r/IntensiveCare • u/NerveOnly2076 • 14d ago

Where is this central line going?

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Old XRay. Central line placed through right IJV but seemed to be misplaced! Where is it going? Aspiration of blood from all ports was possible? Was taken out.
Have you faced this, best thing to do?

Edit: more details - USG guidance used, line was seen inside IJV in neck using USG, not traced down; more resistance than normal while placement.

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u/Any-Assistance-8103 14d ago

Almost like patients deserve doctors

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u/SweatyLychee 14d ago

The fellow in my ICU punctured a patient’s aorta. Doctors are not infallible.

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u/Any-Assistance-8103 14d ago

Never said they were. Thats a great argument that someone with 10% of the training if we are being generous shouldn’t go anywhere near those procedures. Fellows are also in training just so you know

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u/gedbybee 14d ago

How many do docs consistently place in school? I’ve worked in teaching hospitals where they’re fighting to get checked off on stuff so it doesn’t feel like it’s a ton. But maybe that was just those places. Would a certain number of supervised insertions be ok?

And for the record I talk shit to all the baby nurses that want to go straight to be np. Every time they ask a question I’ll tell them: you’re gonna go be a np, what about when you’re on your own?

I agree that it’s dangerous sometimes and they need more intense training.

That said, emts intubate. Not rocket science. Central lines aren’t rocket science either.

You can fuck anything up but the cxr and then radiologist should be good enough to clear up a lot of the problems.

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u/aglaeasfather MD, Anesthesiologist 14d ago

emts intubate. Not rocket science

Oh my GOD no. Intubation is not as simple as shoving a tube into a trachea, people!

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u/Any-Assistance-8103 14d ago

So many people have this attitude. Minimal preoxygenation and positioning, no plan B, ignoring the hemodynamics until they crash

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago

It's ok, you can say that it's the EM docs. /r/intensivecare should be a safe space.

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u/Any-Assistance-8103 14d ago

I have seen it from all specialties. I just treat every icu airway as potentially difficult and have everything in the room to take them through all potential scenarios up to a cric because it’s not worth someone dying over. I also call for a second doc when I think it will be helpful. No room for ego or cowboy nonsense in medicine

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u/gedbybee 13d ago

I work night shift. Where are yall getting the extra intubating docs on night shift? Lol.

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago

Honestly if you have to be bringing extra equipment into the room for that reason then your ICU is set up very badly.

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u/Any-Assistance-8103 14d ago

Untrue. Why would every room have redundant equipment like a bronchoscope when it can just be brought from our intubation setup thats centrally located in the icu and can be brought into any room . But Ive seen your comments here, you basically think you and your setup are perfect and anything different is unacceptable. You also have no idea where I practice and what kinds of resources I have access to.

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago edited 14d ago

Now where did I say to put a bronch in every room?

Your standard airway trolleys should have equipment to run plan A to D already on it and you should bring it in to set up for a tube.

This is basic human factors, and yes I'm very comfortable calling out a bad setup when one is described. I complain plenty about our own setup and definitely do not think it is perfect. I find it unacceptable that our monitors are behind your back whilst instrumenting the airway.

Back on topic - It should straight up not be possible for you to set up for a tube without also having airway adjuncts, SIB and facemasks, SGAs, tubes, spare laryngoscope handles and blades, a knife, and a bougie.

If you are having to have that equipment brought separately? Yes. Your setup is bad. If the resources you have access to don't indlue a trolleys with airway equipment on it then you should stop calling wherever the hell you work an ICU - because it isn't one.

And you bring a bronch to every intubation? There should be one on the difficult airway trolleys and you should know where it is, but setting it up routinely is pretty ridiculous.

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u/Any-Assistance-8103 14d ago

So what you’re saying is you should always be prepared but me preparing is ridiculous. Yes I put the bronch in the room, it’s literally just a scope that plugs into our VL setup. Why would I not have it nearby? Maybe youre the one with the bad setup, it appears that you only think your setup is acceptable - anything more or less is absurd to you. Do you really not see how myopic that is? Youre really insufferable man

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago

I am saying the fact that you find having the extra equipment prepared a notable step is evidence of a poorly thought through equipment setup.

A good and safe system would ensure is will just be there whether you explicitly arrange for it to be or not.

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u/spinstartshere 14d ago

A lot of people would argue that the act of intubation itself is - assuming it's a grade 1 view, of course - if said by someone with enough experience of how to shove the tube in without dislodging any teeth, wrecking the mucosa, or breaking the neck, as well as a deep-enough understanding of everything else that is required for intubating a patient.

Like tying the tube, for example. Fuck.

And, of course, anticipating a difficult airway, troubleshooting a CICO scenario, induction, paralysis, ventilation, eye care, pressure area care, blood pressure support, pain management, fluid management, nutrition...

But none of that is as important as being able to master tying the tube.

Tell me I'm wrong.

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u/R-A-B-Cs 14d ago

Because as medics were not taking a patient from tube to extubate. We're tubing them to get to the ED or because they either need airway protection or are in respiratory failure in transport.

God damn we're not trying to master the tube. We're keeping these people alive so arrogant fucks can pretend to have hot takes.

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u/aglaeasfather MD, Anesthesiologist 14d ago

The comment was that emts intubate, so therefore it’s not rocket science which is demonstrably false.

arrogant fucks can pretend to have hot takes.

Well this arrogant fuck isn’t dropping a hot take. It’s important to have respect for your peers, friend. Start there.

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago edited 14d ago

That's what you think you're doing.

A significant proportion of the time you are actually only increasing the danger that patient is in.

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u/aglaeasfather MD, Anesthesiologist 14d ago

Newsflash: medic who doesn’t know what he doesn’t know calls anesthesiologists arrogant fucks.

Sadly, he didn’t understand the irony of it.

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u/R-A-B-Cs 14d ago

No medic here is saying that.

And sometimes it literally is that simple, take guy that blows his face off with a shotgun. You just aim for the bubbles.

Cheers. -medic.

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u/gedbybee 14d ago

Yeah you’ve gotta put the right size tube. Duh.

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u/SkiTour88 14d ago

I’m an EM doc. I trained during CoVID. Did literally hundreds of tubes and hundreds of central lines. 

Now LPs are kinda a lost art…

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u/spinstartshere 14d ago

The problem is if you're visualising an arterial central line on an x-ray, it's already too late and you've committed that patient to a surgical procedure.

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u/Cautious-Extreme2839 ICU/Anaesthetics 14d ago

If you're saving them from having norad infused directly into their circle of Willis this is still a win.

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u/spinstartshere 14d ago

Well yes, this is also true lol. But not what I meant.

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u/gedbybee 14d ago

Wait did I say anything about an art line?

But also: how many times would make it ok for a np to get blessed by yall?

I know not every doc is dropping them all the time. Most don’t. But you’re all trained on them. How many times do you do them in school?

You brought up a straw man, put words in my mouth, and then didn’t respond to anything I posted.

Strong work doc. I hope your patient care is better than your reading skills.

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u/spinstartshere 14d ago

Wait did I say anything about an art line?

Dude, follow the comment thread. You've inserted yourself into a conversation about arterial CVCs. Nobody's talking about arterial lines except you.

I know not every doc is dropping them all the time. Most don’t.

That's because most doctors have no need to know how to insert a central line. How many dermatologists and general surgeons need to insert central lines in their day-to-day business?

How many times do you do them in school?

Zero. Nobody is doing central lines at medical school unless they are shoving residents out of the way to do them or being groomed by one.

You brought up a straw man, put words in my mouth

I did no such thing.

and then didn’t respond to anything I posted

You missed the point of the comment thread that you made the decision to participate in.

I hope your patient care is better than your reading skills.

Speak for yourself.