The joy of ABG

Recently, I completed the posting which is known to be the best in the twelve months of internship; my stint in the emergency medical services (EMS). The EMS, as will be obvious at first glance of the queue of trolleys and throng of patients who are there perennially, 24x7x365, can be termed as the most pulsating place in all of KEM. To be working here, to actually be a part of running this ordered pandemonium is the stuff that our ER-fuelled dreams are made of. To say that every intern waits for his days in the EMS would be an exaggeration but, it is the one time that you are working so hard that you don’t know when morning ended and evening began. Although, most interns (me included) who look zonked will tell you ‘EMS night maara’, with a pained expression, their expressions belie their inner joy, of being there, in the heat of the moment, on their toes, ‘doing‘ something. Maybe I’m getting carried away. Most times, you are doing the same old ‘collection’ of blood to be sent for various tests. But there is learning by seeing that is always happening, simply because of the sumptuous volume of patients and variety of diseases that are there.

And then there is ‘learning by doing’. Now, in the beginning of my posting, most things were fun to do but the words that filled me with dread were “Veena, is patient ka ABG maar.” Now, an ABG stands for Arterial Blood Gas analysis. For this blood needs to be collected from an artery and sent to a laboratory where someone will then put two drops into a nifty machine which tells you the acidity of the blood, the amount of oxygen, carbon dioxide et cetera in it. Sounds pretty straightforward. So, what’s my job? Only the blood collection bit. See, for most patients we have to send blood for a few routine tests and additionally an ABG. For the routine tests we collect blood from veins, a job which is simple enough. Just ask the patient to make a tight fist, ask the relative to hold his (the patient’s, I mean) upper arm and squeeze like crazy. A shy little vein will soon get engorged with blood and become nice and fat. Slip the needle into this vein; pull the syringe and a jet of dark venous blood rushes in. Smooth, clean, over in an instant.

But, an Arterial blood gas analysis, as I mentioned earlier, obviously needs blood from an artery. Now here’s where the trouble begins. First, we have to explain to the patient that this ‘tapas’ (that is the word for investigation in Marathi and not some funky Mexican food dish!) is different so I need to collect blood again. Most patients are already a little grumpy but they relent and extend their arm out again and make a fist, prepared for the second needle prick. That’s when you tell them that this blood is to be collected from a different place and they don’t need to make a fist. The blood is mostly collected from the radial artery in the wrist. (This is the same thing that all the doctors in Hindi movies feel before they declare a person dead on screen). Herein lays the trouble. The artery, unlike the much more co-operative vein, cannot be seen, its pulsations must be felt and the needle inserted where you feel the pulse best. It takes quite a while to master this. And the sufferer is the unsuspecting patient. When he gave you his hand for the second time he had no idea that this prick would be so much more painful because sometimes you hit the bone that lies underneath and at that moment I’m sure every patient wishes he was dead rather than go through such horror. Also, since interns are learners, one prick is almost never enough to draw out the blood and we, on an average, prick twice before the bright red colour of arterial blood fills the syringe and suffuses our faces with bright smiles.

Now, in the first few days in the EMS, I had a tough time getting the artery (or, should I say, my patients had a tough time). It got so bad that one of my hapless victims had to be rescued by the ABG mama, who, miraculously, hit pay dirt at first prick in a patient I had pricked at least four times without success. Then, I asked my co-intern who seemed to be getting arterial blood quite often what I was doing wrong. So, for the next ABG she came along and pointed out my mistake. I was inserting the needle perpendicular to the direction of the artery (in the same plane, though) which did seem like quite a foolish error. So the trick was to enter parallel to the direction of the artery which happens to run up the arm. That little word of advice just seemed to wipe away a lot of problems. That particular ABG I got instantaneously. One prick and zwoop, the blood rushed into the syringe. Such an acute thrill as I felt! Few things can feel as great as getting a procedure right. You get this rush of joy at having succeeded at something which is slightly difficult. And the feeling of complete bliss is very different from anything I’ve experienced before. This is close to how a sculptor must feel on appraising an idol built by his hands, this is how a master chef feels looking at his three-tier wedding cake, and this is how the surgeon feels after performing a difficult Whipple’s surgery meticulously. While my task may not be anywhere near the difficulty level of these, the sense of accomplishment I felt is probably the same. After that there have been innumerable ABGs. Many have taken a little digging and prodding for the artery and some have taken several pricks. But I’ve definitely improved and each time that I have succeeded the delight has remained unchanged.

So, the moral of the story, when you’re feeling blue, go out there and “do something” with your two hands. Don’t sit and read a book or watch TV or check your e-mail; do something. Oh, but don’t maaro ABGs for kicks, it’s still extremely painful for patients. Moral number 2: If you don’t get the ABG after three to four pricks and the registrars are too busy to help, ladies and gentlemen, its time to call ‘ABG mama’. This guy is a class 4 worker (a mama) in the emergency department who can get most people’s ABGs in one prick. And surprisingly, he doesn’t look too old, so it’s not as though he’s picked it up by hanging around the place for twenty-five odd years. Well, some people are gifted. The others just have to learn. Unfortunately, the poor patient who comes to KEM becomes the pin-cushion and laboratory mouse in our learning curve. Is this the price that he pays for very cheap treatment? I suppose that’s a complex ethical poser that has no right and wrong answers. So we shall leave it be.

As for the ABGs, maybe it’s a sad statement of how my life is right now, but getting it right is the high-point of each day.