My new rotation this month is Intensive Care Unit (hereforth, ICU). The other resident and I have the responsibility of rounding on all of the ICU patients with pulmonary issues (about 12-20 patients), rounding on the “floor” patients who have continued pulmonary issues (another 15), and seeing new consults. The hours aren’t bad: 7AM–7PM, Monday through Friday, plus one weekend this month.
It can be a little tough to “learn” new patients who I haven’t seen before and wade through pages of poorly-scribbled doctors’ notes to figure out what’s going on! It should get easier as I get into it. One such patient has a sternal wound infection after a heart valve replacement. When I saw her yesterday, there was a VAC (Vacuum-Assisted-Closure) dressing in place. This is basically a black sponge covered by plastic with suction. The sponge distributes the negative pressure evenly, stimulating better wound healing.
This morning, however, it was Dressing-change Time when I walked in her room…the wound care nurse was there, and I was more than a little horrified when I turned to look at the patient. With every inhalation, her rib cage expanded and the two halves of her sternum (breastbone) separated. And there was her beating heart! I could see the aorta and pulmonary arteries to boot. It was easy to hear heart sounds as I placed my stethescope on her chest, since I had a visual cue for each heart beat!
Today I lost a few style points on my central line technique. An attending was overseeing me as I placed a line in the Peri-Anesthesia Care Unit. Having been a couple months since I’d done it, I was hoping I’d remember all the right steps… Essentially, a wire is introduced into the vein (as illustrated above), the skin is dilated with a small cone-tipped plastic tube that fits over the wire, and then the catheter is inserted over the wire. I introduced the wire into the vein, then dilated the skin. The next step would be to slide the dilator off the wire, leaving the wire in place. Unfortunately, the dilator looks deceptively like another device called a cordis which a Swann-Ganz catherer can be put through. Being a little confused, and much to my attending’s dismay, I pulled the wire out with the dilator still in! It was back to squre one…but fortunately the second attempt went smoothly, and we finished the central line without any more (mis)-adventures.