflection, the parsing of words we use when talking to the patient or their family. This is not to imply we treat people like they are stupid or uneducated, though that happens quite often as well. What I mean, however, is the way some residents will lower, or raise their tone the way you might change your inflection when talking to a dog or small child. Some slow their speech as if to make sure each fact gets through, while others speed up perhaps hoping to get all the worst info out in one go. Everyone has a different way of speaking and one we never seem to use when speaking to colleagues, calling consult, instructing nurses, or even chatting with the cafeteria staff. It’s a special way of speaking used just for the patient and their families.

Most of the time, it is used to break bad news. “I’m sorry but you have cancer.”

Other times it is used to force families to make hard decisions. “We need to know what your father/mother would have wanted-should we continue to leave them intubated?”

And these days, I find myself using it as a means of authority. “Miss, he’s coding and you NEED to leave the room while we work.”

At first, I felt like most of the authority came from the coat. It was my armor, my shield, and I could hide behind it and spout great pronouncements of fortune and favor or doom and despair. Later, I thought it came from the education. I knew the jargon, and I could rattle off big words and fancy phrases until the average person would agree just because they no longer knew how to disagree. Now I have learned that it comes simply from The Voice.

When I use The Voice, it’s not about defending myself, or sounding smart. It’s stating facts, what I think is best for the patient, or what information I need to be provided in a tone that brooks no argument. It is neither insulting nor cajoling, just a pure issuance of confidence that I have found people respond to. And because of that, it gets results. History that was previously hidden, difficult family stopping to listen, even if they disagree. 

And because I get such good results, I find myself using The Voice more and more often. In some ways, I am watching my future hospital me develop, one skill at a time. Right now, it is still Dr J using the voice as part of his work toolbox. But I can easily see it developing its own personality, and becoming the hospital Dr J, while regular Josh continues to develop in his own ways outside the work environment. 

And while you may disagree, I think it’s a good thing. A way for me to separate my work and pleasure, my yin and yang, the two halves of my personality that just cant seem to reconcile with each other despite the things they have in common.

Or maybe I am still looking for any safety net I can grab as intern year draws to a close. 

Ah yes, back in the ED. Now normally I am not a fan of the fast paced, minimal follow up, shift work mentality that the ED creates by nature. However, it does make for some fascinating stories…a brief selection of the patients I saw today by chief complaint

1. Triage Note CC: Chainsaw Wound to the Face

No, i was not fighting zombies, and neither was this 40 year old landscaper. No, he was merely up in a tree cutting branches with a chainsaw, when it backkicked and cut into his face. He was so startled by the ordeal (and cmon, who wouldnt be?) That after cutting his face up with a chainsaw, he fell out of the tree. Not to worry however, as while he will have a nasty scar along his lip (think joker smile) his facial nerve was intact and the cut didnt even go all the way through his lip or hit his tongue, so no long term damage, just some cosmetic plastics work.

2. Triage Note CC: Exploded Left Boob

A 27 year old young lady who was not satified with her natural endowments went in to see a plastic surgeon for a boob and nose job…aka the trifecta. About 6 hours after the surgery, she noticed that her armpit was damp, checked it and saw rather a lot of blood. So she called the surgeon who told her to go to the ER. On my inspection, her inciscion had dehisced (i.e. the sutures came out and the wound opened) and her newly accquired “assets” had begun to fall out of the pocket. As if her sliding boob was not bad enough, as it began to come out it got caught on some hook in her bra or some other sharp edge, and then sprung a leak. Hence, exploded boob to the ED!

Best part of the conversation between my attending and the plastic surgeon over the phone
Surgeon: Are her breasts swollen or enlarged?
ED Attending: They look pretty enlarged to me, but wasnt that why she went to you in the first place?

She ended up signing out AMA to go back and have the surgeon redo her boob rather than stay the night to make sure she didnt pass out or have an infection

3. Triage Note: LOLFDGB (little old lady fall down, go boom)

An 86 year old woman came in with a swollen ankle and knee after having fallen down sometime over the last several days somewhere in her apartment building. Why all the vague details? Because said 86 year old lady was DRUNK. Like chronic alcoholic drunk. But a cheery one.

Dr J: Do you drink
LOL: Nope, never.
Dr J: what about today?
LOL: of course I drank today…what a good doctor you are, good job!
Dr J: Erm, thanks…what did you drink?
LOL: ALCOHOL! ahahahahahahah

There was also a lot of “doctor doctor look at me look at me look at me…never mind!” On further talking with her family, we learned that she had been a chronic alcoholic who had pushed most of the family away with her random behavior and frequent entertaining of male visitors (as put succinctly- ‘my aunt is kind of a hobag’) While In reality this is a sad situation, for the moment, she was the cheeriest person in the whole ED and we simply made sure she had no fractures and sent her home with a relative who promised to look after her so no more fall down go booms would occur

And Now to catch you up on some of the previous drama from my last wards rotation

The Jerry Springer Heart Failure Patient

One of my patients on my last service was an obese noncompliant male with terrible heart function. It was so terrible that he ended up having to be intubated for a time and required over 31 liters of fluid to be dialyzed out of him. That means we took roughly a small child or large dog’s worth of weight off this gentleman. While we were rounding on him one day, we noticed a woman sitting by his bed. Now as we had not been able to get in touch with the family prior to this, my team thought they had finally shown up. So my attending introduced herself

Attending: Hi I’m Doctor ****
Woman: hello, I’m ****
Attg: You’re a family member?
Woman: I’m the mother of his children
Dr J: (hmm, that’s a weird way to introduce yourself)
Attg: So you live with him?
Woman: No
Attg: (maybe they divorced) Oh, so he lives with his children?
Woman: No, he lives with his wife, but she don’t take care of him like I do

OH SNAP! Baby Mama Drama about to bust loose in the house. Later that day, the social worker managed to get in touch with the wife and asked her about the baby mama. The transcribed hospital note went something like this:

Social Worker (SW): Informed mrs *** of pt’s ‘baby mama’ visiting at which point Pt’s wife became hysterical and angry. She informed me over the phone that “That bitch aint nobody’s baby mama, we done got dna tests and he didnt leave no sperm in her slut belly to grow out anything, and we done got a restraining order gainst that ho and if she shows up again y’all better call the police or I will come down there and leave her in the hospital” Informed pt’s wife that the police would be contacted should the woman show up again and politiely ask her to leave

Situation defused.

——-

Greek Easter On the whole went well this year. Sadly I was quite pressed for time and had to make a smaller menu with some things not coming out entirely to my satisfaction. The spanakopita wasnt quite flaky enough and the easter bread not given enough time to rise. I opted not to photograph the food this year because I wasnt happy enough with it. However, the only ones who knew the difference were my greek friend and his mother and everyone else gathered together for a good meal and excellent conversation which is really what the important thing is. This year, some of my chicago friends were unable to make it out to cali to celebrate easter with me, which was unfortunate as we have all been doing this together for the last 5 years.

I wanted them to all gather together to have a greek easter dinner like we all did when I was there. However, plans can be difficult to put together with work schedules and excuses and my absence. So I did the one thing I knew would bring them all together and short circuit any objections: I sent a check. One of the nice things about being a doctor versus a med student is that I can afford to splurge every now and again on little things, and by sending money to a friend I knew wouldnt try to return it, I managed to effectively gather everyone and make sure they had the same experience that we were having back home without even being there. Well done, hypothetical me!
————

So As you can see, I have been incredibly busy what with hospital shifts, complicated and crazy patients, holidays, and upcoming travel, hence the lack of time for putting thoughts to virtual screen. But I promise I havent abandoned you and will continue to post as the inspiration strikes me. Til Next time, stay well, and keep smiling

-The Josh

I have my own panel of patients now…which is kinda neat, admittedly.

To elaborate, every thursday afternoon, I have what is called my “continuity clinc”. It is supposed to teach you how doctors follow up their patients over the long term, providing continuity of care…one doctor, one patient, no illness left behind yada yada yada. What it has actually been for the most part is an urgent care center where once a week I see patients with simple complaints like pap smears or colds or medication refills because their regular doctor isnt available to see them.

But in the last month or two I have been starting to slowly get my own panel of patients, people for whom I am their primary care doctor, their gatekeeper to hospital medicine. If they need a referral, it comes through me…if they want to see how their blood pressure control is, I am the one with whom they make an appointment. It’s rather empowering, and makes me feel just a tiny bit more like a doctor having a group of patients to whom I can point out and say “these? they are MINE.”

And of course at least half that panel is spanish speaking only as I am one of only 3 residents and apparently only 20 some odd physicians in my hospital who speak enough spanish to carry on a conversation in it. Which I find staggering, as I work in California where white people are actually a legitimate MINORITY now. (and yet still no affirmative action grants and loan forgiveness for us, go fig.)

However, I like the added challenge of speaking with a patient in a foreign language. It turns even the most mundane visit (i need a refill of my blood pressure meds) into an exciting conversation and telenovela (PERO DOCTOR, NECESSITO LA MEDICINA POR MI CORAZON Y PRESION!).

——————————

Speaking of Mi corazon, i am going to go off on a brief tangent here about Valentine’s day. I am not super anti holiday, but neither is this my favorite holiday as I tend to spend it alone for one reason or another. However, several friends and I have a singles tradition as it were whereby those of us unable to secure dates for the occasion will instead stop by hallmark, pick up a nice, generic card and then bring it with us…

…to the local strip club. Where following several rounds of drinking and leering, we then each present a different exotic dancer with a valentines card to let them know that their hardworking efforts at putting themselves through school are appreciated by somebody.

I like to think that we help to improve their day just a little bit, like hugging your garbageman or leaving a surprise cupcake in the mailbox for your postman…it’s all about catching people by surprise.

Of course one friend who is new to this tradition called me up the other day to happily decry…”dude, I was in the grocery store walking past the card aisle for valentines and I started feeling all bummed that I didnt have a gf and then I remembered…strippers!”

And just like that valentines day will never be a day of misery/frustration/longing for a certain subset of the population again.

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

Okay, I admit it.

Much as I complained and whined about ccu, it has already made me a vastly better doctor in terms of my knowledge base and how confident I feel in dealing with patient medications. It happened so gradually I didnt even realize it.

Not even one month ago I would make a note about medications I though should be changed and wait til I could bring it up in rounds phrased as a “maybe we should…what do you think?

Now I am making changes as I see fit in the mornings, and present on rounds with here is what I have done in reaction to my findings. And if I erred (and sometimes I do, but less often than I was worried I might) I am corrected and learn something else from it. I am finally starting to stay ahead of my patient’s findings instead of always chasing after labs. I am beginning to learn to anticipate and develop my clinical judgement. Which is a nice holiday gift

Which is good because I am working on both xmas and new years. But at least I am back on R service and have once again found my small joys. It makes a difference

So xangaland…wishing you and yours a happy holiday season and a merry xmas full of all the small joys you can find. Hope they have added up to a great year!

-Dr J.

Sometimes I stop and think how strange it is to be a doctor

I see people when they are sleeping and totally vulnerable. They tell me things that they wouldnt tell their best friends, family, or even priests.

I alter their very body chemistry-Magnesium too low? give some IV! Now tell me, when was the last time you ever even thought about your magnesium level, or that you had one? And yet here I come to tell you that your current level is unacceptable, and I am going to “fix it”. And this is a minor thing, which leads me to…

I tell people that they need to be cut open, or have tubes shoved through their groin to their heart, or that they have to start taking pills to thin their blood and/or make them pee for the rest of their lives, and THEY AGREE TO THIS. Now dont mistake me, it is important for them to do so, and I have justification for these pronouncements…but the fact that people take what I say at face value just because of an article of clothing I wear blows my mind.

and that’s all for that.moving on to another fun er junkie story

“I was on my way to my girlfriend’s place and did some meth in the car because if I waited till I got there she and her roommate might use it all. But there was something wrong with it and I began shaking, and got real dizzy, and then began puking all over the steering wheel. Then my vision got blurry and I couldn’t see the road very well, and I was afraid to pull over cause then a cop might come try to help me, and I’d be in deep shit, so to be safe I started driving as fast as I could to get to the nearest emergency room”

and here is a fun little picture for no good reason

Currently I am rotating in the coronary/cardiac care unit, or ccu.

I dont like it.

I have been a doctor for almost half a year now, and this rotation is the first time that I have actually felt like what I do is “work”. I dont remember being so unhappy even when I was doing my two months of night float, running to every code and socially isolated from everyone else.

Every single day on this rotation has taught me, but it has taught me in such a way that I go home feeling defeated, disappointed, and dumb. I look at an EKG and I have learned to recognize specific types of abnormal rhythms, but cant wrap my head around the spatial orientation of the leads that those rhythms represent. (by contrast: the fellow looks at a morning EKG and can say, oh the surgeons will probably find this vessel occluded because lead v2 has an inverted t wave-wtf?)

I come in earlier and earlier each day and still cant seem to stay on top of all my patients before we round. I know what happened during the night, I know what meds they are on, but I will forget bits and pieces of the their other problems or plan during my presentation because I will mix up details between the 6 people I had when I left, and the 3 new ones who came in this morning, all 9 of who I am apparently supposed to have memorized to the smallest detail by 8:30am.

The fellow subtly reminds me and the other two interns on an almost daily basis now that if we cant get all this done in a timely fashion, we might just have to come in earlier. I already get there at 6am, and that’s after a 40 minute commute. Then he will tell us how back in his day, he used to be responsible for more people, earlier and it could always be worse.

Yes, but it could also be better. Isnt that why things like duty hours and other resident sparing measures were implemented to begin with?

I feel like I am a constant disappointment to the attendings when I am pimped and even when I come up with the correct answer its not fast enough to suit them. Now, to be clear, neither the fellow or the attendings are in any way mean or belittling. Quite the contrary. All the suggestions they make are legitimate, and necessary and really will make me a better doctor…it just would be nice if every once in a while I could hear that I did something well rather than that I could do something better.

Or maybe I really am just a terrible doctor.

It’s the constant doubting of myself that this rotation is causing that is really taking it out of me. Now I have a habit of becoming a little bit more easily depressed during the winter months (as do many people) and I was hoping that being in california with more sun, among friends, and enjoying what I do would help with all that.

But I dont see the sun…I get to work and leave work when its dark. I am friendly with all my coworkers, but have really only one or two I trust enough to call friends and complain to without having to worry about who might say what to whom. And I dont have an academic interest in the heart to begin with and this rotation certainly isnt going to improve it.

I am a categorical intern for internal medicine. And I need to know this stuff. But learning it like this is slowly killing my spirit. And I dont know how much more I can take and still put on the “thank you sir may I have another” act.

I know I chose a hard profession, and it wont always be fun and games. I just didnt think it would get to me this early. and take away so many of the simple joys, like having time to myself, or cooking dinner, or stopping to watch the sun out the window.

I guess I just wish there was someone else who understood. and who I could trust enough to confide in.

Oh well. Happy Holidays.

I think there is an unspoken expectation that people at the time of their death will have last words. Some final message they have been waiting to impart, whether it be words of reconciliation for long estranged relatives, or a simple goodbye to those they love. In this archetypal deathbed image, family members are gathered around the bed of the dying, who is clear, lucid, and distills a lifetime of experience into a few words of wisdom before sighing once, and passing on.

The sad reality is that most people never get a chance to say anything before they die, because they have long since lost the power of speech.

I recently sent a man home to die. A man who, a mere month ago, I had treated for a relatively straightforward pneumonia. Unfortunately, old age is insidious, and at a certain point, it can become quite hard for individuals to recover even from straightforward diseases. On his readmission, this elderly gentleman stated his pneumonia had resolved, but he still had fatigue. So we admitted him, and began working him up to locate other possible sources of the infection his labs indicated he still had.

And I spent the next 2 weeks watching him slowly but gradually decline from an interactive, lively, hard of hearing old gentleman breathing on his own to a nonverbal, nonambulating, shell of his former self, lying in bed on oxygen, while the family met with the palliative care team. A thorough inspection had revealed no infectious source, his cardiovascular status had gone from poor to practically nonexsitent, and finally I had the dubious responsibility of telling his family, “I’m sorry, there’s nothing more we can do. Perhaps it’s time you think about taking him home.”

The family, while saddended by the news (understatement though THAT be) understood, and we discussed the options available before they decided they were in agreement with comfort measures only, a do not resucitate order, and bringing the patient home to die in a familiar setting.

I signed the discharge orders, knowing I would never see this patient again. I tried harder than I could say to recall when the last conversation I had with him was, reaching to find anything at all that could be construed as last words and not just my one sided questioning of daily symptoms to which he could only respond with nods. I came up with nothing.

So I sent the family home with last words of my own: Whatever your beliefs are, I sincerely hope that your loved one finds peace and happiness in accordance with them. Then I stepped over to the computer, clicked the order to discharge, and watched as they disappeared forever.

The numbers on the clock read 3:30. 30 minutes until I am protected from admissions, 90 minutes until I get to go home. I spend my time idly performing chart review for my research project, digging through months of notes to grab minor details for the statisticians. Suddenly the pager goes off.

“Oh no oh no oh monkeyfeathers!”

“Hi Dr J, we have a patient for you to admit, and this is a good one for the subintern, so have him do the H&P.”

I inwardly cringe. The sub-intern on my team is a nice guy, but like all students cant help but slow me down when I was hoping to knock this out and be out by 5. Nonetheless, I agree, the sub-I and I briefly review the pts chart and down we go to visit him.

The pt is a 55 yr old gentleman with a past history of high blood pressure, high cholesterol, and recurrent urinary tract infections here with another urinary tract infection and some shortness of breath. I let the student take the lead in questioning while I scribe notes. After 10 minutes (my patience threshold when I am trying to go home) I subtly begin to help direct the students questions to the pertinent information.

The biggest concern with our gentleman is his low blood pressure. Someone who reports a history of high blood pressure coming in to the ED with 74/61 is worrisome. More so when that blood pressure barely corrects after 4 liters of fluid. To clarify, I want you to imagine you have just drunk 2 of those giant soda bottles.

Despite the fact that this man is sitting up and talking to me, that he appears relatively healthy, he is in septic shock. Lab tests revealed more disturbing values. A creatinine (kidney function measurement) of 5.4, where a normal level is 1.0 So on top of his sepsis, he had acute renal failure. Oh yeah and troponins were elevated as well (heart injury lab) meaning he had some demand ischemia (almost, but not quite heart attack) also likely due to his sepsis.

So it was off to the ICU with him. I called up the admitting fellow and informed him of our plan.

“Yeah that sounds fine, but drop a central line in him so we can give pressors and antibiotics”

No problem, except I had never done one of those before. Looked at my watch. 5:30pm. Duty Hours and my internal devil are telling me to sign it out and call it a night. But how in good conscience am I just supposed to walk away? Do I tell the family, sorry, residents have an 80 hour cap, some other doc will come in and jab a needle into a major vessel.

So I sighed once for my lost evening, and went to track down an attending to supervise me while I placed a central line. A central line is a large bore catheter placed in either the neck, chest, or groin. Most interns/residents tend to opt for the femoral option as it is 1)slightly easier to place a line and 2) does not carry the risk of puncturing the carotid artery or causing a pneumothorax among the more traditional complications of the procedure

I, however, am not most residents.

I explained all the risks of the procedure to the patient, and then the benefits and why I thought he needed this and should consent. I clearly managed to convey the appropriate authoritative and experienced image because rather than saying “YOU ARE GOING TO JAB A HUGE NEEDLE INTO MY JUGULAR VEIN? ARE YOU EFFING CRAZY?” instead he went with the more traditional-”whatever you think best doctor.”

Perhaps he may not have had the same level of confidence if he knew this was going to be my first one ever. But hey, that’s the price of going to a teaching hospital, right? The secret to success is sincerity-once you can fake that, you’ve got it made.

Gowned and gloved in sterile attire, I palpated the gap between the two heads of the sternocleidomastoid, finding that magic triangle, in which the ultrasound tech located the compressible vein. Then, after cleaning the site, and injecting lidocaine to numb away the sensation of having a rookie poke around in your jugular area, in I went!

I wish I could tell you I was insanely talented and got it on my first try. However it took about 3-4 times of advancing and retracting the needle, and finally moving more lateral away from my initial puncture wound before I finally saw the inrush of venous blood. I maintained my serious doctor face the whole time while my internal monologue was screaming “YOU HAVE A NEEDLE THE LENGTH OF YOUR HAND IN THIS MANS NECK, QUIT MUCKING ABOUT!” and successfully inserted the catheter with only a modicum of blood spilling onto my gloves, and no complaints of pain from the patient.

I had successfully inserted my first central catheter, with no complications, and in a more challenging location. I ordered a chest xray to check the placement, and sent him off to the ICU. The time was 8pm, 3 hours after I was supposed to be off, but totally worth the experience. Next time, I will be much less hesitant and once again, I will go for the throat!

Dr J