prescience

Driving home from the hospital, I got stuck in traffic around a recent accident. Sitting and waiting, I calculated that from the amount of debris on the road and the number of flashing lights involved, it must have been a fairly serious accident, which would mean a good likelihood that at least one person involved would show up as a trauma alert somewhere. And only five minutes from my hospital. . .

Two minutes later the trauma pager started going off, describing that accident.

Not sure what the moral of that is; maybe not to carry a trauma pager when I’m not on trauma call. But it was fun to know more than anyone else in the traffic jam about what was going on.

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at last

Done with trauma!

It only took me three extra hours to get out of the hospital in the end, which I was kind of resigned to, considering it’s the middle of Labor Day weekend (a fact I only realized when the ER staff started commenting on the number of people who started their drinking spree early, and thus showed up in the ER earlier in the day than usual). In addition to the usual deluge of traumas at the nominal signout time (nominal, because there’s a better than 50% chance that something major will happen five minutes before or after), I felt like I had to stay and tidy up every single loose end on my patients before I could leave, since I won’t be back to fix it tomorrow.

I won’t be back to fix it tomorrow. I’m not even going to look in the direction of trauma for the next two months. I won’t even have to interact with that monster of a service on call. I don’t care how many foreboding warnings I’ve been given about my next service, it’s not trauma, and that’s all that matters right now.

Funny, though. I like the trauma bay (getting the patient, having to figure out very quickly which of their complaints are serious or lifethreatening and which aren’t), I like the workup (lots of CTs to look at, the responsibility to page through all of them, because whenever the radiologist gets around to reading it, it will be too late for most things if we don’t see it first), and I like the ICU care (paying attention to details, seeing people get better, get off the ventilator) – but somehow I don’t like the sum. If we could skip rounding with the attending, it would be quite nice. Hmm. . . don’t see that happening.

 

hit the green button, please

The beeper is an amazing object, and whoever invented it ought to be relegated to one of the lower circles of the Inferno.

(On second thought, remembering in the books the old paging system, overhead, which must have been infinitely more painful, perhaps a middle circle would be adequate.)

This time of year, on a sunny Saturday, the trauma pagers go off with predictable regularity: five minutes after signout in the morning, and five minutes before signout in the evening, and every forty-five to sixty minutes in between. There’s kind of a reflex shrug we’ve all developed, standing in a circle in the unit, when the combined beeps and twitters and buzzes of our pagers, and the charge nurse’s pager, and the respiratory tech’s pager, all go off at once. Some people try to ignore it, and pretend that it’s not their beeper that’s going off. I’m more the type, when other people have their hands full, to pull my pager out and announce at least how many minutes we have before impact (five or sixty – it can make a difference), and perhaps the nature of the injury if it sounds really sensational or serious.

(Although it’s amazing what poor aim the people in my city have: multiple gunshot wounds to the face routinely get discharged in excellent condition in a few days; we’ve had guys shoot themselves multiple times in suicide attempts, and get off with only one broken bone; we’ve had gang warriors shoot everything and everybody except anything remotely resembling a vital organ on the person they were aiming for; I’ve seen more gunshot wounds to the calf than any other kind.)

 

the end is near

No dramatic events. I am one day further along in my quest to escape from the trauma ICU before any permanent damage is done.

The nurses are a little puzzled by my excitement, and kind enough to say they’ll miss me. I guess, since they persist in calling me about every thing that happens on the unit, regardless of whether I’m following the patient or not. Flattering, and fairly safe, since I’ve now gotten better than I was at the beginning of the month at following what’s happening to all patients, whether they’re “mine” or not, but difficult to handle delicately: when to waste the nurse’s time by telling them to call a different resident, when to defer to another resident’s handling, when I wouldn’t have chosen that method myself but there’s nothing downright wrong with it, and how often to call another resident to tell him what I and the nurse did with his patient.

Two days left. Labor Day weekend. This is not going to end quietly.

 

useless

A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” – but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all.

Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so businesslike, not high on my list. But you have to. And then there were all the other patients who needed to be paid attention to, and just because one person died is no reason to go neglecting or ignoring the others. So I went and did all the appropriate procedures, and they weren’t much fun. A needle here or there. . . but I couldn’t save the one guy who really needed help.

I don’t know which was worse, talking a family through their loved one’s death, when I’d only seen the patient for five minutes beforehand, and we only had an hour to work through it (like yesterday), or handling it after a month of struggling together, like today. Strangers or long-term acquaintances, it doesn’t get easier.

I’ve been calculating all month, and I work out my prospects for the rest of the year as follows: nearly all the second year rotations are unpleasant, and nearly all of them last for more than one month. So the chances of September being even more miserable than August are at least 70%. This is not good. Without hope, things fall apart.

 

Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all.

I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds to tell me what they were doing. In textbook style, as soon as they opened the peritoneum, blood came pouring out onto the table. They packed all four quadrants with quantities of lap pads – I have no idea how they can ever keep track of how many went in where – until the bleeding was controlled. Then they started in the corner where they knew there were no problems, and proceeded to explore. Between me being there to be lectured and quizzed, the attending being an extremely conscientious character, and the chief being the inquisitive kind who wanted to see everything and visualize every possible maneuver (Kocher, Pringle, etc) while he was there, it was quite educational. And also beneficial to the patient, who did well.

(Kocher maneuver: reflecting the duodenum medially in order to visualize the head of the pancreas. Used in trauma to gain control of the IVC, and in surgical oncology to reach tumors in the pancreas. Pringle maneuver: clamping the porta hepatis (portal vein, hepatic artery, hepatic bile ducts) to get control of devastating hemorrhage from the liver that can’t be controlled with packing alone.)

The chief spent most of the day in the ER (nine patients in two hours on a weekday morning, as though all the old ladies in the city had decided to fall and hit their heads at once, while several un-drunk drivers managed to have serious accidents), and complained that he hadn’t been able to see the unit patients. I, on the other hand, had more than my share of the unit, and would gladly have bailed out of it to share in the chaos in the ER; but we each had to stick to our own responsibilities.

 

slough of despond

Halfway through rounds the medical students were asking me if I was all right. There was nothing wrong, just the insanity of the trauma unit, and my dysfunctional method of communicating with the chief and the attending. The chief and I have a very strange interaction; we like each other, and it’s certainly better when he’s around and responsible for things instead of me, but somehow he makes a day in the trauma unit even more complicated.

So the students are trying to help me, and I don’t even have the energy to be polite to them. All I can remember is the resident I knew when I was a student, trapped in the unit for months on end. He didn’t talk to students much either, although in my memory he was still more helpful than I’m being. That’s bad, because he had it even worse than I do – unless someone takes it into their head to schedule me into the unit some month in the near future. At this point, I can’t even finish my sentences; it feels like wading through molasses to get anywhere, and talking to people just takes too much effort; so I don’t talk.

I can’t believe it’s only halfway through the month. This seems to have been going on forever.

The attending for the next several days is another one with whom I clash constantly. The only good thing is that he’s predictable in his own unbearable way. (You may be asking whether there are any trauma attendings I get along with. There are two, and they’re sane only because they spend as little time in the unit as possible. Unfortunately, that’s not an option for me.)

 

miniature soap opera

I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU – a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be able to have a gigantic fight and still keep going.

Apart from that central explosion, nothing much else happened. I’m fortunately not on call tonight, which is ok with me, because the trauma pager is going off with one unhelmeted motorcycle or ATV accident after another. You may conclude that the weather is quite fine. Tomorrow morning I will have further evidence that young men are fools (for not wearing helmets) and/or sissies. (Because they all scream and cry about nonexistent or minor injuries. No one makes as much noise as the 20-yr-old guy with a broken clavicle and a lot of road rash; a woman the same age with an open tib-fib, or an older man with an open femur, or an elderly lady with 10 broken ribs, will all be much more stoic. I have had no sympathy for young men since the day that one of them had me persuaded he had a broken clavicle, a dozen broken ribs, and a broken femur, from the amount of noise he made; after giving him dilaudid, we got through CT and xray, and found that he had a cracked clavicle, and nothing else. Pfui.) (And I’ve injured myself in sports too, and didn’t scream for more than five minutes, so I’m allowed to talk.)

 

continuity of care

It was a Saturday night, and I was on the vascular service, so being on call meant I was covering the vascular patients, plus urology, plus plastics. Which can add up to a lot, if the urology attendings have decided to do a couple of radical prostatectemies and urological reconstructions before leaving for the weekend. Or if plastics is on call for traumatic injuries. Fortunately, urology was quiet, and plastics was only on for hand injuries, of which there were none.

So when, around midnight, five or six ATV accidents started coming in in short order, I had time to go help. I had one end of the trauma bay, and I got the third helicopter transport, a young man, fairly alert, with some scalp lacerations, lots of bruises and lacerations everywhere else, and a mangled left leg. ATLS protocol, by the book, didn’t show much of anything – except for that leg. The foot was hanging at a strange ankle, and the foot looked quite pale compared to the other side. No pulses were palpable and he could only wiggle the toes.

The orthopedic resident was moving from one stretcher to another, distributing splints, and making notes for who would get to go to the OR first. He cocked his head at this one. “I’m not getting any pulses here, perhaps you guys should consult vascular.” “It’s ok, I am vascular,” I told him. I had already dug up the hand-held doppler, which is the mainstay of vascular workup in the ER: if you can hear pulses, it’s not too bad; if you can neither feel nor hear the pulses, then the limb is truly ischemic and will be dead within a couple of hours (6 is usually quoted).

The trauma attending finally had time to get to that end of the bay. “This is a pretty bad open fracture. Can anyone feel pulses? Maybe we should consult vascular surgery.” “Yes sir, I am vascular; I was just helping out down here. I think it’s bad, there are no dopplerable pulses, and we’re about to call our attending.”

The situation was fairly textbook: an open fracture with clear distal ischemia. Don’t pass go, don’t collect $200 or any further studies, proceed straight to the OR. Since I had nothing better to do except sleep, I helped move the patient into the OR, and watched the orthopods fit the pieces back together and fasten them in place with an ex-fix (external fixator; like lego outside the leg; it stabilizes fractures, especially contaminated ones, for a couple of days, usually in preparation for definitive internal fixation; they’re cumbersome, and people often try to ignore their presence, but it’s actually easier for the patient if you move the leg by holding the ex-fix, since that won’t make the broken bones rub against each other, which is what really hurts).

Then, since my pager kindly remained silent, I got to help the vascular attending and chief (one of my heroes: smart, and good to work with), who were by this time fairly beat, since it was the fifth emergency case of the weekend. We prepped both legs, and the chief and I harvested the saphenous vein from the uninjured leg through a series of small incisions that we tunneled between to reach the whole vein, while the attending cleaned up around the injury on the other side, and found healthy artery on both sides for the anastomosis. He and the chief each took one end, and attached the saphenous vein to the healthy artery, while I started closing all the incisions on the other side. Ortho had already made the fasciotomies (long ugly slashes through the fascial covering of the four muscle compartments in the calf, necessary to relieve pressure and prevent ischemia after a serious injury or period of ischemia), so all we had to do on the injured side was wrap yards of kerlex and gauze around the entire structure of the ex-fix and our incisions, and we were done.

The poor vascular team still had two more cases to go, and I had to go attend to some urology patients about whom I had received no signout. It made for an incredibly long call day, but that was my favorite night to date: a dramatic, classical injury, which I got to follow from the door through the OR, and then round on for the next few days. Talk about continuity.

 

triage skills

I continued my attempts to be in three places at the same time, to no one’s particular satisfaction. I ought to pick one place to be, and do a good job there, and then at least those people will be happy, instead of all three groups being displeased at once. I can’t somehow manage to 1) round with the attending in the trauma unit 2) discharge patients in another unit 3) be present for resuscitations in the ER, all at once. Result, patients are not discharged in a timely fashion, the unit attending is displeased because I’m not continually present, and don’t everything about all the unit patients, and the admitting attending is displeased because I’m rushing in and out of the resuscitations, and trying to get done with them as fast as possible so I can go back to the unit.

(In addition, there are a few secretarial jobs that the residents absolutely have to do, and somehow they’re always lowest on my list of priorities, which means the attendings who care about secretarial details will be out for my hide after a few more days of this neglect. I know it’s coming, and I still can’t find the time to get it done, even with spending 14-15hrs in the hospital.)

And I’m upset with myself, because I miss details on my own unit patients, and because the interns I’m supposed to be supervising turn up all day long with surprising statements like, “Shall we wait to do the CT scan till this patient has had the blood transfusion?” [what blood? I thought the count was just fine; why are you transfusing for that count? are there some symptoms I haven’t heard about?] “I have to go talk to this patient’s family about discharging them to a nursing home tomorrow.” [nursing home? they’re on the verge of sepsis; who said we could discharge them?] “This patient’s pain is not controlled on a fentanyl drip, what shall we do?” [how did they get on a fentanyl drip, and at that rate? how about some non-narcotic medications?] “I’m going to get a consent for a trach and peg on this patient.” [oh, nice; I thought we were going to extubate them in a few days; what went wrong?] And this kind of conversation ought not to be happening; I ought to know, and if I can’t find out for myself, I ought at least to keep close enough track of the interns that they tell me these things sooner. If I could stop running my hands through my hair when three people talk to me at once, perhaps it would encourage the interns to tell me things more.

On the plus side, I got to supervise a couple of procedures today, lines and chest tubes, and was able to refrain from saying too much, and then was able to complete things correctly when the interns stumbled. Which was reassuring to all concerned.

My sickest patient didn’t die overnight, which was a very nice thing to discover in the morning. That’s one ray of light for the day – he’s still around, still worrying all of us to pieces; but at least he’s there to be worried about.