Last night the trauma pager announced, “transfer, head-on MVC, fluid in abdomen by CT, suspected liver lac, >1hr ETA.” Oookay. You think the guy has a liver laceration – and the only one I’ve seen so far died of massive hemorrhage, and you’re transferring him by ground over an hour’s distance? Adds up to it must be nothing serious. But on the off chance of a trip to the OR, I went to the trauma bay when he arrived. Young guy, no obvious injuries except a few abrasions, far more disturbed by all the commotion around him, and by an hour spent on the backboard, than by anything else. Of course, he had no abdominal pain, the FAST exam (rapid ultrasound of abdomen) was negative, and the perfunctory repeat-CT-to-be-read-by-inhouse-radiologists was negative.

While I was standing with one of the residents in the ER entrance, killing time till the next trauma (warned by beeper) should arrive, a team of paramedics suddenly rolled in and halted in front of the astonished triage nurse. The patient was intubated, being bagged, visibly seizing, and in a state of complete disarray. “Didn’t they tell you? We called ahead!” one paramedic exclaimed. Everyone in the area kind of descended on them (first and only time I’ve seen this ER-like move, people randomly showing up, not assigned), led them into one of the trauma bays, and started hooking up the ventilator and monitors, and finding a dilantin drip. The poor woman had had an outpatient elective procedure, under spinal anesthetic, at a surgery center across the river, in the city. She had gone into respiratory distress and started seizing in the recovery room (we never got the exact sequence quite clear). She had then been transferred to the Heart Hospital (because it was the closest ER, not because they were qualified or interested in treating her), and eventually booted across the river to our big ER. And there she was, apparently in status epilepticus, despite having received ativan and other antiepileptic agents en route (I thought Valium was more useful for acutely stopping a seizure?), intubated, with very wet lungs, needing almost continuous suctioning. Flash pulmonary edema was what I heard. Everyone was horrified at this outcome to an elective procedure, without even general anesthesia, and of course disgusted at the management of the patient – taking an intubated lady on a trip around town, without calling ahead, or a transfer call from the surgery center or the other ER. Very sad.

Then, I was sent by the resident to see an in-house consult (why they decided to consult us at 8pm, I.do.not.know). Pleasant older man, appearing older than stated age, speaking hoarsely due to having been on a ventilator for three months several years ago after surgery. (Danger flag number one.) He had had a CABG at a young age, and a sternal dehiscence. (Danger flags two and three.) He had insulin-dependent diabetes, and had smoked for 25 years, although he quit awhile ago. He usually requires a few liters of oxygen. (Danger flag four.) In short, a guy whom you would do anything to avoid operating on. Problem? Abdominal wall mass, and mass on CT. Trick: they were not the same mass. History and exam revealed no major issues other than a slowly simmering diabetic ulcer on his foot and another on his leg, and a softball-sized lump in the lower abdominal wall. No pain, no tenderness, absolutely no other symptoms – and for this one I did go through review of systems in order. On CT, he had a mass between the pancreas, spleen, kidney and colon; radiology called it distal pancreas. A cystic structure in the spleen. A huge mass by the bladder. And this thing in the superficial abdominal wall. Three or four lesions, none of them connected. The resident and I sat for a long time, debating what abdominal cancer might present in this fashion. It’s not pattern for any of them. Compared to a CT a few months ago, almost all of them grew to remarkable size in very short time. And no symptoms. Something this aggressive ought to case some kind of systemic symptoms. The attending was not tickled at how long it took us to report back to him that we had no clue what was going on. Plan: biopsy as many objects as can be reached under local anesthetic. And pray it’s nothing that should need surgery, because he’s not going to get surgery.

In between this, the resident was called to see an elderly lady who was, apparently, trying to die. She looked grey and was breathing with extreme and obvious difficulty. Her heart was in some wacky rhythm. We eventually called it afib with RVR, rather than the more ominous V Tach. An ABG was with difficulty obtained (her pulse ox varied between 98 and 56%, and we didn’t believe either one). While we waited for it to come back, the resident stood in the hall, flipping through the chart, and remarking that this was why she was going to make a living will, and she never wanted to be intubated if she got to this pass. I couldn’t help sympathizing. After all, if we intubated this lady, given her remarkably frail physique, her sick heart, and her surgical issues, she would probably never get off. At length, the ABG came back showing pO2 of 300 (normal is around 100; too much oxygen is 200; this meant we had her oxygen mask up way too high), and everything else dead normal. We turned the oxygen down, and were finally able to hear what she was saying: “Don’t let me die.” Her heart rate and respiratory rate were both down, so it looked like she was ok for the next few hours, maybe even the night. But talk about making the wrong assumptions!

I think maybe we young people jump to that “just let them go” too easily. For us, we know (or assume) that we have decades still to enjoy before we get there. Compared to that length of time, a few more months at extreme cost don’t seem to be worth it. But for these elderly people, those few weeks or months are all that are left, and it seems that they value it far more highly than we do.

Slept through the gunshot and stabbing trauma pages (I figured, either they were nothing, or by the time I woke up and got down from the top of the hospital to the trauma bay, everything would be settled), woke up and rounded on two patients, and raced over to OSCEs at school. This was my favorite day of med school, certainly of fake patients, so far. They told us to act like doctors, discuss the differential and treatment plan with the patients, in addition to doing the history and physical and writing everything up. I love it. Nobody told us it was this much fun to make decisions, and tell people what’s going on, and what can be done about it. This is great. Figured out a lady with gallstones needed to be admitted to the hospital and have a surgical consult. A lady with rapidly increasing angina also needed to be admitted for observation. A lady with asymptomatic anemia in my opinion didn’t need anything at all, but could try iron supplements and see if she liked it. (She was reading a book on acupuncture. . .) And a smoker with “bronchitis” – four days of runny nose – got a lecture on smoking, and no antibiotics. (The simulated patient was much more pleasant about it than a real one would have been.) It was tremendous. I know I missed bits here and there – didn’t ask everyone their allergies, didn’t ask everyone what their grandfather died of – but overall I’m sure I got the main things, and the main physical exam, and the main differential, and a good treatment strategy. And I loved it. No more, I can’t really say what it might be, let me talk to the intern/resident/attending, and we’ll see what they think. Now if only it was real.

Maybe I can be a doctor after all.

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