My list of patients has steadied down to a group of long-term ICU inhabitants. Good, because I don’t have to figure out four or five entirely new patients every morning. Bad, because since they stay so long, they get very complicated. Rounds are always full of pitholes from the attending: “A new arrhythmia, eh? Let’s consult cardiology. Oh, we already did consult cardiology? What did they say?” “Um, actually [flipping wildly through the chart and the computer] we consulted them five weeks ago with a questionable MI, which they said wasn’t significant, and they seem to have signed off a while ago. . . I can’t see any notes in recent memory here.” “Ok. . . this drain here, where does it go?” “Sir, I really couldn’t tell you. The various operative notes refer to a drain by the liver, a drain in the pancreatic bed, two drains in the pelvis, and a jejunostomy. There’s only one tube left, I have no idea where it goes to, and I doubt that you want me poking it or pulling it out in order to find out.” “This patient initially had a heart attack? What is he doing on our service?” “Well, the heart attack led to a car accident, which led to bilateral pneumothoraces [guarantee that no medical service will accept any responsibility for the patient for the next two months], plus he broke a good many bones. Which bones? I have no idea. He’s been here so long, they’ve nearly all healed, and ortho doesn’t want any weight-bearing restrictions, if only we could get him strong enough and off the vent enough to move out of bed.” “Why is this patient on imipenem? Don’t you think zosyn [or vanco, or cefepime] would be more appropriate?” “Sir, to the best of my understanding, this is the fifth episode of pneumonia this patient has had, plus three UTIs and one questionable line sepsis versus line colonization due to pre-existing bacteremia, and as far as I can tell, the bugs are becoming progressively more resistant, which makes this the best antibiotic. Plus, at the third episode, we consulted ID, and this is what their note says to use.” [And please stop trying to make me explain ID's reasoning, since those attendings insanely round an hour earlier than the surgery residents, no doubt to avoid our questions, and their notes consist of "Events noted. Cultures pending. Continue antibiotics." Which is hardly enlightening.]

Then the attending tried to teach me to do bronchoscopy today. I think I made him dizzy. You stick this thin flexible tube, with a camera on the end, down the trachea (it helps if you have a trach already in place to go through), and move it with your right hand, while your left hand supports the piece to look through, plus controlling suction and flexing the end of the tube. Yes. And then you have to make the whole thing go left and right, plus up and down and sideways, using the unidirectional control in your left hand. Apparently the key is to turn the piece that you’re looking through around and around – and your head goes around and around, and then it won’t go any farther, so you have to spin 180+ degrees, and try again from the other direction. The attending very helpfully looked in through his scope and explained in a running commentary while I wandered around: “There you see the anterior wall of the trachea – and now the posterior wall – there’s the right bronchus – no, go down the right one first . . . all right, back out and try the left side – no that’s right, you already did that one – no, that’s still right, you need to go left – no, the other left -” I was ready to try standing on my head at one point. I got a little better at controlling up and down, but I have no idea where I was at any point in the proceedings. Fortunately we didn’t find anything, so I didn’t absolutely need to know where anything was. I guess there’s a reason the lung is diagrammed in such detail in Netter’s Anatomy.

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