I'm on vascular surgery this month which brings with it a whole new patient set. These patients aren't adorable kids like in the world of peds surg and they aren't misfortunate like the burn patients. Well, sometimes the burn patients are a little stupid. I mean, really what kind of person burns trash with gasoline? Gasoline doesn't burn, it explodes. But, I digress. The vascular patients are a whole new breed.
For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.
Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.
And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.
I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.
Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.
So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.
There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.
And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?
It takes a toll on you.
As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.
I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.
10/10/10
10/3/10
It's not a pager, it's a leash.
My last few posts have been kind off depressing. I don't want all of you out there (you know, the 2 people that read this thing) to think that my job is just one depressing event to the next. And, I don't want to dwell on just the sad stuff either. I see older residents who are angry and bitter because they can't get past the sad. When something good happens they can't enjoy it because they are so jaded. I don't want to become that kind of doctor and I don't want you all thinking that that's the way it is either.
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
9/27/10
Time of death
I watch a lot of movies and a lot of television. One of my favorite shows is M*A*S*H. I can't remember when I started watching M*A*S*H. It must have been on Nick at Nite. But, I eventually bought the box set and I've watched every episode a dozen times. I can quote it, I can give the blow-by-blow of most episodes. But, there are some episodes that stick with me more than others. One in particular is a Christmas episode where an injured soldier is flown into the unit during a party on Christmas Day. Colonel Potter, BJ, Hawkeye and Hot Lips keep everyone else in the dark while they try and save this man. Eventually they realize that he can't be saved and they instead settle for keeping him alive just long enough so that his kids don't find out that their father died on Christmas. Unfortunately the soldier dies just before midnight. They bluff the death certificate anyways. It's a good episode. One of many good episodes. But, like I said it always stuck with me.
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
9/20/10
Proud owner of a used heart
On occasion my chiefs will tell us lowly interns about what it was like when they were first years. Sometimes it will be just to tell us how easy we have it, or how they were better than us. But every now and then you'll get a little nugget of truth out of one of them. A few weeks ago one of my chiefs told us how he used to go home and curl up in the fetal position while listening to Megadeath. He said it soothed him.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
9/16/10
2 year olds shouldn't die.
It was one of those days where things are amazing and awful all at the same time. Today I took a kid who twenty years ago would have spent his life pooing into a bag and created a brand new rectum for him. He won't even remember this first year of his life when his non-functioning rectum meant that he was dependent on an ostomy. And that was amazing.
Imagine if this kid had grown up with an ostomy. We all know how cruel kids can be. The nicknames would have been awful, and would have haunted him in everything he did. I mean, who would go to prom with the kid that everyone calls "shitbag?" It's nice to think that it would have made him a stronger person, a better person. But that's more often the exception than the rule. Fortunately we don't have to wonder about any of that because we took the ostomy and reconnected it to a newly created, functioning rectum. I can honestly say that I helped make this kids life better.
Unfortunately there is a 2 year old girl lying in our PICU for whom I can not say that. She was ejected from her car seat in a motor vehicle collision and suffered multiple skull and head fractures, she was bleeding into her brain and she was taken to the nearest hospital. A rural hospital. They did CTs of her head and body and intubated her. Then they kept her there for EIGHT hours before sending her to us. Who are we? We are the only level 1 pediatric trauma center in the state. We are where she should have been sent the SECOND she was stable. We should have been notified of her the second she rolled into their emergency department. We would have had her on a chopper and in our trauma bay in an hour.
Instead she was transported to us by ground and that delayed her definitive care by another 3 hours. Do you know what happens when a 2 year old bleeds into their brain for 11 hours? They stop clotting. They start oozing from orifice. Their core temperature drops. They become hypotensive and tachycardic. They become unresponsive. Their pupils dilate. They lose their basic brainstem reflexes. They die. That's what happens. And we all stand there incapable of saving her. All of us, interns, residents, attendings, nurses we try to put in lines and get her blood products and warm her up, and raise her blood pressure and slow her heart rate. We call in ENT, Neurosurgery, Optho because we know our limitations. The pediatric surgery and pediatric critical care attendings do all the procedures because she isn't someone that can afford a resident mistake.
This isn't a learning experience for us. This is a desperate attempt to save someone who can't be saved. Because the thought that this little girl is going to die no matter what we do isn't something any of us can bear to entertain. So the attendings pull out all the stops because at some point they know they are going to have face her parents. And when they do they are going to have to look them in the eye and say "we did all we could."
But none of that is going to change the end result. Right now that little girl is lying in a PICU bed. She is intubated, sedated, paralyzed and receiving enough blood products, fluids and medications to keep her heart beating. But, neurosurgery already told us what none of us want to face. She is brain dead. We're keeping her body alive even though what made her who she was is gone. Someone will talk to her family about her donor status. And maybe some part of her will go to another little girl. Maybe that's a silver lining. But it doesn't change the fact that 2 year olds shouldn't die.
Imagine if this kid had grown up with an ostomy. We all know how cruel kids can be. The nicknames would have been awful, and would have haunted him in everything he did. I mean, who would go to prom with the kid that everyone calls "shitbag?" It's nice to think that it would have made him a stronger person, a better person. But that's more often the exception than the rule. Fortunately we don't have to wonder about any of that because we took the ostomy and reconnected it to a newly created, functioning rectum. I can honestly say that I helped make this kids life better.
Unfortunately there is a 2 year old girl lying in our PICU for whom I can not say that. She was ejected from her car seat in a motor vehicle collision and suffered multiple skull and head fractures, she was bleeding into her brain and she was taken to the nearest hospital. A rural hospital. They did CTs of her head and body and intubated her. Then they kept her there for EIGHT hours before sending her to us. Who are we? We are the only level 1 pediatric trauma center in the state. We are where she should have been sent the SECOND she was stable. We should have been notified of her the second she rolled into their emergency department. We would have had her on a chopper and in our trauma bay in an hour.
Instead she was transported to us by ground and that delayed her definitive care by another 3 hours. Do you know what happens when a 2 year old bleeds into their brain for 11 hours? They stop clotting. They start oozing from orifice. Their core temperature drops. They become hypotensive and tachycardic. They become unresponsive. Their pupils dilate. They lose their basic brainstem reflexes. They die. That's what happens. And we all stand there incapable of saving her. All of us, interns, residents, attendings, nurses we try to put in lines and get her blood products and warm her up, and raise her blood pressure and slow her heart rate. We call in ENT, Neurosurgery, Optho because we know our limitations. The pediatric surgery and pediatric critical care attendings do all the procedures because she isn't someone that can afford a resident mistake.
This isn't a learning experience for us. This is a desperate attempt to save someone who can't be saved. Because the thought that this little girl is going to die no matter what we do isn't something any of us can bear to entertain. So the attendings pull out all the stops because at some point they know they are going to have face her parents. And when they do they are going to have to look them in the eye and say "we did all we could."
But none of that is going to change the end result. Right now that little girl is lying in a PICU bed. She is intubated, sedated, paralyzed and receiving enough blood products, fluids and medications to keep her heart beating. But, neurosurgery already told us what none of us want to face. She is brain dead. We're keeping her body alive even though what made her who she was is gone. Someone will talk to her family about her donor status. And maybe some part of her will go to another little girl. Maybe that's a silver lining. But it doesn't change the fact that 2 year olds shouldn't die.
9/15/10
Blerg
I am very, very tired. I worked for 31 hours. I've been up for about 33. It is so bed time but I just had to drop a couple lines about the events of last night.
So, last night I managed a couple of patients without any hand holding. I made decisions and then called and told my fellow or chief. The sky didn't fall. I didn't do things perfectly or with very much finesse but everyone came out alive and not much worse for the wear. That being said I totally had a break down crying moment this morning. Granted, I'd hit that wall that you always hit when you've been up for too long.
I needed a Chest X-ray on a patient whose chest tube we were planning on pulling that afternoon after we'd water-sealed it the night before (basically taking it off suction). I'd might a slight error in the order. I'd written post-pulling eval instead of pre-pulling. Well, the nurse took it upon herself to cancel the order instead of calling clarifying. So, 9 am rolls around and no CXR. My team is pissed.
So, now I order a stat Chest X-ray, which should happen within 30 minutes. It takes 2 hours. Now, I'm pissed. And somewhere in all that I cray in two different supply closets and the work room with my co-intern (he's going into Ortho) sitting beside me made very uncomfortable by this display of womenly emotion.
Also, that was not an easy call. I was never really completely on top of what I needed to handle. So I had this residual I'm not quite competent enough feeling. Added to my frustrations in managing my sick patients not quite perfectly. And then not being able to get a damn chest x-ray done. I was a ticking time bomb.
Okay, my bed calls. I'll sleep till 4 and then wake up so I can actually get a decent nights sleep tonight. before being back at work at 5 am.
So, last night I managed a couple of patients without any hand holding. I made decisions and then called and told my fellow or chief. The sky didn't fall. I didn't do things perfectly or with very much finesse but everyone came out alive and not much worse for the wear. That being said I totally had a break down crying moment this morning. Granted, I'd hit that wall that you always hit when you've been up for too long.
I needed a Chest X-ray on a patient whose chest tube we were planning on pulling that afternoon after we'd water-sealed it the night before (basically taking it off suction). I'd might a slight error in the order. I'd written post-pulling eval instead of pre-pulling. Well, the nurse took it upon herself to cancel the order instead of calling clarifying. So, 9 am rolls around and no CXR. My team is pissed.
So, now I order a stat Chest X-ray, which should happen within 30 minutes. It takes 2 hours. Now, I'm pissed. And somewhere in all that I cray in two different supply closets and the work room with my co-intern (he's going into Ortho) sitting beside me made very uncomfortable by this display of womenly emotion.
Also, that was not an easy call. I was never really completely on top of what I needed to handle. So I had this residual I'm not quite competent enough feeling. Added to my frustrations in managing my sick patients not quite perfectly. And then not being able to get a damn chest x-ray done. I was a ticking time bomb.
Okay, my bed calls. I'll sleep till 4 and then wake up so I can actually get a decent nights sleep tonight. before being back at work at 5 am.
9/9/10
You can't practice on the patient
So, yesterday was kinda shitty in the OR. Back in December/January I was in the OR all the time as a 4th med student. I got to throw in a couple sutures at the end of a case, suction a little bit, even make a couple tiny incisions. It was pretty sweet and I got pretty good and then I took a long ass vacation from the time I match till the time I started. I drank, I partied, I visited, I traveled. I did not practice my surgical skills or study. It was going to be my last vacation ever and I wanted to take full advantage of it.
I am now regretting this decision. Don't get me wrong. It was the best vacay ever. And I really wouldn't trade it. But, when I get in an OR and I get handed the scalpel or asked to close or any number of tasks I feel clumsy. My hands feel to large and I feel the sweat dripping down my back. Gross, I know but an OR is a hot place. You're wearing a heavy gown, gloves, a mask, a hat, you stand under hot lights and it isn't exactly a stress free environment. Plus, we keep the rooms warm because our parents are open, lying naked on a table. So, yah I get a little sweaty.
Anyways, I know how to do all these things. But the added pressure of being a doctor instead of a med student, not to mention having gone without practice for so long makes things difficult. I can feel myself willing things to go right, willing myself to do it quickly, to do it efficiently. I can feel the attending's eyes on me. I can feel my upper level resident judging me. It's paranoid and insane, I know. But, it's the reality.
Every time I apologize for not being perfect, for not being fast enough, for not knowing the answers my words are brushed away with a simple, "you'll learn." And I know it's supposed to be comforting. But, for some reason that makes it worse. It's like be an awkward teen all over again. Yah, I know it'll get better some day. But, right now it kinda blows and I kinda wish it could be "some day" already.
On top of all of that there is the fact that these skills I'm learning are being learned on a human being. This person that I speak with in the holding area, that I round on every morning, this person that trusts me not to fuck up. Well, interns fuck up. I've been lucky, I haven't as yet. But, I'm not special. It will happen. Most likely it will happen right when I start getting cocky. It's how we are humbled. Because in order to hold your hand out and ask for a knife you have to some amount of hubris. But too much and you get dangerous. It's unfortunate how often it takes a mistake to realize how in over our heads we can get.
I know there are times in the OR when I hold back. Which is very unlike me. But I get into my head and I worry too much about hurting the patient. But that means that I won't learn properly and then when I don't have the luxury of doing these procedures with a safety net things will go badly. Which means, that I have to get out of my head. I have to stop worrying about what the others in the room think, I have to stop envisioning every worst-case scenario happening because of something I do wrong. Not because these things won't or aren't happening. But because dwelling on them makes me a bad surgeon.
I owe it to the patients I am operating on to learn as much as I can from each case. To do that I need to put my own insecurities on hold, keep my ego in check and focus 100% on the task at hand. Single-minded determination is what is required. If I can't do that I don't deserve to operate.
I am now regretting this decision. Don't get me wrong. It was the best vacay ever. And I really wouldn't trade it. But, when I get in an OR and I get handed the scalpel or asked to close or any number of tasks I feel clumsy. My hands feel to large and I feel the sweat dripping down my back. Gross, I know but an OR is a hot place. You're wearing a heavy gown, gloves, a mask, a hat, you stand under hot lights and it isn't exactly a stress free environment. Plus, we keep the rooms warm because our parents are open, lying naked on a table. So, yah I get a little sweaty.
Anyways, I know how to do all these things. But the added pressure of being a doctor instead of a med student, not to mention having gone without practice for so long makes things difficult. I can feel myself willing things to go right, willing myself to do it quickly, to do it efficiently. I can feel the attending's eyes on me. I can feel my upper level resident judging me. It's paranoid and insane, I know. But, it's the reality.
Every time I apologize for not being perfect, for not being fast enough, for not knowing the answers my words are brushed away with a simple, "you'll learn." And I know it's supposed to be comforting. But, for some reason that makes it worse. It's like be an awkward teen all over again. Yah, I know it'll get better some day. But, right now it kinda blows and I kinda wish it could be "some day" already.
On top of all of that there is the fact that these skills I'm learning are being learned on a human being. This person that I speak with in the holding area, that I round on every morning, this person that trusts me not to fuck up. Well, interns fuck up. I've been lucky, I haven't as yet. But, I'm not special. It will happen. Most likely it will happen right when I start getting cocky. It's how we are humbled. Because in order to hold your hand out and ask for a knife you have to some amount of hubris. But too much and you get dangerous. It's unfortunate how often it takes a mistake to realize how in over our heads we can get.
I know there are times in the OR when I hold back. Which is very unlike me. But I get into my head and I worry too much about hurting the patient. But that means that I won't learn properly and then when I don't have the luxury of doing these procedures with a safety net things will go badly. Which means, that I have to get out of my head. I have to stop worrying about what the others in the room think, I have to stop envisioning every worst-case scenario happening because of something I do wrong. Not because these things won't or aren't happening. But because dwelling on them makes me a bad surgeon.
I owe it to the patients I am operating on to learn as much as I can from each case. To do that I need to put my own insecurities on hold, keep my ego in check and focus 100% on the task at hand. Single-minded determination is what is required. If I can't do that I don't deserve to operate.
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