In one sense it was a bad night, because I didn’t get much sleep, spent a lot of time in the ER, and had my patient die anyway. On the other hand, I surprised myself by handling the problems well. I probably shouldn’t talk about it too much, being just starting into a month of night float, with so many upcoming opportunities to make mistakes and act idiotically. But . . . I talked on here a lot, especially a year or two ago, about how much I admired the senior surgery residents. . . how they took control of bad situations, and knew what to do, and stayed calm. I thought I would never be like them. Much to my astonishment, and I have no idea when or how it happened, I found myself acting like them last night.
It was one of those messy situations, where the ER knows the patient being flown in needs surgery of some kind, but the diagnosis is unclear till the patient can be seen and have a CT scan. At least this time they called the surgical services ahead of time; perhaps after the series of fiascos last week our attendings yelled at them enough to impress the importance of calling ahead for ruptured AAAs and such like. (Not that the ER got around to informing the surgery residents, but my radar is getting pretty good.) Which meant that I, also bearing past miscommunications in mind, called the OR ahead and had them getting ready. So everyone was in the right place when the patient arrived.
He looked deceptively good for about 30 seconds, and then fell apart. Maybe it was a little longer, because I had time to at least make sure to my own satisfaction that he belonged to my service and no one else’s, so he was mine. Then it was the usual chaos of trying to intubate and do CPR all at once, get iv access, get monitors on, get blood and fluids lined up. . . The ER attending was technically responsible, because we were in the ER, and the patient hadn’t been officially diagnosed yet (I was just extrapolating freehand, taking the most pessimistic interpretation of the available data); but I was responsible too, because I knew if we could stabilize him, my attending needed to operate on him; and if you’re a surgeon and you’re present, you can never blame anyone else for anything that happens. The ER nurses and attendings knew he was ours, so they kept looking to me for directions. Gratifying, but scary.
Also I got a central line so fast, despite my hands shaking, that I was almost too surprised to finish threading the catheter. Now the ER folks think I’m magic, which is fine, I guess.
I’m not saying I have the calm part completely down; I was certainly pacing back and forth, and – not quite wringing my hands, but touching everything, the ivs, the bags of blood, checking for pulses repetitively. But I didn’t change orders and contradict myself, or give orders too often to be meaningful, and my voice wasn’t squeaking.
In the end we stopped. Despite occasional fleeting spontaneous pulses, we weren’t getting anywhere very encouraging with CPR, and it was clear that the patient was never going to be stable enough to move to the OR, let alone even start an operation on, which made further efforts futile.
The only thing I really still want to fix is, my voice keeps breaking when I talk to family members. It’s bad enough getting a midnight phone call to say your loved one is dead or dying, you would think the doctor should at least be able to speak coherently and audibly. It doesn’t really do much good for me to call people to give them bad news, and then have my voice be too shaky to communicate anything except that something bad is going on, leaving them to imagine for themselves what that must be. . . I know, sympathy and emotion from the doctor are good. . . but when you don’t know each other from Adam, probably simple transfer of information would be more valuable.
I especially hate calling 80-something wives – widows – who you know are home alone in the middle of the night. They’re half deaf, and sleepy, and don’t want to hear that their husband is dead. . . and when they do hear you, you can hear them just about collapsing. . . but so often the wife is the only phone number listed, and if you want to reach the adult children you have to go through her. . . . and you can’t just not tell people, and hope the morning will make it better. . . I have no idea how, but the ER social worker does miracles. She discovered the pastor and sent him over to keep her company. Now that was probably the most useful action of the night (and another profession to add to my list of people besides doctors who don’t get to sleep at night).
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