How to Insert a PICC Line
Not gonna lie: it’s been a long week so far.
On the first day (Monday), my heart rate shot to a resting rate of 130. Once or twice in the evening when I moved about, it spiked to 170. The burn came immediately and mercilessly back, as if Ra the Sun God were holding a grudge. The skin has started to chafe and peel around the PICC line, which freaks me out. I have paranoid fears of them pulling off the bandages and swaths of my skin coming off along with it.
The PICC line is a delicate business. Friends who are undergoing the same treatment on the other side of the coast reported to Dena that Mark, the one undergoing the treatment, had his PICC line break this morning. As I’ve described in previous posts, inserting a PICC line is no easy thing. It runs from your arm through a vein curving around the front of your shoulder before dropping down into your chest to empty into the vena cava, the big vein carrying blood to your heart. Every night you go to sleep delicately tucking this tubing emerging from a hole in your arm into a safe place, the clear lines tucked neatly on the outside of the covers so that you don’t accidentally rip it out of your arm, maybe during a sleepy tuck and roll to get warm, causing the wiring to recoil from your heart and whip through the smaller basilic vein in your arm, like one of those measuring tapes with automatic recoil, and come whipping out of your arm, a headless snake twisting about the room.
So Mark’s line breaks?
Blood squirting across the walls kind of break?
Turns out that the line didn’t break in Mark’s arm but on the exterior. Rather than doctors and nurses and cleaners rushing in to stop the hemorrhaging, it only required a PICC nurse to come in and repair the line.
It’s true. I have an overactive imagination, but it’s not entirely my fault. When I checked in to Duke for my round of IL-2 this week, I had a new PICC nurse. The last guy was good, and he talked to me about what he was doing primarily, I think, as a way to keep me distracted. (Everywhere I go I make nurses with needles nervous.) So he showed me the ultrasound that he would use to coil the tubing through my arm.
Nicolas, my new PICC nurse, also good, took my education to a new level. He told me that he himself passed out around needles. At first this made me feel comforted, that the nurse got it and understood that some people just don’t handle needles well. Clearly he would not be one of those nurses that sticks and then says “Oh” and then sticks again and says with accusing eyes, “You don’t have good veins” and sticks again and you wake up to with two or three nurses and doctors hovering over you, calling you “Sugar” and snapping salts under nose while asking if you can lie back and would you like some apple juice or a cold towel for you head.
Nicolas’s fear of needles went beyond even mine. In an effort to beat his fear, he told me, he decided to become a nurse. And over and over during his training he’d approach the poor bastard getting ready to get stuck, and his hands would start to shake and he’d pass out.
You can imagine how this might create anxiety on the part of the patient. While I appreciated his empathy, I began to get a little weasy. This was not a little needle withdrawing blood. It was a large needle, more than one in fact.
“You’re not going to pass out on me while you’re doing this, are you?”
Nicolas found my question amusing. He laughed. Which I took as somewhat reassuring. Or sadistic. No, he told me. He said that a kind nurse took him under her wing and took him to her house, sat him at the kitchen table, pulled out a bag of frozen black-eyed peas and told him to go to work. So he would move in, needle in hand, and she would hold the frozen peas to his forehead to keep him cool. Eventually it worked. Nicolas was able to get over his phobia and pass through med school with flying colors — and is now a member of Duke’s world clas picc line team. I assume he sends that kind nurse flowers every year. (Or bandages and disinfectant.)
Nicolas asked if I would like to understand the whole procedure.
“After the procedure,” I said, “and if neither of has passed out, then yes, yes I would.”
The PICC line went in without a hitch and Nicolas turned his collection of tools to me. The first step, after inserting a local anesthesia to numb the pain, is to insert a steel needle of about three inches directly into the basilica vein – the one that runs up the inside of your arm until it connects with the cephalic vein. The cephalic vein is the one you see bulging on biceps. These two merger near the shoulder and create a larger vein that rounds the shoulder and drops down into your chest and empties into the Superior Vena Cava, a thick short vein that dumps directly into the right atrium of your heart. In other words, this path created by the PICC nurse allows for the interleukin to be dumped directly into the heart and spread rapidly through the bloodstream throughout the body.
One tricky part during this procedure. While snaking the PICC line along the basilic and cephalic veins, near the point where they merge below the neck, there is a risk of the line going off course and sliding into the jugular vein. Yes, the jugular. The one your neck that bulges when you are angry. The one pit bulls go after. The one your wife grabs and shakes when you ask her if dinner is ready. And it does happen sometimes — the PICC line veering off. Nicolas told me of one incident in which the patient complained about feeling something weird and ticklish in his throat, prompting Nicolas to pull back the covering fearing that he would see the tubing popping out of the patient’s throat like a periscope. The sensation the patient was complaining about wasn’t the tubing but a kind of ghost scratch created by the tubing entering the jugular. Nicolas was able to withdraw the line and reposition it without much trouble.
So after the initial steel needle is inserted into the basilic vein, a dark wiring that looks like piano wire is then inserted into the opening created by the needle. The piano wire is pushed up further into the vein about 10 to 12 inches. It will serve as a guide for the tubing. At this point, the hole in your arm isn’t big enough to get the PICC line into it.
So out comes a second needle. Nicolas described it as a synthetic needle. It was aqua in color and appeared to be made of a hard sharp plastic. This needle is both longer and wider than the first one. It is about six inches long and as it is is driven in it swallows the piano wire in the way a snake eats a small rodent. The back of the synthetic needle is even wider and strips open. So once the needle has swallowed the piano wire, the back of of the needle is pulled apart, creating a broader hole, one large enough for the clear tubing of the PICC line to enter. This clear plastic tubing is then snaked up the basilic vein, using the piano wire as a guide. Once the catheter is on course, the piano wire is withdrawn from the vein, pulled out the back of the broad hold of the synthetic needle. (Definitely something you could use to illegally break into a car.) After that, the process is as I described it in previous posts, with the nurse carefully coiling the tubing through the veins, using the ultrasound as a guide, until he hits paydirt with the vena cava.
So that’s my PICC line story and I’m sticking to it. I am currently on Dose 8 and despite the lousy things I described above, I’m doing okay. I have a lot of chills (I’m having a little trouble controlling the shaking with my fingers as I type this; my skin is ridiculously red; I have trouble sleeping; I have had some muscle rigors but have managed to avoid morphine so far; I still take laps around the ward, which seems to impress the nurse and doctors; they had to skip one dose yesterday because my heart rate was too high and my blood pressure was too low, but we seemed to have found the right prescription drug combo to get me back on track.)
The only thing left at this point is to take some more pills and wait for the exciting season finale of Burn Notice.