US Guided Subclavian Lines

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Subclavian lines can be useful when accessing the internal jugular (IJ) or femoral vein is not ideal. For example, you may choose to avoid the IJ in patients who are wearing a c-collar, have a tracheostomy, or have trauma to the head and neck. In addition, some femoral sites are avoided due to pelvic trauma, a large pannus, or a contaminated inguinal region. Using ultrasound to place a subclavian central line can decrease procedure time as well as potential complications, such as pneumothorax, nerve injury, arterial cannulation, thoracic duct injury, hematoma, and hemothorax.

Anatomy: The Subclavian vein is a continuation of the axillary vein as it courses under the clavicle of the first rib and joins with the IJ. The subclavian vein is located inferior and anterior to the subclavian artery. The lung and pleural cavity are deep and interior to the subclavian vein.

There are 2 approaches to placing a subclavian central line: the supraclavicular approach and the infraclavicular approach.

For the supraclavicular approach stand at the head of the bed as if you were placing a central line in the IJ. Place your linear probe above the clavicle to visualize the vein in short axis (you can find the IJ first and trace it until it joins up with the subclavian). Visualize the vein and proceed with Seldinger technique, taking care to note where the pleura is in reference to the vein. You can try to avoid puncturing the pleura by aiming the needle at the rib just under the subclavian vein, so if you overshoot you will be stopped by the rib.

The infraclavicular approach can be done in short or long axis view. If done in long axis, place the probe in the infraclavicular fossa. Your needle in this approach is much more lateral when compared with the landmark-based approach. Identify the point where the axillary and cephalic vein joins with the subclavian and insert your needle past that junction. You will not be able to visualize the artery and vein simultaneously in this view, so use doppler or rotate the probe to short axis so that you can see both the artery and vein at the same time. Proceed with Seldinger technique.

Tip: shrugging the patient’s shoulder opens up a window to puncture the subclavian vein over the 1st rib. In a neutral position, the 1st clavicle lies over the vasculature. Raising the shoulder lifts the clavicle and opens up this space. In this position, if the needle doesn't hit the first rib it will often arch over the first lung, rather than puncture it.

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NG Tube for SBO

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Is a nasogastric (NG) tube really needed for management of small bowel obstruction (SBO)? NG tube placement is one of my least favorite ED procedures. I therefore find myself hesitating every time surgery requests one, but what is the evidence behind it?

 

Surprisingly, there is little data and no randomized control trials on the use of NG tubes in SBO. A chart review in 2013 looked at 290 patients admitted with SBO. 20% of those 290 patients had a NG tube placed. They found that ⅔ of these patients were managed non-operatively, irrespective of NG tube placement. In addition, decompression with an NG tube was not found to be associated with decreased bowel ischemia or need for surgery. Use of an NG tube was actually found to be associated with worse outcomes, such as increased length of hospital stay, higher complication rate, and longer time to resolution.

 

Part of the reason that I dislike this procedure is the apparent discomfort we cause when placing them. Patients routinely rate it as one of the most painful procedures performed in the ED. We attempt to decrease pain with anesthetics, even though many ED physicians do not believe them to be effective. A RCT was done assessing the use of surgical lubricant versus topical lidocaine and phenylephrine for the nose with tetracaine and benzocaine spray for the throat. Patients reported a significant decrease in discomfort when providers used vasoconstrictors and topical anesthetics compared to surgical lubricant. 

 

However, there are some cases where NG tubes may be indicated. Patients who are vomiting after antiemetics or have a significantly distended stomach may benefit. Rather than placing them on all patients diagnosed with an SBO, we should select patients for this procedure based on their symptoms.


Thanks for reading!

Ariella 

Resources:

Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422-8. PMID: 23574854

Paradis M. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion? Emerg Med J. 2014 Mar;31(3):248-9. doi: 10.1136/emermed-2014-203617.1. PMID: 24532357

Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: a randomized, controlled trial. Acad Emerg Med. 1999 Mar;6(3):184-90. doi: 10.1111/j.1553-2712.1999.tb00153.x. PMID: 10192668

Witting MD. "You wanna do what?!" Modern indications for nasogastric intubation. J Emerg Med. 2007 Jul;33(1):61-4. doi: 10.1016/j.jemermed.2007.02.017. Epub 2007 May 30. PMID: 17630077

POTD: History of the Match

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In celebration of everyone who successfully matched today, I wanted to talk about the fascinating history of the Match, from the crazy days of pre-Match chaos and to the unsung heroism of one medical student that changed it all!

In ye olden days...

Back at the turn of the century, residencies were only just in their nascency, and there was no strict requirement of residency in order to practice medicine. Scary thought, considering I didn't know how to order Tylenol let alone practice medicine when I graduated from medical school. In fact, residencies were once called "undergraduate repair shops" in the 1910 Flexner Report (a revolutionary-but-also-definitely-morally-grey-and-racist education reform paper). They became more popular with the rise of medical specialties, where graduates would essentially apprentice until they felt comfortable to practice on their own. However, as more specialties developed, the value of residency rose, and by the 1930s, most hospitals were requiring residency training before completing boards exams.

By the 1940s, competition for residencies grew fierce. Offers were given out increasingly earlier, so much so that they were being extended to students only in their second year of medical school. It got so bad that medical schools were embargoing recommendation letters to prevent the hospital equivalent of cradle-robbing. Soon, competition got so bad that "exploding offers" were being made that had a 12-hour expiration date, leaving many students scrambling to send off telegrams and make phone calls. No bueno STOP

Thus, the first Match system was born.

The Match that never was:

In 1951, the Mullin-Stalnaker algorithm was in works to be implemented in the first ever match process, and it was being championed by the high echelon of medicine including the Dean of Harvard Medical School. Thousands of dollars were being poured into making this event work, and it would be entirely derailed by a maverick medical student named William Hardy Hendren III. A Navy veteran with lots of chutzpah, he noticed the algorithm was flawed in several ways, and even presented his argument on the blackboard with the Dean and entire medical class present.

I won't go into the nitty-gritty of the Mullin-Stalnaker algorithm for sake of brevity, however it's actually super interesting and explained really when in this blog (https://thesheriffofsodium.com/2020/02/03/the-match-part-2-getting-under-the-hood-how-does-the-match-work/). Long story short, this match process penalized students who ranked "reach" programs, and it often produced what we call unstable matches - matches in which more favorable matches existed for both parties and were not considered or passed on. This encourages "elopement" by either party to make deals outside the matching system.

Going back to our story, Mr. Hendren realized this, and despite multiple threats from the Dean about withholding his graduation and that "[the Dean] didn't give a damn if any of [the students] get internships," he persisted in his quest for reform. In the historic frantic following weeks, Hendren led a movement and gathered over half the student leadership of medical schools across the country and created their own algorithm, "The Boston Pool Plan." This new plan assumed a "deferred acceptance" algorithm, in which a student was tentatively assigned to a hospital until or unless they match at a higher ranked place. There was, as suspected, resistance from the powers-that-be, of which Hendren replied:

"If you don't change the plan, it will be the end of it. I have votes from 95% of the students in the country...These same students have said they're going to bolt if you don't change the plan. We're not going to sacrifice our futures because of the errors you all have made in setting up this plan the way that you have."

The leadership deferred to the demands of Hendren and the students, and the following year the Boston Pool Plan was implemented for the first ever match. Hendren went on to become a renown pediatric surgeon, remaining on to serve as emeritus chief of surgery until his death just this past May at the age of 96.