(That flower is roughly where I put the central line in this entry.
Talk about a teaching aid. Can you believe I'm considered "faculty?")

Saturday, October 28, 2000:
Last real book I bought:  Secrets of the Samurai ($9.99 at Border's).
Just Saw:  The Seven Samurai (on our new DVD player!).
 Feeling:  A bit guilty about my fascination with Korea's historical oppressors. 
Nasty Dreamer:  Green-eyed water tiger.

 

---

THE ONE SAMURAI

"Are you tired of fighting yet?"
-- Kanbei (The Seven Samurai)

 

Ten more minutes and my watch would be over.  

Then the next guy would get the disaster beeper. 

With nine minutes left, the nurse pages me with the desperation of a village in trouble.

"Is this B-service?  We need a doc down here."

"I’ll need a little more information than that.  What’s going on?"  I ask, trying not to roll my eyes.  

"The patient's pressure is dropping.  He’s on pressors but we lost his I.V. and we can’t get another one in.  He keeps saying he’s going to die.  He’s full code too.  He was doing the same thing all night …," she answers.

Well, he was obviously wrong last night, I think to myself not nearly as impressed as the nurse.  If you're in medicine long enough, you don't get a golden watch, you get a jaded one.  

"Did you call the attending?" I ask, already knowing the answer.

Sometimes the nurses call us without calling the primary doctor first, which is the wrong thing to do.  If the patient’s doctor is in the hospital, then it’s his job to fight his own battles.  

"He was just here, and we told him.  He said to call B-service and he left."

Damn it.  Lazy bastard.

"Fine. I’m coming down."

I don the white robes and weapons of my profession and head out.

 

 

I wasn’t too upset at the primary doc.  I mean he’s not a hospitalist or an Imperial Samurai, the title I’ve magnanimously bestowed upon my self (we hospital dogs do have to keep ourselves amused, you know).  He’s a clinic doc, lord of his own little plot.  He’s got patients to meet in his office and he probably hasn’t drawn the sword for an emergent procedure since his residency.  Think of all the patients that won’t complain about how late he was today.

Whatever.

 

 

I look for his chart, the map to the battleground as it were.  It helps with formulating a plan of attack or at least explains why you're losing ground.

The first thing I hear is one of the charge nurse complaining on the phone to someone.

"B-Service hasn’t even called back.  We’ve got a guy crashing here and he won’t even come to see –" the charge nurse accuses, like an ungrateful farmer.

I’m a bit peeved, since she's indirectly insulting me and my honor.  I interrupt.

"What are you talking about?  I *am* B-service.  I just spoke to the nurse on the phone two minutes ago.  Why do you think I’m standing here while you tell someone how I haven’t called back yet?"  Fucking retard.

"Oh … Dr. Scott … I didn’t know … we’re glad you’re here …," she starts to fumble.

There are certain kinds of nurses who like to say how dumb the students, residents, and doctors are every chance they get ... sometimes while one is standing right behind them.  It’s not a nursing thing.  It’s an individual thing.  They are usually the laziest of the bunch who enjoy blaming everyone but their own Nurse Hathaway-wanna-be happiness-challenged megalomaniacal adipose-laden asses.  Sometimes they end up in nursing administration.

I used to ignore it.  But these days, after hearing it for seven-plus years, I tend to shut them down with righteous impunity, and I enjoy it.

 

 

Needless to say, my adrenal glands have already squeezed a shot of epinephrine (adrenaline) into my bloodstream before I walk into the room.

Mr. Dume, the white-haired patient, is helplessly tilted head-down as if on a torture rack.  The head down position is to increase the bloodflow to the brain since it’s all about saving the brain.  His brain is perfusing well enough to allow him to freak out so he is okay for the moment,

"What’s going on here?  What’s happening to me?"

"We put him in trendelenberg (head down), but lost his I.V.," the nurse reports.

I recognize the mortal bandits in his chart.  He has cardiomyopathy (bad heart), and sepsis (blood infection).  Two good reasons for his blood pressure.  He was already on dopamine and epinephrine to keep his pressure up.  Without I.V. access, he wouldn't get a drop though.   

He just needed a royal escort to bring the goods to the village.  

"Central line kit, triple lumen, please.  Size 7 ½ gloves," I say.

I throw his blankets aside and meditate for a pulse in his groin.

"His pressure is 72 over 34 now," the nurse portends.

"It’s 66 in the other arm," the nursing assistant says ... helpfully.

"That’s why I’m not checking that arm," the nurse chuckles.

His femoral pulse gallops like cavalry.  I almost smile.  It’s the first happy thing I’ve experienced all day.

"His I.N.R. is above 5 right now," the nurse squelches my joy.

In other words, for various reasons he’s prone to bleed a lot without stopping like a normal person, from any bump or cut, and especially into a major blood vessel (like the femoral).

I hesitate as the stakes go up another notch.  There’s never a break in situations like this.  When it rains is when the final battle takes place.

"Well, at least in the leg, we can sandbag it if he starts bleeding.  Use furniture if you have to.  I’m still doing the line now.  Are you comfortable with that?"  I ask the nurse.

She nods yes.

Cool.

Tuck the tie in.  Snap the mask on.  Feel the blood rushing in.

I unfold the rice paper thin wrapping of the central line kit.  The needles, wires, and tubing feel like a warrior's favorite family weapons.  

I have a slight tremor at first.  The last time I felt this was in the video arcade a few weeks ago when I realized the opponent next to me might be better than I was.  I was out of practice then too.

"Iodine."

I barely resist ceremoniously and sloppily dumping the rust-brown solution over half his body like sake in a bonfire.  That’s what we do in CPRs.  Half the time those dark stains on resident scrubs are just iodine (the other times, it’s blood).  I restrain myself and limit the iodine to just the left groin this time.

"Who are you?  What are you doing to me?"

"I’m Dr. Scott.  I'm here to put an I.V. in your leg."

"Ohhh … I’m going to die.  I know it …."

"Not while I’m here.  You’re fine.  Now, don’t move."

Morale is half the battle.  Or at least ten percent, I'd venture.

"I'm going to die."  I can’t remember how many people have said that to me.     Sometimes they ask if they’re going to die.  I just smile and answer, "We all are, just not anytime soon," and leave it at that.  "Soon" is subjective.  

Those warrior-classes were obsessed with mortality.  They were always looking for that good death.  Come to think of it, getting run in by a sword with adrenaline pumping through you sounds a lot better than dying from a gangrenous wound or colon cancer, or in a hospital bed for that matter.  On the other hand, dying at thirty doesn't sound all that much appealing either.

The nurse looks at me when he says he’s going to die.  It’s that feeling of impending doom; when you see that dark army crest the horizon.  I don’t believe it’s a psychic premonition.  I think it just feels that way when you are barely getting enough blood to your brain.  Either way, the outcome is often the same.

"I said don’t move! … I need more lidocaine."

He’s numbed up enough this time, so we’re both much more comfortable.  I place a finger over his pulse and aim the needle a couple of millimeters beside it.   I know exactly where to go to create a gushing mortal wound and where to go to send lightning shocks of pain down his leg and up his spine.  In this century, I use that knowledge to know what to avoid.

I’ll know if I hit the artery when bright red blood starts pulsating out in rhythm with his heartbeat.  And with his bleeding index, he won’t stop.  With a larger blade, that would be a quick death.  But my clan doesn't believe in quick deaths.  

I angle the needle, take a breath, and plunge it in.  He doesn’t feel a thing.  I watch the attached empty syringe for the first signs of blood.

Empty.  Shift.  Empty.  Damn, I know it’s in there somewhere.  Should have hit it by now.  I’ve done this on people with no pressure and no pulse.  Where would it be –

"Got it."

Dark flowing victory wine, just thicker, fills the syringe.  Venous is my Venus today.

I disattach the syringe and thread the wire and then the thick I.V. line into his femoral vein like sheathing a sword.

"All done," I say and sew.

The nurse connects the pressors and antibiotics.

"90 over 50.  I’m happy with that.  Don’t check the other arm," the nurse tells her assistant.

"We’re all done Mr. Dume.  You did great.  Thanks for being so patient," I tell him and his blue eyes look at me, slightly less frightened.  I can tell his hands used to be much stronger.

"You’re lucky Dr. Scott was here today," the nurse says to him.

"Who?" Mr. Dume looks around.

"Bye, Mr. Dume."

Outside, I order some tests and I pass the beeper to the next sentry, twenty minutes later than usual, and start the rest of my day, at last.

 

 

The following week, that same nurse finds me in the nursing station.

"Dr. Scott, remember that guy you put that central line in last week?"

"Oh yeah, how is he?"

"He died, three days later.  The family made him chemical code only.  Good thing too," the nurse says.

He died with adrenaline (epinephrine) pumping into him and had been pierced by a flurry of needles and tubing.  It still doesn't sound like a good death to me.

 

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