Hello, Hickman: Insertion + Healing

An empty operating table with several screens surrounding it.

How is it that the words ‘nil by mouth’ manage to trigger the most intense hunger and thirst you’ve ever known? I’m uncomfortably hungry and, consequently, uncomfortably cranky. Every minute seems to stretch on for eternity, but also fly by like a loosed arrow. Time seems to loop back on itself like a Möbius strip, both molasses-slow and lightning-fast. I lay back against my pillows in exasperation. I have felt like this a thousand times, but I won’t ever get used to it. 

I loathe the waiting period. If anything needs to be done to me, I’d much rather it happen first thing in the morning – or that I do not know about it until immediately beforehand. Luckily, there’s only about an hour more to wait before I’m wheeled down to have my Hickman line inserted. I’m terrified, but eager at the same time. Knowing I’ll be getting sedation helps, but until the procedure is underway, nothing can quiet the anxiety in my brain, buzzing away like so many bees. 

Eventually they come for me, but not before I have another name band fastened around my ankle. Like a prisoner under house arrest, I think. I clamber into the bed and fold my hands across my front, avoiding meeting the pitying eyes of the visitors thronging the corridors as my bed is wheeled out of the ward and through the hospital. 

An anxious half-hour drags by in the Interventional Radiology department while I wait for the doctor to come and complete my consent form with me. All the while, I can’t stop thinking about how little I actually know about the procedure – which is why I’m writing about it now! He warns me about the potential complications (bleeding, pneumothorax, etc.), but he’s reassuring about it all. I’m barely listening at this point: I know these things already, and I’m not put off. “It’s okay,” I reply. “I have colonoscopies a lot. The risks are there, but that doesn’t mean you don’t do all you can to avoid them!” He looks heartened that I’m not put off. 

On being wheeled into theatre, my first thought is: how does anyone find their way around this room? So many machines standing around, dangling from the ceiling, attached to walls to be swivelled around. It looks like an obstacle course. I clamber onto the bed, although it can’t really be called a bed, even though there is a pillow. Operating platform, maybe? With how nervous I was feeling, it may as well have been a sacrificial altar. This feeling is only reinforced when I am strapped down across my abdomen. “We had a patient fall off the table once,” one of the doctors admits to me. Suddenly I think that maybe it’s not so bad to be secured to the table after all. 

Before anything else, the doctor who’ll be performing the insertion takes an ultrasound to my collarbone to look at the veins. “We prefer the right-hand side,” he confesses, “because it’s a more direct route. If we go in on the left, we have to do some crossing-over.” Luckily, both my right and left side veins look great! A far cry from my PICC insertion, where we only managed to find a vein large enough on the third attempt, and it ended up incredibly awkwardly placed (on the underside of my arm, just above my elbow).

At this point, I am sedated. The dizziness that always accompanies a dose of midazolam engulfs me, but I know it’ll pass. I immediately start feeling better. I love the sedation. Not only does it erase the anxiety that follows procedures, but also the general anxiety that hangs over me like a dark cloud. I take a few deep breaths with the oxygen in my nose, (and why does it always smell like plastic?) and a placid calm settles over me. 

First, I am vigorously doused in disinfectant. A drape covers me. Since the surgical field is my collarbone and chest, the drape covers my face at first, but one corner is lifted up and tented on a spare IV pole (genius!) so I can still see. To make the procedure easier, I need to have my head turned to the left anyway, so I don’t mind the obstruction at all, and my field of vision is pretty complete. There’s not much to see: a clock, some boxes of supplies, and one of the nurses by my side. If I was feeling more cognitively sound, I would have measured how long the procedure took, but by that point I just didn’t care enough to make the effort. 

Now comes the part I was dreading: local anaesthetic, which stings just enough to push it from ‘Things I Will Tolerate Easily’ into ‘Things I Would Rather Not Undergo Given A Choice’. But… there’s no sting. There’s the feeling of a tiny needle in my skin, and then nothing. “How did you DO that?” I ask in amazement. 

“Sodium bicarbonate,” the doctor replies, sounding pleased. “Our secret weapon.”

I am bamboozled. This is entirely new to me. I decide to sear the words SODIUM BICARBONATE into my brain forever.

“Okay, can you feel anything here?” He asks me.

“Nope,” I reply cheerfully. And so off we go. There’s a set of tugging and pushing sensations, almost like an overzealous massage, and I can feel the distinct sensation of the tube being threaded under my skin, but only just. It’s not painful, or even uncomfortable. It bothers me about as much as if someone were sliding a tube across the surface of my skin – which is to say, not at all. 

Midazolam makes time fly for me. In my perfectly relaxed haze, I hear the whirr of the x-ray machine above my head. I can’t see it, thanks to the sterile drape blocking my view, but I know it’s in action. “Take a picture there,” I hear the doctor murmur. I feel triumphant. It’s in, it’s settled. The hard part is over. All that’s left is suturing, which I also hardly feel. The snip! of scissors has never sounded so sweet. 

“And we’re done,” the doctor announces cheerfully. 

“Already? Wow!!” 

“All that’s left is to apply the dressings, so just stay like that for a moment longer,” he requests, and I’m only too happy to comply. 

Dressings on, area cleaned up, and I’m wheeled back to the ward. The sedation is already fading, so I’m not even sleepy, although I’m much calmer just by virtue of the procedure being over. I am triumphant: this is one more step towards being able to go home and start managing this myself. Beaming with pride, I snap a quick selfie to send to my mum, who is fretting all the way back at home. She is as relieved as I am. 

And so here we are. I’m advised that it will be sore for about 48 hours, or, in the words of my gastroenterologist, “you’ll feel like you’ve been kicked in the chest”. As I write, an hour after returning to the ward, it’s starting to feel uncomfortable, but only in a bruise-like fashion, and even then only if I turn my head or otherwise use the muscles around the incision site. I’m confident that I’ll be able to manage the pain. I’m more concerned with finding some food. It’s 3pm now, and I haven’t eaten or drunk anything since 6am! But it’s well worth it to have the line in place. We can start using the Hickman for my TPN tonight, and if all goes well, my PICC can be removed tomorrow. 

So here it is: I’ve conquered another unfamiliar procedure. I’m honestly very proud of myself – my anxiety had me convinced it was going to be worse than the PICC insertion, but it was actually a thousand times easier. Who’d have thought it? While I was researching, I didn’t find much information on the details of the procedure itself. Only the basics, which don’t serve to satisfy my curiosity or my anxiety! I need something more. That’s why I decided to write this post: Hickman insertion day, from before the procedure to afterwards. I hope it can be of use to someone else who’s about to undergo Hickman insertion in the future. And my final tip: remember to ask for sodium bicarbonate in the lidocaine. Honestly. It’s a game-changer.

 

P.S. (24 hours later)

On post-op pain: the local anaesthetic starts to wear off pretty quickly, and within a couple of hours the pain starts to set in. For me it reached its zenith about 8-12 hours after the procedure. Have some painkillers at the ready! Don’t feel ashamed. I had to remind myself: remember, you’ve been cut open today! Luckily, the first evening was the worst for pain. By the next morning, I was extremely sore and still didn’t want to move much, but the day after that I had most of my mobility back and was merely feeling bruised.

 

P.P.S. (16 days later)

Oh my goodness, it’s been over two weeks and I’ve just been sitting on this post the entire time. After a week with the Hickman (coincidentally, my day of discharge from the hospital) I got the stitches at the entry site removed. Easiest thing ever. I couldn’t see what was happening because I don’t have the neck of a giraffe, but with a couple of scissor snips and a slight tug they were out. Painless, and somewhat of a relief – as the site heals, the stitches tend to tug on the skin a bit and become itchy and uncomfortable. Afterwards, I set to marveling at yet another new scar to add to my collection. 

On Thursday I get the stitches at the exit site removed, along with the securement device, because three weeks ought to be enough time for tissue to grow around the cuff in my body. This means it’s very hard (but not impossible) to just pull a Hickman out like you can a PICC. Side note: my PICC was removed right there at my bedside and it was as easy as removal of an ordinary peripheral cannula. I was asked to take a deep breath, felt something move inside my chest, and then… voilá! A very long tube (with surprisingly little blood on it, I thought) and a cool little hole in my arm, which is almost fully healed now, and looks like it’ll produce another neat little scar. 

Either way, I’m looking forward to having the stitches out and the securement device removed – it’s getting itchy under there and that’s no fun, especially in this heat. TPN is going well, though, and I’m putting on weight. I’ve slightly less of an appetite than when I was in the hospital (I guess I was just less stressed while I was in hospital, paradoxically), but it’s reassuring to have the TPN to lean on in case there’s a day when I can’t manage much orally. To know that I’m getting enough calories and not to panic about losing more weight is such a weight off my shoulders. My first appointment with the nutrition team is on the 17th of September, so let’s see how much I can gain before then…

 

Header photo by sandro porfirio on Unsplash.

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