A medical short story: High five

An excerpt from The Little Boy Inside and Other Stories.

“Hey Altman,” the chief resident says.

We’re in a small group outside a patient’s room. I look up.

“One of the high-fivers needs a central line over on Two North.”

High-fiver. Another code word from the secret language of medicine. High-five means HIV, positive or full-blown AIDS.  Probably half the patients on Two North are dying of AIDS. “Got it,” I say.

He smiles. “Make sure you double glove.”

***

Tom is forty-one, has AIDS, history of PCP, and Kaposi’s Sarcoma. The chart indicates he has newly diagnosed cryptococcal fungus in his cerebral spinal fluid. I stop in the doorway, a baby blue gown over my scrubs, wearing a flimsy mask with a built-in plastic face-shield. I’m double-gloved and holding a central line kit.

Tom stares into space, a cloudy film yellowing the whites of his eyes. He’s sedated, an oxygen mask over his nose and mouth, and incredibly cachectic — hollowed out cheeks with taut skin over bone. He’s restrained with straps around his wrists and ankles, tied to the side rails.

His shallow breath sounds sharp and junky. The room smells stale with a faint hint of urine.

I say hello but he probably can’t hear me, although you never really know. I roll the tray table close and adjust its height, then open the kit, creating a sterile field. I open the packet of betadine and pour the mud-colored liquid into the tray reservoir. I slide the sheet down, move the gown aside at the groin.

His legs are as thin as my forearm, the contour of the femur obvious, condyles at the knee splaying widely. His sunken abdomen is retracted, really, creating a sharp drop-off from his rib cage — muscle attachments and insertions painfully visible.

I push two fingers into the groin, where thigh meets abdomen, to feel for the femoral arterial pulsation. The anatomy plays back in my head, the order of structures inside to out, medial to lateral — vein, artery, nerve. I remember this by VAN. I picture it in the groin, front end smashed up against the vein.

I find his thready pulse and ink a line right over it with pen. With the small sponge from the kit, I paint the area with betadine to sterilize it, then unfold a sterile drape sheet, a small hole in its center, and rest it over the area.

The needle is a sizeable gauge with a sort of platform around its upper end. I wrap two fingers under the plastic platform, my thumb on the top of the needle. Ready to jab. Deep breath. Once I hit vein, I’ll have to move quickly, thread a thin guide wire through the needle center, into the vein. Then the needle comes out, I dilate the hole, then bury the catheter.

At least that’s the plan. I’ve only done this once before.

Blood will ooze, no doubt. Infected blood, a death sentence if it mixes with my blood. Even a drop.

I touch the needle tip to the skin surface, over the ink line, angle best I can away from the artery. I steel myself, push. The needle pierces skin. Tom bucks slightly. I wait. Push again. I angle this way and that — a little medial, a little lateral, push deeper, and pull back.

Bingo.  Dark blood bubbles out of the needle tip onto my fingers. Warm blood. Infected blood. I grab the wire while holding the needle steady with the other hand, feed the wire tip into the bloody needle. The wire staunches the oozing.

When the wire is far enough in, I apply pressure below the needle then start to retract it over the wire, being careful not to let the wire slip out.

The needle comes out and I plop it in the tray as if it’s burning hot (well, it is in a way). I thread the plastic dilator over the wire to make the hole just a tad bigger, in out, in out.

I drop the dilator back in the tray and grasp the catheter tip in my fingertips. It’s like threading a needle and it takes a few awkward tries before the catheter is over the wire.  I snake it down the wire and the tip disappears under skin, into the femoral vein. I keep sliding until the catheter is all the way in, hubbed, as they say.

Just need to get the wire out, cap the catheter and I’m home free. I pinch the catheter and start slipping the wire out. I put subtle pressure at the needle hole, over the catheter. Breathe.

I can’t tell where the wire ends and it pops out, wanting to coil back up. The tip flicks, taking a few drops of blood with it and sending them sailing up to splash across my mask and eye shield. I freeze. Don’t feel anything on skin. No wetness, no warmth. I turn my lips in under the mask. I want to run but I can’t.

I click into automatic. I screw the cap onto the catheter, grab the hemostat and thread with a curved needle. I throw one stitch into skin next to the catheter, faster than I’ve ever done before, then wrap the thread around the catheter and tie, securing it in place.

I drop the tools in the tray and peel off the bloodied outside gloves. Holding them out front, I drop them in the tray and rush to the mirror above the sink. I stare at my face. Blood droplets form a bloody smile across the mask, beginning by my chin, arcing upward toward my left eye. Nothing in my hair. Nothing on any exposed skin as far as I can tell.

I release the mask straps from behind my ears, slowly and carefully, as if I’m handling a bomb. I hold the mask between thumb and forefinger, take a last look at it then drop it in the biohazard container.

I walk closer to the mirror, face right at the glass. I look at my face, hands. Then again. I check the inside gloves. They’re clean.

I’m still standing, searching for blood in the mirror, while Tom stares at the ceiling.

Glenn Gray is a radiologist and author of The Little Boy Inside and Other Stories.

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