Greenhorn Volume 1: A Catheter in Hand Is Worth Two Sticks in the Back

“We have a blood patch heading up from the ER.” “Of course.” If the first six weeks of life as a CA-1 had taught Greenhorn anything, it was how to hide how completely lost he often felt. He found that curling and uncurling his toes kept his face or hands from betraying his bewilderment. This was especially important when working with Dr. Avery, whose low tolerance for the mistakes common to those at his level was both legendary and terrifying. The words had barely escaped the lump in his throat that had formed upon seeing the young attending on the schedule for his first call shift. “Have you done one before, Dr. Greenhorn?” She said, looking up sharply as if she could sniff the lie on the air. “Once, Ma’am.” Curl. Uncurl. Curl again. The attending’s lip twitched just for a moment. Was she so recently out of residency that she knew his game? “We can race, then. I’ll do the sterile blood draw and you do the epidural. Then you will push 20cc slowly into the epidural space. Loser owes the winner a soda.” He recognized the gift of her explaining the procedure. The toes relaxed. For just an instant, before an important phrase came back to him. You do the epidural. That procedure he actually had attempted. His first try had taught him the invaluable lesson of what a wet tap felt like, or so a much gentler attending had explained to him as he sat, horror-stricken, in the anesthesia office with the fountain of cerebrospinal fluid still gushing in his mind. He saw it again for an instant, followed by a replay of the debacle that had been his second attempt. That massacre had consisted of two levels, three sticks, six pauses to re-position and roughly fifteen redirections of the epidural needle prior to the same gentle attending finally taking hold of the needle and leaving it millimeters from the space for him to finish. Greenhorn was less than confident with Dr. Avery’s arrangement, but there was nothing for it. Suddenly, he was staring at the prepped back of the uncomfortable women, noting the faint nail mark blanching from where he had taken his best guess at the L4/5 space. Dr. Avery looked up from prepping the blood draw and motioned impatiently toward the epidural kit. He very nearly cut himself opening the ampule of bupivacaine, realized he did not need the bupivicaine, and promptly pulled the plunger clear out of the back of the glass syringe. It was all he could do to keep from celebrating when the fallen plunger stayed on the sterile field. Finally, gloves wet with saline and trembling with anticipation, Greenhorn picked up his seeker needle and stuck. “SHIT!” It was precious seconds before the stunned CA-1 realized that the same expletive had come from both the patient, whom he had forgotten to warn, and the attending, who was surprised by the sudden jerking motion. He could feel Dr. Avery’s seething glare even while her reassuring words calmed the sore patient and got her back in the correct position. There was nothing to do but proceed. His shoulders slumped as he felt the crunching acceptance of the needle by the supraspinatus, followed by the wavy course of infraspinatus. Suddenly, incredibly, he felt the needle loading itself in the stiff ligamentum flavum. He tensed, but his face betrayed a smile, and he allowed himself a peak down at the blood draw field while he removed the stylet to attach the syringe. Dr. Avery glared back from where she was fishing for an IV. Her eyes widened when she saw the syringe, and she quickly returned to her work. It was too late. Greenhorn slowly advanced and felt the plunger give way as he proudly exclaimed, “I’m in.” “Nice work, Doctor,” she said flatly. Greenhorn could barely contain his excitement as removed the syringe and stared at the perfectly placed epidural needle. His shoulders relaxed, and his contentment only grew as Dr. Avery struggled to pull back enough blood. The catheter threaded like butter. A few minutes later, Greenhorn stared at the syringe of blood reluctantly handed to him by Dr. Avery in confusion, which slowly faded into disbelief. She was mostly through cleaning up the IV site when it fully rang home to him that he held the syringe in one hand and an epidural catheter in the other. The epidural needle sat triumphantly with the other discarded sharps in the kit. He barely heard Dr. Avery asking him how much blood he had given so far… “You still technically won,” said Dr. Avery later as she deposited a cold Shasta from the PACU fridge on his desk in the resident room, where he had been reliving the ordeal. “That was a new one for me. But it doesn’t have to end up on any evaluations.” Greenhorn, stunned, leaned forward to listen. “The condition is that you tell this story to your classmates. That you start talking about all of it with them. Missed intubations, blown IVs, if you freaked out thinking the patient was in Vfib because they were being prepped. All of it. The best advice a mentor of mine gave to my CA-1 class early on was to talk about the struggles. Once that happened, we each stopped thinking that we were the only one that didn’t get it.” Greenhorn nodded, looking thoughtful. He saw again the vision of the catheter in his hand, but this time he started to laugh.