ER


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.

The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it’s only strictly indicated the patient codes while being wheeled into the trauma bay, or shortly thereafter. For penetrating trauma, the rules are a little broader, involving loss of pulses anytime after the medics get there.

The trauma team was short-staffed. It was the kind of day where all the junior residents know they’re supposed to come and help if things get hairy and they can manage it. When the page went out, “trauma code, gunshot wound to chest, unknown male, intubating, eta 5 min,” we knew it was finally real. Our trauma center tends to do a lot of fake penetrating trauma: gsw to chest, really through the flesh of the shoulder; gsw to abdomen, a glancing blow across the flank; stab wound to chest, a 1cm flesh laceration; and so on; which are all billed as trauma codes, because they’re quote penetrating. But if this guy was getting intubated – that’s real. I was in the ER anyway seeing a flow of consults, and now I was just waiting for CTs to get done. I knew they wouldn’t happen while there was a trauma in the vicinity, so I had time to go see.

The trauma chief and intern always put on gowns, face shields, and shoe covers for these things, because you never know how much blood there will be. This time we all, including the attending, who rarely has to get his hands dirty, covered ourselves from head to toe in paper and plastic. The trauma bay looked more like an operating room than a space in the ER by the time the ambulance rolled up. The trama chief, who’s done this a couple times before and doesn’t really need instructions from the attending any more, was very organized, determined to avoid the kind of chaos that sometimes ensues when a trauma is halfway between nonsensical and deadly serious. He handed out orders: I’ve got the thoracotomy tray, you put in the left-sided chest tube, you do a cut-down and get access, you look for an ABG, you’ve got the airway, you help with the airway, keep xray out of here there’s no time for them.

One of the techs looked out the door as the ambulance rolled to a stop. “They’re doing chest compressions, guys,” he reported; and the chief broke the final seals on the sterile thoracotomy tray.

The medics wheeled in, transferring the patient onto our gurney, giving their meager report: gunshot wound, down for maybe twenty or thirty minutes by now, maybe more, pulses in the field, lost in transport, finally intubated a few minutes ago. Then there was a perfect storm of activity, but all in dead silence, because no one needed instructions, and we could all tell by the skin’s gradual transition from pink to grey that this story was not likely to have a good ending.

I think my mind did something funny, because I somehow didn’t even look until the chest was wide open and the chief had his hands deep inside, probing for the aorta to cross-clamp. Ok, so I had been assigned something else to do, but you would think I would look at the first time I’ve ever been present for this legendary maneuver.

It didn’t matter, in the end. The bullet had torn straight through the apex of the heart, shredding the muscle. A liter of blood and clots poured out when the chief had the chest open, and then the heart was loose and floppy in his hands. The hole was too big and ragged to do anything about, and there was no blood left inside to try to keep in, anyway. (Which makes me question the theory of his having had pulses until just before he arrived; I don’t see how he could have lived twenty minutes with that big a hole in his heart. Tamponade, maybe.) Somebody had good aim; unusually good aim; fatally good aim.

(The cops are kind of funny at these scenes. They hang around at the edge of the trauma bay, fascinating to us because maybe they know what happened, and we don’t, and most likely they’re going to arrest someone based on what our attending tells them. Then one of them steps forward as the assembled techs, nurses, and ER residents fade away, and asks, “Is he deceased, then?” And we all shrug, and I’m left to answer. “Yes sir, he’s dead.” His chest is gaping open and most of his blood is on the floor, there’s a tube in his throat that’s not connected to anything. Yes, he’s dead.)

Everyone else is gone now, and it’s just handful of surgery residents left standing in the blood and litter of papers on the floor. The man’s face is completely grey, a strange contrast to the blood scattered so liberally over the rest of his body, and indeed over us as well. Without a whole lot of conversation, the attending grimly motions us all over to the right side of the chest, determined to make sure that we all know what the aorta feels like when you’re hunting for it blind, arm reaching in past the elbow, the view obscured by the lungs being inflated by the ventilator, and no time to think. Based purely on feel, the chief had somehow separated the aorta from the heart above it, the esophagus beside it, and the spinal muscles behind it, and clamped it just above the diaphraghm. It felt strangely limp, unnaturally empty. For this guy it’s too late; but we’re not going to waste the opportunity, since nothing can hurt him any more, to learn things that could save someone else’s life in the future.

It was somehow not as dramatic as I’d expected, the actual event. Perhaps because the conclusion was so clear from the moment the medics walked in. Perhaps it would have been different if we’d really though there was a chance.

But it raised the same old questions for me: the chief tore this man’s chest open and plunged both arms in, recklessly dissecting down to the aorta. Will I ever be able to do this? Do I want to be the kind of person who can do this?

The chief said almost nothing, before, during, or after the incident. He’s grown a silent, protective face over the last year. I remember in July, his face used to give things away, and he would get hurt by it, when confronted by an attending in the OR or in M&M conference. Now his face is almost always the same, no matter what’s happening – years older and locked like a bank. He’s got two months to go on trauma; and that’s the only thing pulling him through; that, and his wife. So I think inside, things like this disturb him, too; but he doesn’t talk to us much about it anymore. Maybe his wife hears, but no one else.

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