A Million Thoughts

Hope I picked the right side.  She's so thin.  I've gotten away with this before, but you never know, do you?  I wonder if there'll be enough tissue...  Such a nice lady... Antibiotics?  What about the irrigation fluid, antibiotics there, too?  Figures: the vein looks tiny.  Micropuncture'll probably be easier.  We'll numb her up well - can never have enough anesthetic.  We'll work lateral.  Grab some more.  Then medial,  A bit more.  Then one a bit deeper to numb the pre-pec fascia.  Good.  Blade.  Why can't they use the 15 blade?  Damb 10-blade's so big.  Gotta remind 'em to change that.  Okay,  Bovie.  Nice.  Not much tissue here.  Damn mastectomies; bilateral, no less.  We should be fine.  There's a little more tissue here and if we extend the pocket this way.  Yeah, should be fine.  Now, ultrasound.  Hope we get it on the first pass.  Come on...   Okay, there's the blood.  Seems to be flowing freely.  Wire.  Good.   Hmmm, resistance.  Flouro.  The first part looks okay.  Why won't the wire pass?  You don't get many tries if you miss... Pull back.  There.  Now advance.  Come on, come ON!  There.  Feels good.  Fluoro.  Oh, thank God!  Normal course.  Angle to the SVC looks pretty acute.  Dilate, Preform the sheath - hope it doesn't kink.  Good.  Wire passes fine. I wonder if I should doble wire this.  Yeah, safer, especially this time of night.   Good choice.  One lead at a time.  Counter-clock.  Septal.  Stylette back.  Nice.  Let's try here.  Alright, maybe a bit more apical.  Better.  Those are decent R waves.  10 turns.  Nice injury current.  Threshold?  Perfect.  It'll be 0.5 mV in the morning.  Keep moving.  Pre-pec fascia first.  Make sure there's enough lead.  Perfect.  Three ties to the muscle then tie the lead.  Be sure I'm over the sewing sleeve.  Good and tight.  Yeah, it looks pinched.  Leave a 1/4" of suture.  Cut.  Now the A lead.  Big atrium.  Blue stylette.  Nice movement.  Good.  Try here.  Excellent.  10 turns, screw's out.  I like the movement.  Nice injury current.  Same thing.  2-0 Ethibond, good and tight.  Again.  Good.  Leads lie smoothly on the floor of the pocket.  Seems to be a bit of tissue there.  Bovie.  Good.  Check for bleeders.  Bovie.  Let's irrigate.  Look again.  A bit more.  Okay.  Should be fine.  New gloves.  Device?  Atrium first - don't drop it.  Never forget when I did that once.  Set screw looks good.  A little tug.  Nice.  Ventricular lead.  I see the distal lead tip in the header - perfect. I like lots of clicks.   Leads have to lie flat.  No protruding.  Good.  2-0 now to secure the header.  I think there'll be enough tissue.  Gotta be careful about this closure.  Bury the knots.  Coming together  pretty well.  Should be enough tissue.  3-0.  Good.  Too much dimpling.  Try that one again.  Better.  4-0 layer.  Nice.  No pressure on the skin.  Run it carefully.  Bury the knot.   Good.  Benzoin?  Steri-strips.  Make sure they lie flat.  Good.  Gauze dressing.  Tegaderm.  I think we'll be okay.  No swelling, dressing dry. 

"All done, Mrs Smith.  You did great!  No problem at all.  Just gotta watch for arm swelling, as we discussed, okay?"

-Wes