Jugular Catheterization: Fear of Failure, Chapter 16
The work habits I learned in my previous rotations came back to plague me in my Equine Surgery rotation. Mornings started out in the theater in the large animal area of the clinic. Each day a few students discussed a case, presenting case history following with diagnostic thoughts and medications, after which the case opened up to a general question, answer and opinion period, returning to our own disciplines about ten o’clock.
Equine surgery was hard on me because a lot of time there was nothing to do. Other than a few quick procedures in the early part of the day it was terribly slow those weeks. I do not handle boredom well. Deciding I could better spend my time elsewhere, I left the equine area when things slowed like this, similar to behaviors I had started with my summer rotations. When things were slow, I split.
Equine Surgery was different. This rotation was much more a top-down command sequence. The clinicians told the residents their jobs, the residents relayed orders to the interns and the students were there to watch in awe the practice of equine medicine. No matter what wasn't happening; I needed to be physically present while I was in this rotation.
During the rotation, I spent one overnight a week in the horse barns, sleeping in a small room between treatment episodes. I was also there to help with after-hour intakes. A junior veterinary student was assigned to assist me for the first four hours of my shift when it was time for evening meds.
About 7:00 pm one night my assistant and I were interrupted in our medication duties by an admit, a horse experiencing colic came in. The junior was a small animal gal, meaning she acquiesced readily to my equine musings, and we were having a pleasant evening. She followed me into the treatment area where the noise was coming from. Here we found the horse, a sorrel mare standing in the stocks relaxed and quiet.
"The intern must have given her a tranquilizer," I said expecting a colicky mare, antsy and agitated. But, she was standing still with her head hanging low, and her feet glued to the floor, a sure sign she'd been sedated.
I don’t know where the owner or the intern went to, probably to fill out paperwork to arrange payment and treatment options. For some reason, I felt I would be doing the clinicians a favor by jump-starting the workup.
"Well gee," I decided, "Here take the lead rope. Why don't you hold the mare while I look for a sleeve?" Handing my assistant the line, I found a rectal palpation sleeve and began to lube it up.
“What are you doing?” the student asked.
“I’m palpating the horse to see where the colic is coming from," I explained authoritatively.
“Are you allowed to do that?”
“We’ve done this before in equine lab,” I replied, carefully advancing my lubed glove into the horse’s rectum. Unable to figure out what was going on I pulled out and stripped the glove off, shaking my head.
Here is the jugular vein bulging out, a perfect spot to place a catheter
“I can’t feel anything,” I admitted. Then I had another idea. I would place a jugular catheter in for the intern. The horse evidently was going through the admission process, that’s where the intern and owner went, to sign paperwork.
Yes, I could be helpful.
I shaved the hair over the jugular vein on the right side of the neck, put on sterile gloves, unsheathed the jugular catheter, and attempted to place the catheter inside the jugular vein. However, this was my first attempt to catheterize a jugular vein, and I went too far in. Instead of the 1 ½” steel needle I used on the bull for a temporary infusion I employed a 6” long Teflon catheter which could be left inside the jugular for a few days.
However, this was my first attempt to catheterize a jugular vein, and I went too far in.
I went into the jugular vein pushing the six-inch long metal stiletto deep, deeper, even deeper, waiting for blood to come back. That would mean I was inside a vessel. Once inside the vein, I pulled the long metal stylet out, leaving the Teflon catheter in the vein. At least that's what I thought I did.
“Oh, Oh,” I mumbled as the surrounding neck started to swell with blood. This was unexpected, it meant I nicked the carotid artery.
Time for anatomical review. How did I go all the way through the jugular? Well look how close the two are right here in the neck region, these guys are side by side. And notice that this needle in the picture here is the shorter 1 1/2" one, not the long sleek teflon one that seems to have an affinity for carotid arteries.
The carotid artery lies right under the equine jugular vein in that area of the horse's neck. In my inexperienced hands the long catheter was advanced right through the jugular another inch too much until it punctured the carotid artery. I knew I was in the carotid because the higher pressure of the artery caused blood to leak into the surrounding tissue, and the neck began to swell.
The swelling continued to enlarge, the growing tumescence obliterating the typical architecture of the muscles and jugular vein. I waited for help before proceeding further. I had done all I could to help this case get started.
The intern panicked the moment he saw the rapidly expanding bump on his patient's neck. He called up the resident who called the clinician. The intern waited twenty minutes for the resident. The junior student, my assistant, disappeared, not wanting to be part of this circus.
Ignoring me, the two clinicians focused on placing a new catheter on the other side of the neck while I stood there feeling like the young fool I was. After setting a catheter in the correct place, the mare was set up with her meds. I was brought to a corner and told I was to have a meeting with the clinician the next morning.
At that meeting, I was told I had taken decisions into my hands inappropriately. The clinician was also angry with me for leaving early when I was bored. For my transgressions, I was sentenced to spend fourteen days of my Christmas vacation reworking the rotation. I made sure I did not leave early during those two weeks.
These setbacks at school were only temporary. I still had high expectations of my profession and looked forward to graduating in June. Practicing veterinary medicine is a perfect combination for me, employing both physical and mental tasks on different jobs every day. In general practice, the cases vary widely, so I didn't usually become bored with the daily routine. I remained committed to being the best vet I could be.
Once the large animal rotations finished, I went to the upstairs of the VMTH to learn the aspects of small animal medicine, spending the rest of my senior year in small animal anesthesia, intensive care, surgery, internal medicine, radiology, dermatology, and ophthalmology. I even did a brief stint in the exotics ward, where we took care of birds, rodents, and reptiles. But I felt this was a waste of time. Who would want to spend their time and energy trying to treat such weird animals?
During the spring, it was time to take National and California Exams in Veterinary Medicine Practice, my last step in becoming a legally practicing veterinarian. I passed these exams and looked forward to working in my new profession as soon as I graduated.
Audiobook is finished!