This morning started off to be bad. I saw all the bariatric patients in their unit before one of the residents appeared, and then only the junior one, who was equally disgusted that the chief (our not-favorite one) had apparently decided to not even put in an appearance at all. We then drifted off to the OR, trolling for cases – more precisely, for attendings or chiefs who would let us in. The chief of the staff service apparently has been taking pity on the resident all month, giving her every spare case that he has, and he invited her along to a splenectomy.

I thought I would just come watch from the sidelines, since he has his own medical student. But the CRNA remembered me asking to intubate someone else a week ago, and very sweetly offered me this one. I got the esophagus instead, which motivated the anesthesiologist who was watching to invite me to come along and help intubate patients all morning, so I could get it right. This guy was unbelievable. He just picked me up, talked to me for half an hour about intubations and anesthesia, and linked me up with two or three of his colleagues. With his help, I stayed busy all morning, attempting intubations. Once I got the esophagus again; after that I was cautious, and refused to do anything without seeing the cords very clearly (for the first time today, I saw the difference between the epiglottis and the vocal cords; the distinction had been primarily theoretical/imaginary for me before), so I got two in the right place after the doctor or CRNA moved the laryngoscope so I could see well. Two other patients turned out to be very difficult (six and a half foot tall guy – you had to practically put your hand in his throat in order to see anything), and the anesthesiologists had to take over. I learned that you need to do heavy lifting with one hand to intubate: another reason (in addition to retracting properly) that I should really take up weightlifting.

The anesthesiologist was truly amazing. Early on, he mentioned some of his own mentors, Indians who had been trained in Britain, who recounted having spent hours listening to their attendings teach – to the extent that they didn’t have to read books or look things up, because their teachers taught them what they needed to know. I guess that legacy is still affecting his style, because he cheerfully answered all my questions – more accurately, he volunteered tons of useful information that I wouldn’t even have known to ask about. He found all the friendliest CRNAs, and between them they repeated the steps of intubation to me so many times that now I at least know what I should be doing. Previously, it had been a matter of me begging to be allowed, and then imitating the motions I’d watched – with haphazard success. Now I feel like I have been instructed in intubation – out of the blue. This morning was like a giant windfall, like stumbling across the pot of gold at the end of the rainbow.

In addition, this doctor said that this particular hospital is the busiest in the state, even busier than places in the state capital; in fact one of the busiest ORs in the country. I knew it was fast-paced here, but not that fast. (Maybe that’s why all other scrub techs look lame compared to here.) He did his residency in the capital, and asserted that both for trauma and general surgery volume, this single hospital beats all the others.

As if in proof, around 1pm the trauma pager started going off. The helicopter left for one place, another hospital was transferring someone, and then the big one: “bus accident in littletown, helicopter on way, unknown number of injuries.” The OR controllers ordered a couple of cases held back, and started rolling up nurses and scrubs, in anticipation of a mass casualty event. After the trauma pager went off four more times, for four different events, I figured that was enough intubation attempts for one day, and ran down to the trauma bay to see if I could help. Three different attendings were there, as well as almost all the surgery residents in the hospital. The proper trauma chief was stuck in computer training somewhere else, and her beleaguered third-year deputy was grateful for the flood of senior assistance. (That appears to be the mass casualty plan for this hospital: surgery and emergency residents and staff attendings show up en masse; there were a fair number of ER techs, nurses, and lab personnel too.)

 The only casualty of the bus accident turned out to be the driver (empty bus, thank God – now the dispatcher gets a lecture from multiple people on giving important specifics in his messages!). He had a leg fracture and abdominal pain, stable enough to go to CT. I haven’t heard what happened with him yet. The youngest attending and I moved on to another room, to handle one of the less-urgent cases while the senior attendings and residents dealt with the incoming transports that might still turn out to be in need of intervention. Our guy had had a car crash, and some outside hospital read his CT scan as concerning. He had no symptoms. Comparing it to an old scan on our computers, it was obvious that the finding was months, if not years, old.

Then, that attending invited me back up to the OR for a “butt abscess drainage.” Strangely enough, no one else was interested. (That should have been a signal.) The same CRNA and anesthesiologist were there. I was a little disheartened by continued failure all morning, and didn’t ask for the intubation, but they handed it to me. This time, with great effort, I managed to do enough of the visualization myself that I think I can claim this as one that I did. At last!

When we turned the guy over, and saw the horrific mess, I was about ready to run out of the room. (“Alice, what on earth are you doing here? Why on earth did you have to volunteer for this case? Why do you want to be a surgeon? Get out of here!” mental commentary) (Yes, I somehow managed to get to my fourth-year elective rotation without even seeing a peri-rectal abscess before, let alone being present at the drainage of one – or any other abscess, for that matter.) However, the attending had promised that I could do it all myself – and I couldn’t walk away from that; not to mention losing face. We did a very cursory scrub (as the attending said, for this case, you scrub afterwards), cleaned things up, and draped him. The general procedure was: attending points in a general direction, Alice bovies wildly in that area, everyone slaps lap pads over the blood and pus. It was such a disaster already, the attending didn’t even care what particular shape of excision I made, or what depth I debrided to. It was truly “medical student discovering the bovie.” Notes: touch the skin, before turning the bovie on, otherwise you get a messy start. Try not to be shaking with excitement, it’s easier to cut straight that way. The attendings who said you can’t bovie in a sea of blood were correct. It takes a lot of bovie-ing to stop a bleeding artery – or even an arteriole. And finally, the attending will be more impressed with you if you don’t echo the nurses’ exclamations of horror.

I was thrilled to pieces to be the one with the bovie in hand – and also by default the one making decisions about where and how much to cut – but I was also almost nauseated by the general grossness (this from someone who now feels pretty comfortable with amputations). On the other hand, the guy is going to get better because of my actions, and there was no way he was going to ever improve without surgery. He was really miserable previously (and is still going to be for a couple weeks!), and he sure needed help. (You can see me talking myself out of backing away from surgery forever because of this.) But I now understand why the residents are all so blasé about I&D cases (incision and drainage).

And I’ve still got a whole night of weekend call ahead, with the nice [Mormon] resident, and the trauma service getting busy again. This rotation is going to finish with a bang!

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