On difficult access

So the last hour and a half of my shift today was spent trying to get access on a patient. What a term – get access. It the world of medical lingo, this simply means “to successfully stick a vein, or artery, to obtain necessary blood work and to place a line.” My access today was the femoral artery. Numb up the area with lidocaine first, then stick your needle in and go for the gold – or, in this case, the red. There is something immensely satisfying about getting access; as physicians, we are always there to get access on the difficult patients, or to get central access on the sickest patients. These lines are some of the initial “monsters” of intern year – they take up your time, you fail at them over and over again, and eventually you come out on the other end being fairly decent and fairly timely at doing them.

While all the other gray areas of medicine – there is even very little evidence for one of the simplest things: the two or three medications we give during a cardiac resuscitation – are something we stumble through from day to day, barely able to justify with hard evidence, getting access on a patient is black or white. It stands in a class of its own. You get the blood work, you get the line, or you don’t. And after getting it, no matter how long it takes, you feel a grand sense of accomplishment. What did I do today? I got blood. A virtual vampire. Success. Instantaneous results. I am a champion.

Over the course of intern year, I have felt more satisfied – and more fulfilled – by getting access than I have by doing anything else. Talking with patients and their families is often tedious and depressing, and it makes me want to walk away immediately – this instinct is a kind reminder as to why I chose emergency medicine in the first place. So I can walk away. Not deal with these chronic medical issues, these slow, treacherous journies to the end of life. Furthermore, treating patients is something I often feel ambiguous about, because treatments have risks and benefits, and there are many patients whom we treat regardless of whether or not the risks outweigh the benefits.

Case in point: a woman with metastatic breast cancer, who continues to come in and out of the hospital, over and over again, for fluid accumulation in her legs, her body, and her lungs which is making her more and more uncomfortable. Should we admit this lady to the hospital, stick her multiple times for blood work, and continue her chemotherapy? Is this really how she wants to spend her remaining days, under the circumstances? And why has her oncologist not had this discussion with her? When I bring it up, her daughters are in tears, asking me all kinds of questions about how much time she has left and if this is the right thing to do – as if no one has ever talked about these things with them before. The only reason I can be candid – and, in doing so, remain true to myself – is because I know I will not have to face them tomorrow. Or the next day. Or the day after that. But in this moment, I can tell them what I believe, and I can also make sure they understand that the future is not rose-colored. They deserve this, and so does the patient.

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