I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great.
They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities.
Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don’t need a large chest tube). The nurses seemed equally uncertain about where to find the supplies, or what to do with the supplies once we had them. Meanwhile the patient’s vital signs became more and more unstable, reminding me very unpleasantly of those questions which occur on every single test from third year medical school up till specialty boards, about the patient with hypotension and tachycardia and absent breath sounds on one side, who will die unless you perform an immediate needle thoracostomy. If you wait and do a chest tube, you always get the question wrong. Now we see why tests are bad for you, because this patient was still ok, but I have seen so many of these questions on tests that I got needlessly concerned about the possibility.
Fortunately at this juncture a senior resident wandered by, noticed the large congregation in the room, and stopped to see what the fun was. He pointed out a couple of errors I was about to make, and with his supervision the catheter got in the right place. (Rather to his surprise, since he seemed not to have done many of these either.) Everyone relaxed. The senior resident left to attend to his own patients. The congregation dispersed.
And then it turned out that the patient had inadequate iv access. Very inadequate. Moreover, nearly every site you could imagine trying was unuseable, for various reasons, including the fact that several attendings had already tried to place central lines, and failed. The nurse, however, continued persistently to fiddle with the lines, and every time I suggested giving him some treatment (because his blood pressure continued to be erratic), she would remark, “That’s fine, but how do you want me to get it into him?” and continue with a litany about how every line was either blown or already in use. So (again with a little supervision) I put in a line, in one of the spots that the attendings had already failed on. That’s why I’m now inordinately pleased with myself; and it’s nice that the senior residents kept walking by and being impressed, too.
I feel like a surgeon. I can do (difficult) lines and procedures on an unstable patient, and be successful, and the patient survived (so far, at least). I made some other decisions, too, which caused the seniors (who were suddenly much more interested in hearing about my problems than they were the last couple nights) to raise their eyebrows and make remarks about clinical indications or the absence thereof – but the morning labs bore me out.
I know that tonight I will get in trouble, because it’s impossible to be so happy with myself, and not make a mistake. “Pride goeth before a fall.” So I remind myself that I was being supervised (some of the time), and that really it was more my good luck that things turned out ok, rather than that I knew precisely what I was doing. Moreover, next year I’ll need to handle, not one, but several critical patients at the same time. This one alone occupied my whole night. I still have a long way to go to being able to balance several ICU’s worth of patients – in four months.
Part of the fun of the night was working with the ICU nurses. They make a great team for each other, always moving to share work whenever anyone’s patient becomes too critical. For this particular patient, since it was such an unusual case, and neither they nor I knew much about what to do, we got along very well: they told me whatever they could remember of “what we did the last time this happened,” and I told them the specifics that I had gathered from the attending’s hasty and detailed instructions, and we did fine.