In A Lighter Vein

Action Potential, an Australian Medical Student Blogger, speaks of her first blood draw and the North Korea-South Korea standoff (with USA in the fray: where there is war, there is USA!) in her post There will be blood. Reading this reminded my of my first IV Cannulation. Now, in my hospital, there is no phlebotomist so, the juniormost doctors have to play the role of the phlebotomist. From drawing blood to placing central lines, we do it all.

Anyways, so my clinical rotations started with Psychiatry, which was an OPD based department. We did not have an Indoor, so there was no need for any blood draws of IV Cannulations. About 10 days in, one of my friends called me as we were wrapping up the OPD. She had ER shift that evening and was too ill to come in. She had tried a lot of our friends but they were either otherwise tied up or unavailable on such a short notice. I was, of course, free for the rest of the day once OPD closed up, so she requested me to fill in for her. I was glad to have got some action at last, after sitting around talkingtalkingtalking for ten days. So, I got out of the OPD, grabbed some lunch and rushed down to the ER and made it just 10 minutes before her shift was due to start.

Now, let me give you a background check on how most of the ERs in teaching hospitals all over India are run: they are run by Interns, with a couple of residents from different departments and an attending and nurse chipping in.

When I entered the ER, a surging tsunami of patients met my eyes! I was standing there, transfixed, when the resident, who was already swamped asked me if I was supposed to be on duty. On getting an affirmative, he immediately handed me a patient, who had explosive diarrhea for the last 18 hours and had just decided to come into the ER. He wanted me to secure an IV cannula in place and start him on IV Fluid resuscitation. Even before I could find my voice to say that this was my first day in the ER, he had thrown himself into the surging throngs of the sick and was lost to sight.

I had drawn some blood and my experience with putting in an IV Cannula was almost directly proportional to the information yielded by how-to videos from You Tube – like this one:

I trudged over to the patient and was met by a spectacle. A frail old man lay surrounded by 15 or so people of different ages. The ladies were lamenting on what they had done to bring down the wrath of the high heavens down on their family and the male members were looking around, acting stoic and unperturbed at the disaster. I did a cursory history and physical examination and found that the man was not only having diarrhea, but also was vomiting. He had taken some Biriyani the previous day, when he was alone at home, and his family had gone to some relative’s home. A classic case of food poisoning, if there was one. Besides, he had thought that it would “go away” and decided to not tell his family about it. They had found him, collapsed outside the bathroom at home and brought him in, It was on the way in that he told them what his problem was. The patient was really dehydrated and was at risk of dying. So, I decided to get the line in and rushed back to get the stuff.

 

As I headed back, I found that the man was getting worse by the second and was almost unconscious. I realized the need to start IV resuscitation immediately. It was quite some task trying to clear the room out, so that I could deal with the patient. The family members started crying out louder when they were thrown out of the room finally.

Now, left alone with an almost unconscious old man, with imminent risk of death, I was acting all cool, calm and collected, but I was seething with tension within. I tied the tourniquet, cleaned the area, raised a vein and did all the pre-procedural rituals with a lot of attention- clearly stonewalling, hoping that some miracle would get me out of the mess. But when it did not, I decided to go in! I had not, of course, considered the fact that the old man would give such an almighty yank when I tentatively pricked his skin with the big fat needle. So, what happened was that I DPed (double punctured) a perfectly cannulable vein. Now, since there were only two other doctors, and just a single nurse, I had no one else but someone from the family to hold the patient steady for my untrained hands.

I poked my head out and picked up the burliest and biggest looking guy from the family to help me. It would be a big mistake, as I would get to know soon enough. So, he comes in, holds the hand steady for me, I put the tourniquet in, raise another vein (with much difficulty), clean and prep the skin, and I know, this time, with the big man with mean eyes towering over me, I need to get it in as smoothly as possible. I push the needle in, and to my utter delight and surprise, the chamber wells up with blood,indicating that it is in place. Then, I get so excited, that I yank out the needle without putting pressure on the vein or fixing the IV fluid line. And blood flows out freely. For a moment, I panic, but manage to pull off the cap and lock the line in to stop the blood, but just as I do it, I hear a sigh and a thud, as the big, scary man goes down in a heap.

It took me a moment to understand maybe the sight of blood was too much for him, and he may have had a vasovagal attack. Thankfully, I have seen this happening to a lot of my friends (especially females, ahem!) in the Surgery OT to know that this is not anything supremely dangerous and usually the person comes to in a few seconds, and the only thing bothering them then is intense embarrassment.

Anyhow. Both the diarrheal patient and his big, mean looking relative lived: thanks to (or despite) my prompt intervention! 🙂

However, soon, like the rest of my classmates, I also became proficient in placing IV Cannulas! At one stage, I was (like many of my co-interns) so obsessed with it, that when I would meet people, I would go: “WOW! Big VEINS! Nice cannulate! YAY!” But thankfully, that weird phase passes off soon enough, when we realize that the people with big, nice cannulable veins are always someone else’s work, while ours is the 90 year old dehydrated, obese female with thrombophlebitis whose veins are either hidden beneath mounds of subcutaneous fat or are so inflamed and thickened that they stand out like cords under our palpating fingers.