Learning my Lines

... but not in the musical theater sense.

This month I've been in the ICU. A very intense rotation. I've been dealing with patients sicker than any I've ever seen before. I've seen medicine do things I didn't know were possible. I've seen countless people who were clinically dead brought back to life with electricity and drugs. I've seen people who should be dead kept alive for days, sometimes weeks, using medications, ventilators and a little luck. It's been a long month.

The reason I've chosen to do ICU (as a family medicine resident, it's not a required rotation) is for the procedures. Now I'll be doing another 2 months of it as an emergency medicine resident in the coming year, but I figured another month of it would be more helpful than my other choices (including palliative care, more internal medicine and more geriatrics). There are lots of procedures done on a daily basis in ICU that come in handy in the emergency room. Before this rotation I had superficial experience with most of them, but I figured this would be a good chance to hone my skills.

Not so much. I have had a horrible streak this month. If anything, I think I'm getting worse at the procedures I should be getting great at. Central lines have become the bane of my existence. Before this rotation, the only experience I had with central lines was one subclavian under close observation in a trauma situation. But technically, I was one for one. This month I've had two subclavian attempts. Although I got both, one gave the patient a pneumothorax (a known complication of subclavian lines, but I can't help but feel bad about it).

IJ's, the mainstay of central lines, should be routine for me by now. Instead, the only attempts I've gotten have been on patients who are awake. Now for those of you who have never attempted an IJ, imagine trying to perform a delicate procedure involving sticking long needles into people's necks in people who are combative, can't lie flat, won't stop touching the sterile drapes, keep turning their heads to see what you're doing and often don't understand enough English to follow simple instructions (Damn, I wish I spoke Italian!). In short, I am 0-for-three in IJ's, and frustrated to tears.

Femoral lines aren't often done in the ICU where I am currently working. I have seen one done, that's it. So according to the 'see one, do one, teach one' rule, I should be trying the next one. But there's not much chance of seeing another one in the two days I have left.

Chest tubes are another procedure that I've been eager to learn. In an entire month, I've done one. That's all. I was successful, but to put things in context it was a large pneumothorax in a small, thin, 40-ish woman. NOT the typical patient. I can only hope I'll be just as successful when I'm called on to do the same in people with much more tissue to cut through.

But the issue with the central lines has been really discouraging. Particularly for me, who apparently has placed far too much of my professional self-worth in my proficiency at various procedures-- after spending the first three years of medical school thinking I was going to be a plastic surgeon, I do tend to pick up things like this easily. And now I seem to have grown extra thumbs and some kind of gypsy curse, to boot.

Oh well, there's always intubations. Crap, now I've probably cursed those too.