Thursday, July 10, 2008

Bullets and Bones

Two more call nights down, both much busier than the first. The vast majority of the time was spent doing floor work, but I also got to sew several lacerations and remove a bullet from a man's chest (learning point: when removing bullets, never touch them with a metal instrument, otherwise you can mess up forensics/ballistics).

We had a lot of really tragic traumas. One was a pedestrian struck by a car who came in intubated and unresponsive. I performed the primary and secondary survey, and actually picked up all her injuries (brain injury, rib fractures, pelvic fracture, ankle fracture) on my physical exam. I went with her to the CT scan while my senior went to the OR--we did the head CT first which showed a very large bleed between her brain and her skull that was pushing much of her brain into the other side of the skull. It was large and obvious enough that I called neurosurgery immediately without needing to talk to the radiologist or my senior first. The neurosurgeon came quickly and whisked her away to the OR for a craniotomy.

That night, I went up to one of the floors to talk to a patient with pancreatitis who was very upset that we weren't allowing him to eat. He stated adamantly that he was going to go home--I let him rant for a while, acknowledged his frustration, and then talked him into staying. I have discovered that the best way to deal with people like this is to try to agree with them as much as possible, then use their own words to change their minds. Getting defensive or arguing just makes it worse.

When I left his room, a nurse came up to me and asked if I had any new orders for an appendectomy patient--problem was, we signed the discharge orders that morning, and had assumed (fatal error) that the patient had gone home. When I expressed my surprise that the patient was still here, the nurse cheerfully explained that the patient had decided she wanted to stay another night. Uh...yeah....what with hospitals not being hotels and all, patients don't actually get to decide whether or not they stay--that is a doctor's decision. Struck speechless, I went to talk to the patient. Her mother was in the room, and told me that they hadn't wanted to leave earlier in the day because the patient was dizzy, and that the nurses had told them they could stay the night and that "the doctors" would see them in the morning. The patient then walked cheerfully out of the bathroom, and told me she was feeling much better. I explained to them that I was one of "the doctors" and that she could go home. I sent them out around 11pm. I probably should have had a gentle conversation with the nurse about this, but since I didn't know the details and I'm sure there was miscommunication from someone on my team at some point that day I didn't pursue it. Bottom line was that the patient we wanted to stay stayed, and the patient we wanted to leave left.

Friday, July 04, 2008


I have finished my first call night as an intern. Fortunately, it was probably also my easiest call night as an intern. I am on trauma surgery this month--an enormous service with 3 senior residents, 5 junior residents/interns, six medical students, and several NPs. And, of course, several attendings who take turns supervising the service. As July is the prime season for the knife and gun club, our patient list is very large.

On trauma call nights, there is a senior, a junior/intern, and one or two medical students in house. This month is set up so I will always be on call with the chief resident and the same senior and junior medical students. The intern has the trauma/floor pager--his job is to respond to traumas and to manage all patients on the wards (ICU patients are on a different service). The senior student carries the consult pager and staffs consults directly with the senior. The junior medical student (backed up by the senior student) has to update the patient list, and gets to go to traumas and do odd jobs that come up.

At traumas, our team trades jobs with the ER residents every week--this week ER is captain (directs the trauma) and trauma is doc right (performs the primary and secondary surveys, essentially a rapid physical exam to pick up any life-threatening injuries). My first call night we only had one trauma, and I was doc right for the first time in my life--somewhat intimidating. The trauma actually came early in the night, so after taking care of some issues (including signing my first prescription and discharging my first patient as an MD) we all went to bed around 1:00 am. I was only paged once in the middle of the night, so ended up getting about two hours of sleep. Very unusual--most of the time trauma interns are inundated with floor calls all night. We rounded the next morning, then I found out that our chief decided that today would be considered a weekend day thus all not-on-call people would get it off! Very good news, it means that I will have at least one day off every single week of the month--I was expecting not to get a day off for the first two weeks. The only thing is that I feel a little guilty--my first week of being an intern has been exceptionally easy. Oh well, I'm sure next week will make up for it.

It is very scary getting calls about patients from the nurses. All the ones I got were simple questions, but at this point in my career I am constantly questioning all my decisions. Just giving an order to give the most innocuous medication is terrifying--I order tylenol, and then envision that patient being the one person in a million who goes into rampant liver failure from it. I got a call from a nurse about a patient who had a little bit of bloody drainage around a wound. The nurse wanted to hold the patient's anticoagulant (which we were using for prophylaxis against blood clots). I didn't think we needed to hold it, but kept envisioning the patient getting his/her dose, then suddenly having a massive hemorrhage and dying from shock. I ran it by my senior (again, the nice thing about having in house residents--I would have felt really stupid paging someone at home about this, but since I saw him every couple hours I could run a list of things by him regularly) and he confirmed my initial decision. Fortunately, we have excellent seniors--I wouldn't be afraid to call any of them with stupid questions which really is the primary responsibility of interns at this point in the year.