Case of T.M.
It was a typical day in Urology with an ever- changing list and add-ons in place of patients who were unexpectedly found to have COVID. After a fairly straightforward TURP (transurethral resection of the prostate), I was informed that my next case was a woman T.M. coming from the emergency department that has an obstructed stent and hydronephrosis (blockage to the kidney). The story came to me in bits and pieces while I was finishing up the previous case. It was a youngish lady (in her 40's) who had been in the emergency department for the past 3 days, because our hospital was over-capacity and there were no beds on the floor. Her creatinine had sky-rocketed up to the 600's and her blood pressure had been continuously low for the past few days. The next tidbit I received was that there was a history of bedbugs so we had to treat her with contact precautions. Great.
When T.M. arrived to the preop area, I called over to ask them to give her a bolus of fluid to bring up blood pressure but the nurse told me that the patient's IV was very small (22g) and precariously placed in the back of her hand. No problem, I said. Just put in a bigger one. I texted our anesthesia assistant and asked him to go over and assess her to put in a larger IV. He returns in a bit 20 minutes and has unfortunate news. T.M. was a very difficult to find IV access which is why she had been in the emergency department for 3 days and never had a larger one placed. Her history included previous IV drug use which is why many of her veins were already blown. Luckily, the bed bug issue had been sorted out because she had been decontaminated in the emergency department!
When I went to go see her, I felt her skin and she had tough thicker skin that you normally feel in someone with scleroderma. I could see the marks from all the previous IV attempts and the one IV that remained. Fortunately, T.M. wasn't very large and I could see that she had a nice looking external jugular vein in her neck. However, when I mentioned this to her, she adamantly refused to have any intravenous access in her neck. Then I suggested using her lower limbs, because we occasionally find veins to use in her legs or even feet. Again, she staunchly refused. This is when I started to bristle. A well functioning IV is an important and necessary step in having any sort of surgery done. It was even more important because her blood pressure was low and she required fluid resuscitation, vasopressors and IV antibiotics. I wasn't willing to risk all of this on a tiny precarious IV in her hand. I explained to her that we needed an IV to potential resuscitate her and save her life if her heart stopped or her blood pressure required treatment. T.M. was not convinced and said that she would rather die than have intravenous access in her neck or lower limbs. I was speechless. I didn't know how to respond or what to say to something like this. I even offered to attempt another IV under general anesthesia, after putting her to sleep through the tiny one she already had. It was still a firm no. There was nothing else for me to do except to document my discussion with her and the potential consequences of her decision. I really was at a loss on the reason why she so stubbornly refused any other location for venous access.
As the nurses brought T.M. to the OR, I was discussing this case with one of my colleagues and the anesthesia assistant. My colleague said that she would refuse to do the case if the patient wasn't allowing for adequate IV access. That seemed a bit extreme to me, especially because there was a small IV in place already. I looped in the surgeon to the discussion and my concerns with proceeding without better venous access. He agreed that it seemed unreasonable and went to try his hand at convincing T.M. to let us place one in her lower limbs or neck. The anesthesia assistant suggested that we consider intraosseous access, which is something that is used in the emergency department for urgent IV access. I perked up. That was a great idea! I asked our charge nurse to phone over to the emergency department for the supplies and my colleague offered to see if she could find an IV in the patient. Gratefully, I accepted and headed over to the emergency department.
I recognized one of the nurses there who gave me a quick tutorial on how to use the intraosseous (IO) gun. I have never used one in a real patient and only learned about the technique at previous ACLS courses. It seemed straightforward enough! On my way back to the OR, I received a text that the patient had adequate IV access now and we could begin the case. My colleague had been successful! My plan was to just do the case under monitored anesthesia care, local anesthesia and sedation, since it wasn't supposed to be a very long procedure.
The case started off okay but then the surgeon started struggling with identifying the anatomy and the orifice inside the bladder. The patient was restless and moaning a bit, so I increased her medication and tried to get her to settle. After half an hour, the surgeon requested that T.M. be put to sleep so that he could dilate the bladder more fully. I agreed that this was an option now that we had proper IV access. I prepared to induce general anesthesia and after giving a few medications, I waited the appropriate time for the meds to take effect. T.M. continued to look at me and blink her eyes. After a second bolus of medications, I checked her IV and to my surprise, realized that the new larger IV placed was now interstitial and pumping fluids and medications into her adipose tissue. Obviously this wasn't going to work!
I called back my colleague for help, the anesthesia assistant and an advanced care paramedic from the emergency department to help with IO access. My colleague again was able to place an IV using ultrasound guidance in the upper arm but I wasn't convinced that it was going to hold, so I was keeping a close eye on it. I decided to continue with the induction through the small 22g IV and then place a bigger one after she was asleep. After induction, I noticed that the second new IV was also interstitial and no longer functional, so I was just back to the one tiny IV in her hand. I paused at this moment to consider my options. I could proceed with just the small 22g IV, but if I lost it at any point, I would have nothing and she would be very difficult in an emergency situation. I could put an IV in her femoral vein or external jugular but this would be going directly against the patient's wishes, who told me that she would rather die than have an IV place outside of her upper limbs. Or I could proceed with intraosseous access (IO) in her humerus, use it for the case and then let the surgeons decide how to proceed with IV meds postoperatively. Everyone had their own opinion on how to proceed and I was getting various conflicting advice.
I decided to go with an IO in the humerus and obey what the patient had told me. No IV line in her lower limbs and in her neck. The paramedic talked me through the IO procedure and it went smoothly. Once I have a 14G line in her humerus, I was happy as a clam and I put in a request for a PICC line to be placed the next day. Usually IO lines only stay in 24-48 hours afterwards because there is an increase risk of infection. The rest of the case went uneventfully and the surgeon was unable to find the bladder orifice so we just gave up after a while.
I heard the next day that my colleague went to the ICU to put in a PICC line and she had pulled out her IO line once she woke up. They ended up putting in a central line in her neck. How they convinced her, I'll never know. But I'll sleep well at night knowing that I followed the patient's wishes.