Monday, November 15, 2010

Baby's First Chest Tube

Well, I finally finished medicine.  I can't help but shout a good and proper WOOHOO!!  because I really was getting pretty tired of it, after so long.  Don't get me wrong, internal medicine is important, and of course I have to know how to manage a heart attack or a stroke or blah blah blah.  But honestly, so much of medicine is simple paper pushing, or dealing with "soft admissions" (someone who really didn't need to be admitted but we did it anyways to cover our asses), or patients trying to get out of work, or whining about pain.  I exclude the ICU from this criticism, because I feel like I learned so much from my two weeks on ICU.  Those patients are actually sick, and because there are less of them but with more problems, you can really dig into the physiology aspects of all of the disease processes and get a bigger picture of sepsis, end stage renal disease, end stage cancer and post-operative management.  I have two more weeks on ICU coming up that I am really looking forward to, but I just wish that my surgical program required us to do two months of ICU, instead of forcing us into a month of medicine.

My last day of medicine included a 24 hour call.  In our hospital, the night shift manages the patients for 6 nights a week, which means that their night off must be covered by a 24 hour call.  It's not so bad, but they only put two interns to cover a fully functional hospital, which includes things like discharges, transfers, writing daily progress notes and taking in lots of new admissions.  Our census was especially full this weekend, and my co-intern and I could see that things were going to be somewhat nasty.  I agreed to take step-down / telemetry (boo!) so that I could also get the ICU, gambling on not too much drama happening in the ICU, allowing me to focus on the extra-packed telemetry unit.

Boy, was that a stupid mistake.  The previous night, a young guy came in after not being able to breathe for a long time.  Because he was young and healthy, his heart came back after several rounds of cardiopulmonary resuscitation, but the damage was already done and his brain had suffered from lack of oxygen.  It was a very sad case, made worse by the fact that his family was so calm and quiet through the whole thing.  I spent the whole day fighting back tears and thinking of my parents, and how awful it must be to suddenly lose someone so precious to you.  (This was made worse by the fact that this patient was SMOKING HOT, which I know shouldn't matter, but it was like God gave a gift to women and then selfishly took it away.  Just wrong.)  So I spent the morning accompanying him to the CT machine so that we could evaluate the extent of damage, then talking to the family about options for transfer.

The sanitized version of putting in a chest tube.
I had not yet been able to write a single progress note on a patient when E, one of my favorite surgical residents, mentioned a patient of mine on telemetry who seemed to have fluid building up in the space around her lung.  This patient had just undergone a very minor and routine surgical procedure the day before, and her chest x-rays were getting progressively worse.  E paged me to say that it looked bad, and since her oxygen saturation was dropping and she looked pale, we would have to place a chest tube and try to drain whatever was accumulating.  We were all hoping it would be pus or some other fluid, and not blood, but the odds didn't look so hot.  E generously offered me the chance to put the chest tube in, which I jumped at, because I had never done one myself and I knew I would have to when I rotated at an outside hospital.

There are times where the human aspect of medicine collides with the surgical aspect of medicine, and it's frustrating because it's so easy to just dismiss the human part.  This patient spoke very little English, and she and her husband were both frail elderly people.  We explained multiple times, with a translator, the emergent need for the tube, why we needed fresh blood samples, and why it would be better if everyone stepped out of the room for the procedure.  But it was hard to stay patient with them as they struggled to understand - all they could see was that we kept sticking her with needles for blood, and why weren't those samples good enough?  And why can't our daughter come in, and our son-in-law, since they all speak English?  And why is this so serious?  And where is the attending who did the procedure yesterday?

Not the real patient, but you get the idea.
I have to admire E for her composure, I know that she was irritated by how long it was taking to get started, seeing as the patient was in impending respiratory failure, but she still spoke so kindly to them.  When we finally set up, it was with the husband on the opposite side, and our student holding her arm up for support.  She showed me how to drape the area, mark the rib space I was aiming for, properly administer the lidocaine for local anesthesia (I find it weird to hit a bone with my needle and inject onto it, I'm not sure why), then cut into the space and stick my finger into it.  Yes, I actually jammed my finger between someone's ribs.  The trick is to use a curved Kelly clamp (looks like scissors but no sharp ends) to bluntly separate the tissue enough to get your finger in, and then use your finger to guide the Kelly further in until you poke a hole into the space surrounding the lung.  Usually, you know you're in because you'll see a gush of fluid coming out.  And, damn, it did.  At least half a liter of blood came pouring out of the space, and we struggled to get the tube into the space because I unfortunately had not widened the hole enough.  (I didn't realize how tough that tissue is in between the ribs!)  E helped me out, and we got the tube in place, stitched it securely, then connected it to a vacuum system.

We knew she was going to be ok when, as we rolled her in, the ICU nurse welcomed her with a "Hello, babushka!" and she responded "Babushka is KAPUT!!!".  We all nearly died of laughter, and she settled down for the night with lots of fluids running.  My patient did well overall after being transferred to the ICU, and her x-rays after the tube looked a lot better.  I spent the rest of the evening fielding snarky comments from the medicine attending about how I hadn't finished my notes yet, but I didn't regret taking the time to be a part of the procedure.  I learned a lot from that first chest tube, starting with the fact that I find them oddly satisfying (much like lancing open a giant abscess), and I will work on being more efficient with placing them.  I learned that even really minor procedures can carry big risks, and I shouldn't ever take post-operative recovery for granted.  I also learned that, once in awhile, you have to take the heat for focusing on the sicker patients and not worrying about the paperwork.  There will always be an attending, a resident, a nurse who is irritated that I wasn't there to do what they wanted or needed from me, but that's medicine.  Sometimes I will get pulled in different directions, and the important thing is to triage patients and get the most important stuff done first.  (It's also important that I grab opportunities to learn how to do surgical procedures when they come, so that I can do them by myself later on when nobody is watching my back.)  If it means writing the notes later in the evening, or drawing routine lab work at an odd hour, it's not the end of the world.


  1. Congratulations on finishing medicine!

    I'm sorry about the patient who died. It's so hard when it comes out of nowhere.

    I'm glad you liked your ICU stint. Have you done any time in Emergency? I'd be interested in hearing your thoughts on that, as it's a contender for my own post-med school career.

    I've seen a chest tube placed once, but for a spontaneous pneumothorax, so nothing *visible* came gushing out (I'm well away from performing that kind of procedure myself). I'll be doing two weeks of surgery (neuro and acute general) during my summer break, so will keep your lesson about post-op recovery firmly in mind! It'll be my first exposure to surgery, so I"m really looking forward to it!

    What's your next term?

  2. I just completed my first shift in the ER, it wasn't too bad overall but I'm glad I don't do it for a living. A lot of people consider ER to be the manly and acceptable alternative to surgery, but I just don't do well with shift work. I'm one of those people who can fall asleep the second I stop moving, and I like that I can catch some zzz's in the call room if I have a quiet night on surgery. In the ER, you have to stay by the desk no matter what, which is pretty torturous for me. But that's just my body physiology, and a lot of people prefer shift work to taking call, especially if they are planning families. (I simply plan on pawning off all future spawn onto the grandparents. Grandbabies are like crack for them.)

    The thing with post-operative recovery is that you really can't take anything for granted. We all see a million cases of very routine, even tiny procedures where nothing goes wrong, and we assume that there's really nothing to worry about. But accidents do happen, and it's important to be vigilant.