Pdf Book Name: Complications: A Surgeon’s Notes on an Imperfect Science
Author: Atul Gawande
ISBN-10, 13: 9780312421700,0312421702
Pages: 269 Pages
File size: 1 MB
File format: PDF,EPUB
Complications: A Surgeon’s Notes on an Imperfect Science Pdf Book Description:
The patient needed a central line. “Here’s your chance,” S., the chief resident, said. I had never done one before. “Get set up and then page me when you’re ready to start.” It was my fourth week in surgical training. The pockets of my short white coat bulged with patient printouts, laminated cards with instructions for doing CPR and using the dictation system, two surgical handbooks, a stethoscope, wound-dressing supplies, meal tickets, a penlight, scissors, and about a buck in loose change. As I headed up the stairs to the patient’s floor, I rattled. This will be good, I tried to tell myself: my first real procedure. My patient fiftyish, stout, taciturn was recovering from abdominal surgery he’d had about a week before. His bowel function hadn’t yet returned, leaving him unable to eat. I explained to him that he needed intravenous nutrition and that this required a “special line” that would go into his chest. I said that I would put the line in him while he was in his bed, and that it would involve my laying him out flat, numbing up a spot on his chest with local anesthetic, and then threading the line in. I did not say that the line was eight inches long and would go into his vena cava, the main blood vessel to his heart. Nor did I say how tricky the procedure would be. There were “slight risks” involved, I said, such as bleeding or lung collapse; in experienced hands, problems of this sort occur in fewer than one case in a hundred. But, of course, mine were not experienced hands. And the disasters I knew about weighed on my mind: the woman who had died from massive bleeding when a resident lacerated her vena cava; the man who had had to have his chest opened because a resident lost hold of the wire inside the line which then floated down to the patient’s heart; the man who had had a cardiac arrest when the procedure put him into ventricular fibrillation. But I said nothing of such things when I asked my patient’s permission to do his line. And he said, “OK,” I could go ahead.
I had seen S. do two central lines; one was the day before, and I’d attended to every step. I watched how she set out her instruments and laid down her patient and put a rolled towel between his shoulder blades to make his chest arch out. I watched how she swabbed his chest with antiseptic, injected lidocaine, which is a local anesthetic, and then, in full sterile garb, punctured his chest near his clavicle with a fat three-inch needle on a syringe. The patient didn’t even flinch.S. told me how to avoid hitting the lung with the needle (“Go in at a steep angle; stay right under the clavicle”), and how to find the subclavian vein, a branch to the vena cava lying atop the lung near its apex (“Go in at a steep angle; stay right under the clavicle”). She pushed the needle in almost all the way. She drew back on the syringe. And she was in. You knew because the syringe filled with maroon blood. (“If it’s bright red, you’ve hit an artery,” she said. “That’s not good.”)
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