The end of med school is a strange time.  You’re rewarded for four years of intense training with your MD.  You get a longer, more professional looking white coat.  You get to introduce yourself to patients as doctor instead of med student.  You can sign your own orders and wear a beeper that matters.  Your responsibility and value to the team increases exponentially. 

And yet you are worthless.  You know nothing useful.  You are painfully inefficient.  You’re a doctor, technically speaking, but are really just beginning your practical education.

And then the year progresses and things improve.  You gain more and more confidence and autonomy.  You feel less and less like a fraud.  You can feel the book knowledge and experience beginning to come together. 

It’s at this point that you’re probably at your most dangerous, and it was in this context that I made my most egregious error as a doctor.

I was halfway through a rotation in our cardiac intensive care unit.  It was 2am, and like thousands of other interns on call that night I was making my way through a list of tasks, trying to ink in my remaining open squares.  Next up was a patient who, for some reason or another, needed a central line placed.

I had put in a handful of these by now, and had earned enough leeway from the senior resident to go at it unassisted.  It was to be a femoral line, so I cleaned and draped the area around the groin and inner thigh.  On went the sterile gloves, sterile gown, mask and hairnet (for all this trouble should I go ahead and take the appendix out too?)  I stuck the needle in the leg, pulled back on the syringe, and got some nice dark blood back.  Yes sir, I thought, as I removed the syringe from the needle, I am the man.  Now working quickly I threaded the guidewire up the femoral vein through the hollow needle.  I took the needle out, nicked the skin where it met the guidewire, placed and removed the dilator, and then threaded the central line into the femoral vein.  All three ports worked well, so I sutured the line in place.

As I began collecting all my sharps, I noticed something was missing.  Many of you I’m sure have already guessed what and where it was.  I didn’t know yet but was just about to find out.  I looked under the tray, through the sheets, and on the floor but couldn’t find it.  And then, in a truly horrible moment, I knew exactly where it was. 

This was my own personal wanna get away moment.  I waited for a second, hoping maybe the ground would open and swallow me up, but no such luck.  So instead I willed my legs to move, and walked over to the senior resident, to tell him that I had left the guidewire in the patient.

This is a big time problem.  The wire can potentially float up to the heart and cause cardiac arrest and death.  It can perforate the vein, cause a blood clot to form, or serve as a nidus for infection.  At the very least, it causes me to have to call vascular surgery in the dead of night to tell them what I’ve done so they can immediately take the patient for wire removing surgery, leading to me being known for the rest of residency as “the idiot who left the guidewire in the patient.”  All throughout my training when putting in central lines the one thing I heard every single time was to “never let go of the wire,” so much so that I would roll my eyes when I inevitably heard it.  And now I had actually gone and done it.

The senior resident looked at me with a very predictable mixture of incredulousness and disgust.  We walked back over to the patient who most fortunately was intubated, sedated, and unaware of the stupidness being unleashed on him by his intern.  The resident cut the sutures I had placed and began slowly retracting the line.  I grasped the line with a pair of hemostats and did I feel the crunch of metal at the core?  Or was I just fooling myself into thinking so?  Finally we pulled the line all the way out and there, to my almost incomprehensible relief, was the guidewire jutting out from the end of the line.  The resident relieved me of my central line duties and, after a moment or two to gather myself, I went on to the next task on the list.

Med students, some advice: never let go of the wire.

Edit: Hat tip to Kevin, MD for the link and great pic.