Sometimes it’s not how you say it

But what you say…  

(Thanks to dillinja for the post idea)

We had a subarachnoid hemorrhage the other day.

It was actually a woman in her early 30s, no prior medical problems, and she was the wife of a cop so everyone was on high alert because he and his partner were right outside the room. I was in another patient’s room when they came in with her so I wasn’t there from the jump. When I walked out there was all this action in the resuscitation room so I wandered over to see what was going on. It became quickly obvious that it was a code situation and right as I got near the bed she started vomiting. Never good.

So I try to make my way from the foot of the bed to the head so I could help suction the airway so that one of the senior residents could intubate her and protect her airway. But there must have been 20 people in the room and about half that around the bed. There was an attending, two residents, a med student, at least 3 or 4 nurses, an equal number of techs, the EMTs who brought her in, respiratory therapy, and a handful of Pharm Ds. And it’s not that big of a room. So I was being shoved out of the way by some of the nurses. I made eye contact with our attending who motioned me to make my way to the head of the bed. It just wasn’t possible. Moses had an easier time parting the red sea. 

I walked back outside the room and one of the nurses in the main area asked me why I had left. I said “I really should have never gone in. There are too many people in there already. There’s nothing for me to do.” Then something awfully strange happened. Another nurse came over and bear hugged me and told me to “shut your damn mouth”. I was somewhat confused but I went back to taking care of my other patients. The nurse who bear hugged me came over a few minutes later and said 

“What you said earlier was pretty inappropriate.” 

Uhhhhhh what? 

“Never open your mouth when you walk out of the resuscitation room, you never know who’s standing around. The patient’s husband, a cop, was right next to you when you said that.” 

Ohhhhhkayyyyy, but I didn’t say anything wrong. 

“You said there was nothing you could do and you shouldn’t have gone in there.” 

No, I said there was too many people in there and I couldn’t get near the bed.

“Well that’s not what I heard. Just try to be more careful and thoughtful in the future.”

Now that’s never bad advice. And again, I don’t think that’s what I said or how it came off. It’s certainly not what I meant. But at this point the seed was planted and I started to beat myself up. I almost broke down while I was writing a note on another patient. I felt terrible. I thought I knew what I said, but I can’t be sure. And I’d hate to think that I caused the poor man anymore grief than he was currently going through. 

She got a head CT not too long after and they found a subarachnoid bleed. For the uninitiated that means she had burst an artery that sits directly on top of the brain. They’re very bad and much worse than epidural or subdural bleeds which are arterial or venous bleeds that are a couple connective tissue layers in the dura mater that surrounds the brain. 

She died early the next morning up in the ICU. I’m not sure they know what caused the subarachnoid bleed. For the husband and her family that information rarely helps anyway. I think the most comfort it gives is that they did everything they could and there was no way it could have been prevented. I just hope that my possibly careless words did cause them any more pain than they were already going through. Yet another lesson that you have to be 100% on when you’re taking care of other people’s lives.

My first overnight shift in the ER

It managed to produce several other firsts of it’s own.

We were pretty slammed and didn’t have a whole lot of room in the ER. A lot of people who needed complicated work ups or were waiting for a bed upstairs. I was really just hanging out at the beginning of my shift waiting for things to happen. And that’s usually one of two times when badness happens in the ER. When you’re sitting around not doing a damn thing or when you’re so damn busy that you can’t imagine being able to handle anything else. 

So of course that’s when we get a call from an EMS crew that they have a guy found slumped in his car on the side of the road. Cardiac arrest. So we get the resuscitation room ready and everyone decides I should put in the central line. Now when you get a call from an ambulance you can never be sure that it’ll be exactly what was reported over the EMS radio. Sometimes you’re told the patient is in arrest, but they get to the ER and they’re alert with a semisteady pulse. Other times you get exactly what you expect. This was one of the latter times.

Patient comes in with full arrest. I go to place the central line in the patient’s L thigh after cutting off his clothes. The central line will allow us to dump a lot of fluid in very quickly (in case he’s bleeding internally) and deliver heart stimulating drugs directly to his heart even faster than we could with an IV line in his arm. Unfortunately he has no pulse, so it’s a bit of a crap shoot. You find the anatomical landmarks and aim for the big vein deep in the thigh. I wasn’t doing it briskfully enough so one of the attendings grabbed my syringe and showed me what needed to be done. After you find the vein with the needle, you thread a wire through the syringe and into the vein. Then you make a small nick in the skin with a scalpel, twist in a dilator over the wire to open up the pathway from the skin to the vein, pull that out, and then put in the catheter over the wire, remove the wire, and then suture the catheter into place. 

It sounds a bit easier typing it out than it is in real life. Especially when real life involves people performing full on CPR right next to you. The patient is shaking with each chest compression. You’re a bit shaky because you haven’t done this before. And the person in front of you is dying. You start to think if you’re really cut out for all this. All these people around you have been doing this rather expertly for at least 2 years more than you. They can do it in half the time, maybe less. But they walk you through it, alternating encouraging words with barking orders. 

Once I had the central line in, I went to the side of the bed to assist with chest compressions. It’s one of my favorite things to do: it’s been shown time and again to save lives, I know what I’m doing, and I’m pretty good at it. At least that’s what I’ve been told. We continued our life-saving efforts for about 20 minutes in total before my attending called the time of death. He was down at least 30 minutes before he got to our ER with EMS. There truly wasn’t much more we could do. He never had any electrical activity in his heart and his pupils were fixed and dilated, a sign of brain death. 

We waited for the family to gather and then told them what had happened. That’s always the hardest part of any unexpected death. As you begin to talk to the family, they almost always know where you’re going. You can see it in their eyes and you feel terrible. We’re taught to be direct and stick to the story: what we know about how the patient came to our ER, what we did, and what the outcome was. The last part is always the same. And we’re taught to always end with “And despite our best efforts, they died”. You never say “they passed” or “there was nothing else we could do” or any other euphimism. It’s best to be direct. 

Last night there were about 14 various family members. I’d been involved in talking to family members before after a patient’s death. This wasn’t the worst time or the best time. Actually, I don’t think there’s a best time. And maybe every time is the worst time. It doesn’t seem like it ever gets easier.

A few hours later, we had to intubate an intoxicated gentleman. I’ve intubated a handful of people in the OR with anesthesia before surgery, but never someone having difficulty breathing. There’s a lot that goes into it… I don’t know that the details are very exciting. I made a couple solid attempts but I couldn’t get the tube to pass properly into the trachea, so after a couple tries, my senior resident took over and was able to get it in properly. Both he and the attending admitted it was a bit more difficult than they first suspected. We went over my technique and what I could do differently next time. They complimented my effort and the fact that I never seemed rushed or frustrated. But in the end I failed. Which sucks. I’m glad someone got the tube in to help the guy breathe, because he wasn’t doing so hot, but I wish I had been able to do it.

Everything that went down last night I had done before in one capacity or another. I’ve put in central lines in the thigh in the middle of traumas but it’s been at least 10 months. And when you haven’t done it much before it’s easy for your skills to get rusty. I’ve talked to family’s before after a patient’s death, but as I said earlier, I don’t think it ever gets easier. 

I guess at the end, there’s going to more firsts and more ‘failures’ during first attempts… although I hope not too many. But there’s also going to be a lot of second, thirds, fourths, etc. It’s a learning process with a damn steep learning curve. Hopefully, I’m climbing well.

Tales from Week One of Doctoring

The first two days were a nice ease-in to what I’ve got in store for the next year, 5 years, and really the rest of my working life. We had double resident coverage so I really never had more than 3 or 4 patients. But when the holiday weekend rolled around? Yeah, I got bodied. At one point I was seeing 8 or 9 patients at once. And a good half of them were pretty damn sick. 

I think the thing I was least prepared for was that now that I’m a resident, some attendings feel little need to get overly involved except with the sickest patients. They have total faith that I either a) know what I’m doing or b) will figure it out on my own. I’m so damn slow because I sweat over whether my Vicodn scripts should be for 5, 7.5, or 10mg of the narcotic portion. Should I only write for 12 or is 24 okay if they have a legitimate pain diagnosis? 

I’ve also learned that I’m the type of doctor who is willing to send people home if they’ve been in our ER for 8 or 9 hours and their pain is gone or their original problem has been more or less fixed even if it was somewhat serious on arrival to our ER. We have some doctors who just want to admit everyone to cover their ass. I think it’s a waste of the patient’s money and possibly taxpayer’s money. I also don’t think every headache needs a spinal tap or that everyone with new numbness deserves a neurology consult. If the head CT was normal and all their bloodwork was normal and the patient now wants to go home? Their numbness wasn’t that severe to begin with, especially when you’re now begging me to go home. 

The winner of the week though was this drunk guy who was threatening to kill everyone in the ER if he didn’t get his methadone (he’s been on for 14 years). He started to try and flip over his bed and then threw a chair at one of our transportation guys. So he bought himself 4 point restraints and some haldol. I went in to talk to him 10 minutes later and he was very sweet and apologetic and asked if we could at least reposition him so his back didn’t ache as much. I told him we couldn’t because it took 4 cops, 2 techs, and 2 nurses to put the restraints on and everyone was worried what would happen if we loosened the restraints. He ended up getting admitted for his blood alcohol level of .37 and his questionable history of shakes/seizures.

It was an exciting week that reassured me that I have much learning to do. I already knew that but it’s different having daily and hourly reminders.

In some ways it wasn’t very different than being a med student.  I don’t know all that much more. It’s not like they handed me an MD and then the dean layed hands on my head and I was suddenly bestowed with all medical knowledge. Although talking with some of the med students rotating through our ER, I do know a little bit more than they do.

 
It’s just that now that I have a long coat and a temporary physician’s license and can sign my own prescriptions and orders without needing a co-signature from a resident or attending, there’s this added sense that I SHOULD know more. You discuss your patient with an attending and they’re like “so what do you want to do?” Sometimes you hit it on the mark, but most times I forget something that should be more obvious to me, or I add something that shouldn’t have mentioned. Or I’ll take a look at the order list and notice that the attending added some medications or tests, which is a bit more embarassing than had they just told me to my face that I had forgotten something and I should order this or that.

I told a friend over the weekend that every day I re-learn that I know very little about this job. I think that should be the mantra of every intern. As long as you know what you don’t know and you’re willing to ask questions and look dumb in front of someone, at some point you’ll be able to do things on your own.

Welcome to the Jungle

We got fun and games.  ….   Well we don’t really have fun or games here.  It’s not that type of blog.  As the header up there says, I’ll be mostly posting stories from my residency.  But my hope is that the stories will be insightful, informative and occasionally amusing.  

I tried the blog thing once a long while ago.  But that was before I was an intern with all of these exciting stories.  I’m hoping to update this at least once a week, more often if I’ve got good stories or personal insights/reflections to share.

Quick shouts to the OKP family in general for convincing me that these stories were worth telling and that I should be the one to tell them.  Special thanks to Payne for the blog name and to Rob for the inspiration of said name.  Enjoy.