Ooh! Ooh! PICC me! PICC me!

Happy (Belated) Turkey Day! (11/24/07)

So this week was another exciting episode in the world of doctor appointments, pokings, and pseudo-information gathering. As you may have noticed, I've started adding pictures. Some will be random, but some, like the one to the right, will be relevant. That thing on my right arm is the dressing for the PICC (peripherally inserted central catheter) that will allow the docs to put in the chemo drugs without burning out my veins. Ah, but I'm getting ahead of myself. It all started bright and early Monday morning...

(Wayne and Garth strafe across the screen, wiggling their arms and fingers up and down and saying "Doo de-loo! Doo de-loo! Doo de-loo!)


Slim PICC-ings
(Caveat: This post is all about PICCs. If you have no interest in such things - well, you have free will and all, so make your own decisions about whether you want to read on.)

Woke up bright and early on Monday morning (about 6:40am) to get to the hospital to have my PICC inserted. Typically chemo drugs can be pretty nasty on the veins and irritate the smaller ones (like those in your arm), so they usually want you to get a central line inserted. That way the meds can go directly to your heart and get pumped through the body from there. From my understanding, you've got two choices: a PICC, which goes in through the arm and up almost into the heart, or a port, which goes directly into the chest (and requires a minor surgery). Both are pretty much the same functionally, except that I'm not supposed to lift more than 15 pounds or do repetitive motions with my PICC-arm. Plus the PICC is a lot easier to pull out if it gets infected.

Anyhow, we got to the hospital bright and early, and actually, before the PICC saga could begin, I had to get an injection of radioactive dye for my bone scan later that afternoon. So first I went to nuclear medicine around 8am to get injected with some stuff that would circulate through my body and make my bone marrow glow (on the imaging scan) if anything suspicious showed up. My mom came with me for what would turn out to be a long, long day. The dye injection is just like any other injection, except the syringe comes in an ominous looking lead tube holder. It's a dose that's less than a CT scan, but for folks who are handling the stuff every day, it's good to have some protection.

After that, it was off to get a PICC line. From previous discussions, I had gathered the PICC was a pretty simple thing to put in - I thought it would take a few minutes, and then my mom and I would get to go home for a few hours while we waited for the radioactive dye to circulate and we could return for the bone scan itself. Oh, not so. It turns out that putting in a PICC is a fairly involved procedure, and there are only 5 or so nurses in the entire hospital trained to do it (and that's what they do, all day every day). Compared to surgery, I suppose it's not that bad, but it definitely takes a bit of time.

Step 1 - I go into the room and lie down on the gurney with my left arm straight out to the side, resting on a table. The nurse (Darcia) does an ultrasound of my arm to find a good vein to put the catheter in. Hopefully it's not too close to an artery or a nerve... luckily mine wasn't.

Step 2 - The nurse scrubs her hands and opens up this package wrapped in sterile blue cloth. She puts a sterile cloth over your arm with a hole in it for the site on the arm. She folds up one side of the cloth so that I can't see, or more importantly, breathe on my arm. She also gets on a sterile gown, hairnet, and sterile gloves to handle all the tools.

Step 3 - She scrubs my arm with about four different kinds of scrubs (soap, alcohol, some chemical whose name I can't remember, and that same chemical combined with alcohol). Each scrub has for some reason its own applicator, too - one's a sponge, one's a sponge attached to the end of a handle in which the scrub liquid sits (I think you can kind of crack the handle like a glowstick to make the liquid come out), one's a set of three oversized q-tips (alcohol I think), and one leaves your arm a nice shade of blue that makes it look like you've either been bruised really badly or had a run-in with an ornery smurf.

Step 4 - At this point, the blue cloth is shielding my view of the goings on, but roughly this is what happened next. She gives me three shots of lidocaine to numb the area (the shots themselves are probably the most painful part of the whole thing), and sticks the PICC line in with its associated guidewire. At this point my skin is mostly numb but I do feel a bit of pressure as she pushes the catheter in. She sutures the little holder clamp to my skin with one stitch, and then ties knots around the clamp to keep the catheter in its place.

Step 5 - The nurse puts on a sterile dressing so that we can walk down the hall to get a chest X-ray and verify the placement. At the X-ray area, she has a radiologist read the X-ray (here's where things start going badly). According to the radiologist, the catheter needs to go in a few more inches. Sure, why not? He's skilled at what he does, right? Anyhoo, we go back to the PICC room and Darcia pushes some more length into my arm/chest. Then, she bandages me up, and I'm good to go. . . or so I think. . .

As it turns out, radiologists don't always know what the heck they're doing. After getting the PICC, we went to grab some quick food before the bone scan, and I noticed that when I bent over in a certain way I would feel some weird heart palpitations. I thought that was a bit odd, so we went back to the PICC office to get Darcia to take a look. According to the X-ray (or rather, the radiologist's read of the X-ray) the PICC was in the right place, just above the right atrium in the superior vena cava. It's rare, but sometimes the PICC can "tickle" things in just the right way to cause an arrhythmia. Well, since I had to get to the bone scan quickly, Darcia decided to pull back the catheter about 1.5 cm without an additional X-ray, to get it away from any areas where it might cause issues. I felt okay after that and went to the bone scan, where I basically took a little nap on the table as the scanner moved over my body for 40 minutes (actually it was my body that moved, but you get the picture). We left the hospital around 2pm or so, went to the grocery store, and went back to the apartment where my mom was staying. All was fine and dandy til I sat on the couch a certain way, and there it was again - weird palpitations. Urgh. At this point it was getting close to 4:30 or so, and we called to find out if the PICC nurses were still around. After leaving a couple messages, we decided to just go back to the hospital. Darcia was luckily still there with her colleague, Nadinne, and so she took me to get another X-ray, after which she pulled the PICC back another 2 cm. So finally, I went home, thinking the problem had been solved.

Later that night, though, as I was sleeping I turned onto my left side, and had - you guessed it - palpitations. So, the next morning I called my adviser, who happens to be a cardiologist specializing in ultrasound, and he suggested coming into the hospital so he could take a look. Once again, we drove to Stanford (we had another appointment there that day anyhow), and he snuck us quickly into an empty room to do the ultrasound. David (my adviser) confirmed that indeed the radiologist had probably read X-ray incorrectly, because the tip of the PICC was well into my right atrium and almost at the valve leading into the right ventricle. So, once again we trekked down to the PICC office, where Nadinne (one of the other PICC nurses) was able to pull the PICC out another 4 cm. David even printed out a copy of the X-ray showing how much needed to be pulled out. So all in all, the PICC actually needed to come out about 7.5 cm from where it was initially. We suspect that it's mostly the radiologist's fault, since after the first X-ray, he suggested that Darcia actually should push the PICC in about that much. Argh - I think she had the thing in the right place to begin with. . .

Anyhow, that's the PICC ordeal in a long-winded nutshell. On the bright side, the CT folks at the children's hospital were ecstatic to see that I had a purple Power PICC when I went for my chest CT on Wednesday. Apparently it was the first of the kind they had seen, and they were able to use it to inject the contrast for the CT. Usually when people come in with a different kind of PICC, the nurses there have to tell them they have to get an IV anyway (which sucks, since one supposed benefit of the PICC is that it keeps you from having to get stuck all the time for tests). Why was I at the children's hospital, you ask? Well, that's for another post...

My PICC nurse, Darcia, applies a dressing to the PICC entry site. Notice the sterile gown, mask, and headgear...


Here's what the entry site looks like up close. The disk is a "Biopatch", which helps to curb infection.

Close up of the lines that they will use to infuse the drugs, draw blood, inject contrast, etc.