Tuesday, August 09, 2011
Okay, I'm pissed and I want to get this out of my system...
The other night, I was on call. I was covering a patient signed out to me by another one of the ward teams. He was a large (575 pounds) gentleman in for cellulitis. His blood pressure had started dropping and he had continual fevers of 102 and up. The team had transferred him to the ICU and told me to keep an eye on him.
As the night progressed, Mr. Jones (my favorite 'patient name') continued to spike fevers and drop his blood pressure. He was going into sepsis. His urine output dropped. I reacted: we started more antibiotics, added a second agent to lower his temperature and a cooling blanket and began giving him fluid boluses to keep his pressure up.
He had only one small IV and nurses from the floor, the ICU, the transport team and a tech from anesthesia had tried to get a second IV in without success.
Normally, I would have put in a central line myself. I've done enough and do not need supervision. But Mr. Jones was such a large guy that I could not get any reliable anatomical landmarks to guide my approach. Furthermore, I had never put a line in someone this big and did not know what size needle I would need. The risks were greater: if I collapsed a lung in him (even without the sepsis) it would not go well.
I decided to call the experts. I called Anesthesia first. The anesthesiologist came on the phone and politley told me that per hospital policy first call goes to the Vascular Surgery service and that if they could not do it, they would consult him. So sorry...
I called the resident on Vascular Surgery. He told me that I would have to have my Attending call his Attending who would then tell him to place the line. My eyebrows rose as he said this. Whaaa? We had helped each other in the past: he had supervised me putting in my first lines. I had helped him manage pain in his pediatric patients (surgeons are not pediatricians and sometimes don't know the dosages and regimens for kids).
I briefed my Attending (who did not know either the patient or the situation with him until this time). He was surprised that we had to call the Vasc. surgeon. He made the call. The surgeon told us that because we had one IV and did not need pressors (yet), he would not allow his resident to place a line. If we lost the IV, he would send a resident to put in a femoral line (goes in the groin).
Whaa?! First, if he lost his IV and continued to drop his pressure, the patient could die. Second, have you even seen a 575 pound patient's groin. I'd pay money to see someone even attempt put a line there, not to mention that