Finally, a quiet night. I kept getting pleasantly surprised when I answered my pager: “Oh, sorry, wrong person.” “Can so-and-so have tylenol?” “Can so-and-so have ambien?” “Oh, sorry, wrong person.” Some people hate those mistaken identity pages. I don’t. They feel to me like getting a surprise rebate, or a 50% off coupon.

I even got to scrub in and assist on a case which went really long (three hours after I got there, and more after I had to leave to take care of some things). The attending, whom I hadn’t worked with before, was polite to the assistants, funny, and kept explaining what he was doing almost nonstop, which was terrific. Some attendings hardly talk at all in surgery, and if you do ask a question, they answer under their breath (and┬ábehind a mask – almost impossible to hear). Attendings who just chat about what they’re doing in the OR are so much more educational.

There was one patient who developed afib overnight, actually much faster than I’ve seen before. Fortunately he was comfortable the whole time, and I did everything just about right, down to calling the right people at the right time.

Only three more nights of this. I’ve got another three hundred pages to go in The ICU Book. I’m now into the fluids and electrolytes section, which is where I think there’s a hole in my scientific thinking box, because ever since first year med school I get hopelessly lost at this point. I did just barely manage to grasp the mysteries of FeNa (a way to evaluate low urine output which looks like a problem from advanced algebra), but as for hypervolemic/normovolemic/hypovolemic hypernatremia/hyponatremia – I get to about the first level in the branching decision tree on that subject, and my eyes glaze over. Especially since this author starts the chapter out promising to explain a very simple way to approach the whole problem – and then it turns out that the whole evaluation depends on your assessment of the patient’s total body water status, which he himself admits is very difficult to assess reliably, since signs like edema don’t develop until you have 4 or 5 extra liters on board. So basically his simple method boils down to, take a guess about the water status, and then make the rest up from there. (Sorry, non-medical folks, if this doesn’t make sense to you, it’s because it doesn’t make sense to me either.)

At least he gave a very concise explanation of the mechanisms and bad effects of hyperkalemia (high potassium), and what specifically to do about it, which will be very comforting in the future.

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