Vignette L: Losing track of an implant. This case illustrates a relatively “forgotten” device, one that was important during a child’s early years but not in adolescence, when responsibility for device management shifted to the adolescent. This shift has risks as well as benefits related to adolescent inexperience and failure to appreciate or recognize the need for vigilance in device maintenance. Without ongoing involvement in device use or maintenance, parents may lose track of what is happening, especially if the device is not seen as critical to life and health.
Elizabeth, a 16-year-old with cystic fibrosis, had a “port-o-cath” central venous catheter placed when she was 6 years old. This catheter had provided intravenous access for countless admissions and treatments for pneumonia, each requiring long courses of antibiotics. Once Elizabeth entered her teenage years, the surgically implanted device (which consisted of a self-sealing medication reservoir that was attached to a catheter that ended in the superior vena cava) was rarely used.
Elizabeth requested that she take over the device’s weekly care, which involved flushing the catheter. The catheter was imbedded near her breasts and privacy had become paramount to Elizabeth. After following the routine successfully for an extended period, Elizabeth forgot to flush the catheter for several weeks. Then, when she tried it one morning, she had to exert great force and still was unsuccessful. Later that day at dance practice, she experienced sudden and sharp chest pain. The school called an ambulance, which took her to the emergency room of the hospital where she had been treated before.
When the girl’s parents arrived at the emergency room, they told the staff that her lung disease was stable. Neither Elizabeth nor her parents thought to mention the central line, and the staff saw nothing in the girl’s medical record that alerted them to the line’s presence. (Mention of the device was buried in progress notes, and the record included no device equivalent of a medications list.) Because Elizabeth was having trouble breathing, the emergency personnel obtained a chest X ray, which showed that the catheter had separated from the reservoir and had migrated through the vein into the right side of the heart, with part of it headed out into the small vessels of the lungs. Elizabeth then told the physicians and her parents that the device had been neglected for some weeks and that she had been unable to successfully flush it that morning. She underwent surgery to remove the fractured catheter.