So, the next two weeks I'll be working nights. Which means I'll be working roughly from 5 pm every night to 7 am every morning. I'll be on for the burn unit. But I'll also be making sure the patients for Neurosurgery, Vascular and Plastics don't die over night. The average for burns is about 40 patients and the other three add up to about 30-40 depending on the time of week (the lists tend to be cyclic. Emptying out at the beginning and end of the week and filling up over the weekend and mid-week).
A lot of people hate being on night float. And I get the down sides. Especially you have something resembling a life. Being nocturnal is not how people were meant to live. But if you only have to do it for a couple of weeks it's really not so bad. For starters, no 24 hour calls, a guaranteed weekend off, no rounding, a very focused amount of work. Your basic goal is just make sure no one dies. So you aren't worrying about calling consults or dealing with social work. It's straight reflex patient care.
All that being said you are all by yourself. Sure there is a senior resident you can call. But he or she is at home, asleep in bed. And it's always a judgement call. There are basically two bad outcomes and only one good one. Option one you didn't need to call. The resident can yell at you then and make fun of you for the rest of your time with them. Or you can not call when you should have. This is by first the worst thing you can do. Even if you did exactly what they would have done you shouldn't have done it without clearing it with an upper level. And you don't have to worry about a little good-natured you have to worry about loosing your residents trust in your judgement. Which is something that will spread like wild fire through all the senior residents and will make your intern year suck. Of course you can be right on the money about calling. But no one care when you do the right thing. They didn't hire you to screw up.
So, two notable things happened last night. The first was a 12 year old boy who came to us from out in the sticks some where with a second degree burn to one palm and another second degree to a shin. (Random note about burns, when a patient comes in. They have to go through an extremely painful washdown of the burned area as well as a peeling off of all the burned skin because dead tissue is just a breeding ground for bacteria) The hand was basically just one big blister which had to be popped, drained and then peeled off. The charge nurse, a a 6 foot tall bear of a man was in charge of this part of the procedure. While I held the young boys hand and tried to make him believe that the giant man leaning over the bed wasn't going to hurt him. I asked the boy to look at him. I asked him about his pets, a cocker spaniel named cocker. I asked him about his girlfriend. A girl named Cheyenne whom he "guessed was pretty." All of this was in an attempt to keep his mind off the painful procedure that was literally happening an arm's length away from him. But with one painful last tug on the blistered skin the boy snapped his head out of hands and took his first look at the newly exposed hand. "THAT'S MY MEAT, I CAN SEE IT!" he balled before just dissolving in tears. The words were hilarious but watching that boy cry was heart breaking.
Not too long after that a patient on the burn floor I had admitted over the weekend was found by his nurse out of bed, with his IV pulled out, blood all over the floor tugging on the foley catheter coming out his penis screaming about having tickets to the Braves game and having to get out of there. This patient was admitted for second degree burns to all extremities. He was also a heavy, heavy drinker and his Urine tox screen had come back positive for cocaine and marijuana. The trifecta. We knew he was going to be a pain control nightmare. His body being used to a high would need much higher doses of pain medication to relieve his significant pain, but those high doses were going to make respiratory shut down a real possibility. But our main concern was the inevitable alcohol withdrawal. We put him on some meds to try and wean him off the alcohol but it wasn't going to prevent them. And as soon as I ran into the patients room I knew that was what was happening. I immediately asked the nurse to give him some extra ativan and hoped that was the end of it for the night. But two hours later he was at it again. Thrashing against the restraints I'd ordered just in case he decided to pull out another line. I really didn't want to have to fix his penis. We gave him some more ativan but oxygen saturation started to drop and then when he woke up a bit he went crazy again, he spike a fever of 105, his heart rate was going in the 140s and 150s, he was breathing twice as fast as he needed to and wouldn't keep the face mask on so his oxygen was again dropping. At this point it was 4 am and my chief would be in in a couple hours. The charge nurse was telling me he needed to be intubated so he could ride out his withdrawal heavily sedated the respiratory therapist was telling me that if we could just calm him down enough we could manage this with a nasal tube and an albuterol treatment. I was telling myself that I had not idea what to do. I was leaning towards the intubation (for all the wrong reasons, basically it was just the easiest for me). But I knew I was going to have to wake up my chief.
When I made that call he immediately started barraging me with questions. I only knew the answers to about half. And the ones I did know I couldn't get across quite right. I swear that man thought I was a moron. He decided not to intubate, then called his chief who told him to intubate. So there I was calling anesthesia, placing orders I'd never placed before and panicking that I should have made the call earlier, I should have thought about this when I admitted him and a thousand other insecurities. Three hours later I left and now I'm sitting here typing about him and wondering how he'll be when I come back at 5 pm. How long is going to be intubated? Is he going to get pneumonia? Is he going to hate me when he comes off the vent?
I need to get some sleep now. But I know my vent patient and that little boy are going to be my last thoughts as a I fall asleep. And I'm a little worried where my subconscious my head when I'm not reining it in
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