“Surgical Misadventure”

by ERP

The term “surgical misadventure” always kind of cracked me up. It sounds silly and in a way totally minimizes what really should be termed an “inadvertent blunder” or a “f*ck up”. Anyway, recently we had one in the ER that while technically not “surgical”, was nonetheless an invasive procedue gone wrong. Luckily, the outcome was fine and mistakes can happen to the best of us.  Still, a good learning point can come out of this.
I admitted a sick patient to the ICU after I intubated her for respiratory failure from COPD. The PGY III resident came down as the ICU consult and decided the patient needed a central line for fluid resuscitation (which I debated somewhat but figured, ” he’s your patient now, do what you want “) I knew he was certified to do them ( or would not be allowed to be the ICU consult in the first place) so I washed my hands so to speak.
Anyway, about 30 min later, one of the er techs told me the residents had some problem and needed my help. Apparently the wire was “stuck” and they could not pull it out through the triple lumen. I went over and told them to slowly pull the catheter out and take the wire with it but not to fully remove it, once the wire was smoothly moving again, they pushed the catheter slowly back in. Problem solved or so I thought.
5 min later, I was called back with another issue. They were not sure that the line was in the vein after all. They thought it might be in the carotid artery. Oops. The blood did indeed look a little to bright red to be venous so we held the line straight up to see if it shot out. It didn’t, but appeared to come out a little too vigourously for my comfort. Fine, I said. Send an ABG of that blood. Well, it came back with a PO2 of 429! Rat Farts!
Well, I said, ” please tell me you did not use the dilator”. “Uhhh, we did”, was the reply. Double Farts! Now we’re screwed. You can’t pull the damn thing out because the arterial wall has a big fat hole in it. If you do, the patient will either bleed to death, develop a huge expanding haemotoma in the neck, or stroke out as a clot forms and obstructs blood flow to the right brain.
I made the phone call to the vascular surgeon who groaned and came in to take the patient to the OR. Luckily the patient did fine and suffered no significant ill effects. However the teaching point is: DON’T put that damn dilator in until you are totally sure you ain’t in the artery!!!