I can’t get this reel out of my head. I see a hand. I see a hand in front of me; it’s a frail hand, the lady that it belongs to is in her seventies. But it is a healthy hand, a hand that reveals her remarkable well health for most of her life.
In medical school we always get taught to start the physical examination with the hands, examining them for obscure signs, rarely seen and if seen, of little significance. What I know is that it has some use as you start the sometimes laborious process of a physical examination, pouring over their entire body, eliciting clues from their past, looking, listening and poking. Invading. And it is the most simple courtesy to start from the periphery, just on the edge of this persons personal realm, our innocuous hands, always out and touching. It is not so rude to start from there and work your way in. Both people get slowly accustomed to this physical intimate process between two people. And it is especially valued as a student doctor, inexperienced and awkward, sometimes timid, sometimes too rough. This person gives over their body for you to learn and practice on, so the least you can do is be courteous and start with formalities.
Another aspect is that as I see more and more hands, I have only once ever seen and obscure sign that signified directly towards a patients potentially life threatening condition. Other than that, it’s more about your feel for this person. With elderly ladies, they may look frail and weak, but, like this lady, they may be fully independent , compus mentus and capable. Information revealed by strong, non arthritic hands. In contrast to the lumpy, nodular, angular, contorted, atrophied hands of the woman long since disabled by disease.
And these are two things I know. This lady has been relatively well apart from what has bought her into this little side room in the A and E department today. And I am comfortable here, on her periphery, holding her hand.
But she is not, she is not comfortable with what I am about to do, with the cannula that I am about to attempt to put in, summoning up all my little previous experience (maybe twice) in this process of putting a small plastic tube in her arm which will allow the doctors to essentially put whatever they want into her body. It’s their point of comfort essentially, their point of access for this person. So that essentially, whatever happens to this person, and by whatever in the hospital its always assumed the worst, i.e. that they get more ill, they can within a minute get access to this person blood supply and inject life saving fluids into them.
So that is why this woman has her hand in my hand now. Most likely she won’t need any life saving chemicals rapidly infused into her body, but just a drip. A drip in one arm, and later a catheter inserted. And all the liquid that goes in and the liquid that goes out can be recorded in a table in her drug chart.
But back to the cannula. Her hand in my hand. I am poised. She is dreading it, but her daughter, the three other medical students and the tall nurse are all poised with me. It’s a relatively simple process; the plastic tube has a needle inside it that just pokes out of the end. So you insert the needle into the vein then advance the plastic tube over the needle further into the vein. Point of access made.
I am poised, and I go for it, like I know how to do, bravely push that needle through the skin and into the vein. I somehow make it, although the woman is squirming with how uncomfortable it is, I don’t feel like I’m in properly, it doesn’t feel right, there is resistance, I push it further it still resists. She squirms. I squirm and squirm the cannula in more. There is a small flashback of blood, I did hit the vein, but I think I’m just out of it. I try and advance the cannula in and this is the point where the video reel in my head becomes the most vivid, the bit that troubles me. Her hand in my hand, I’m pushing the cannula in under her thin skin, that is sliding about and causing this problem, and her vein, this elusive vein that won’t yield itself to me is twisted like a snake under a rug, she squirms and cries, I watch this battle between cannula and snake play out under her paper like skin, watch the blood bruise build up, the tears well up and I want out, I want this cannula out, I want to be out of this room, out of this hospital, and out of this profession and this training where I bumble and hurt because I don’t know how to do it.
As we get older, skin sags. It moves more. In a young person if you push a needle through their skin it will remain tight. In an older person it all moves and slides around, suddenly your needle is centimetres away from where you thought it was going to and that vein is playing hard to get.
The nurse takes over from me, and expertly slides it into her other hand. Point of access made. They leave for fresh air, a little bit traumatised, with a painful hand. I leave, a bit more traumatised, a little video reel in my head. Her hand in my hand, cannula and twisted snake of a vein at battle, Point of access not made.