Wednesday, July 11, 2007

Days of Wonder


I did a very strange thing yesterday morning, one of the stranger things I have ever done. Details are as follows:

Mrs Chambers in bed four is not a well woman. There is fierce competition between her multiple diseases as to which will be the one to finish her off - at times the renal failure holds sway, then her heart failure will surge to the fore, recently her pneumonia has broken free of the pack.

Now she lies sedated, paralysed and intubated. There are multiple tubes and cords coming out of her and the blank faces of the cardiac monitor and dialysis machine stare off into the middle distance, like stangers forced together in a room.

Because of this she has tubes in her veins and tubes in her arteries and tubes in her veins and tubes in her bladder and throat, and today I got called to put another tube in.

"Have you ever done a pulmonary artery catheter?" Dr Black asked.

"I've seen one" I said.

"See one, do one, teach one" said Dr Black. "Set up and I'll be there."

So we painted Mrs Chamber's throat with antiseptic, laid the sterile towels over her face, and I put the tube in.

The procedure goes like this. You feel in the throat for the big pulse, the carotid artery. It's a little to the side of the wind-pipe. A little to the side of that is the internal jugular vein. They feel quite different - arteries go from the heart, they are muscular and have a pulse, veins go to the heart, they are flaccid, more floppy-feeling.

Anyway, you find the vein by sliding a needle into it (after injecting some anaesthetic). You can tell it's in the vein when you poke through and the dark blood flows back up the needle. If you've gone too far to the middle and hit the artery the blood is bright red and pulses - that's bad.

After you've got the needle in the vein, you slide a length of wire through the needle into the vein. Then you pull the needle out (not letting go of the wire, because if it slips into the vein they may need urgent surgery. I say may because they may go into an arrhythmia and die), and slide another needle over it and after that we thread a long, supple plastic tube, about the thickness of a drinking straw, into the vein.

This is where it gets remarkable. The tube has a miniscule device in it which measures things like how much oxygen is in the blood, how acidic it is, what the pressure is and so on.

And you push the tube slowly in through this tiny nick in the throat of this woman and watch the cardiac monitor and watch as the blood pressure around the end of the tube changes.

First, when you're in the vein, the blood pressure is low. It doesn't need to be high, it just has to get back to the heart.

Then, as the tip slides through the vein and into the heart, you can see the pressure around the tip jump, pulsing with every beat of the heart.

Then, as it emerges from the other side (it's gone along the vein, through both chambers of the heart and out into the big artery that goes into the lung) the pressure changes again - still high, but not fluctuating as much.

So you slide the tube in, and look at the monitor and think "Okay, the end of the tube must be in the start of the heart now, because the heartbeat's fluttering about a bit."

Then a few moments later you think "Okay, I've pushed it into the main part of the heart" and then a few seconds later you stop it because you realise it's where it's meant to go, the end of the tube is in this woman's lung.

Then you stitch it in and we can start using it.

There is something to this, something, I don't know, wondrous.

I don't know exactly how to communicate it, something shimmering and bright, something almost numinous. You get a bit of it when you take blood, when the needle punctures the skin and the dark blood jets into the syringe, you get a whole lot of it when your gloved fingers press up against someone's lung and you feel it rise and fall, inspire and expire.

Years ago I saw cardiac surgery, and I still remember the old man's heart, smeared and scabbed with yellow fat, lurching in the chest, until the surgeon poured the cardioplegic solution onto it and it stilled. And then, when she had finished, washing away the fluid and it started again.

I've got it a few times in psych, that same silent clarity of perception, that same "nothing else-ness".

Like I said, I don't know how to describe these things, don't have the words. But I know these experiences are not unique to me or to my job, to medicine. My brother, one of my favourite human beings ever, works as a boilermaker. He comes over smelling of grease and metal and, once, burnt linen.

Sometimes, he says, he heats up the metal until it is glowing, and instead of welding it, he lets it cool. Then he heats it up again, glowing red and orange and then gold, for no other reason than to see how beautiful it is.

Anyway, thanks for listening,



Blogger The Girl said...

The ability to live in the moment and sense its beauty is a very special thing.

6:08 PM  
Blogger Camilla said...

Oh that's beautiful! I liked both the story about the catheter, and the story about your brother, too. It made me smile to think of you both finding beauty and wonderment in such different lines of work.

(Personally, I like watching a teabag infuse into a still glass of freshly-boiled water.)


8:32 PM  
Blogger Benedict 16th said...

You are beginning to sound like a surgeon. Steve* would be so proud!


* Steve is a pseudonym for well.... Steve

8:35 PM  
Blogger Ozma said...

I can see the appeal. The human power to manipulate nature.

4:22 AM  
Anonymous Anonymous said...

I don't think it is so much 'manipulate' nature, Ozma, but rather getting blown away by how up close and personal you can get to it. I remember a cardiac surgeon grabbing my hand and placing it on a man's heart,who was having a bypass operation, telling me to hold some piece of equipment still (which terrified me) but mostly I think, looking to let me get a sense of that amazing organ which works so hard for us all... It is experiencing nature as much as manipulating it (although I guess it is hard to deny all these procedures are not manipulation, lol)

good call about not commenting, Foilwoman, guilty as charged, and do love to read these wonderful blogs, thanks BJ

and has anyone heard from "Steve" lately?


ps the word recognition "itfch", makes me wonder if I should be cursing my reaction to the pool chlorine from todays swim...

6:43 PM  
Anonymous Dr Rant said...

Bewitching, isn't it?

But does it actually do any good?

Experience has taught me to 'beware the yellow snake of death' (PA catheter)

Love the Repat!

7:39 AM  

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