Back on trauma surgery

The only place where your patient's boyfriend is arrested in the hospital for assaulting your patient over a potato chip--and the only reason your patient is not also arrested is because the police couldn't deal with the four inches of undulating bowel protruding from her abdomen pouring out stool.

Kudos

This morning we had a ninety year old woman who had newly diagnosed breast cancer. Rather than going through the risk of general anesthesia, we performed a lumpectomy under local anesthesia while she was wide awake, not getting so much as a drop of ativan. Immediately after, she went to the pharmacy to pick up some painkillers, then drove herself home (waiting until she got there to take anything, since one can't drive if taking narcotics). She didn't have anyone with her because she didn't tell her son and daughter she was having the surgery until last night so that they wouldn't be able to miss work for her. She takes care of her demented husband at home, so had to be back quickly.

Last night, one of my post-op patients, rather than waiting 5 minutes for the nurse to page me for more pain medication, called a rapid response from her room. What she thought it would accomplish I don't know, since it's composed of nurses who can't give narcotics without an order anyway. Then she called the operator and tried to bully her into calling my attending at home. Quite a contrast.

Back

This month I'm again at one of the local community hospitals. While in a lot of ways more relaxing than the academic hospital, we only have two residents this month so we've been pretty busy. I started out on Sunday, thinking that I could round early, take care of a couple minor issues, then go to church for the first time in a month (we take home call there, so don't have to stay in the hospital if nothing's going on--we just come back if there's a new patient or one of the current patients crashes). That dream ended when I was paged at 5:30 AM by the intern who had been on call Saturday night, to let me know that one of the patients had to be transferred to the ICU overnight, and was doing very poorly. Additionally, a nurse just called him to let him know that one of the vascular surgery patients had a cold and pulseless foot (which, if true, would be a surgical emergency).

So, hopes of a quiet Sunday crashing, I went in to the hospital, stopping at security to get my ID badge and keys, that should have been left there Friday. Only none of the three security guards could find them. I got them to give me a student ID though, so I had access everywhere. I then proceeded to the ICU, first stopping to see the "cold, pulseless foot". It was actually quite warm, and I could palpate a posterior tibialis pulse though not a dorsalis pedis. I looked through his chart, and there was no mention of anyone ever being able to palpate a dorsalis pedis, so I was not terribly worried. I went to see the next patient, and found that she had been made DNR/DNI (no resuscitation or intubation if she crashed) by her family. She barely had a measurable blood pressure despite being on a high dose of vasopressors, was completely unarousable, and had dilated, nonreactive pupils. There wasn't really anything to do, but I called my senior to let her know what was going on. Then I called the family, and confirmed she was really DNR/DNI. They eventually chose to pursue only comfort care, so we stopped the vasopressors and she died within 20 minutes. It was the first time that I had to pronounce someone dead and call the family--fortunately they knew she was doing poorly, so it wasn't a shock. In between dealing with these issues, I was also trying to round on all the floor patients whom I had never met before--thankfully there weren't too many of them.

Once that was done with, we ended up having one OR case that had been added on, a pilonidal cyst excision. I got to do the procedure, which was nice. By that time it was 3:00, and I went home. Nothing else happened, so I slept most of the night.

I do have to give a little note about pager etiquette--when you page someone, you are essentially asking that person to stop whatever he or she is doing and call you back. To be courteous, you need to be at the telephone when that person does call back, and you need to wait by the telephone for a minimum of 5 minutes, in case they're doing something else and can't get to a phone. After 5 minutes, you can leave and let the clerk call you back when the person calls back. It is completely unacceptable, and actually very rude to page someone then leave the phone. I mention this, because there is one particular hospital we rotate through that every single nurse does this every time, so that when I call back seconds after being paged, I am then put on hold for five minutes waiting for her to finish whatever task she has left to go do and actually come back to the phone. It is incredibly infuriating, and essentially is telling whoever you paged that your time is worth more than theirs. Now I wait on hold for a maximum of one minute then call the secretary back and tell her to tell the nurse to re-page me when she has time to talk. It's gotten me a couple of apologies, but they continue to page and leave the phone. This doesn't happen at any other hospital I've been to, so it shouldn't be asking too much. All right, end of rant.

Kids

I just finished a month of vascular surgery. I saw and smelled more foot ulcers than I ever cared to see or smell, and amputated more limbs than I cared to amputate. People, if you have diabetes, please, please take your medications. And if you have neuropathies that have taken away the sensation in your feet, you MUST check your feet EVERY day. If you smoke, stop. There are few sadder sights than a 50 year old man with both legs missing sitting in a wheelchair puffing away, especially when you realize that he'll be dead from heart disease within five years.

I'm on pediatric surgery this month--it's been quite interesting, though taking care of kids is not my cup of tea. It's by far the busiest rotation at my program, I'm on in-house call every second or third night. It is a great rotation though, with a lot of OR time. The attendings are great too. They have two fellows, and in order to give the senior fellow more operative time, they only make him take in house call about twice a month. To do this, the attendings themselves actually take in house call in his place a couple times a month. A bit intimidating for the junior resident, if as happened to me, he or she ends up on call with the chairman of the program instead of a senior resident, but I think it says a lot about their dedication to the fellows' education.

Most of the cases I've been in are pretty straightforward, lots of abscesses, appendicitis, and pyloric stenosis, but we also get all the rare cases as well, biliary atresia, gastroschisis, etc. The worst case I've seen was a trauma that came in last week--a one year old boy who came in without a pulse. He had been beaten by his aunt that evening. He didn't have any external marks, but you could tell the second he rolled in the door he wasn't going to live. We did the whole resuscitation anyway, and got his pulse back for a while, but when I shined a light in his eyes his pupils were completely blown and did not respond at all. The CT scan showed what we all knew, a huge hemorrhage in his brain. He went to the ICU and died a few hours later. What makes it worse is that the police brought his two year old sister in a few hours later after taking the aunt into custody. She had burn marks and sores all over her body, including circumferential wounds around her ankles and wrists consistent with having been tied down for a long time, and an old scar encircling her neck. We did xrays of her entire body and found several fractures that had already started healing in malalignment. She's doing well now, but still starts uncontrollably shaking every once in a while. Her aunt was her foster parent since her biological mother is mentally incompetent, even though she (the aunt) was a known child abuser. Yet the state still allowed her to keep the children. And now one of them is dead. The extended family has been in the little girl's room, and acts very concerned and worried. I've been polite to them, but not especially empathetic, because frankly I don't think any of them should even be allowed to enter the hospital.

Hmmm

Scene: Me, sitting in front of patient's room in the ICU, vigorously writing admission orders and an H&P. Middle-aged nurse sitting a couple feet from me, looking over a chart.

Me (to the nurse): Excuse me, do we have a temperature on this guy?

Nurse (looking up at me with an irritated expression): (sarcastically) No, I haven't gotten one yet since I'm kind of busy admitting the patient.

Me: A'ight (medical abbreviation of all right), carry on.

Nurse (a minute later, looking at the telemetry machine): (growling angrily) He's having PVCs (premature heart beats, often caused by electrolyte imbalances)!!! I want labs!!!!!!!! Who's going to get me labs!!!!!

(Nurse stands up and stomps furiously into room, I follow)

Me: (politely) Excuse me?

Nurse: (angrily) I need labs, what labs??!!!

Me: Actually, we already know that his potassium is low. I just wrote an order for some potassium supplementation.

(Nurse angrily turns around, looks at me, opens her mouth with a snippy comment on the tip of her tongue. Suddenly she halts, and her eyes grow big).

Nurse: (pleasantly and apologetically) Oh I'm so sorry, I thought you were a medical student! Oh, I feel so bad for talking to you like that. Let me start over, I'm Laura (extends her hand). Now doctor, would you like me to give 20 or 40 milliequivalents of potassium? Oh, I'm so sorry for being so rude. I didn't notice you were wearing a long white coat!

Me: It's all right, no problem.

Medical student standing behind me with mouth hanging open: Silence

So apparently treating me like garbage would have been OK six months ago, but is unacceptable now.

Getting things done...not always easy

It's been an interesting couple of weeks. Although I'm actually working the same number of hours this month as I did on trauma, I feel much more relaxed. We have been averaging 3 or 4 patients at any given time, so I have just been rounding on 1 or 2 in the morning, then going home around 3 or 4 unless I'm on call. So far nothing terrible has happened on call.

My attending for the first two weeks is very hyperactive and gets bored very easily. He also has a very direct attitude. I actually really like him, he teaches and makes rounds incredibly entertaining. The anesthesia residents, used to lower-key attendings didn't like him at first but are now coming around. The nurses want to kill him, which has made things somewhat awkward. ICU nurses, at least the ones here, are generally very good. They only take care of one or two patients at a time, so they know their patients well. They are used to taking care of very sick patients, so there isn't much that can phase them. The problem is that their comfort levels are often so high that they think they know how to take care of the patient better than anyone else, and they do all they can to get their way. Whenever one of us (residents) gives an order they disagree with, we have to come by every twenty minutes to make sure that it actually gets done, and that they don't "forget" or get "too busy" to do it. There have been several times I've asked them to do something one way, and a couple hours later I'll come back to find that they've done it the way they jolly well pleased. This makes me very irritated--I really respect ICU nurses, and they often know how things work in the ICU better than I do--if they suggest a plan different than mine, more than likely I'll defer. But doing the opposite of what I say without telling me is unacceptable (and technically illegal). There have been a couple occasions when they didn't like what one of the senior residents said, so the paged the fellow over her head, and lied about not having been able to get a hold of the resident. They are usually better when attendings give orders--the problem is, as previously mentioned, they hate my attending with a passion because he actually insists that things be done the way he orders. So their solution is to call the surgeons with questions rather than the ICU team. This leads to the surgeons' ordering things without our knowledge, which leads to bad patient care from a too many cooks in the kitchen standpoint. It has altogether been very frustrating, and puts me far too often in the position of choosing between being undermined by someone who legally and ethically must follow my order, or making an issue of it and becoming hated by the entire ward and subject to all their passive-aggressive maneuvers. So far I've let things slide. I'm not sure how much longer I'll be able to take it. Many of the older nurses don't bother with the passive-aggressive behavior, they just flat out tell us they won't do something (this is actually why they hate my attending--they've told him that a couple times and he's made them do it). I'm just getting so tired of the squinty-eyed-that's-stupid-I'm-not-going-to-say-anything-but-as-soon-as-he-leaves-I'm-doing-it-my-way facial expressions. I think I find it particularly frustrating because I have always made such an effort to treat nurses like colleagues (and despite how this post sounds, I am actually on very good terms with the nurses in the ICU--which in some ways makes it harder).

ICU

I just finished trauma. I am now beginning an ICU month at the local VA hospital. I had my first call night on Friday--it wasn't nearly as bad as I was afraid it would be. All our patients were stable and I was able to deal with all the issues that arose without having to page anyone higher up.

This month is particularly intimidating for me as 1) these patients are much sicker than any patients I have dealt with before and 2) when I am on call I am the only surgery resident in house (as opposed to last month when I had a chief in the hospital with me whom I would run things by ever couple hours) which means I have to page the fellow at home if I have a question about something. On the positive side our patient census is very low (I only had three patients to worry about).

Another negative thing about this month is that it is at the VA. While I think the VA here does provide good patient care, it is, to put it delicately, a "no-frills" kind of place. For example: my main hospital has a couple decent cafeterias, one of which is open 24 hours a day. When I don't get a chance to eat until 10pm, I can still go down and get a hot meal. The VA has a cafeteria that is abysmal (yet more expensive than my main hospital's), and that closes around 4:30pm. On surgery, one doesn't eat dinner by 4:30pm. There is nowhere else to get food. You can see my dilemma. Fortunately, on Friday there was another resident who had to stay late, so I was able to drive to McDonalds and get dinner there. This will not always be an option. Continuing on the "no-frills" theme, the whole hospital just has this atmosphere that is impossible to describe. Getting logistical things done takes 3-4 unneccessary steps (it took me hours to get my computer access straightened out despite the fact that they gave me a login just over a month ago--and getting meal tickets for call nights [that I may theoretically be able to use some day] was almost impossible). All the employees from clerks to nurses have a "this is the way we do things around here and nothing short of a presidential order no matter how logical or efficient your request will make me deviate from protocol in the slightest" attitude which can really get annoying. That all being said, I'm going to learn a lot this month, which makes it worth it.