Our ED department has some of the fancy new simulators, on which one can feel pulses, observe breath movement, hear breath sounds and heart sounds, and insert peripheral lines, chest tubes, ET tubes, and even foleys. I and two guys had a session with them. After explaining the procedure (one of us is team leader, we have to place all monitors, and say out loud all procedures and tests we want to do, and put in any invasive things we need, as well as choosing from a realistic medicine cart for iv meds, iv fluids, and drips, while the preceptor ran the computer which made the mannequin’s vitals change, and also provided an eerily-realistic “patient voice”), it was time for someone to volunteer to be the first team leader. Since the guys stood by the wall and said nothing, I finally took the job. The only reason our patient didn’t die was because one of the guys was much better prepared than me, and suggested starting fluids and checking glucose when I couldn’t think of anything. Just because he could, the patient then obviously coded, and had to be defibrillated (I felt like a very bad imitation of someone on ER: “Everyone clear. . . charging. . . zap“) and then intubated. Then the guys took turns. Our second run was very very bad: because the patient was talking, we neglected to listen to his lungs, thus missing a spontaneous pneumothorax, which the preceptor then converted to a tension pneumothorax to teach us to pay attention. . . I was bagging the “patient,” and the team leader, who had never put one in, was struggling with the chest tube tray, when one of the observers helpfully commented, “Doctor, your patient is going to die before you get that tube in; maybe you should be doing something else first. . . like a needle decompression.” And when we all literally started turning in circles and waving our hands, he was obliged to continue, “Dr. X says she usually uses a peripheral IV catheter to do that. . .” Amazingly, and probably unrealistically, the patient still survived this experience.

The simulator lab was wonderful. By the last patient we were working a little more smoothly, and didn’t neglect any obvious or elementary proceedings. It did reveal very clearly that we have an abysmal ignorance of the doses of the medications we think we know – just because we know when to use them; as well as that since we haven’t memorized the ACLS protocols stonecold, we forget them completely under stress. OK: six months to memorize the doses and pathways for everything in the ACLS and ATLS books.

With that background: in the evening, I came out of one patient’s room to see a whole crowd of people jammed into the smallest ER room – not a good sign. A patient had been picked up in the hospital parking lot and rushed in there because every other room was full of really worrisome chest pain/pneumonia people. The nurses and respiratory techs were therefore struggling to grab pieces of equipment and bring them in the room (too small to bring the whole cart), and find the necessary attachments on the wall. The patient was still breathing, but quite blue, and the doctor was holding the mac blade. I figured this was too much of a mess for me to ask to intubate; but he waved me up to the head of the bed and handed me the blade. After some further suspenseful moments, an iv was started. The doctor even asked me what drugs I wanted to use – which was a joke, because the nurse already had them drawn up; but that’s one set of drugs and doses I do know. The first time I looked, I wasn’t in the right place, but the doctor wisely insisted on looking over my shoulder before I went any farther. We bagged some more, and I tried again. I saw the cords, and got the tube in – all by myself, so to speak. The first time I’ve gotten in the right place without the anesthesiologist having to adjust the blade for me. I was so surprised – even when the tube misted up, and I could hear breath sounds bilaterally, and the end-tidal CO2 monitor turned yellow, I was afraid I was imagining it all, and kept expecting to have to pull the tube out and try again. Thank you, Jesus.

(I apologize for the infrequent posts here lately. Traveling every third day and working ten or twelve hour shifts the other two days is not as restful as I had imagined, and does not leave time for fiddling on the computer. Especially since I don’t want to talk about the interviews – I was hoping to eliminate more programs, but almost every one is as attractive as the last: not simple.)

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