It’s a routine day on the trauma service: one attending operating as fast as the rooms can be turned around (it somehow takes longer when your patients are from the ICU, because anesthesia takes their sweet time about going to get the patient, and it takes forever to package all the lines, monitors, and vent equipment, and then repeat for the trip back, plus wild stops to check and see why the ekg readings have gone skywire, and whether that O2 saturation reading is accurate or not, and did we hook the bag up to oxygen, or not?), and the other attending operating even more busily on unscheduled eruptions: come to find out, that spleen is going bad, after 24 hours of observation, time for an exploratory laparotomy; oh, undiagnosed viscus injury, five days after trauma, let’s call the OR; washout of an open abdomen that’s looking worse, fit that in somewhere. So the most senior resident is necessarily absent there, and various members of the ICU team also get called away to the OR, leaving patchy signout with the other people.
On the floor, patients are sinking at the rate (today) of about one every two hours; you may or may not hear about it until they’ve actually hit bottom. In the unit, organ systems are failing at roughly the same rate.
I have an extremely competent medical student, so competent that I am by turns tempted to give him more to do than he can handle, or frustrated by his willingness to take responsibility for things that I would have liked to have heard about sooner. But he’s so helpful, I can’t really complain.
Lines are everywhere: infected lines that need to be replaced and pulled, impossible lines that need to be placed (to the fates in charge of femoral vein vascaths (dialysis catheters), I would like, one day, to place one of these in a patient who doesn’t weigh 400+ lbs; please? the adrenalin rush from blood poring over my hands in the depths of a space that I can’t see into is awesome, like skiing down a black diamond hill by accident, but it makes my hands shake).
Plus, you have the steady stream of traumas coming into the ER, so heavy that usually only one member of the team knows about any one of them. Then that person is in the OR, and the other one gets a call: “This little lady in room 23, you know the one with a cervical fracture and a hip fracture, is in afib with a rate of 160, do you want to do anything about it?” “Little old lady who? The only lady I know about is 34 and has three rib fractures and a forehead laceration.” “Dunno who that is, but Dr. X saw this patient in 23, and now he’s not answering his pager, what do you want us to do about the heart rate?”
Or my favorite: a posse of concerned family members standing outside the room of the latest spiralling patient. You walk up, hoping to take a look, maybe gather some clues from a thorough physical exam before you go read the chart and review the labs and medications, and there are they are, concerned about this, that, and the other. Some of which is important, because they know medical history that I need to have; otherwise it’s important because letting a family get angry at you just sabotages the whole thing. We need to be on speaking terms, even if it means spending ten minutes I can’t really afford listening to them and trying to answer questions I have no idea about. (After making sure the patient is stable, of course.)
I’ve gotten used to dealing with half a dozen pages at once about floor-type issues: blood pressure, urine output, pain control. But half a dozen pages about critically ill ICU patients – in opposite corners of the hospital – plus attendings telling me I forgot to do something, PAs trying to sign out to me, and trauma alerts which set a time limit for anything else to get done before they arrive – it’s a little overwhelming. A lot overwhelming. But it’s what I’ll be responsible for, continuously, in three weeks, so I should stop fussing and get used to it.
The really bad part of this rotation is the constant sensation that I am singlehandedly responsible for some very sick people, with unfortunately very little idea of what to do about it. There are things I need to know, that aren’t in books, and no one to teach me. I’ll find out by trial and error, sooner or later; but I wish I didn’t feel so completely abandoned by the hierarchy. There’s something wrong with the system that leaves me, my first time really in the ICU, with so little responsible supervision. Sink or swim, I guess, for me and the patients, and trust to the nurses to stop me from doing (or neglecting) anything truly aberrant. A foresight of the next year, which leaves the unsettling impression that life isn’t going to get better any time soon.
Tomorrow: more of the same, with most of the alleviating factors removed.