Rewarded for last weeks call, saw Star Wars

My chief last night was this really great person who is going to be an attending at this hospital next year. She's a Uconn Med School graduate and just an overall nice person. Plus, she's a wonderful teacher, extremely knowledgable about surgery, and has a great way of explaining things to you so that it makes perfect sense. Every story she told was very captivating and I kept wanting to listen to more. It's funny how after working with a lot of different residents and attendings, I'm starting to realize exactly what it takes to be a good doctor. The most important thing to a patient or colleague is how you make them feel. That comes with listening to their concerns, validating them, sympathizing with them, and treating them like your equal. It doesn't even really require a lot of knowledge above and beyond what the average doctor of that specialty knows. Even if the patient is frustrated as hell, sick as hell, or even dying, he or she will feel like you did something if you just validate them and believe them. Or at least make them think you believe them. That's all it takes.

I mention this because I see this chief as possessing those qualities with a lot of common sense. I would trust her as my surgeon.

Also, I got some sleep last night, so I was able to come home, sleep for an hour and then go see "Star Wars III: Revenge of the Sith". I loved it. It really explained everything and I have to say that I have a whole new respect for George Lucas as a writer. After listening to his commentaries on the movie "THX 1123" I understand what his is going for in his films. He's very good at creating believable alternate realities. But this film was just very well made. It did exactly what that movie was supposed to do: bridge the gap between episode 2 and episode 4. I didn't think that he would do it, but he did. I can't wait to see it again.

Busiest 30 hours of my life

I wanted to tell a story about on night of call that I had sometime during the past 4 years.
It was like a comedy because of the horrific things I saw, the sheer stress I was under, and the complete exhaustion I experienced.

It all started off by oversleeping and not getting to the hospital until 5:15am. Bad way to start the day. Saturdays are definitely the worst day to be on call because it ruins your weekend, the list of patients is enormous and then everyone needs to be discharged. I rounded and wrote notes on around 13 patients, which isn't that bad for a Saturday morning, actually. However, I didn't know a bunch of them. The first guy I saw was the typical patient: older than hell and sicker than hell, and to top it all off, completely unresponsive. Great. Sorted that problem out and then I rounded on the rest of my patients without having any time to write my notes, of course (that will come later). I get down to the cafeteria to "sign out" our patients (which means running through the list of 60 patients we have so that we all "know" about them). This process usually takes 1-2 hours. Of course during this time we have our first trauma of the day.

Trauma #1 - Transfer from community hospital. Drunk guy coming home from the casinos flips his SUV and has a C7 facet fracture, i.e. he had a stable neck fracture. However, he also sliced open his scalp from the tip of his mid forehead to his right ear and I had to numb up and then staple up. That took over an hour to do.

Of course during this trauma, I was paged at least 10 times for various things to do on the floors. I then attempted to finish up my notes and write some orders for the patients, in between the countless interruptions I received from pages. I wish that there was some way I could express how frustrating it is to get beeped every few minutes to mostly answer the same questions over and over again. But I can't because you just need to expereince it yourself.

Next project that was given to me was to change the dressing on a patient with Fornier's Gangrine, which for those of you who don't know, is necrotizing fascititis of the perineum, or more simply put, the flesh eating bacterial infection of the area between the scrotum and anus. The treatment of this disease it quick and very wide debridement of the diseased skin. In other words, all of the skin below his penis is gone. That's including his scrotum, the skin around the anus, the perineum (taint, grundle, etc.), and much of his buttocks. His testicles were freely hanging individually without a scrotum to contain them. So under conscious sedation, I unwrapped each testicle individually and removed the packing from his ass and changed it.

So that took up another hour at least. Then I tried to discharge some patients. We had about 10 who were leaving and that involves writing instructions, filling out prescriptions, and dictating a discharge summary summarizing their stay in the hospital. I've gotten very good at quickly breezing through them, but again, with interuptions every 5 minutes, it's kind of difficult. The worst part about the questions the nurses asked me were that I just didn't know the answer to them because they were about patients on a different team. Fortunately I could just ask my midlevel resident or chief resident, but oh, that's right, they're both in the OR. It will just have to be put off.

Get a consult to put in a central line. I go do it myself, and get it on the first shot! Whoo hoo! Something good about the day! She was comfortable, all 3 ports worked, and everything was great until...

Trauma #2 - Another drunk driver got into a car accident. I walk into the trauma bay and on the other side is an intubated blue faced 170 year old woman with a blood pressure of 30 who was, of course, being given all recussitation measures until the family could come to grips that their dying, great, great, great, great, great, great, great grandmother-in law was finally ready to die. Luckily, my patient was the drunk upstanding citizen next to her with the blood gushing out of his head. He seemed to have a minor scalp laceration, until we realized that there was a puddle of blood below his table. Oops, better fix that one up. So I got a suture and sewed up his head and stopped the bleeding. All right! That's 2 for me today. Of course I'm saturated with his blood so I have to go change my clothes while he's getting his several thousand dollar workup that he won't pay for, doesn't want, does not appreciate, and is completely unnecessary but is the accepted protocol.

Next, I get a call saying that one of my patient's chest tubes fell out and was on the floor for several hours. A chest tube is a life saving tube that it put into the side of someone's chest when they have a pneumothorax, aka a collapsed lung. This re-expands the lung. A collapsed lung is a medical emergency, simply put. Now that her chest tube was on the floor, we had to act quickly to make sure that she was ok. We got a STAT chest xray and of course, her lung was fine, but we needed to put the chest tube back in there to drain out her malignant pleural effusion. She was not too happy to have to go through that experience again, which involves making an incision in the side of your chest, sticking a clamp in between her very narrow ribs, puncturing through the chest wall and into her pleural space and spreading the intercostal muscles to make room for the chest tube. Oh, did I mention, she's completely awake for all of this? Sounds barbaric? Well, it's not if you're able to numb them up properly. We did, luckily, and she was very grateful for it. All right, another good feeling for the day!

Now I finally got some time to eat some dinner (holy crap, it's 7pm already). Somehow we managed to all eat dinner together without interruptions. There must have been something wrong with the pagers.

I finally get a chance to check the labs on my patients, or at least some of them. Of course all of the ones that I check are abnormal and need replacement. I order most of them but the one old lady who needs the most has her only IV access leaking. I have to change her central line over a wire but I can't because there just isn't enough time.

Then I decided to go post-op check the patients who were operated on. Keep in mind, that during all this time, I am getting paged every 5 minutes.

Then we hear the dreaded, "trauma team, STAT to the trauma room! Trauma team STAT to the trauma room!" That's never good.

Trauma #3
A kid was shot multiple times through the chest and abdomen and was crashing right in front of us. We ran the ATLS protocol and put in 2 chest tubes, I put in another central line (again, on the first shot, with a blood pressure of 60 - not too shabby, if I don't say so myself). But he started crashing fast and we knew that he had to find the source of his bleeding in his chest. So right there in the emergency room, we opened up his chest. It's called an "ED thoracotomy". It was the most unbelievable thing I've ever seen. We made an incision from one side of the chest to the other and opened it up like a book. You could see his heart beating right in front of you and his lungs inflating and deflating. Someone started manually massaging the heart, we clamped his aorta, and we quickly rushed him off to the operating room.

On the way to the operating room, we hit a bump, and a bag of blood got disconnected and splattered all over the stretcher, the patient and all of us. This was in the carpeted hallway, by the way. We all just froze and I ended up grabbing it and taking it off the pole. We quickly whisked him up the hallway, leaving a trail of blood behind us that some lucky person had to clean up (it was clean by the next trauma).

In the operating room, we opened up his abdomen to try and find the intrabdominal source of bleeding. There were bullet holes through the intestine, so we removed that, but that was it. So we turned our attention to the chest and pulled back his heart and lungs to see a big hole in his superior vena cava. We sewed that up and then noticed many bleeding lung injuries which we then removed as well. He just kept on bleeding and I kept seeing his heart getting slower and slower. Then he went into DIC and blood started coming out of every orafice.

Somehow we were able to make it out of the OR and to the ICU where he died. As we were in the ICU, the cop, said to us, "oh by the way, there's 2 more coming in," and sure enough we get called down to the trauma room again.

Trauma#4 - A young guy who was shot 3x in his thigh. Miraculously, nothing was really injured. He got his million dollar unappreciated workup as we turned our attention to his next door neighbor.

Trauma #5 - Kid shot by a shotgun 15 feet away. He was sprayed with at least 50 pellets all along his right hand, arm, thigh, and even in his penis and scrotum. Again, nothing deep was injured.

Both of these guys got admitted and it's about 3 am now and my senior level and I decided to finally run through our list of patients. However, I got 4 pages and the first one that I answered, I just snapped and was pretty mean on the phone. She didn't really like it either and she yelled back at me. I felt really bad and right after we ran the list, I apologized to her. I really like the nurses here and her in particular. I could not beleive what this job had done to me. I have never been a rude person but I just couldn't deal at that moment. I just wanted 1 hour to myself so I could possibly rest, but it was not possible. But, I really felt terrible and I think that she forgave me. I hope so.

I decided that it was so close to the time I would have to round on my patients for the next day, I might as well start now. So I was almost done rounding and writing my notes and I would have been able to sleep for at least 1 hour and I hear "trauma team, STAT to the trauma room." Shit.

Trauma #6 - 360 pound man stabbed in his side with a piece of intestine hanging out. If that wasn't bad enough, his feet were the most foul smelling things I have ever smelled. I had a mask on, and we sprayed them with bicarbonate ( which I guess helps stink foot) but it was overpowering the trauma bay. That stench will stick with me to the grave. He was taken to the operating room and they repaired his diaphragmatic rupture where his intestine were up in his chest.

So I finally rounded on my patients, and signed out, and actually changed that old lady's central line that I never got a chance to do.

I did not sleep at all. It was both physically and emotionally draining. It was by far the busiest 30 hours of my life.

Post Call Dream

Here's a dream that I had during my 2 hour nap at home after a long night of Sunday call:

I was driving in my car leaving a Target Express (I'm not sure if they even exist, but they did in my dream). It was at the top of a mountain and it had a big parking lot with an unmanned, automatic machine that collected the shopping carts. I avoided them and drove away to the traffic light at the end of the parking lot. I had a difficult stopping in the intersection, as my breaks did not work that well, but I was able to stop only after rolling a little beyond the "stop" line on the street ending the intersection (this is a common occurrence in all my dreams-wonder what that could mean?). This one was at the top of a little hill with a traffic light. There were flashing lights and I suddenly noticed that it was very cold out and the sudden change in temperature frosted over my outside windshield. I was about to go when I noticed a bunch of flashing lights at all of the 4 corners of the intersection and one of the cops (or they might have been security guards) held up his hand to stop me from going, and I didn't want to so I looked him right in the eye and screamed, "No, f you a-hole!!"

He seemed to get a little mad and came over to the window and tapped on it demanding me to open the door. I pretended that I couldn't see him due to the frosted windows and turned on my defroster instead. He pressed some buttons near him and a large mechanical boom that exists in automated car washes came over the car and gave me a free car wash. The cop was trying to clean off my wind shield so I could see him and talk to him, but I saw this as the perfect moment to take off with a free carwash and give it to the man. I zoomed through the red light, out of the intersection, drove past the flashing light barricade and started weaving my way into and out of streets to make sure that no one would pull me over. It was instantly snowy outside, with around 2 feet of snow on the ground. Good thing I had my 4 wheel drive Subaru at my side. I made it to a parking lot of a nice plaza with a trendy coffee shop.

It suddenly became night time. I was running away from the car through the coffee shop and then a mall and into a back alley. Once there, I realized that this might not be the safest things in the world to be doing, and of course, when I had that thought, a guy with brown long hair, about 6 inches taller than me, wearing a jean jacket started talking to me. I talked back not thinking anything of it and he started telling me how he's in a lot of pain and really needs some pain medications. I started walking away from him and he kept up right next to me, becoming very threatening, saying "well, now you're alone, outside." He starts begging me for some or some money and I remember thinking to myself, "do I compromise my medical judgment and proper medical ethics just to save my life? Or should I just give him some money and be out on my down payment on my house?" As I was thinking these thoughts the guy started hawking up a large wad of saliva and phlegm and I thought he spit in on my leg as I narrowly escaped him. It turned out to be my car keys covered in a thick goo. He shouted, "you're going to get pretty tired trying to start your car." I didn't really hear the rest, but I remember being extremely scared.

I go out to the car and Marji was there but she was half Marji, half my sister's boyfriend's friend's fiancé (random). This made perfect sense in my dream, however. I gave her the car keys and we each tried starting different cars that all could be mine, but looked a little different. We couldn't understand how we didn't remember which car was ours. I was about to reach the peak of my dream where everything starts becoming very emotional, scary, intense and it's where I usually wake up, but at that point, music started playing and I was safe in a room with Marji, who is now 1/2 Marji and 1/2 Rosie Perez (the girlfriend from the movie "White Men Can't Jump") and we were with a 6 year old boy with blond curly hair, who looked very similar to Jonathan Lipnicki, the kid from Jerry McGuire. Marji-Rosie was explaining to me and another woman in the room how the guy who threatened me had tested positive for cocaine, benzos, and narcotics. Then the other girl in the room was bitching about how long it took her to get heme-onc to finally come and see him. I'm not sure why heme-onc was necessary but he ended up being a known drug addict who ultimately became my patient. Then I suddenly realized that the guy was hiding in my back seat when I came out of Target Express and the cop was trying to get my attention to warn me. The guy did something to my car so that I would not recognize it or start it. This was a common thing that he did. It was such a feeling of everything coming together.

Then I started hearing music (with lyrics of "when you fell under pressure, when you feel under pressure... " set to a blue grass nursery rhyme tune), like a movie was ending, and I saw credits on the wall of my parent's bedroom, and the Jerry McGuire kid was dancing and playing on the bed as he hung from a miniature green rollercoaster in the room. The credits said that he was the star of the movie, we all started laughing, and had a great feeling of satisfaction, and I woke up to my alarm buzzing.

Hospital Horror

One night of call, I had a memorable and disturbing experience. We got an overhead page “trauma team, STAT to the trauma room” which either means that the pagers aren’t working or there is something really bad. Unfortunately, it was something awful. As I walked into the trauma room, I saw the stretcher from the ambulance filled with blood right by the head of the bed. Not a good sign. I get in there and it was a 20 year old boy who was shot in the head. He had an entrance wound in his left side of his forehead with brain spilling out of the hole. Not good.

He was not breathing, had no blood pressure, but had a pulse. He was intubated and we shot a lateral x-ray of his skull which showed the bulled lodged in his brain with fragments of bone and a huge linear skull fracture. We pronounced him dead right after that. However, then we told the family and needless to say they did not take it well. The father came and identified the body. I could not really tell what his emotions were because his face was just a blank stare. However, his sister exploded with emotion in the emergency room and started screaming and crying. Then she came into the room and was uncontrollably hysterical lying over her brother’s bloody dead body. She kept screaming asking questions about if he’s brain dead or not. She was in agony, and I stood there helpless and numb and continued to fill out the paperwork on the trauma we ran on her brother. This residency has made me quite thick skinned to horrific diseases, traumas, and psychological tragedies that the human body experiences but that moment will stick with me forever.

Well, got to get to sleep now so I can finish up my last Friday-Sunday call at this hospital.