trauma


Driving home from the hospital, I got stuck in traffic around a recent accident. Sitting and waiting, I calculated that from the amount of debris on the road and the number of flashing lights involved, it must have been a fairly serious accident, which would mean a good likelihood that at least one person involved would show up as a trauma alert somewhere. And only five minutes from my hospital. . .

Two minutes later the trauma pager started going off, describing that accident.

Not sure what the moral of that is; maybe not to carry a trauma pager when I’m not on trauma call. But it was fun to know more than anyone else in the traffic jam about what was going on.

Done with trauma!

It only took me three extra hours to get out of the hospital in the end, which I was kind of resigned to, considering it’s the middle of Labor Day weekend (a fact I only realized when the ER staff started commenting on the number of people who started their drinking spree early, and thus showed up in the ER earlier in the day than usual). In addition to the usual deluge of traumas at the nominal signout time (nominal, because there’s a better than 50% chance that something major will happen five minutes before or after), I felt like I had to stay and tidy up every single loose end on my patients before I could leave, since I won’t be back to fix it tomorrow.

I won’t be back to fix it tomorrow. I’m not even going to look in the direction of trauma for the next two months. I won’t even have to interact with that monster of a service on call. I don’t care how many foreboding warnings I’ve been given about my next service, it’s not trauma, and that’s all that matters right now.

Funny, though. I like the trauma bay (getting the patient, having to figure out very quickly which of their complaints are serious or lifethreatening and which aren’t), I like the workup (lots of CTs to look at, the responsibility to page through all of them, because whenever the radiologist gets around to reading it, it will be too late for most things if we don’t see it first), and I like the ICU care (paying attention to details, seeing people get better, get off the ventilator) – but somehow I don’t like the sum. If we could skip rounding with the attending, it would be quite nice. Hmm. . . don’t see that happening.

The beeper is an amazing object, and whoever invented it ought to be relegated to one of the lower circles of the Inferno.

(On second thought, remembering in the books the old paging system, overhead, which must have been infinitely more painful, perhaps a middle circle would be adequate.)

This time of year, on a sunny Saturday, the trauma pagers go off with predictable regularity: five minutes after signout in the morning, and five minutes before signout in the evening, and every forty-five to sixty minutes in between. There’s kind of a reflex shrug we’ve all developed, standing in a circle in the unit, when the combined beeps and twitters and buzzes of our pagers, and the charge nurse’s pager, and the respiratory tech’s pager, all go off at once. Some people try to ignore it, and pretend that it’s not their beeper that’s going off. I’m more the type, when other people have their hands full, to pull my pager out and announce at least how many minutes we have before impact (five or sixty – it can make a difference), and perhaps the nature of the injury if it sounds really sensational or serious.

(Although it’s amazing what poor aim the people in my city have: multiple gunshot wounds to the face routinely get discharged in excellent condition in a few days; we’ve had guys shoot themselves multiple times in suicide attempts, and get off with only one broken bone; we’ve had gang warriors shoot everything and everybody except anything remotely resembling a vital organ on the person they were aiming for; I’ve seen more gunshot wounds to the calf than any other kind.)

No dramatic events. I am one day further along in my quest to escape from the trauma ICU before any permanent damage is done.

The nurses are a little puzzled by my excitement, and kind enough to say they’ll miss me. I guess, since they persist in calling me about every thing that happens on the unit, regardless of whether I’m following the patient or not. Flattering, and fairly safe, since I’ve now gotten better than I was at the beginning of the month at following what’s happening to all patients, whether they’re “mine” or not, but difficult to handle delicately: when to waste the nurse’s time by telling them to call a different resident, when to defer to another resident’s handling, when I wouldn’t have chosen that method myself but there’s nothing downright wrong with it, and how often to call another resident to tell him what I and the nurse did with his patient.

Two days left. Labor Day weekend. This is not going to end quietly.

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.)

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