ICU


I think I mentioned before that, along with being the insane Christian conservative of the hospital, and being too polite to be a surgeon, the other residents tease me about doing procedures on anything that moves – or doesn’t move, more accurately.

Today I blew my last chance of pleading innocent. Being at loose ends (as seems to be usual for me on this rotation), I was just wandering around the ICUs to see what kind of trouble other people were having, and maybe cheer myself up that I wasn’t having to take care of those problems. I found a couple lines to put in – various people having too many things to do at once, needing to be in the OR, etc, so I volunteered to put in their lines.

The guys found me apparently lost in the MICU, in the middle of a real mess. “What’s up, Alice? Is this your patient?” “No, I’m just putting in a line.” They cracked up, and claimed not to believe my explanation of having a really legitimate reason for being involved.

The best part is, those were some of the hardest lines I’ve done – and they could see that they were hard sticks. I’ve decided to embrace this game. If I can’t be in the OR, placing tricky lines is stressful and satisfying enough that I’m happy to be the one who comes to mind when people want lines done. After all, that’s part of a community general surgeon’s practice.

Sorry folks, nothing useful to say. I’m going through another disillusioned-and-bitter phase; judging by precedent, it shouldn’t last more than a few days. Will return with regular programming then.

(The funny thing is that, even though I feel depressed and bitter and cynical, I’m still known for being cheerful and optimistic. The chiefs are still telling me, “Wait a few years and see if you’re still so happy about everything.” I feel like I’ve turned into all the cynical surgery residents I knew as a medical student, but apparently it doesn’t come across that way – yet. I guess that concluding every consideration of a patient’s worsening symptoms and grim vital signs with the hope that they could still turn around in the next two days has to count as incurably optimistic; and persisting in treating people who complain of pain seriously has to qualify as insanely credulous.)

(Although if they could hear my interior monologue when answering pages, they might understand better. I had another several of my favorites today, calls where the nurse goes on for several minutes, telling you normal vital signs and urine outputs and stating that the patient has taken all their medications as directed, and you keep waiting for some kind of punchline – what’s wrong enough to be worth calling me about? – and there never is a punchline, and you’re left to say as politely as possible, “Thanks for telling me.” Or my other kind of favorite, the one that invariably happens right after I scrub in, while I’m supposed to be prepping and draping, and the circulating nurse kindly answers the page, listens with a widening mouth, and then says tentatively, “Your patient in ICU room three has a pressure of – let me check – 62 over 30, is there anything you would like them to do?” Um, find me a time machine so I can be in two places at once. And the attending cheerfully motions to me to finish draping, remarking that this is one of the purposes of training, to learn how to juggle multiple serious responsibilities at once. Thanks sir, that really helps.) (The patient did very well in the end. I never calculated pressor doses that fast before.)

A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” – but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all.

Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so businesslike, not high on my list. But you have to. And then there were all the other patients who needed to be paid attention to, and just because one person died is no reason to go neglecting or ignoring the others. So I went and did all the appropriate procedures, and they weren’t much fun. A needle here or there. . . but I couldn’t save the one guy who really needed help.

I don’t know which was worse, talking a family through their loved one’s death, when I’d only seen the patient for five minutes beforehand, and we only had an hour to work through it (like yesterday), or handling it after a month of struggling together, like today. Strangers or long-term acquaintances, it doesn’t get easier.

I’ve been calculating all month, and I work out my prospects for the rest of the year as follows: nearly all the second year rotations are unpleasant, and nearly all of them last for more than one month. So the chances of September being even more miserable than August are at least 70%. This is not good. Without hope, things fall apart.

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.

Halfway through rounds the medical students were asking me if I was all right. There was nothing wrong, just the insanity of the trauma unit, and my dysfunctional method of communicating with the chief and the attending. The chief and I have a very strange interaction; we like each other, and it’s certainly better when he’s around and responsible for things instead of me, but somehow he makes a day in the trauma unit even more complicated.

So the students are trying to help me, and I don’t even have the energy to be polite to them. All I can remember is the resident I knew when I was a student, trapped in the unit for months on end. He didn’t talk to students much either, although in my memory he was still more helpful than I’m being. That’s bad, because he had it even worse than I do – unless someone takes it into their head to schedule me into the unit some month in the near future. At this point, I can’t even finish my sentences; it feels like wading through molasses to get anywhere, and talking to people just takes too much effort; so I don’t talk.

I can’t believe it’s only halfway through the month. This seems to have been going on forever.

The attending for the next several days is another one with whom I clash constantly. The only good thing is that he’s predictable in his own unbearable way. (You may be asking whether there are any trauma attendings I get along with. There are two, and they’re sane only because they spend as little time in the unit as possible. Unfortunately, that’s not an option for me.)

I’m tired of trauma. I feel like I’ve been doing this forever, and it’s going to keep going forever. Every day starts out ok, and then goes on for a whole lifetime, with twenty lives in my hands, and thirty or forty people wanting something from me (ranging from the medical students wanting something educational or useful to do, and I don’t have the time I owe them to be educational, to the nurses as usual reminding me of what their patients need, to the attendings wanting me to do a dozen different things, reminding me of things I know I should be doing, or asking me the same question for the third time in five minutes, to the families, who need to be talked to, and all want more time than I have).

That is one thing I’ve figured out. I’ve decided which of all the trauma attendings is most difficult to work with: not the one who rounds for nine hours at a time, not the one who rounds so fast it leaves you breathless, not the one who listens to himself talking all day and gets nothing done. No, the one who lets you give a whole presentation, then asks you three times for information you stated at the beginning of the speech. And writes it down, looks at something else, and then asks you again. Halfway through rounds with him, I’m ready to scream.

Many of the nurses give me a vote of confidence by seeking me out to ask questions of. It’s nice to know they trust me to manage a lot of things – but it would also be nice if they asked the other residents sometimes!

I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU – a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be able to have a gigantic fight and still keep going.

Apart from that central explosion, nothing much else happened. I’m fortunately not on call tonight, which is ok with me, because the trauma pager is going off with one unhelmeted motorcycle or ATV accident after another. You may conclude that the weather is quite fine. Tomorrow morning I will have further evidence that young men are fools (for not wearing helmets) and/or sissies. (Because they all scream and cry about nonexistent or minor injuries. No one makes as much noise as the 20-yr-old guy with a broken clavicle and a lot of road rash; a woman the same age with an open tib-fib, or an older man with an open femur, or an elderly lady with 10 broken ribs, will all be much more stoic. I have had no sympathy for young men since the day that one of them had me persuaded he had a broken clavicle, a dozen broken ribs, and a broken femur, from the amount of noise he made; after giving him dilaudid, we got through CT and xray, and found that he had a cracked clavicle, and nothing else. Pfui.) (And I’ve injured myself in sports too, and didn’t scream for more than five minutes, so I’m allowed to talk.)

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