In medical school, I learned a bunch of rules for putting in any central venous catheter. I will admit, I've stolen these rules quite blatantly from a friend of mine. This is not a guide or 'How to' but are quite simply some rules that you must adhere to when doing a central line:
- The most important rule for putting in a line is to NEVER EVER LET GO OF THE GUIDEWIRE. If you fail to do this, then I will bring upon you a wrath so fierce that Satan himself will tremble. NEVER let go of the guidewire until it is entirely outside of the patient. But I need to get the dilator! DON'T LET GO! But I need to thread the catheter! DON'T LET GO! NEVER NEVER NEVER LET GO OF THE GUIDEWIRE.
- A central line is 90% preparation, 10% procedure. If you do everything you need to prepare, then the actual procedure part will be quite easy. That means consent, examine anatomy, get supplies, clean, prep, drape, the whole 9 yards. If you can't do the preparation, you have no business doing the procedure.
- The procedure itself involves a healthy dose of luck. I got the first 5 or 6 on my first try without any help. The site didn't matter: femoral, IJ, subclavian. I was the central line master. Then, I missed 3 in a row. Now, I'm back on the wagon and I've got my last 5 or so attempts, but if you can't get it, it's not because you suck. The stars didn't line up right. (and you may suck too, but hopefully it was the stars)
- If you're gonna do the procedure, you should do the admission and get the consent. Procedures are for the strong, not the lazy. Don't come to me wanting procedures but bitching about admissions, and don't you dare prep for a procedure, then tell me you didn't get consent.
- Like pitching, the follow through is as important as the wind up and the pitch. If you prepped for the procedure, did a fantastic job on it, but you popped the lung and never got an x-ray to check, you have actually fucked it up, despite doing everything up to and including the procedure correctly. Make sure you follow through.
- The last but the second most important rule about procedures is that it is done on a human being as part of their medical care. All the time, I see procedures being done without good reason, so that someone can get another procedure in. When I see this, I get steaming mad. It is your privilege to learn from your patients. They are not there for your amusement.
And there you have it. These are my rules for CVC insertion. You will note at no time do I actually tell you how to insert a CVC. That is because inserting a CVC has very little to do with the process of placing a central line.
EDIT 1/11/07 - What did I tell you about the guidewire?!? That thing poking out of his neck is a guidewire left in by a cardiologist after CVC insertion. It was in there for months. Thanks to NEJM for this one. Click on the image for the story.