ER


It’s starting to dawn upon me that all the chiefs and attendings I’ve found very annoying or stressful have actually been teaching me a great deal. Most of them, because it was their personal demand for excellence and thoroughness which was irritating me; a very few, because their laziness was forcing me to take more responsibility for being the thorough member of the team.

Too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me.

But I recognize now that my regard for getting some degree of social history; my attention to looking at all the available imaging; my goal of knowing absolutely all the details of the medical history before calling the chief or attending; my thinking about electrolytes in the ICU; my thinking about DVT prevention – they all came from chiefs and attendings whom I found nearly intolerable at the time – because I wasn’t yet prepared to think that hard or that thoroughly about “only” a surgical patient.

Now if I can just think of that when I’m getting annoyed at someone. . . what is it that they’re teaching me?

I remark on the above, in order to avoid relating in detail how extremely annoyed I am at an ER resident and attending, who called us ten minutes before signout with a claim of appendicitis, on a college-aged female, without obtaining a white count, a pelvic exam, or a CT scan. I’ll grant that the CT scan is probably unnecessary. But they seriously seemed to expect us to book the patient for the OR without knowing any lab values, and without anyone having done a pelvic exam. (She had pain, but no peritonitis.) Please tell me if I’m mistaken, so I can stop being annoyed at them; but in the real world do ER physicians call surgical consultants without either a CT or a pelvic, on a young, sexually active female patient?

(I’m sure they’re teaching me how to be polite to frustrating referring physicians. . . like the PCPs whose first test for gallbladder disease is the HIDA scan. . . I haven’t quite learned it yet.)

A call-night story:

Sometime after the third unsuccessful code, and after walking the intern through a line in the ICU while we were both being paged by four or five separate nurses for patients with increasing abdominal pain/no urine output/difficult to arouse/heart rate of 150, we were admitting another patient in the ER, when the ER radios started chattering, and then people started walking up to me (the charge nurse, some ER residents, the tech who’s best at getting ivs on hypotensive patients): “Alice, did you hear yet? We’re getting a ruptured AAA. It was exciting the last time we did this together, huh? We’ll make sure to give you a heads up when the helicopter gets closer.”

The intern was also excited at the prospect. I used to be excited. By now, though, ruptured AAAs are no longer new and thrilling, they’re old and stressful. I would be just as happy not to be the point person for coordinating the response, and finding out if I can move things fast enough to save a person’s life. (I am still looking forward to actually being the lead resident on my first open AAA; probably that won’t be as great as I expect, either.) Called the OR, called the ICU, made sure that the ER had already told my attending what was happening. Then I ran upstairs to swing through the ICUs quickly, check on my hypoxic vent patients (solved by turning everyone’s PEEP up), and warn the nurses to ask quickly if they needed anything, because we would be unavailable for a while.

Back in the ER, five minutes ahead of the helicopter; the charge nurse came up to me again. She’s not usually very cheerful, but I think there was a lot of adrenaline going around, and she was almost smiling. “Alice, I just want to let you know, we brought a patient back with a cold leg. The ER staff haven’t seen her yet, but I thought you would like to know. She’s in room 10.” I had time for one quick look at the cold leg, which wasn’t too impressive. The patient was a frequent flier on the medical services, and vascular surgery had often been consulted for her legs, but never felt moved to intervene. I decided it wasn’t worth spending time on right then.

The AAA patient arrived: intubated, unresponsive, pale, unable to get a pressure, everyone in the room frantically feeling for pulses, unable to decide if we actually felt them or not. No time to waste. “Don’t worry about monitors or blood draws or better access – let’s get up to the OR and sort it out there.” We ran (as fast as you can when you have to wait for an elevator), and soon arrived in the OR. Anesthesia was not completely thrilled with our plan, which was to move the patient on to the table, scrub while they started inhalational agents, and then let them figure out iv access (only one or two peripheral ivs so far) and blood pressure monitoring (none so far) while the attending and chief resident started cutting. The anesthesia staff were good, though; by the time the surgeons were down to fascia, the patient had a central line and an a-line started.

I left an intern to scrub in and help retract (remembering how thrilled I’d been to have that job once), added his pager to my collection, and went back to look at the cold leg. Now 45 minutes later, it was clearly cold and pale. But given the patient’s complicated medical history, and the number of times I’d been consulted for a cold leg (on this particular patient) which turned out to be a non-issue, and given what was happening in the OR, I couldn’t recommend immediate surgery. So I called the radiology resident: “This patient has a cold leg. You could probably do thrombolytics, and in any case you could give us a definite diagnosis of where the obstruction is. Get your attending to come in, right now. My attending wants this done. He’s scrubbed in a ruptured AAA, don’t make me interrupt him to tell your attending to come in.” (Radiology and vascular surgery have a semi-complimentary, semi-adversarial relationship at my hospital. Friendly during daylight, but if you want a procedure at night, you have to dig in your heels and scream bloody murder. Sometimes it does come down to the vascular attending calling radiology and throwing his weight around.)

They came in, and it was a good thing they did, as the angiogram showed a lesion I hadn’t entirely expected. It still required surgery, but by then the AAA was stabilized, and the attending could pay attention, and started a second room.

Not a big deal, really, but I took great pleasure in treating that cold leg all on my own, without talking to the chief or attending till it was all settled; and a little perverse pleasure in taking my attending’s name in vain to get the necessary procedures done.

At the end of the day, all the patients and all their legs were still alive, which was a little astonishing. The only people who seemed to be in danger of collapsing were the vascular attending and chief resident, who had been operating for nearly 24 hours straight, and still had no end of their duties in sight. I don’t know whether to be excited or scared that I’m little more than a year away from that role.

Half of the general surgery attendings at my hospital will do appendectomies laparoscopically. The other half routinely do them open, arguing that it’s faster and requires less equipment (and is thus less frustrating than trying to get techs trained mainly on ortho equipment to get right in the middle of the night), and that a 2cm open scar is no more painful or unsightly than three 0.5-1cm port sites.

My problem is that, after two and a half years, I still can’t remember which half is which. Thus, when I’m explaining to patients – you have appendicitis, you should have surgery tonight, I’ll call my boss and set it up – I usually give them the wrong spiel. Whether that laparoscopy is quick and easy, or that an open incision is quick and easy –  I always get it mismatched. Overall I’m getting better at telling patients ahead of time what the attending’s plan is going to be, which only makes it more painful to have to go back and correct. . . (You may wonder why I’m trying to predict the plan. It looks extremely unintelligent and unprofessional to take the history and physical, and then walk out of the room without explaining anything. If you can’t give the patient some kind of diagnosis, and an idea of whether they’ll be admitted, and whether or how soon they’ll need surgery, it looks as though you’re completely clueless, and not a doctor at all. Much more satisfying all around to immediately say, this is what’s most likely wrong, you’re undoubtedly being admitted, and I expect surgery tomorrow morning; let me check with the boss, and I’ll let you know the final plan. Of course, only satisfying if you get the diagnosis and plan right the first time.)

Tonight it was fun, though. One of the ER residents, feeling cocky, decided to try selling us a case of appendicitis based only on history and physical (how old-fashioned). I had to admire his idea (unlike some of his colleagues’ other attempts, he picked a patient with an appropriate history and physical, rather than say a 24-yr old woman with atypical symptoms). So I bought it, and then I managed to sell my attending on coming in to operate in the middle of the night without a CT scan. . . and we were both right, which was good for us and for the patient.

(And you thought the title referred to the Democrats’ scheme of taking the “public option” off the table to quiet public outrage, then slipping it back in and squeaking it through without adequate debate. . . don’t get me started. Here’s to obstruction and deadlock in the Senate.)

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).

Whatever white cloud I once had, it is definitely gone now. My chief is beginning to be over-satisfied with the number of consults I pick up when we’re on call.

Yesterday, the chief called me: “I’m about to scrub in for the next case, but I was just looking at a patient in the ER. He looks pretty sick; his white count is sky high, and his heart rate was at least 140. The ER says he has cholecystitis, but I don’t quite believe them. [our ER's ultrasounds are notoriously unreliable]  If he does, he should come to the OR next. Go figure out what exactly is going on, sort it out, and let me know.”

I was on the other end of the hospital from the ER, so I started walking. By the time I got to the ER, there was a certain electricity in the air – literally. The charge nurse looked up from the front desk. “Whoever you’re here for, they need some help in 5. They’re having a code.” 5 was where I had been heading.

The code went on for an hour, increasingly pessimistically, but it was impossible to stop till we were certain. Usually, in a code, the patient has no cardiac rhythm whatsoever – asystole; and in that case the protocol calls for compressions and drugs, but no defibrillation. This patient remained in vfib forever; and we defibrillated over and over – enough to satisfy any ER junky – to no effect.

Finally, after we called the code and the ER doctors had started trying to figure out contact information, I went up to the OR. “I’m afraid that patient coded. We did CPR for an hour, but we couldn’t get him back.” The chief cocked an eyebrow at me. “I told you to take care of things; I didn’t mean you had to do it that drastically.”

That was one code I found it impossible to feel too badly about. If the patient was sick enough to code in the ER, he would not have survived surgery. Moreover, you don’t develop cardiac arrest from acute cholecystitis, even a severe case. There must have been something else going on.

On the other hand, that makes three patients I’ve lost in the last week – more than in the previous six months together.

One of the ER bloggers a while back mentioned something about “knowing how to talk to surgeons on the phone,” and I didn’t know what he was talking about. I do now.

There is nothing more annoying, in the middle of the night (or a busy day), than to get an ER doctor trying to give you a five-minute presentation on a patient. I really do not care what time the patient went to the outside hospital, or how exactly they got transferred here; unless the creatinine is 3, I don’t care what the chemistry shows; unless you have a positive urinalysis, and are apologizing for calling me anyway, I don’t care what the urinalysis showed (yes, sterile pyuria – white cells and no bacteria – can help confirm a diagnosis of appendicitis; on the phone, I still don’t care); unless you got a CT scan without asking us (which would be ok, if it shows appendicitis), I don’t care if you got xrays on a patient whom you think has appendicitis; I also do not care which ADHD and asthma meds the kid is on (unless they include high-dose oral steroids); I don’t care whether (when calling for appendicitis), you think the abdomen is distended or not, or whether Rovsing’s sign is positive or negative. All I really want to know is, what room is the patient in, and a name or medical record number, so I can track them down when they change rooms. Apart from that, you can be as impressed as you like by the abdominal exam; you could think they have peritonitis. I don’t care, I have to touch it for myself, and until you give me a room number I can’t do that! (At my own hospital, about half the ER residents, I would care what they think about whether the patient is truly surgical or not; here, I haven’t had time to learn to trust the ER staff, so. . . I don’t care whether they think there’s rebound or not.)

Bottom line: you called the surgeons because you want us to touch the patient. So give me the location of the pain, and the location of the patient, and stop talking. The best calls are from the male PAs, who usually are not too chatty: name, age, medical record number, chief complaint, white count, “I think it’s real” or “I’m not sure, just come see.” End of conversation.

Unfortunately, I don’t know a polite way to say that to attendings, fellows, or residents I don’t know (ie the entire ER staff at the children’s hospital),  so I get very frustrated at night.

I’m also puzzled by this: the surgery resident’s ethos puts a lot of stock in instant response: if you call me with a consult, I will be there in five minutes if I’m not doing something important; and if I’m in the OR, I will be there five minutes after the end of the case. (And if the nurses call, I will address their concern immediately if it’s urgent, or as soon as it comes up on my triage list otherwise.) In fact, sometimes it’s the only thing that keeps me going at night: I can’t think straight, I’m not sure which elevator goes where, or what floor I’m on or am trying to get to, but I will be in the ER two minutes after getting called. So why do the ER people call, then act surprised when I show up? Or why do the general peds teams call us at night with a consult “for you to see in the morning”? If you call me now, I will see it now; I will not save work for the morning. If you don’t want the patient and family woken up at 11pm, don’t call me at 11pm. (I know some residents aren’t like this, but it’s not just me, because I learned this from the chiefs getting angry at me if I wasn’t ready to report on a consult within ten minutes of getting the call, or the first time they heard about it, whichever came sooner.)

Ok, I’ll stop being grouchy now. I hope I have any personality left at all when I get away from this hospital.

Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all.

I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds to tell me what they were doing. In textbook style, as soon as they opened the peritoneum, blood came pouring out onto the table. They packed all four quadrants with quantities of lap pads – I have no idea how they can ever keep track of how many went in where – until the bleeding was controlled. Then they started in the corner where they knew there were no problems, and proceeded to explore. Between me being there to be lectured and quizzed, the attending being an extremely conscientious character, and the chief being the inquisitive kind who wanted to see everything and visualize every possible maneuver (Kocher, Pringle, etc) while he was there, it was quite educational. And also beneficial to the patient, who did well.

(Kocher maneuver: reflecting the duodenum medially in order to visualize the head of the pancreas. Used in trauma to gain control of the IVC, and in surgical oncology to reach tumors in the pancreas. Pringle maneuver: clamping the porta hepatis (portal vein, hepatic artery, hepatic bile ducts) to get control of devastating hemorrhage from the liver that can’t be controlled with packing alone.)

The chief spent most of the day in the ER (nine patients in two hours on a weekday morning, as though all the old ladies in the city had decided to fall and hit their heads at once, while several un-drunk drivers managed to have serious accidents), and complained that he hadn’t been able to see the unit patients. I, on the other hand, had more than my share of the unit, and would gladly have bailed out of it to share in the chaos in the ER; but we each had to stick to our own responsibilities.

I’m not exactly sure how it happened while I was assigned to trauma, but I spent a lot of the day assisting with vascular-type patients. At one point in the ER, there were three or four residents trying to sort out an AV fistula – or rather, a patient with an AV fistula.

The fistula, created and valued for having a lot of blood running through it, fast, under high pressure, had sprung a leak. And such a leak. I’ve seen lots of fistulas oozing persistently, or even enthusiastically. This one gushed continuously, despite a muscular young man having both hands clamped on it; and if anyone let go, it started shooting for the ceiling.

The patient took this all quite calmly, until we were at the most delicate point of trying to get the first stitch somewhere near the hole, which necessarily entailed a lot more blood out of the patient, and all over him and us and the room (in order to see something of where to put the stitch), when he suddenly started moaning and complaining of being cold and dizzy and unable to breathe. Not reassuring.

In the end, we had it sewed up very tightly, it wasn’t bleeding any more, and the patient felt relatively fine. And I have another instance of how being obliged to do something makes you competent. Walking into the room, I wanted nothing more than some senior person to show up and fix everything. But there were no seniors left; they were all in the OR. And from a handful of residents in my year, everyone was looking at me to fix it. So I did.

It was a Saturday night, and I was on the vascular service, so being on call meant I was covering the vascular patients, plus urology, plus plastics. Which can add up to a lot, if the urology attendings have decided to do a couple of radical prostatectemies and urological reconstructions before leaving for the weekend. Or if plastics is on call for traumatic injuries. Fortunately, urology was quiet, and plastics was only on for hand injuries, of which there were none.

So when, around midnight, five or six ATV accidents started coming in in short order, I had time to go help. I had one end of the trauma bay, and I got the third helicopter transport, a young man, fairly alert, with some scalp lacerations, lots of bruises and lacerations everywhere else, and a mangled left leg. ATLS protocol, by the book, didn’t show much of anything – except for that leg. The foot was hanging at a strange ankle, and the foot looked quite pale compared to the other side. No pulses were palpable and he could only wiggle the toes.

The orthopedic resident was moving from one stretcher to another, distributing splints, and making notes for who would get to go to the OR first. He cocked his head at this one. “I’m not getting any pulses here, perhaps you guys should consult vascular.” “It’s ok, I am vascular,” I told him. I had already dug up the hand-held doppler, which is the mainstay of vascular workup in the ER: if you can hear pulses, it’s not too bad; if you can neither feel nor hear the pulses, then the limb is truly ischemic and will be dead within a couple of hours (6 is usually quoted).

The trauma attending finally had time to get to that end of the bay. “This is a pretty bad open fracture. Can anyone feel pulses? Maybe we should consult vascular surgery.” “Yes sir, I am vascular; I was just helping out down here. I think it’s bad, there are no dopplerable pulses, and we’re about to call our attending.”

The situation was fairly textbook: an open fracture with clear distal ischemia. Don’t pass go, don’t collect $200 or any further studies, proceed straight to the OR. Since I had nothing better to do except sleep, I helped move the patient into the OR, and watched the orthopods fit the pieces back together and fasten them in place with an ex-fix (external fixator; like lego outside the leg; it stabilizes fractures, especially contaminated ones, for a couple of days, usually in preparation for definitive internal fixation; they’re cumbersome, and people often try to ignore their presence, but it’s actually easier for the patient if you move the leg by holding the ex-fix, since that won’t make the broken bones rub against each other, which is what really hurts).

Then, since my pager kindly remained silent, I got to help the vascular attending and chief (one of my heroes: smart, and good to work with), who were by this time fairly beat, since it was the fifth emergency case of the weekend. We prepped both legs, and the chief and I harvested the saphenous vein from the uninjured leg through a series of small incisions that we tunneled between to reach the whole vein, while the attending cleaned up around the injury on the other side, and found healthy artery on both sides for the anastomosis. He and the chief each took one end, and attached the saphenous vein to the healthy artery, while I started closing all the incisions on the other side. Ortho had already made the fasciotomies (long ugly slashes through the fascial covering of the four muscle compartments in the calf, necessary to relieve pressure and prevent ischemia after a serious injury or period of ischemia), so all we had to do on the injured side was wrap yards of kerlex and gauze around the entire structure of the ex-fix and our incisions, and we were done.

The poor vascular team still had two more cases to go, and I had to go attend to some urology patients about whom I had received no signout. It made for an incredibly long call day, but that was my favorite night to date: a dramatic, classical injury, which I got to follow from the door through the OR, and then round on for the next few days. Talk about continuity.

New attending syndrome. It’s the well-known phenomonen of attendings fresh out of residency being a little hesitant to diagnose anything during the month of July.

Mostly you can work around it, but when a radiologist comes down with it, things start going haywire.

There’s a new radiologist on staff, and I keep running into her and her readings. So far they’ve been exemplars of non-specificity, but today was the worst. I got called about a patient in the ER, a boy with abdominal pain. “The radiologist says he could have perforated diverticulitis, please come and see.” Now a teenager shouldn’t have diverticulosis, let alone diverticulitis, let alone perforated. So I looked at the scan, and I couldn’t really make out what the radiologist was worried about, but hey, I’ve been not-an-intern for two weeks, and this is an attending radiologist, so I’d better be careful. I went and saw the patient. He was sore, but not too bad. In fact, he and his father seemed more scared by what the ER doctors had told them about the CT reading than about his actual symptoms.

I looked at the scan and I looked at the scan, and all I got was more puzzled. Finally I went and told my attending that the patient was tender, but not too extremely so, but I was concerned because we had an official dictated and signed report saying possible perforated diverticulitis vs. small bowel obstruction due to Meckel’s diverticulum. He listened to me arguing back and forth with myself, and came to see the patient. He spent a long time calming them down, but when we finally got outside of the room he wasn’t exactly pleased. “That radiologist! What is she reading it like that for? A third-year medical student could tell there’s no diverticulitis. In fact, there’s no inflammation of any kind whatsoever!”

So now I feel like an idiot. I knew the patient wasn’t sick, and I knew there was nothing wrong with the scan, but I let the radiologist talk me into miscalling it, and presenting it to the attending as something concerning. I’ve learned not to trust the radiology residents too far, and now I’m afraid I have to learn not to trust the radiologists much at all (except for three, who are nearly infallible, and all the attending surgeons take their word as gospel). Which scares me more than anything, because I don’t think I’m good at reading CT scans, and clearly I need to be a lot better.

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