Yesterday there was absolutely nothing happening all morning, so I went to the ICU again, and managed to get pimped on ventilator settings – of which I know absolutely nothing. Back in November, one of the medicine residents explained the difference between assist-control (when the patient takes a breath, the machine makes sure they take in enough air), and IMV (I forget the words, but it means the machine does the timing, and all the work) (unless I’ve gotten those two settings mixed up), but I obviously forgot most of what he told me. So here they have this burn patient who keeps becoming acidotic, even though his CO2 isn’t very high. So they change the vent settings around, and check blood gases every two hours; and depending on who the attending for the day is, they make different decisions. The day before, the attending who just got back was a great believer in pressure-support (which I think is used for weaning patients off the machine), so they did that with most of the vents in the ICU. And the burn patient became even more acidotic than before. So yesterday a different attending was decrying the manifest folly of putting everyone on pressure support, and the residents were nodding enthusiastically, to communicate that they agreed with him, but couldn’t say out loud that it was all the other attending’s fault, and boy were they glad he wasn’t around today. Then they got on to I-to-E ratios, and inverse I-to-I ratios, and did I know why one would do that? The attending was very pleased to have discovered something I didn’t know the answer to; but since even the residents don’t study this till their second year, it wasn’t too bad, and I ended up with a pretty good understanding. I love the ICU. I don’t know where I could find this stuff written down, certainly not in a book for students; but by listening to them discuss it, I’m getting to understand it fairly well, and can guess what they’ll do next, at least some of the time. I didn’t know surgeons were the ones who did most of this complicated management.

Then, at 1, the students have lecture. I realized to my dismay that lecture was supposed to continue till 5. I did. not. want. to spend my last six hours on the trauma team listening to boring lectures (since the lecturers all pulled out a piece of paper and said, “I was assigned to cover these objectives. I’m not sure why, since I had to look up a lot of the answers myself, and this isn’t my area of specialty at all, but let’s go through this article from UpToDate.” Which was game of them, and they put in some nice stories; but it was no better than what I could read for myself. So when the beeper went off with one 82yr-old male falling, and then an 83yr-old male falling, and then a 78yr-old woman getting kicked by a cow, all in fifteen minutes, I just ran away, back to the ER, trusting the other students to cover for me, and profess our total ignorance of the rule that lectures are more important than anything else, in case anyone asked. (They never did.)

So, in the four hours from 3pm, we had four trauma patients and three consults. 1) Man who fell off a hedge. The chief thought his spinal CT didn’t look too bad, and he was asymptomatic, but the neurosurgeon, who is a bit of a drama queen, declared that it required immediate operation. (I say she’s dramatic because, earlier in the day, the intern consulted her on a cervical MRI which incidentally showed severe central canal stenosis. She chewed the intern out for not telling her 24 hours earlier, and had the patient made NPO, in view of possible surgery, and would have done the surgery too, except the patient said he was having no problems, and refused to consent.) 2) Very elderly man who fell as he was walking into a doctor’s office. He arrived with a huge hematoma over one eye, and a GCS of ~10. (GCS= Glasgow coma scale, giving points for opening eyes (spontaneously, to pain, etc), motor response (to commands, to pain, random, none), and verbal response (talking, jabbering, nothing). Maximum is 15, comatose is 3.) His CT showed only a small subarachnoid hemorrhage, but he proceeded to deteriorate badly. By the time his daughter arrived (he came by helicopter), he was down to 7 (not opening his eyes, just moving randomly). A GCS of 8 is an indication for intubation, since it shows that the patient has too much neurological deficit to maintain his airway. Around this point the daughter arrived, and became hysterical at seeing her father, whom she had driven to the doctor’s office, completely unresponsive. Her brother arrive, and calmed her down some. He has the power-of-attorney. So we asked them how much they wanted done. Since the surgeons could only say that it looked bad, but they couldn’t tell whether he might not recover or not, they obviously said they wanted everything done, at least for now, till they could talk to other family members.

They were taken up to the ICU waiting room. The chief told the other resident to take him upstairs and intubate him immediately. And then she added, “Let Alice try to get the tube in.” The resident and I both stared at her, but she was back to some paperwork. When we got upstairs, the nurses had somehow been told that he was already intubated, and stable. So they were not pleased to find that he needed to tubed, and was very unstable. And when the resident added that I would be doing the tube, they looked very harassed. One of the nurses, who had very kindly been helping me do ABGs earlier, started to joke that whenever she sees me coming, she wonders what procedure I’m there to ask for. As the respiratory therapist was getting things ready, the resident asked me how many tubes I’d done. I couldn’t believe what the chief had said, anyhow, so I told him, none at all, and I would be very happy for him just to do this one, and let me learn first on younger, stabler patients in the OR. He was relieved to have me un-volunteer, and put the tube in without any difficulty.

3) Back in the ER, I found the chief and attending just sending a young man upstairs for immediate appendectomy. (I can’t figure out their criteria, since the other appendicitis patients I’ve seen have looked sicker, but been made to wait 6-10 hours for their surgery; I think the trick is that this guy came in right at the end of the day, rather than in the middle of the night.) When I turned my back, the two doctors disappeared, so I went to pre-op holding, to keep an eye on the patient, and make sure he didn’t get into the OR without me knowing it. The anesthesiologist came up to get her history from him, and I had her almost persuaded to let me try intubating him, when she was paged to a stat Csection. So the surgery was delayed till the night team was ready, in half an hour, and the other student got to scrub in. As the team was signing out, the ICU residents were paged upstairs for our new patient; so I would be very surprised if he made it through the night.

That was a good ending to my trauma rotation. After three days of almost zero activity, we had several interesting patients all at once. And the chief must be impressed enough with me, to even offer me an intubation. Hopefully that’s a good sign, that I will get to do some in the OR, on the general surgery service the next couple weeks.

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