“Take a stab at it.”
This phrase took on a whole new meaning when I had a chest drain pack in my hands, a patient in my direct view and no idea how I was going to do this.
It’s stupid, because as a medical student I saw dozens of chest drains being inserted. I even assisted with a few. But it was always at arm’s length, quite unrelated to my role as a scribe and a pair of spare hands. I’d maybe do the incision, or describe the procedure, or simply push an already placed drain further at most. If anything went wrong, the intern would sort it out. If I couldn’t get the technique right, my senior would intervene.
There was no senior anymore. I was the intern.
It had been a quiet night. I don’t consider myself superstitious, but I definitely winced when the MO in charge said the Q word and suggested we split the call after midnight. Splitting, I don’t mind. Jinxing the patient flow of casualty by commenting on how not busy it is, I take great issue with. But what could possibly go wrong? I only had two hours of my split with a single patient on the bench, and I’d done longer, more busy splits before. So I gladly took first shift.
Within half an hour, the procession of stab chests started stumbling in. At first, I thought I could handle it. Everyone was stable, there were no indications for immediate drains without imaging. So I sent everyone off to x-rays and then tried to calm myself. On clinical examination, one probably had a haemothorax. There was also an unlikely pneumothorax. But the rest were probably just going to need shots, stitches and oral antibiotics and analgesia. The radiographer on call was notoriously slow. The patients would probably only be back after my split ended. If not, they were stable and the senior intern was coming in next. Help was on its way.
No problem. Breathe. You’ll be fine.
I hit up some internet resources and revised some theory. Landmarks. Danger zones. Cautions. Tips. Aside from the suture–darn pursestrings!–I was almost done revising. Then the next intern came in for her shift and I felt the blood drain from my face.
She wasn’t the senior intern. She was one of the newbies who’d just started two weeks prior.
Of course! I reminded myself. They’d never leave a newbie to a solo split without bookending them with more experienced interns. And apparently, eight months in, I was experienced.
I debated my options. I couldn’t leave her alone. There were bound to be at least two chest drains due from the crop of stab chests. We spoke briefly, and it was clear she hadn’t seen (let alone done) a drain in years. I could call the MO for backup, but that seemed premature. I knew the theory and had vague recollections of the practical, and the least I could do was try before waking him from his brief sleep.
I steeled myself against what was coming as the first patient returned from x-rays.
Haemopneumothorax. An obvious one. Just my luck!
I asked for a chest drain trolley to be prepared. The nurse I was working with was flustered. I was flustered. The patient was drunk and beligerant and refusing treatment. I explained as patiently as I could why he needed the drain, but he simply threatened me and the nurse. Security was called. He was set aside to cool off while I saw the next patient.
Haemopneumothorax. Again. Just not my day.
I put on my gloves. I explained the procedure. The patient was also drunk (same party, same fight) but was slightly more cooperative. I managed to anaesthetise the area. before he changed his mind and told me he didn’t want the drain. I think the size of the trocar on the trolley did it for him. I explained that I wasn’t planning to use it, that it came with the set and showed him that the skin where I’d anaesthetised had no sensation. He calmed down. I cut. I blunt dissected down to where I thought I reached the parietal pleura. I tried to puncture.
I tried to dissect further, but I could feel that I was at the right place. I tried again. Bone. Tried to remember again where the neurovascular bundle was. Redirected the forceps in the opposite direction. Steadied my instrument and applied pressure. Nothing. No give. Nada. Lutho.
Now I was annoyed. I’d come this far. I’d taken the plunge. I’d taken initiative to try before surrendering. This didn’t make sense. What was I supposed to be feeling here? Why had they never let me do a drain from start to finish during student internship? Why had I never asked?
I took a deep breath and tried again. Slowly, steadily…give.
My patient screamed.
I nearly lost my nerve, but I felt the loss of resistance so acutely that I knew I was in. I did a finger sweep and nearly cried when I felt it. Warm, soft but firm, slightly slippery–the visceral pleura lining the lung on the other side of the space. I was in. I didn’t know how I knew it–maybe some vestiges of dissection memories from Second Year anatomy or just some clinical instinct–but my finger confirmed what my theory told me. I’d reached the pleural space.
I placed the drain. My patient wimpered. I knew I hadn’t aneasthetised the pleura fully at this point, but I didn’t want to waste any more time. My colleague had just let me know there were three other drains pending, and it was still an hour till the next doctor’s split. She was suturing the wounds of patients with no indication for intercostal drains, having confided that she simply wasn’t comfortable trying yet. I couldn’t judge her, I remembered my first few calls where simply prescribing antacids had caused me to have palpitations. Imagine virtually stabbing someone in the chest but hoping not to cause any harm, all during your first month…
My drain was in and needed to be secured. I frowned. I’d been interrupted in my review process, so I wasn’t really sure how to accomplish that. Also…well…I was already sterile. My patient’s local anaesthetic was wearing off. He was drunk and impatient. Would it really matter?
Of course it would, I chastised myself remembering all the poorly sutured chest drains I’d had to remove in the wards. It took triple the time if there were no pursestrings, not to mention it made the patient grumpy because they often needed a new suture or two to close the wound afresh…
But I figured they’d have to forgive me. Maybe this is why those drains had been sutured the way they had. Maybe those patients had been someone else’s first time too?
My priority was my patient. He needed a well secured drain and he needed to get to the ward. I did my best impression of a pursestring–and later smacked myself on the forehead when YouTube reminded me how simple the real thing is–and then handed him over to the nurses.
Then I turned around and saw the winding line of drunken men with stab wounds in their chests and x-rays in their hands. I sighed for the millionth time.
It was going to be a long night.