Hurricane Jill

Schadenfreude

It’s been a fun couple of days in the ER. Exhausting, but definitely interesting. Yesterday we had a guy come in with an extremely large and deep neck laceration that miraculously missed every major nerve and vessel. So the task of sewing it up fell to me, the intern.

It was not a simple task. The laceration was Y-shaped and ran at a 30 degree or so angle to the plane of the overlying skin, with a dog ear at one end. Last July I wouldn’t have had a clue how to approach the problem, but now it seems easy. That’s what three months of plastics will do for you. The scar won’t be as pretty as I could have made it–he’s a guy, and he wanted bragging rights for the most stitches among his buddies. So I obliged, and closed it with closely spaced interrupted sutures instead of the running subq I’d have done otherwise.

We’d had a patient the previous evening who’d taken a pretty bad beating to the head, and had a multitude of 1-2cm lacerations across his occiput that were bleeding profusely, along with some facial fractures. Not coincidentally, he was also drunk and high on a number of illicit substances. He’d been talking on and on to me about how he was a God-fearing man, and had lost his woman, and loved her so much and wanted her back, etc. etc. All the while I was injecting lidocaine in his scalp in order to irrigate his wounds and staple them up, which was taking some time because they were all under his C-collar and he wasn’t really cooperating. But then the craniofacial intern came down to see him. For some reason, the patient took an instant dislike to said intern, and stood up on the bed, pulled off his IV and started cursing at all of us. For a moment, the patient and I made eye contact, and I thought for sure he was going to launch himself off the bed at me. So I very slowly backed up a few steps and walked behind the curtain. And like an infant with no sense of object permanence, he forgot I existed, instead launching himself out the door of Resus 1 and toward the back desk of the ER.

He was tackled by security, and eventually sedated and restrained, and the other intern and I continued with our respective tasks. It’s so much easier to irrigate and staple lacerations when the patient is snowed. If he hadn’t gone nuts on us, I’m not sure I could have done it.

Then today I put in a chest tube on my own, with correct placement and without complications. And then I did my first femoral arterial stick for a trauma code, and got it on the first try. And all shift I was getting lines and blood draws when other people couldn’t. In fact, we had a patient with exactly the same invisible roly-poly little veins as my 2nd year classmate/blood draw victim, and I got a line on my first try. Now that’s a milestone.

Now if I could just get an opportunity to put in a central line…

Hema-tomato

Alright, I’m still alive. If a bit loopy. My head still hurts, but after some Tylenol it was much better. In retrospect, we probably should have scanned my head. I take two different drugs that affect platelet function. Neither of them are common enough to send up an immediate red flag in most surgeons, so I don’t fault anyone for not picking up on it, but I knew better. In any event, no harm done.

And I have one more thing to say about the whole being a trauma patient thing: that backboard? Not uncomfortable at all. Seriously, my empathy is gone. Unless you actually broke something, in which case I still feel for you.

As for my minimally injured self, I’m now more worried about my knee, which has developed a pretty impressive hematoma. It’s actually a distinct pool of blood in the subcutaneous tissue. I know that has a different name, but I can’t remember it. I’ve gotten one before, and it took weeks to resolve. Although that one wasn’t over a joint, so there wasn’t the ongoing trauma that’s happening everytime I bend my knee now. It’s very uncomfortable. Although not painful, and the knee itself works just fine.

Fortunately this occurred on the last of my four shifts in a row, so I have a couple of days off to recover.

Hardheaded

I guess I’m not quite as much of an old lady as I thought. I had my own little GLF today (that’s ground level fall, for you non-medical types) in the ER. I tripped over a cord that was suspended about 5 inches above the ground between a patient bed and the wall. I had nothing to grab and catch my balance, so down I went. I hit my forehead, the side of my nose and my left cheek right on the zygomatic arch. Given the number of years I took prednisone, I ought to have broken something. But no, all I had was a piddling 1cm laceration in the middle of my forehead. It bled profusely enough to freak everyone out, but turned out to be very superficial.

If I had been a real old lady, I would have had some significant facial fractures, and possibly a subdural hematoma. I guess I could still have the latter, but it’s probably just a concussion. We didn’t CT my head, so who knows? But there was no loss of consciousness, and I remember the fall in detail, so anything worse than a concussion is very unlikely.

Strictly speaking, the laceration didn’t even need sutures. We could have dermabonded it, and it would have been fine. But I’m just vain enough to want the smallest scar possible, and dermabond wouldn’t have approximated it as well. So our trauma doc, who also happens to be a plastic surgery resident, put in a couple of tiny sutures, and I got a nifty Bugs Bunny bandaid on top. I figured the sutures would be a lesson in empathy for my patients.

Nothing could be further from the truth.

Seriously. I warn people about the burning sensation with lidocaine infiltration, and still they yell and curse because it “hurts so bad.” Please, people, get a grip. It’s not that bad. Also, it doesn’t take 5 minutes to work. I was numb within the amount of time it took her to open the suture tray and put sterile gloves on. Also, if you just drip lidocaine on intact skin, that’s pretty much enough to numb the epidermis. Granted, it was a tiny and superficial laceration. But still. People who think it hurts have clearly never experienced any real pain.

Afterward, I finished up my paperwork and was sent home. Now I’m just trying to stay awake so that I’ll hear the phone when it rings. I’ve assigned some people to call me throughout the morning to make sure I’m not dead or comatose from an epidural bleed. It’s a little dramatic, but, doctor’s orders. Although I’d probably know already if one were present. And a mid-forehead bonk doesn’t seem a likely mechanism to me.

As with most things, either it is or it isn’t going to happen. But ouch, my head sure does ache. I guess that’s what I get for having such a hard head.

Are the other interns not operating AT ALL?

Yesterday the case numbers for the intern class were sent out to all of us. I was surprised to see that I actually have more cases than just about any other non-categorical intern. I’m actually on par with most of the categoricals.

I find that very hard to believe. From my perspective, it seems like I hardly operate at all. It’s got to be that the other interns just aren’t entering all their cases.

Seriously, I’ve done most of the rotations where the intern gets operative time: burns, plastics, and formerly, trauma (not so much now that they’ve reconfigured the intern assignments). And I know that a number of my fellow interns have done those rotations as well. Since that time I’ve done anywhere from 2 to 10 cases per rotation–significantly less than I hear other interns are doing on the rotations in question. Yet their case numbers are one-half to one-third of mine.

It’s true that I am very meticulous about recording my cases. More so, I’m sure, than most interns. I’ve recorded nearly all my cases since the beginning of my core surgery rotation in medical school (however, only my cases as an intern are logged in the database). So it’s pretty much second nature to collect an ID label for every patient I operate or assist on. And probably the prelims for other specialties are tracking their cases in specialty-specific databases. But I have more cases than all but one of the undesignated prelims, and by a long shot. And they should definitely be recording their cases in the same database as me.

This can’t be right.

Out of season

I finally feel human again after yesterday’s ER shift. The previous night’s crew started getting hammered with traumas at about 4am, and when we came in at 7am, every bed was full on the trauma side. Five patients whose charts contained only their story and an incomplete physical exam were signed out to me by the prior night’s intern (who is a friend of mine, so I told him I’d do his neuro exams if he’d do the ABIs. Except then I had to teach him how to do ABIs, so it didn’t actually save me any time. But no big deal.)

This wouldn’t have been any kind of problem, except that the traumas kept coming, and coming, and coming. We would only just be done with the primary survey and maybe trauma films when the next trauma would roll in and overhead we’d hear the dreaded words “Trauma doc! New patient in Resus 2.” At one point it got so ridiculous I just starting laughing hysterically (and inappropriately) whenever I heard it. By noon the whole team had this dazed, punch-drunk look on their faces. It finally slowed down at about 2pm that afternoon.

But it didn’t really end. Instead, it transformed into a steady stream of garden-variety trauma punctuated every hour or two by major, attending-level, multi-line-and-tube, open chest, headed to the OR ASAP injuries.

Amazingly, none of them died in the ER. Possibly one was brain dead before arrival, but no one left the ER without a pulse on our watch. And I got to put in a chest tube, hooray! But then they opened the chest, which kind of defeats the purpose of a chest tube. Oh well. I’d never seen an ER thoracotomy before, and yesterday I saw two. One was even a clamshell (a bilateral thoracotomy, which basically lifts the entire chest wall up off the heart and lungs). It was funny, because we’d just been talking about that earlier in the day.

I guess, after watching all of that, I can see how general surgery would appeal to people. The gen surg chiefs and fellows and attending basically swooped in and got the patient’s heart working again, and whooshed him off to the OR in heroic fashion.

But I’m sure that every field has cool and exciting things about it. And if you consider only that, there are a number of fields that look interesting and rewarding. But I think you really have to like the mundane stuff as well, because that’s at least 95% of the job. And that’s where neurosurgery wins the game, for me. Operating is fun, at some level, regardless of the body part. But it’s all the other stuff that makes the difference.

Anyway, it took me until 4pm just to dig myself out from under the charts that had been signed out to me that morning. But then my own charts were much easier to finish, and surprisingly, the major trauma chart was easiest of all. It was just a chronology of events and exam findings, and since the patient was only in the ER for half an hour, and I was at the bedside the entire time, it was easy to document what happened, when and why.

But I was totally wiped out when I got home.

Rumble in the fishbowl

If you’ve ever worked in an ER, you’ve probably noticed how each day seems to have its own theme with regard to the presenting complaints. For example, last Sunday’s theme was kid trauma, and particularly kids falling out of windows.

Sometimes you know going in what the theme of the day will be. On the 4th of July, it’s obviously going to be firework injuries. On New Year’s Eve, MVCs involving drunk drivers. But for most days, it’s the proverbial box of chocolates. You don’t really know the theme until late in the day when someone finally says, “good lord! what is it with all the {insert diagnosis} today?!”

So today was head bleed day in the ER. Both the medicine and the trauma sides had more than the usual share of them. Unfortunately for the neurosurgery service, they get consulted no matter which side the bleed gets triaged to. The poor neurosurg resident on call was running around like crazy trying to keep up with all of them.

On the trauma side, though, the work was steady and not overwhelming. At one point in the afternoon, we were all sitting around doing nothing, and for some reason started talking about hyponatremia. Actually there was a reason–one of the head bleeds on our side was also hyponatremic. So at first it was serious, but then it rapidly degenerated into a mockery of medicine rounds, with each surgery resident trying to sound more intellectual and pedantic than the next. Of course, the medicine people were standing right there in the fishbowl with us, and started mocking us in return for all the dumb surgical clearance consults we send to them. It was all in fun, though, so hopefully nobody was offended.

I actually really like ERs that are set up like ours is. There’s a surgical side and a medical side, and patients are triaged to one or the other. Although here the surgical side is all trauma and emergent operative problems, while subacute but potentially surgical disease goes either to fast track or to medicine, with the appropriate surgical service merely consulted. So the experience we get from having to staff our side is a really valuable part of our training.

Interestingly, the attendings who serve as trauma doc when the R2’s are off, are all internal medicine-trained. It’s really odd, but it seems to work.

Laparoscopic brain surgery? I don’t think so.

Extremely slow day in the ER. Thank God. Yesterday was busy enough for two days. In fact, I think I’ve developed biceps. And perhaps lost a pound or two. Although I could be imagining either of those things.

I have vacation coming up, and I’m trying to decide where to go. Maybe Mexico. Definitely someplace warm and sunny. The problem is, I spent a large portion of my savings interviewing for PGY2 spots, and I don’t know if I can afford to go anywhere.

Wednesday a bunch of the interns, including me, have a training session on how to do a laparoscopic cholecystectomy. Now I ask you, my 3 or 4 faithful readers, when would I ever have occasion to actually do a lap chole? Would it not be a far better use of my time to attend neurosurgery grand rounds that morning instead? Not that I would mind playing around with the laparoscopic instruments on any other day, and I did beat all those general surgery gunners at one station of the laparoscopic skills competition on my surgery rotation in medical school (in fact, none of the winners were actually going into general surgery, if I recall correctly). But it bugs me that I’m required to learn how to do this operation at a time when I could be elsewhere, learning something I actually need to know.

This feels like work

Now I really know why they call it the Zoo. Oh my god, that ER is crazy. And yet I still haven’t seen it anywhere near the worst it gets.

I went to a school where we didn’t have to draw blood or place Foleys or insert IVs. I have placed a few Foleys, and art lines, and done bits and pieces of chest tube insertions. But aside from my mandatory blood drawing lesson back in 2nd year of med school (where I had the misfortune of trying to stick a classmate with tiny little roly-poly veins and a generous amount of subcutaneous fat, meanwhile she got to stick me with my supersize antecubital and thin skin), I’ve never actually had to place an IV or draw any labs. So I’ve learned a whole bunch of new skills in the last few days. And my arms are sore from rolling patients to check their backs.

It’s pretty fun, despite that. Although I’m glad I only have one month of it–I think it would get old after a while. I seem to spend most of my time trying to keep track of data, rather than diagnosing or treating anything, and trying not to let any of my patients languish too long without making any progress either upstairs or out the door. So far I’ve been able to keep up with my trauma sheets, and not get too far behind with writing down all the exam results. A few months ago, one of my fellow interns got stuck in the ER two whole hours after his shift ended, because he hadn’t kept up with his charting.

My goal is to be out the door by 7:15 at the latest.

The weird thing is, traumas here are handled completely differently than they were at the hospital where I did my trauma surgery rotation. Or maybe the med students there just weren’t as involved as they are here. Here they basically do what the interns do, the only difference is they have to have their charts and any medication orders cosigned. From a student perspective, it’s a much better experience.

So it’s been interesting and fun so far. But not a substitute for neurosurgery.