Losing 18 Inches of Wire In a Patient? As Inevitable as … Doomsday Itself

Sometimes a doctor must place a large-caliber catheter into one of the body’s biggest veins: the internal jugular in the neck, the subclavian in the chest, or the femoral in the thigh. These are “centrally-located” — in close to the torso — and the catheters accessing them are thus called central lines.

This happens about 5 million times a year in America. So even rare complications happen with regularity.

The catheters are too large to just jam in. Once a site in neck, chest or thigh has been cleaned and anesthetized, that large vein, often deep under the skin, is carefully punctured with a finder needle. It’s not uncommon to accidentally hit the artery next door. I’ve done this, as have most acute care physicians. (When blood is spurt-spurt-spurting out of the carotid, it’s good the finder needle is relatively small-bore.)

Like most things in medicine, this sounds Godawful but is actually more nuisance or embarrassment than crisis. A teensy hole in the carotid resolves with direct pressure. If a medical student is around, guess who just got an exciting new task! I remember as a med student in Washington D.C. being surprised when called to bedside to manage a doctor’s screwup.

View of finder needle passing the sternocleidomastoid muscle (SM) to puncture the internal jugular vein (IVJ). Note nearby lymph nodes and carotid artery. Image from this excellent article on using ultrasound for central line placement.

“Here, hold pressure. Yup, like that. Don’t let go for the next 10 minutes or so — if you do he could die,” he said. “Just sayin’.”

“Wait, what?” said the patient and I together — the patient muffled from underneath a plastic sheet.

“Good luck!” the attending said as he hurried off.

“Getting into Big Red,” as some cowboy-speakin’ docs refer to puncturing the carotid, is the exception. The rule is that the finder needle is neatly placed in say a plump internal jugular. Next, a soft, springy guide wire is fed through the needle into the vein. The finder needle is removed, leaving the wire behind. If using ultrasound (instead of just feeling for a pulse and not going there), this is when most of us will triple check: Yes, we see the wire in the vein; no, it does not go out the other side into the artery, but stays in the vein. Check.

That settled, then with scalpel and a plastic dilator the path to the vein is widened — this briefly may be a bloody mess — before the central venous catheter itself is slid down the guide wire; the wire is removed in the same motion, and everything gets cleaned up, capped off, sewn and taped in place.

A portable chest X-ray is ordered to confirm all is well. Sometimes the catheter has looped back on itself, so instead of pointing straight toward the heart, it U-turns — up toward the head, say, or if in a femoral vein, down toward the feet. Such a wayward catheter would be removed. Other times — about 1% of the time, actually — the chest X-ray reveals a collapsed lung. That’s a known complication of poking around in the neck or chest with a big needle. I have been guilty of this as well; it’s a saying in medicine that, “If you haven’t dropped a lung, you haven’t done enough central lines.”

(What if we do collapse a lung? Well, for starters — everyone involved makes more money! Yes. We never talk about that. It’s one of the many aggravating absurdities of a fee-for-service / “get-paid-for-whatever-happens-next” healthcare system.)

During my emergency medicine training, attendings would warn me that once I’d fed a guide wire into a vein, I had to keep a hand on that wire until it was back out. I’ve placed hundreds of central lines since residency in Boston, and I admit I sometimes let go of the guide wires. Usually this is a wire about 18 inches long, with about 2/3rds of its length outside the patient. If I let go, it just lies there, protruding from the patient’s neck, maybe bouncing up and down gently on the sterile field. My hands are free to reach for and use scalpel, dilator, central line catheter.

And then, one day, I turned to reach for scalpel, dilator, central line — and when I turned back, the wire was gone. Puzzled, I looked more closely and saw it disappearing into the patient’s neck.

Quickly I pinched the last little inch between gloved thumb and forefinger. I drew it back out; released it; watched as it slid smoothly back in; stopped it again.

It’s not supposed to do that!

Well.

Like a good doctor I finished placing the line, and compartmentalized away for later thoughts of how close my patient and I had come to a disaster. Maybe even a life-changing disaster: Sometimes, the doctor does this procedure and never notices a wire is missing — floating somewhere inside the patient, for days, weeks, months to come.

Never Say Never

Losing a foot and a half of wire inside a patient is the very definition of what medicine calls a “Never Event.” As the term implies, these select errors are hard to forgive.

And yet the Never Events never stop.

Consider the extreme scenario of “wrong patient / wrong site / wrong surgery” cases. That’s when Mrs. Jones in bed 12 is scheduled for appendectomy and Mrs. Jones in bed 14 for a breast biopsy, and somehow one of them gets the other’s operation. Or maybe they each go to the correct O.R., but Mrs. Jones has the wrong breast biopsied. This is incredibly rare, a 1-in-100,000 event. But we do millions of surgeries, so even unicorn events accumulate. About 100 “wrong patient / site / surgery” errors are reported every year (!) across America — and those are just the ones that get reported.

Guidewire protruding from man’s neck (left), and then seen on CT imaging (right) floating in central veins. Graphic from the New England Journal of Medicine.

What about my specific scenario of losing a central line guide wire inside a patient? Even a cursory review of the literature reveals multiple compilations and case reports, here, here, here, here

For example, there’s the case report several years back out of China, where a runaway central line wire only declared itself six months later, when the patient came in with a length of metal sticking jauntily out the back of his neck.

Or the self-flagellating report out of Iran, which showed a sad X-ray with a central line guide wire floating in the chest, alongside the broken-English editorial conclusion: “This is a very rare complication that is a human error and is totally preventable by doing the procedure by a skilled doctor.”

I share the sentiment that this is rare and often preventable. And I admire medical crusaders who have looked to other professions — skyscraper engineers, commercial aviators — for insights into reducing error amidst complex, dangerous medical processes.

Yet despite all of our efforts — the checklists, bar-coded wrist bands, hard stops in the computer — everyone in medicine knows the Never Events will never end. The wrong teeth will be pulled and the wrong kidney biopsied, the wrong-type blood transfused and the wrong-side ovary removed. EKGs will be misread, fractures will get missed, central line guide wires will be lost. Newborns will be discharged home with the wrong family (one documented case in 2016).

This is deep knowledge that medicine has: There are no Never Events.

The End of Civilization: Just Another ‘Never Event’

Enter COVID-19. At this writing the coronavirus has killed more than 90,000 Americans; fear of the virus and government-recommended control measures have combined to crash the economy, and soon we will see the deaths of despair that accompany every recession.

As heart-wrenching as it all is: This is not a Never Event. It is not Armageddon, not the end of the world.

But living through a pandemic does help us, as sleepy humans jarred out of our day-to-day routines, to imagine Armageddon.

A nuclear war would be that thing. It is the ultimate Never Event. Sure, none of us truly believes it will happen — to the point that many instantly stopped reading at the very mention of it. But who among us truly believed we would ever be hiding in our homes from a virus? (What surgeon ever truly believes they might one day cut off the wrong leg?)

A nuclear war will happen.

The experts have told us so, in increasingly frantic terms.

This is because we insist on keeping massive nuclear arsenals all pointed at each other on hair-trigger alert, like a bunch of twitchy gunslingers in a Mexican standoff. This inevitability — the absolute certainty of a nuclear war that no one wants and no one expects and no one believes in — is as dependable a future event as our pandemics, nuclear power plant catastrophes, and societal mass shootings.

You’re outraged our government wasn’t better supplied with N 95 masks, that it made a mess of coronavirus testing? Me too. It certainly makes my job as an emergency medicine doctor miserable! But really, that’s all small potatoes.

Recently published data confirms that even a small exchange of nuclear weapons — less than 1% of world arsenals, like a squabble between India and Pakistan — would erase all global warming we’ve so appropriately worried about, careen us back toward a global cooling, and crash planet-wide agriculture. Under COVID-19, have you enjoyed struggling to find toilet paper or being overcharged for rib-eye steaks? That’s a tiny taste of the collapse of all food supplies and of global civilization itself that would come with any exchange of nuclear weapons anywhere.

The International Red Cross, the International Council of Nurses, the American Medical Association, Pope Francis, former U.S. cabinet officials from defense and state — these and so many others have begged the world to stand down and ultimately disassemble the thousands of nuclear weapons we have pointed at each other. The world is a receptive audience, and in 2017 the United Nations passed a treaty, sullenly ignored in Washington but under spirited debate abroad. It is approaching ratification and at that point will declare all nuclear weapons illegal (!) and ban them outright.

In response, Washington doubles down, and to this day insists doggedly that it could use nuclear weapons at any point — for any reason. Most Americans don’t believe or understand this; we assume the only reason we cling to our nuclear weapons is to prevent others from using theirs. Not so. Not even close. If “we” (meaning, a White House-Pentagon groupthink session) decide it’s “in our national interest” — not necessary to our survival, just a bold chess move — then we reserve the right to intentionally kill millions of innocents.

That could be more innocents killed in an afternoon than the Nazis killed in the Holocaust years. Compared to this, the coronavirus is a walk in the park without a surgical mask.

But what if we did reserve these genocidal devices only for self-defense? What if we only threaten to vaporize millions of other people when, you know … when we have to? Well, as your doctor, I have to point out: You are threatening to incinerate every kindergarten in a city, every NICU, every PICU. To burn to death every baby, every first-grader, every second-grader. And there is no scenario where that is O.K.

I would add — more cruel truth — you supporting this? however regretfully?

Kind of makes you a coward.

Sorry. But that’s what I would call it, using other people’s first-graders as your human shields.

Physicians have a long tradition of condemning the eye-rolling immorality of nuclear war plans. If the doctor can’t tell it to you straight, who can? But many of us who practice high-stakes clinical medicine also question the competency of the planners. We know from professional experience that it is impossible to eliminate Never Events. Yet that obstinately, recklessly, idiotically, remains Washington’s plan.

Spending $35 billion a year to keep hundreds of nuclear weapons on hair-trigger alert, aimed at others, who point their own creaky, hair-trigger’d missiles right back at us — this does not keep us safer. Both George W. Bush and Barack Obama have publicly spoken out against hair-trigger alert, shorthand for the policy of launching missiles after just minutes of a panicky Pentagon briefing. The practice has been called outdated and “absolutely insane” by a former CIA director, and “absurd” by a former NSA director. One former head of all U.S. nuclear forces has testified to Congress that it needs to end; another former head of all of nuclear forces has asked Americans to say prayers for this. Yet it continues.

Again: See “Standoff, Mexican”! It’s a Hollywood trope! The most unsafe scenario known to cinema! But whatever.

Anyone involved in hospital-based medicine has lurid stories of how good intentions slid sideways: Punctured carotids, collapsed lungs, wrong-site surgeries, lost guide wires.

So do U.S. nuclear war planners, who once accidentally dropped two nuclear weapons on North Carolina; once accidentally dropped four nuclear weapons on Spain; once spent six panic-filled minutes scrambling to launch a nuclear war before they realized they were responding to a computer simulation; once called the White House at 2:30 am to warn the president of thousands of Soviet ICBMs screaming towards us, only to stand down sheepishly a few phone calls later (culprit: a defective 46-cent computer chip); more than once had to work around a president belligerent and intoxicated on alcohol …

There is only one way to reliably eliminate Never Events from a complex system:

Shut down that system.

We do not have that luxury with healthcare. So we can only strive to do better: Follow checklists, use closed loop communications, and don’t let go of the guide wires. Think ahead and plan for the worst — including the patient surges from hurricanes, pandemics, and mass casualty incidents.

But we do have the power to prevent the Never Event of a nuclear war. That requires scrapping the nuclear weapons systems — just as we’ve already done with other indiscriminately murderous systems that also blow back on those who use them: chemical and biological weapons.

We simply have to take nuclear explosives off of hair-trigger alert, and then in cooperation with other nations — as we’ve done with chemical and biological weapons — ban and dismantle them. As horrible as the coronavirus pandemic has been, if it could broaden our imagination and focus our thinking, maybe it could help save us from ourselves.

Interested in joining everyone from the Pope to Henry Kissinger, and working towards a nuclear-weapons free future? Support Physicians for Social Responsibility, or International Physicians for Prevention of Nuclear War, or the International Campaign Against Nuclear Weapons; get yourself, your town, city, state and Congressional delegation to sign onto the Back from the Brink pledge.

Born in DC, studied at UNC-Chapel Hill, now living in Massachusetts. ER physician, EMS medical director, recovering journalist & Russia-watcher.

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