ER


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.

Another memory that sticks out from my third year surgery rotation was the night I was on call with the trauma night chief. Nights at that hospital, the trauma service was responsible for all ER consults and emergency surgeries, as well as a fairly busy knife and gun club, and several major highways and intersections. So they had their hands full. The trauma chief had his own hospital-provided phone, because he made and received so many calls that it would have been impossible to function with a beeper alone.

There was one patient he was trying to see in the ER, to explain the reasons for doing or not doing surgery (I forget by now which one it was). The phone went off about three times in four minutes, and finally he handed me the phone and said, “Please take this thing out of the room and take care of it for me for a couple of minutes.” In the next five minutes, I answered four more calls and took notes along the lines of, “The patient in ICU 13 just got reintubated.” “The OR will be ready for you in fifteen minutes.” “The trauma patient in ER 34 is having increasing pain and tachycardia, what does he want us to do?” “The xray on ICU 14 came back, the feeding tube is in the wrong place, please come change it.”

When he came back for the phone, he seemed to think that wasn’t too bad of a haul. And I thought, I was ready to pull my hair out, just holding the phone and taking messages for five minutes. Am I ever going to be able to handle this in real life?

And here I am, taking pretty much the same kind and volume of calls, and so far nothing’s fallen apart. I’m not looking forward to doing this overnight, and the prospect of two years’ worth is rather depressing – but one day at a time, it’s not too bad. Eight or ten consults in eight hours, one to the OR, not too horrible. The ICUs had the sense not to make much noise, which helped. I made the ER resident quite furious by declining to admit one patient, and insisting on sending it to medicine; the fact that I got another patient into the OR in half an hour didn’t make him much happier. Most of the trouble came from the medical ICU, which gave me half a dozen perfectly useless consults, of the kind where I had to spend five or ten minutes simply figuring out why on earth they had consulted me (usually it turned out to be a reason they were unaware of, eg their consult order listed abdominal distention, whereas the patient was having GI bleeding, and really needed a GI consult, or the order listed GI bleeding, and what they really had was gallstones). Then I had to call the attending on those, and he got upset at me for wasting his time with such nonsense. Which is why within a couple of months I can see myself being quite crushing to the MICU residents if they call me with such things.

The trauma team has a running contest with the ER. It’s kind of like a slow-motion version “hot potato,” where the patient is the object of interest, and the question is which bed they end up in. The ER has a laudable goal of getting all patients out of the ER as fast as possible. To them, trauma patients are a golden opportunity, because pretty much everyone who comes in as a trauma alert is guaranteed at least an overnight admission, until we get the Cspine films officially cleared by radiology (such a stupid liability issue), or for observation after a concussion, or until ortho fixes the broken bones, and so on. So the ER nurses are on us, basically from the minute we finish the secondary survey in the trauma bay, to find out where the patient is being admitted to, so they can stick it on the bed board and start the process of waiting for a bed.

We, on the other hand, don’t have such a simple equation, especially when it’s the trauma ICU residents working the alerts. We have a very strong interest in the patients not coming to the ICU – partly to save ourselves work in the morning, but more because if we let the trauma ICU get filled with not-so-serious injuries during the afternoon, that means the really bad gunshots and motorcycles and high-speed drunken car crashes that won’t come in till midnight or 1am won’t have a bed open in the trauma unit, when they really need it. Which means we might do a desperate operation at 2am, and then have to stick that patient, with drains coming out of everywhere, and an open abdomen, and four pressors, and reverse ventilation, in the medical ICU, which really gets kind of flustered with these patients.

So we insist on waiting till all the scans have been completed before we announce whether this patient needs an ICU bed, or just a plain monitored bed will do. It’s tricky, because sometimes the ER nurses catch us out, and we slip up and say, “ok, ICU,” or “ok, monitored,” and then later on in the workup something turns up, and we change our minds, and by then the patient has already been assigned a bed – maybe report has already been given – and we make everybody very upset by insisting on changing the arrangements. Which is why it’s better to get it right the first time. (It’s also a shocking reminder of what a responsibility it is to be the MD: the nurse can be as senior as she likes, and as angry as she likes, but if I put my foot down and say, it has to be this way, that’s what happens. Just because I’m the doctor. So I try not to make an issue of things that don’t need to be major. . . or things like, this 300lb patient needs to be turned over and have dressings changed three times a day . . . and the nurses make a face, and do it. . .)

I am, again, pleased with myself. We have a patient who’s septic from quite mysterious reasons (well, I suppose positive blood cultures ought to explain why he’s septic, except you still have to figure out how it got in his blood, and why he’s growing, as the nurse said, “everything but the kitchen sink” in there – gram positive cocci, gram negative rods; gram positive rods, gram negative diplocci; and who knows which of those to believe). (Not to mention what he’s doing on the trauma service; but that’s another perennial issue, how we end up with general surgery, orthopedic surgery, neurosurgery, and downright medical ICU patients on our service. Educational, but frustrating.)

Anyway, the a-line was going bad, and we needed another one. I spent nearly two hours on him, and had to ask for help, but in the end got my own line in the brachial artery. Which is technically a no-no, since the brachial artery (at the elbow) is the only major arterial supply to the hand (unlike the radial artery, at the wrist, which is duplicated by the ulnar artery), and if it gets in trouble, you have a serious problem. But it was acceptable in this patient, who had no other arterial access; and my first brachial line.

Plus, later in the day, running more trauma resuscitations, with the attending standing by making sarcastic remarks about me and all the other staff: “You’re forgetting something, Alice. . . You don’t know what you’re forgetting? . . . Does the patient have iv access? You can’t trust these nurses when they say they have an iv. You have to check what gauge it is. Just because it’s there doesn’t mean it’s working. These nurses don’t care about ivs, just about drawing blood. . . Are you going to get an xray? Where are the xray techs? Do they not come to traumas anymore? You are going to get an EKG, right? You wouldn’t forget that, hmm? Make sure you look at it yourself, because I don’t trust these ER doctors.” And so on. All true, that I ought to be doing those things, but really not helpful to be ripping up the staff while we’re trying to work together on something. Now I know why the seniors have all developed this particularly flat, matter-of-fact voice for using in the trauma bay. It’s the only way you can answer him.

Now if I could figure out how to stop getting chewed out by the trauma attendings for things I didn’t do – in fact, wasn’t even in the hospital at the time – life would be better. So far I and the other residents just duck and don’t say anything; and that’s the only thing to do. But I’m going to get tired of being rebuked for things I couldn’t even theoretically be responsible for.

Memorial Day weekend + the first good weather in a few weeks = traumas galore. And if you bring in enough trauma victims, sooner or later you’ll find enough serious injuries to keep the ORs running. Ortho, neuro, general surgery – the attendings were resigned, the residents were fairly cheerful, but the techs and circulators who got called in for backup and more backup when they were trying to sleep were not exactly pleased.

In addition to the trauma scene, the black cloud that’s hanging over the surgical services continued to rain. The ER couldn’t tell what had come over us: we spent the day in the ER, admitting like there was no tomorrow. Every time they gave us a name, we took one peak and said, “Yeah, sure, it’s our patient, they’re sick, it’s our problem, call for a bed.” No discussion, no fights. I don’t think we even looked at the labs. They’re sick, bring them in. No question about it. At one point one of our attendings was even walking through the hallway looking for patients. The ER had barely sat them down on a chair in the hallway before we agreed to admit. (Ok, those were surgical complications, and they’d called the attending before coming in. Streamlines the process, for sure.)

And in the OR, we just gave up on keeping track of night and day. Another case? Sure, book it right now. At one point, my attending and chief looked at each other and said, “What gives? It’s 2am, we’ve been in here all day and all night, let’s just do the next add-on case now, instead of waiting till daylight, and then we can all round at 5am and maybe leave the hospital.” That didn’t really work out as well as expected. . .

The junior resident was nearly overwhelmed with calls, and started handing me his work, and I took it, and looked down the calendar a month. I thought I was getting slammed with calls and admissions; he was hearing all my reports, plus the other intern’s, plus a constant barrage from the ICUs. I am not looking forward to that.

I’m making a resolution, to stop talking to anyone (in my real life) about how unprepared or puzzled I feel. “Professional” covers a lot of ground, and it includes acting like you know what you’re doing, and not letting on to the nurses or those junior to you that you’re scared and confused by a situation. I was on call Sunday, July 1st last year. I was so lost; I didn’t even know where the units were. I got stat pages, and was running in circles around the elevators trying to figure out how to get to the patient, or where a phone was so I could ask the junior for help. The greatest thing about that day was the junior. He strolled around (this is a different one; strolling is good) and calmly sorted out everything I said. I realize now that it was his first day taking call like that, and he must have been at least as stressed out as I was, figuring out what to do with the ICUs. But he didn’t show me any of that. He acted as though everything was under control, and he could help with anything that happened. So that’s going to be my gift to the new interns: I’m going to try to act as reliable and cool as that, because if I let us add my worries to theirs, we won’t be able to function. Plus, if you act calm and intelligent hard enough, you actually will be calm, and at least semi-intelligent. Sometimes, now, I tell the medical students that I don’t know what’s going on. I’m not going to do that anymore, to students, or to the new interns. If I don’t know, I’ll be quiet; but I won’t talk about it. (But I will call the chiefs if I need help; that’s different.)

If Memorial Day was bad, I can’t imagine what Fourth of July is going to be like: bigger parties, better weather, and residents newly promoted everywhere. . . Please, folks, if you have to ride a motorcycle, wear a helmet. That way at least you’ll be able to wake up and talk after we repair all your broken bones and arteries.

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