After finishing the final set of exams from my first year of medical school, I am both relieved and shocked to have finished. I spent much of my first year learning how to be a medical student, without focusing much on how to be a doctor. I learned how to organize my notes, study every day, and balance school, health, and social life. I put off extracurricular clinical experiences until this summer. I am now spending each day for the next two weeks in the hospital with an internal medicine team.
I still have a little red dot in the middle of my antecubital area (the inner elbow crease) of my left arm from where the third year medical student on my team threaded a venous catheter when we were practicing on each other in the rounding room of Seven East, the Internal Medicine ward of Ronald Reagan Hospital. His shaking hands did not inspire much confidence as he drew the beveled access needle towards to my vein, but I patiently watched as he punctured my skin. He, our attending, and I all watched for the “flashback” of red blood into the clear hub of the needle – the telltale sign that he was in the vein. Nothing. After several attempts pushing further in, pulling back, and redirecting came to no avail, our attending skillfully guided the needle into my vein. The student then threaded the catheter over the needle, removed the tourniquet on my upper arm, and applied pressure over the vein just above the catheter to prevent blood from coming out at he retracted the needle. Finally, he connected tubing and a syringe to flush the line. When our attending was satisfied with the “cath” placement, the third year removed it with one graceful motion, his hands no longer shaking. Gauze, pressure, Band-Aid. All that is left is that little red mark.
When it was my turn I was determined to find the vein and place the catheter without my attending’s help. When the third year said that the only thing that made him queasy was the feeling of needles, I joked that I hoped in that case he had good veins so I would not have to dig. That must not have inspired much confidence in him, as he did not, in fact, have visible veins near the surface of his skin. Though my hands were steady and I identified a decent vein by touch, my first attempt did not bring about the flashback, nor did changing angles, directions, or making a second puncture. His face turned an ashy shade of gray and he began to sweat, so we stopped, and my attending offered his own veins up for my practice. This time, I got a flashback on the first try. I released the tourniquet, threaded the catheter under the skin, applied pressure, retracted the needle, and connected the tubing and syringe. Right as I began to feel proud of myself, my attending reminded me to flush the apparatus with the saline from the syringe. I somewhat absentmindedly pressed partway down on the plunger, only to realize a second later that I had pressed too quickly as I watched the skin around the access vein balloon up. I had “blown” the vein. I swiftly removed the catheter, my hands now shaking. Gauze, pressure, Band-Aid. Today as my attending picked up the phone to answer a page, I guiltily noticed his bruised hand.
Luckily for me and my attending, the damage to his hand was minor, but I still feel guilty and a little ashamed as I look down at the barely-visible red dot on my own arm. The doctor brushed it off as a learning experience and no big deal, and I know that – in the grand scheme of things – it was. What is still bothering me, however, is that my inner celebration at a success distracted me from carefully finishing my task, and this oversight resulted in harm.
As students, the expectations on us are fairly low, and more often than not we are forgiven for our mistakes. We practice procedures on simulation dummies, cadavers, and one another so that when we are asked to place a line in a patient our hands do not shake and we do not blow out their veins. This summer, I have the opportunity to see the planning, collaboration, and oversight that goes into the correct management of care for hospitalized patients as well as the chance to review cases where mistakes were made. I will also be honing my physical exam skills, and practicing minimally invasive procedures – all implicitly assumed to be performed properly in quality patient care. My attending has already forgiven and will likely forget my mistake once his bruise resolves, but I am grateful for and will remember my first lesson of the summer.
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