The latest in my collection of interesting CXRs.
Both of these lines were NOT placed by me.
This IJ was placed low with a lateral approach.
...and this was an IJ that looped into the right subclavian vein:
We were flying to SoCal for my step- brother's wedding. We were late and had to run through the entire terminal. Devin stops 100 feet short of the gate and grabs his crotch: "I have to go potty!" he screams at the top of his lungs. I looked at my watch. The flight was scheduled for 6:20. It was 6:18. I yelled across the terminal: "Run, Devin, Run! You can go potty on the plane!" People began to stare. Devin didn't budge. In the end, we made it. Southwest rocks! they waited for us!
I'm finishing up here in SoCal, and Lara moved into our new place in Oregon.
The truck took a while to get there, and Devin and Lara had to spend a night on the floor.
Our new place has a beautiful back yard with a creek that backs up to forest.
Devin was so excited when his toys came!
We went for a walk in downtown SLO - we raced leaves down the creek and fed bread to the ducks. Devin saw some girls using sidewalk chalk, and just walked up and started talking to them. He charmed 'em, and next thing you know, they're all painting a birthday cake!
A common mistake - the ETT was 24cm at the lip. I heard diminished breath sounds on the left, we pulled it back and taped it. After the CXR came back, we rechecked - it was 28cm at the lip. No wonder the vent was alarming high pressures.
As an intern, I've done a few IJ lines and a few femoral lines, but last night I did my first subclavian. My coworker put in a right IJ, and the patient got agitated and pulled it out. I put in the subclavian, and I knew something was wrong when I advanced the line over the guidewire. It just felt like it was directed too superiorly. I fully expected it to be up in the neck when I got the chest xray - a complication I had seen several times before. This is what I got:
The radiologist's report was: "Interval insertion of right central venous catheter with tip in the region of the left subclavian"
I inserted a guidewire and redirected it into the SVC with flouroscopic guidance - what a pain in the ass...
Here are a few mnemonics I picked up that helped me out...
HAD CLOTS: PERC Rule - Risk factors for PE
Leg Swelling - Unilateral
O2 Sat < 95%
Surgery/Trauma History - Recent
AMPLE: Important history items in trauma patients
Past Medical/Surgical History
Last Meal/Last Menstrual Period
PHAILS: Toxins that cannot be decontaminated with charcoal
DUMB BELSS: Cholinergic Toxidrome
ME DIE: Differentials for Osmolar Gap
Diuretics (Mannitol, Sorbitol)
MUDPILES: Differentials for Anion Gap Acidosis
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents
AEIOU: Indications for dialysis
I STUMBLED: Toxins that can be removed by hemodialysis
AEIOU TIPS: Differentials for Altered Mental Status
Toxins, Trauma, Tumor
Stroke, Seizure, Shock
Now that I'm 40 inches, I can go on roller coasters! Today I went on Thunder Mountain, Gadget's Go Coaster, and Splash Mountain! When each one was done, I told Mommy and Daddy "AWESOME!"
I also got to meet Woody and Jessie, and I told Jessie "You're pretty". That made her blush!
I'm writing this post from my iPhone using the WordPress app. It's nice to be more connected. I'm also using a cool FTP picture uploader to send photos from the iPhone to my gallery. Look for more up-to-the-minute updates and photos from wherever I am!
Here's a photo of us at Disneyland yesterday. There's more in the gallery!