Access is Everything

It was 2:00 AM when the call came in to the emergency room alerting us to the arrival of a young male patient with an apparent drug overdose. Paramedics were already performing assisted ventilation as they wheeled him into the available trauma bay. The patient was poorly responsive, with a ghastly gray complexion, pinpoint pupils, a barely palpable blood pressure and a purple hue to the fingers and lips. As a second year resident on my ER rotation, his care fell to me.

We needed to gain immediate access to a vein in order to administer life-saving drugs and intravenous fluids. Several attempts to access a peripheral vein were frustrated by severe scarring at every available site – the result of years of self-injections of heroin. Even leg veins and groins were impenetrable. A hematoma under the tongue suggested that this patient had even tried to use the sublingual veins to get a desperately needed fix.

With no time to spare, I prepped the area just beneath the right clavicle to perform a subclavian catheterization with a large-bore catheter: “Check the landmarks, penetrate the skin just beneath the clavicle at the junction of the middle and lateral thirds, and aim for the opposite shoulder…” Success! Venous access established and within minutes the patient was awake, thrashing about, and breathing on his own.

I have vivid memories of similar heart-racing moments to gain access to critical bodily compartments: from delicate scalp-vein venipunctures on premature newborns, to emergency chest tube insertions in patients with an acute lung collapse, to difficult spinal taps in patients suspected of acute meningitis. Until we had established a reliable port of access, any attempt to reverse the patient’s deteriorating condition was compromised at best and sometimes impossible. (Watching "ER" on TV has often caused a visceral reaction as I relive some of those moments.)

Reliable central venous access is also essential for the administration of Interleukin-2 and, to facilitate that access, I had earlier undergone the placement of a semi-permanent device called a Port-a-Cath. This device consists of a titanium reservoir which was surgically implanted beneath the skin just below my right clavicle. The reservoir is connected to a catheter which is inserted into the major vein that empties into the right upper chamber of the heart. Unfortunately in the last two days, persistent tension on the overlying skin has compromised the capillary circulation resulting in the development of a pressure ulcer at one edge of the reservoir. As a result, I will now require revision of the implant. We leave tomorrow for Charlottesville to have this done. If not attended to, I will not be able to receive the planned second round of the Interleukin-2 therapy, scheduled for mid-June.

Access is essential in many arenas. It was to improve my patient’s access to timely and personalized medical care that I established Personalized Family Medicine a little over two years ago. The result (in my humble estimation) was a dramatic improvement in the quality of each patient encounter, in patient satisfaction, and hopefully in clinical outcomes.

Throughout this personal encounter with cancer the one thing that I have grown to appreciate more than ever is the direct access I have to the Great Physician. Because of what Christ has done, I have an open line to an all-powerful, loving God who is anxious to infuse me with spiritual health and strength that enables me to face any challenge (Ephesians 2:17-18, Hebrews 10:19-22). I am grateful that the One who is on call 24 hours a day, seven days a week, lovingly resuscitated me when I was near death (Ephesians 2:4-5).

It is also because so many of you have gained access to that same source of power through prayers of faith that I am witness to His awesome mercy and grace. Please continue to do so as we return to UVA to take care of this complication.

I will keep you updated,

Dan