Wednesday, April 30, 2008
Who would have thought? The whole month had been pretty quite in comparison to my first ER month. There were more traumas, but not nearly as many resuscitations and no cardiac arrests (no chest compressions).
The morning started out quietly at
I looked at my secretary, “I’m going to resus.” And smiled.
I gathered the equipment: laryngoscope with a #3 Miller blade, suction, 8-French cuffed-endotracheal tube, 10cc syringe connected to the endotracheal tube and tested, bag-valve mask with oxygen running at 15 liters/minute, oral airway and my guts!
The nurse administered the sedative and paralytic, and we bag-mask-ventilated the patient to reach 100% oxygen saturation in the blood. I scissorred open the patient’s mouth, swept the tongue to the left with the miller blade and advanced the blade into the patient’s throat. I lifted the laryngoscope to view the airway and…I only saw secretions. I grabbed the suction to clear things out, but I could not see the vocal cords. I reseated the laryngoscope, but still saw nothing good. I handed the equipment to my partner and she took a few moments to get the tube in place.
We got the patient stabilized and I decided to go check on my module which, of course, had a new patient waiting for me. The new patient had a chronic cough for two months but came to the ER because she just health insurance. After a couple of minutes of hearing her history, I hear “Medical doc and staff to resuscitation. Code one medical, arrival in one minute.” I excused myself and walked over to resus.
The patient was an older woman and the events unfolded exactly the same. (I tried to intubate, but was not successful.) We got her stabilized and I returned to my module to find another new patient. I finished bringing in the first patient and started on the second and, after about 20 minutes from the last resuscitation, “Medical doc and staff to resuscitation. Code one medical with CPR in process, arrival less than one minute.”
I scooted into resus and found my fellow resident in a gown and face shield, so I gowned-up and was just putting on my mask while getting briefed that the patient has no IV access and had not been intubated, when I hear a call from the hallway, “We need help with CPR and getting this patient into the room.” I ran down the hallway and jumped into the ambulance to find a very, very, large man. I started chest compressions as the other
We delivered the patient into resus and got CPR started up again. My fellow intern tried to intubate (I did not even ask) while I worked on the CPR with the other techs. After several minutes of trying, the decision was made to perform an emergency trach and my attending asked me to go clean up my module since there was yet another new patient in there.
I brought in the two new patients and staffed them all with the attending. Then it was time for the attending switch and after about ten more minutes, “Medical doc and staff to resuscitation. Code one medical, arrival in three minutes.”
I walked over to the resus module and found that I was the only doctor there. I started gather all of the equipment for airway management and intubating. The new attending finally walked in and said, “What’s going on?” I laughed and said, “Well there’s got to be some doctor here doing the work!”
This is my favorite attending. He is the head of the ER residency and was the attending that talked me through my first central line placement on the very first day of my intern year, if you remember that story. He was the one that told me to “take the thingy out,” so I took out the guide wire just to hear him say, “not THAT thingy!” To which I said, “Man, you’ve got to be more clear than thingy!” We had each others number right away.
He asks me to list all of the equipment I have read, which I do as above: But, still no patient. So then he starts talking about how men who masturbate have few prostate problems to which I say, “Well, then I’ll be okay! As a matter of fact, just five minutes ago…” All of the staff just started laughing. I would find out later that the attending daughter was standing next to him!
I scissor open the mouth and swipe the tongue to the left with the laryngoscope. I grab the suction to clear her secretions and light the laryngoscope to view her airway. “Nope! Don’t see it!”
“Common! This is the money shot!” As the attending pushes on her neck I see the vocal cords come into view. “Yup! I got it, now!” I grabbed the tube and slip it between the vocal cords. I inflated the cuff with the 10cc syringe and we attached the bad ventilator to the tube. I listened to the chest and heard breath sounds on both sides, but right a little greater than left. I deflated the cuff and pulled the tube back about 1 cm and reinflated the cuff. Now the breath sounds were equal! We gave the PT some diuretic to help her pee-off all of her excess water and get her out of congestive heart failure.
The rest of the day was filled with chest pain, cough, vomiting and dizziness. There was one last patient who arrived for nausea, close to the end of my shift. I went to just “eyeball” her to make sure that she was stable enough to wait for the next shift. I heard the background story and decided to go ahead and take the full history. At one point, she was talking to her daughter who was at the hospital and coming to see her. A few minutes later I’m looking down the hallway when I see one of the secretaries associated with my residency program. Not a person I normally see in the ER. When she started shaking her head, I realized that this was the daughter!
Boy, am I glad that I did not totally blow off that last patient.
Saturday, April 26, 2008
Tuesday, April 15, 2008
I shift over to day-shift today which means most of my fun is over. Now there will be twice as many residents, more attendings and students all trying to the their hands on the patients. This also marks the last nine shifts of hard-ish intern work. Then there's just two months before the move to Maryland and, with any luck, I will take step 3 before we move! (I've been trying to get ready for it for 5 months now and have just been too distracted.)
Monday, April 07, 2008
Perfectly clear, round pupils surrounded by the deepest dark brown eyes--solid brown, framed by naturally thick lashes that gently curve back. The kind of brown eyes that easily peer right into your soul. Light, creamy, smooth cheeks only gently kissed by the
In far slot in the resuscitation bay, she lies strapped to the back board resting atop the gurney. A ventilator is positioned to my right with the equipment to intubate behind me if her airway starts to be compromised. To my left is the defibrillator warmed in case she goes into cardiac arrest. Portable ultrasound and manual blood pressure cuff are on my left if needed. At the foot of the bed the resuscitation nurse is at her station recording vitals and ready to pass in any needed medications. Two techs with trauma shears are cutting pant legs on the top surface of her legs. Two other techs are cutting up the arms of her shirts and getting ready to place IVs in both arms.
Breath sounds were bilateral, clear and not labored (normal); heart rate was fast but the EKG was otherwise normal; no abdominal pain; no obvious bone breaks; and no obvious bleeding.
“Oh my God! What’s happening to me?”
“You’re in the hospital. Keep your head down and try not to move. Let us move you. We’re going to take good care of you. You’re going to be fine.”
She screams in pain as the IVs are placed in each arm.
I cut the fluorescent tape securing her head. The other ER resident frees the C-collar. He grasps her head and holds her head in near perfect position relative to her body.
“Ready to roll in 1…2…3…roll”
She screams in fear and pain as she’s rolled away from me. The team starts to pull out the board when I stay, “Stop!”
Her hair was caught in the tape which was still attached to the board. I grab the shears I keep in my back pocket and make a cut to release her, along with a substantial amount of her long hair, from the board. (I don’t know if she’ll forgive me for that one.)
“What the hell are you doing to me?! Are you all retarded? Where the hell am I? What the fuck is going on?
“You’re in the hospital. You’re going to be okay. Tell me if it hurts where I’m pushing on your back. Does it hurt here?”
“No.”
Moving down her back, “Does it hurt here?”
“No.”
This line of questions continue from her head down to her butt. With some jelly on my finger, “Okay, you’re going to feel a lot of pressure in your butt.”
“Oh my God! What the hell are you doing?! What is happening to me? Where the fuck am I?”
“Spine is clear. Rectal tone is good.” I said to the nurse.
“You’re in the hospital and we’re making sure you’re okay.”
“Ready to roll back in 1…2…3…roll.” My fellow resident repositioned the C-collar.
“What’s your full name?”
“Are you fucking kidding me? Are you fucking retarded? What the hell is going on!?”
“I need you to tell me know name. It’s important that you tell me your name.” And she does.
“When is your birthday?”
“Are you fucking kidding me? You damn retard! What the hell is going on!?”
“I need you to tell me when you were born. It’s important that you tell me.” And she does.
“Do you know what happened to you?”
“You retard! I don’t know! Where am I?”
“You’re in the hospital. You were in a car accident. Do you remember anything about it?”
“I was in an accident? Who with?
“We don’t know. Do you remember anything about it?
“How could you not know! Are you a retard? What the hell is going on? Where’s my father?”
“Do you know when you last period was?”
She squinted her eyes and tried to think--as a tear rolls down her left cheek.
“Do you know when you last period was?
“No. I don’t remember.”
“Could you be pregnant?”
“I don’t fucking know! And I don’t fucking care! What the hell is happening to me?!”
“You’re in the hospital. We’re going to take care of you.”
One of the techs says, “She was wearing a pad, but it was clear.”
She looks up at me with a calm fear about her and asks,
“Where am I?”
“You’re at
“What happened?”
“You were in a car accident.”
“Who with?”
“I don’t know.”
“Where’s my father?”
“I don’t know.”
I asked the nurse if CT is ready for her, but there were not ready yet. I checked her vitals on the monitor.
She starts again:
“Where am I?”
“You’re at
“What happened?”
“You were in a car accident.”
“Who with?”
“I don’t know.”
“Where’s my father?”
“I don’t know.”
I now understand these are classic symptoms of the concussion syndrome and I start to see myself at age nine and think this must be exactly what happened to me. After about a minute:
“Where am I?”
“You’re at
“What happened?”
“You were in a car accident.”
“Who with?”
“I don’t know.”
“Where’s my father?”
“I don’t know.”
CT calls to tell us they are ready with an open scanner. We pull all of the electronic lines and plug them into a portably monitor. I grab the two bags of IV fluids and place them next to her head and started to roll the bed toward the door. Looking down into her eyes she asks, “Where am I?”
And, out of a scene from Groundhog Day, I say: “You’re at
I cracked a little smile because she must have thought I was reading her mind.
We round the corner of the hallway and she asks, “Where am I?”
“You’re at
We continue down the hall and she asks again. But this time I answered only a question at a time just to see if they would be the same:
“Where am I?”
“You’re at
“What happened?”
“You were in a car accident.”
“Who with?”
“I don’t know.”
“Where’s my father?”
“I don’t know.”
We roll into the CT room and get ready to transfer her. I take control of her head call out, “okay to move in 3…2…1…move.”
She screams out! A chill runs up my spine as I wonder what we just did to her spine!
“Oh God! The bed! It’s so cold! Why is it so cold!? What are you doing to me?”
A wave of relief splashes over me. “It’s really important for you to keep still. We’re going to take some X-rays and we need you to stay perfectly still.”
We walked over to the tech room where everyone is talking about how belligerent she is being and how ungrateful she is acting. (I have certainly left out half of the expletives in this story.) I reminded the team that she has a concussion and really has no idea what she is saying. Then I share with them that when I was nine, the day before my little sister was born, I was on my bike and hit a car and when the X-ray techs were positioning me on the X-ray table, according to my mother, I started cursing them out: “G-d damn it! You’re hurting me! Stop fucking touching me! I’m gonna’ sue you! My dad’s a fucking lawyer! Stop fucking touching me!” My mom described how embarrassed she was and did not realize that her little boy would use this horrible language. Apparently, they smiled and told her, “Its okay. We’re actually happy! That means he can actually feel!” I told the group that even though this young lady is “fucking belligerent at hell, she has no fucking idea what she is saying, she won’t fucking remember it tomorrow, and she could still grow up to get a masters degree, a Ph.D. and M.D.” Then, I told the tech that she is going to have to continually remind her to keep still because she does not have any short term memory past about thirty seconds.
Rolling her back to the resuscitation bay, she asks her questions two or three more times.
Back in the resus, the trauma surgeons want a urine same. Their team goes to place a foley.
She screams louder than anyone else I’ve heard! I found out later that her parents were in the waiting room and heard it and started racing toward Resus when they were tackled by security.
“Oh my God! What are you doing to my crotch?!! Why are you doing this?!”
I was actually surprised, given the majority of bad words she had showered us with earlier that crotch was her term of choice. By this point, I was at the nurses station looking at lab results, so I don’t know what, if anything, they said back to her. I doubt they said anything. Once they were done trying (they were not able to get the urine), I returned to the head of the bed when she said, “I need to pee! How the hell am I going to do that?”
The irony was not lost on me! We told her we were going to get a bed pan and she said that was gross. Again, irony not being lost and thank goodness for the lack of short term memory. By this point I knew who in her family had arrived and I told her, “you mother, father, step mother and step father are in the waiting room.”
“Why isn’t my father here?”
“As soon as we know it is safe, we’ll bring your father here.”
“Where am I?”
“You’re at
“What happened?”
“You were in a car accident.”
“Who with?”
“I don’t know.”
“Where’s my father?”
“He’s in the waiting room.”
Wednesday, April 02, 2008
Don't really have a lot of time to post on yesterday's experience, but let me say this...WOW!
Where else can you go from delivering a baby boy in a car (well, really delivering the body because the head and shoulders were out by the time I cut off the underwear) to performing a testicular exam on a 93 year old man?
Tuesday, April 01, 2008
So, it’s been a LONG time since I’ve updated the blog. I’ve ignored all of the observations made by my friends and family and have not added a damn word. And, now, I’ve probably lost all of my readers!
Hopefully, in time, you will come back to see what is going on in this thing I refer to as my life. Looks like that last update was Feb 3. Oh, I do so miss February. It was my three weeks of interventional radiology (IR) followed by my first week of vacation since starting my intern year. I’m very happy and sorry to say that I really enjoyed IR. Happy because, like I thought, I had the opportunity to combine my patient skills with my manual dexterity in the practice of medicine and I did quite well at the procedures the attendings allowed me to perform. By the third week I was flying solo on all of the ultrasound guided paracenteses (I think that is plural for paracentesis) and I got to perform several ultrasound guided thoracenteses and assist on several fluoroscopically guided procedures such as PICC line placement, kidney stent placement and an inferior vena cava filter placement. A was fortunate to get to work with all three of the interventionalists and see how differently each of them operates. I learned about CT guided lung and kidney biopsies and, well, that’s all that springs to mind at the moment. I am sorry to say that I really enjoyed the work because, at least in the university setting, IR docs are as busy as surgeons! It’s not so bad in the private hospital setting because the vascular surgeons want to perform all of the vascular procedures they can because they make a lot of money off of them, but in the university setting where everyone is paid a salary, the vascular surgeons tend to turf the procedures over to radiology because they don’t get paid extra for doing the work. Unfortunately, the IR doctor doesn’t either. I’ll have found months of it during my residency, so we’ll see what I think about it after the four months. U Maryland is not known for producing IR because all of the residents are sick of it after their residency!
Then there was the week off where ML and I went house hunting. We worked with a realtor at the suggestion of a family friend and we stayed at the brother of the sister who’s mother I lived with when I moved to
I have been on Ambulatory medicine last month, which means on Mondays and Fridays I work in the pediatric clinics. Well, maybe work isn’t the right term. I behave as though I were an M1 and I shadow the pediatric attendings as they work. It’s a little boring, but I got to wear my walking-on-sunshine shoes again and hang out with my pediatric buddies. Tuesday I went to a surgery clinic for a few hours in the afternoons and Tuesday and Thursday nights I worked in a Family Practice urgent care clinic. The latter was probably the most fun! I worked as a real doctor and saw all kinds of patients with different problems…none of them too serious. The worst day was Wednesday, but I only had two bad Wednesday. All day on Wednesday is FP clinic. The first Wednesday I just shadowed one of the senior residents and tried to learn how to use their computer system. The next Wednesday I had off to go to a Radiology conference. It was the third Wednesday that was the worst! I had the super strange attending in the morning with one of those personalities with which I just clash. Here’s an example:
I go see a patient who was listed as having facial pain. I go in and it’s a young boy, which his family, and the day before he was climbing a tree with his sister and he got a pinecone in the eye! Well, as many of you know, eyes are my kryptonite! He clearly had some debris still in his eye but it was too painful for him to keep his eye open for me to get it out.
Flashback: I was in college and just picked up my car from being painted. I’m driving down the road (
I get the full history from this young boy and family and return to the attending. I tell her I have someone to staff and proceed to tell her the story. She asked me what I could see on exam and I told her, “Oh. His eye is too painful for me to exam it.”
“Well, pain is no excuse not to exam the patient. You are a doctor now!” She said.
Trying not to tell her to go screw herself, I said, “Well, the nurse offered to get the eye-kit which I figured would have some numbing drops for his eyes. Since I’ve never used them and really don’t know what is in your ‘eye kits’ I figured you and I could exam the patient together and you could teach me how to do it.”
Then she said that I should have never been given this patient. This patient should have been given to one of the senior residents, not a rotator. (Which I agree.) Then she looked me square in the eyes and said, “Why did they give you this patient?!”
I sat there for a moment wait for the next ridiculous statement to roll off of her tongue when I realized that it was NOT a rhetorical question! I furrowed my brow in disbelief, squinted my eyes ever so slightly and cocked my head to the left and said, “The patient would put on the board under my name, I went in and saw that patient. I have no IDEA why or even HOW the patient was given to me.”
I’m happy to say that ALL of the other attendings were much more rational than this one. It was truly a test of my ability to have unspoken thoughts. Just a few short years ago, if I were confronted with such an asinine question I would have answered, “Why did they give you a Medical Degree?!” Of course it is rude to answer a question with a question so maybe a better response would have been, “Probably for the same reason they gave you a Medical Degree.” Alas, it is rude to point out when someone is being rude.
Now I’m trying to keep myself awake since I start night shift in the ER later today. That’s 6p until 6a for the next 5 shifts. AKA, back to work. To help get myself ready for it, there was a code in the radiology department last week (remember, I was on ambulatory last week, not IR) that I decided to go help with. A patient’s heart stopped during their chest X-ray…purely coincidental. We coded the patient for 40 minutes when we decided since there was no pulse or blood pressure and that we had already coded twice as long as is thought to be of benefit, we called the code and started to pack up. But, the patient started breathing again! Which does not happen unless the heart is working. We still had no pulse or blood pressure, so we asked for an ultrasound—which had to come from the ER because the ones in radiology require an appointment to be official made for them to work. How funny is that! We found that the patient’s heart was working for a little while on it’s own but then it would stop again. We coded the patient for 1.25 hours before getting the patient stable enough to go to the MICU. I went up later that day to find that he only survived 45 minutes once upstairs. Sad, but not surprising.
Is it bad to start ER on April Fools Day?
Tomorrow will be my 11th anniversary of defending my Ph.D. thesis!
I would loop the far end of the string around my thumb and make my Mini-me wave to the little kids...and adults!
The infamous "Walking on Sunshine Shoes!!" Many of the pediatric floor nurses were amazed to find out that I was married...and to a woman!
