Monday, June 18, 2007

New record

This week I broke one of my records without even realizing it until I did some calculations this evening—I worked at the hospital 98 hours this week, shattering my previous record of 90 attained on CT surgery last year. I had to add it up several times before I believed it—100 hour work weeks are much more doable than I ever thought possible.

I have seen so many traumas this week that they have started to run together in my head. The most dramatic was a man who was brought in unconscious after a gun shot wound—we did a rapid assessment, then rushed him to the OR. We cracked his chest as he lost his pulse—I did chest compressions for about five minutes while the surgeons attempted to control his bleeding (he had lost almost two liters of blood from his chest before we got him to the OR, and was rapidly losing more). They found the artery, but it was too late and he died on the table, a sharp contrast to the man last week who lived.

The most memorable was at about 10:00pm when we got the page: “man fallen on by cow”. He was unconscious when he came to us so we weren’t able to get the full story. Amazingly all he had were a couple of cracked ribs, and he woke up the next day, and went home the next. I was able to get the story before he left: apparently a cow had bumped him and made him trip over a feeder, another cow then ran into the first and it tripped over the feeder onto the man’s chest—he is very fortunate to have escaped with such minor injuries.

One nice thing about level one trauma centers is that they tend to be very organized, and they operate on a protocol. When the patient is brought into the ER by the paramedics, he is immediately transferred to the hospital gurney, then the paramedics remove their gurney. The patient is surrounded by an number of doctors and nurses, the doctors are residents from either ER or surgery depending on the week. The captain stands at the foot of the bed and directs everyone. Doc Right stands on the right and performs the physical exam, starting with ensuring adequate breathing and pulses and then moving to less vital areas. The head doctor stands at the head and controls the airway, intubating if necessary. Doc Left (usually a medical student) stands at the left and cuts off all clothing as soon as the patient arrives to expose any hidden injuries. If the patient is rolled away from him while removing the backboard he also checks the back and does the rectal exam. Later, he draws blood from the femoral artery and places the foley catheter if necessary. The attending surgeon stands in the back of the room and makes sure no one screws up. For each doctor there is a nurse who gets vitals, obtains IV access, and performs other duties. If the patient is stable he is then taken to the CT scanner. Depending on what is wrong, he either goes back to the ER, to the ICU, or to the OR.

My last call night I saw the call rooms (room with a bed, desk, and telephone for residents/students to sleep in during down times) for the first time this rotation. Around 1:00 AM I went to bed, but unfortunately it was just a tease—ten minutes later as I was just in the transition zone between sleep and wakefulness another trauma came in. An hour later I went back to bed, and this time managed to fall asleep and stay asleep for 45 minutes before being rudely awakened by (one of the three that I carry on this rotation) pager. When I called back, it was the ER who had a man with a large perineal abscess—why he felt the need to come in at 3:00 in the morning instead of the next day I do not know, but I was pretty annoyed. I went to see him, then paged my poor intern, waking him up as well. It turned out all right though, because three minutes later we got another trauma so we would all have had to have gotten up anyway. This trauma was an assault victim. Five minutes later we got another assault victim. It turns out the first had tried to stick up a bunch of people, and had gotten beaten up for his trouble. The second was one of the people being stuck up who fought back. Fortunately we only admitted one to our service so we did not need to have police guards at both rooms to keep them apart.

Tuesday, June 12, 2007

Death's Door

Trauma surgery has rapidly become one of my favorite rotations. Despite the 14 hour days interspersed with 30 hour call days I find that I am not dying to leave by the end of the day like most rotations I've been on--I've even managed so far to successfully get out of bed at 4:30 (though historically I tend to get up progressively later as the month goes on, starting with getting to the hospital easily ten minutes early and ending with running into the workroom out of breath several minutes late). My most recent call day was Sunday/Monday and it was nuts from 7:00 AM until about 4:30 AM. The first consult I saw was in the ER, a man who had been on a riding lawn mower and made too sharp of a turn which caused the mower to rear up and flip over backwards--fortunately it did not land on him, but his thighs were covered with gasoline just before the mower burst into flames, which made him burst into flames. His inner thighs were totally burned and covered in huge yellow blisters. Fortunately for him the burns were mostly superficial, and we just dressed him with antibiotic cream, gave him fluids, then sent him home the next day with a healthy supply of narcotics. I wrote admitting orders for the first time, which ended up being quite a mess with things crossed out and sentences being continued several lines from where they started, but on the plus side my handwriting is actually legible which is more than can be said for a lot of doctors (but before anyone jumps on the doctor=bad handwriting bandwagon, a study was recently published which showed that doctors' handwriting is actually no worse than any other professions--the only group that had significantly worse than other professions' handwriting was male CEOs).

The next consult I saw was a man with a left buttock mass that had been growing for years--likely a hematoma as he has hemophilia. When I got the consult I was expecting a fair sized lump, but when I went up and saw I have no idea how he functions at home. "Massive" was how it was described by the internist in the chart and I can't think of a word that better describes it (at least that one could write in a chart--"ginormous" might not be considered quite professional). I left before I heard the plan for him, but my guess would be that they'll recommend follow-up as an outpatient (he came into the hospital for other problems).

Around 10:00 pm we had a stab wound to the right flank come in. We took him to the OR for exploration, he was fine. As we were closing him, we got a call that a gun shot wound patient was coming in. The resident and I stayed to close while the attending went down to see the new patient. They rushed him into the OR, and as soon as our first patient was closed the resident left me to see him back to post-op and went in to the GSW case. I came in a few minutes later--they opened him up, and found a lot of blood in his abdomen. They searched around for a while (the patient was literally dying on the table at this point) and finally discovered that the bullet had shattered his left iliac vein--yet had somehow missed the artery that overlies it. At this point there were four doctors surrounding him, so I couldn't see everything clearly, but it was the most intense operation I've seen yet--I wasn't very optimistic as to his survival. Amazingly (and providentially) they were able to repair the vein and I went and saw him this morning. His only complaint was that he was a little sore.

The highlight of today (though very tragic) was an 18 year old with a self-inflicted gunshot wound to the head. In the ER they stabilized him with IV fluids and intubated him, then we rushed him to the CT scanner, then rushed him to the ICU. His pressures were practically nothing, and his pulse was very high indicating hypovolemic shock secondary to bleeding out through his head; several attempts were made to place IVs, and finally they just put a central line in. This unfortunately is one of the cases where despite hours of working on him, most likely it was all in vain--he had brain tissue coming out of the bullet holes which is not a good prognostic indicator.

Wednesday, June 06, 2007

Trauma call

Yesterday/this morning was my first call day--so much better than the other two days I've had. The student on call carries the consult pager which gets all consults from the floors and from the ED, as well as all the incoming traumas and his/her primary responsibility is going to see those patients rather than going into the OR or working in clinic. I saw a bunch of consults. One was a lady consulted to us by medicine who was discovered to have a hard lump in her abdomen--it ended up being mesh from a surgery 15 years ago, and now that she's lost weight it's palpable. There was a young man with a groin abscess in the ED whom we took to the OR for drainage (there was a lot of pus!). There was a lady with breast pain and drainage in the ED (6 months after having nipple ring removed)--she had a mass but not enough to be drained, so she'll get antibiotics for a week. Another was a lady with right lower quadrant pain x 1 day in the ED--CT scan couldn't rule out appendicitis, so she was posted for diagnostic laparoscopy. However, before we could take her to the OR we had a trauma come in. A youngish man had been waterskiing and somehow got his left arm caught in the tow rope handle, fell, and was dragged by the boat by his arm pit. He went to an outside hospital, then came to us three hours later. His arm was huge and tense, and we could not find any pulses by palpation or ultrasound. CT scan showed an open artery until about halfway down his upper arm, then it disappeared. We took him to the OR (the possible appendicitis lady wasn't critical)--it was probably the bloodiest (at least initially) operation I've yet seen. As soon as the resident made the incision about 1-2 quarts of blood streamed out covering his gown and the table in blood--the patient's arm looked like a deflating balloon. When they lengthened the incision we discovered that his biceps muscle had avulsed from it's point of insertion in the upper arm, had flipped down into his forearm, and was now hanging dead from his elbow. His main artery and vein were completely transected and he had a lot of nerves hanging around though his median nerve was intact. The vascular fellow and the resident harvested the patient's saphenous vein from his leg and grafted it between the two ends of the severed artery. They removed the biceps muscle and closed. The attending had me close the subcutaneous tissue of his leg which was very neat--the first time I've ever sutured more than skin. Plastic surgery will have to take the patient to the OR this week to see if anything can be done about his nerve damage. Unfortunately, the vascular surgery attending told me the patient even now has a 50% chance of losing his arm.

We were busy until about 0330, then I had to update the list. By the time I was done it was 0400, and since everyone else was coming in at 0530 there wasn't much point in going to bed. When everyone came in (there's something very cheerful about having the rest of the team come in after only having three people doing everything all night) we rounded on patients then went to Morbidity and Mortality (residents present cases in which something bad happened to a patient and attendings grill them mercilessly and yell at each other about what could have been done differently--though today was pretty tame, they must have been tired) and Grand Rounds. I then helped get all the morning labs, and at 1000 after working for 28.5 hours straight I went home and slept for 6 hours--it is odd how without using an alarm clock I always sleep for almost exactly 6 hours after being on call.

Saturday, June 02, 2007


Family medicine ended Thursday. It was a good rotation, and also the last of my third year:). Yesterday I began my final year of medical school with my surgical sub-i, trauma surgery. Sub-internships are rotations for fourth years in which one theoretically acts as a "highly supervised intern" but without having any actual authority or order-writing ability--I say theoretically because on this particular rotation there are few and scarcely detectable differences between the duties of the sub-i and the regular third year student (both of whose jobs can be summarized succinctly in the word "scutmonkey"). So far the only difference has been that in the two days of clinic per week, the sub-i sees the patient and staffs directly with the attending, while the third year supposedly staffs first with the resident though in reality they also usually staff immediately with the attending. Another difference is that the sub-i's carry a special pager for nursing questions, though as of yet it has never been paged, no doubt because the nurses find it pointless to page someone who doesn't have the authority to act on the problem--but again, it's only been a day, so this could change.

My team consists of three interns, three senior residents, multiple nursing practitioners, three third year students, and one other sub-i besides me. And of course the group of attendings who supervise. Blurring the distinction between third year and sub-i even more is the fact that the third years are in my class and therefore have as much patient experience as I. My school's third year schedule provides one month of vacation--I was fortunate enough to have mine be June, which gave me the ability to postpone my vacation month until next year, and start 4th year early, which means I am doing the rotation with third years who had their vacation months earlier in the year and therefore are still finishing their third years and will not be fourth years until July.

Students' duties primarily consist, as I alluded to before, of scutwork (scutwork by the way for those not familiar with the term [is it used outside of medicine?] is work that is very necessary, but falls to the bottom person on the totem pole and provides absolutely no educational value or benefit whatsoever to the person performing it, and usually is something which could be done easily by a drunken chimpanzee) such as keeping the patient list updated (and there can be up to 70 or 80 patients on our team), writing down morning lab values for said patients, and writing down the final radiology reports for all trauma patients for the interns--basically the duties of a glorified (or degraded, I think I could argue it both ways) secretary except we pay them to let us do the work rather than the other way around. Fortunately, I was warned before about this, so I was somewhat prepared for this. The trade-off is that we should be able to see a lot of really neat stuff. In between scutwork yesterday I saw a urology consult--a 60 year old woman who had her bladder removed last year due to transitional cell carcinoma, and now has a urostomy bag for her urine similar to a colostomy bag. She was admitted because an outside hospital had found a large mass in her pelvis by CT scan, and one of their surgeons did an exploratory laparotomy (incision) and found stool in her peritoneal cavity (bad sign as it should be confined to the colon)--a biopsy found recurrent cancer (very, very bad prognosis unfortunately). However, now she has stool literally oozing from her incisional wound. She will need a study to make sure that only her colon is perforated, and if so, she will need a colostomy. After I saw her, the resident and attending apparently re-opened her incision, drained more than a liter of stool, and packed the wound (at this point I was back to scutwork:).

Tuesday will be my first call night (fortunately since we have five students we will be on call only every fifth night instead of ever second or third as has occasionally happened in the past and we get weekends off unless we are on call which means I get two golden weekends which is two more than I had anticipated--unfortunately my last call night is June 30th which means I won't leave until the morning of July 1st), it should be exciting.