Ok, so I didn't get a chance to write as much while on my Trauma ICU rotation. I really meant several times to sit and write about that day's events. My feelings. My comments on the stupidity of my fellow man. Seriously. Trauma Drama 24/7.
But, I found myself coming home most days, especially after 27 hours on call, exhausted and not wanting to do much more than play with my cats, play on the computer, enter a world of escapism. My cats wondered about my strange hours; getting up at 4:30 to be out the door by 5:30 so I could start rounding at 6:00. Then coming home close to noon after having been gone since the day before and sleeping all day, waking up to eat something, pour some food in their bowls and then going back to sleep. Shampoo, rinse, repeat.
So, some of the stories from this last month on the TICU service: I probably knew more about the surgeries than most of my colleagues, and had actually performed more of the surgeries than the second year surgery residents I worked with. I got to put in central lines, I put a breathing tube in one patient, and I put in an arterial line to measure blood pressure in someone's foot.
There was an article in the local Buffalo newspaper about the inordinate amount of ATV accident victims being sent to the E.D. We had at least 3 - 4 of them, including a husband and wife who got drunk and crashed their ATV. The wife is doing better. The husband, not so much.
We had a number of shootings including a 13 year old shot by a guy rumored to be in a love triangle with her and another 16 year old girl that he'd already shot and killed. A 16 year old shot in a drive-by straight through the head. The CT showed a trail of debris from the front to the back where the bullet lay lodged. Don't know how that patient will do. We had the suicidal patient that decided to shoot themselves through the stomach. They had a large belly and shot from one side to the other. I am still trying to figure out the trajectory on that one.
We had the motorcyclists hit by cars. The drivers of cars hitting other cars, or trees, or flying off the road and flipping over. People hit by other people's cars. A patient hit by their own car which they thought was in park. A patient was hit by a city bus. And, the patient changing the oil who got crushed by their own car.
We had a number of patients that fell off of, got kicked by, or run/rolled over by their horses.
We had the fell off ladder, fell off scapholding, fell out of tree stands.
Alchohol and drugs had a lot to do with a number of injuries, including the patient who got drunk, fell down the stairs, broke their neck, and is now a quadraplegic.
We had the surgical emergencies: bleeding duodenal ulcer, perforated gastric ulcer, dissecting thoracic aneurysm, ruptured brain aneurysm, etc.
I had the end of life talk with two patients' families. I pronounced one patient and wrote the withdrawal of care orders on the second. I developed a rapport with the family of a patient assaulted with a beer bottle to the back of the head who developed a head bleed and had basically lost the right side of his brain as a consequence. As I showed them the CT scan, I learned that the patient was a very talented artist. Art and spatial relations comes from the right side of the brain. I asked the brother if the patient would want to continue on with the part of the brain gone that was their major talent. He told me the patient would want to live. But, he was torn. He considered it more of a religious decision. But, he wondered if they were making the right decision.
I ended my final shift admitting a little lady who had t-boned another car at 50mph and had a liver laceration and the patient with the bleeding duodenal ulcer. As I came home to sleep, I turned the pager on vibrate and placed it on the bottom of my bag. When I awoke some 10 hours later, about 6 trauma patients had come into the E.D. The next morning there were another 4.
I got to do something fun, despite having a cold, on my last day of the rotation:
As part of our residency, we provide medical support at Buffalo Bills' games. So, I spent the game treating the overindulgers, the fighters, the nauseated, the injured, and whomever else wandered into the north side medical clinic at the stadium. I did get to watch a couple of plays, and we all huddled around the TV as the final kick resulted in a win for the home team!
This month I am doing the relaxed, Mixed Bag rotation of Ophthalmology, Oral MaxilloFacial Surgery and Radiology. In med school, we talked about taking the "easy ROAD" R = radiology, O = ophthalmology, A = anesthesia, and D = dermatology. These were considered the high money specialties with a minimum of patient time and or short clinic hours with no weekends and minimal calls. So, I am essentially doing 2 out of the 4 with my weekends off to enjoy... oh yeah, and a week's vacation during the final week.
So, we'll see what excitement I can drum up over the next THREE weeks...
Well, I started my new rotation in the Trauma ICU at ECMC on Monday. It was actually kind of exciting to be back in the ICU, and I was on-call last night. Yes, 26 long hours of fun. Did I mention it's been a while since I've stayed up more than 24 hours straight?
One of the things I love about ECMC, as I have mentioned before, is that patients have the most interesting stories. Now, some of my colleagues will argue that BGH and Children's have their share of stories, and I agree that once in a while a good one will come up, but I still feel that the best stories come out of ECMC. And, getting to know my patients, plus the 5 new admits I had to the ICU, can be an interesting venture.
Two patients came in with blood alcohol levels that put them in the "inebriated" category having fallen. Mind you, both presented to the ED in the morning after their respective falls. They both admitted that they drank "a couple of beers a day." I guess they just didn't specify at what time of the day. Both ended up with back injuries requiring multiple scans and films. One had a broken wrist and the other had spinal shock. Both will end up doing well.
In the "payback's a b*t*h" category, don't mess with a mama's little girl. You might just end up getting a beat down with a lead pipe leading to a broken face, some major bruises and cuts, and the humiliation of having to spend the night under arrest in the ICU. Oh, and again, please stop doing cocaine, I'm having a hard time controlling your pain (because your synapses are all fried) and your blood pressure (because I have some limits on the kinds of medications I can use.)
And, again, you might want to reconsider your life's choices when you're in the ICU because you got kicked in the chest by a mad female. The bleeding led to an infection which led to a worse infection in your lungs which then led to the surgery where they had to cut into your chest to clean things out. Now, your heroin habit caused me problems like your fellow patient's cocaine habit with your pain control. Granted, you have four tubes sticking out of your chest so I feel just a little bit more sorry for you because I know those are uncomfortable. But still... rethinking those life choices might not be such a bad idea.
Of course, the worst are therandom events where someone was just having fun and it led to tragedy. Like riding an ATV and now having a spinal fracture leading to the strong possibility of never walking again. Hard when you're just 16. Or 17 doing something simple like working on your car. Now you'll be lucky to not be brain dead. Luckily both have very supportive families which will help as they'll have very long roads ahead.
One of the more interesting things is being pimped again (meaning being asked questions by the attending that tests your level of knowledge and puts you on the spot.) In the E.D., not so bad. In the ICU, back to pimping "surgery style." But still, very good to be back to the familiar. Can't wait to see what the rest of the month brings...
I always said that I could never be a pediatrician or a veterinarian because whatever happens to children and animals usually is the fault of someone else. I felt I would always be angry at someone when treating my patients, especially the injured ones. Today was a good example of when bad parents happen to children.
Patients seen in the E.D. today:
A 5 year old with a cellulitis, skin infection ("he was at his father's and I don't know what happened to him"). I wanted to give him a dose of antibiotics and then send him home with a prescription. Mom said she was tired of waiting and needed to go "check on her bicycle" which she states she didn't lock. A nurse asked me how they had gotten to the E.D. if the mom had ridden a bike. I said some questions I don't want to know the answers to. Anyway, I asked mom to wait a few minutes, and we would have the antibiotic. Well, she disappeared with her son and didn't return. Our social worker got involved, called the contact number that was for a "neighbor" that lived 1/2 mile away who said they would try to get a hold of mother. She eventually did show up... 3 hours later. We got the child the dose of antibiotics and got them their prescription. I hope she fills it.
When I walk into a room and the mother starts the conversation by saying, "I just got her back from foster care, and she's been sick ever since" I kind of start to wonder what's going on. I don't like to judge people, but this mother was the poster girl for a "Don't Do Meth" campaign and the father looked like, per the RN, something out of "Deliverance." The mom couldn't answer my questions about fevers, vomiting, wetting diapers on her 2 year old. All she could tell me was, "she hasn't really been eating or drinking and the doctor told me to bring her here." I had a nurse ask if the girl had a genetic disease because she "had a look about her." I asked the nurse to go in and look at the parents. We ended up admitting her for hypoxia (low oxygen saturation), dehydration, and hypoglycemia (54, in kids should be around 100). I think social work might be getting another phone call.
Ok, so you're married to a doctor, and you have 4 children under the age of 5. You decide to pack the kids into the car around noon and head off to your local Target and Lowe's to pick up a thing or two. It's summertime. It's midnight as I write this and my thermometer on the way home tonight read 80 degrees with high humidity, so I am sure in the bright sunlight of midday it was much warmer. You get out of the car and leave your kids for "just 10 minutes" with the car doors closed, the windows closed, the car turned off, in the middle of a parking lot. Soon people come by and notice the children in the car, yelling and crying for help. They stand and wait to see if someone shows up while they call the police. The police arrive and wait a few minutes to see if someone shows up before they break the windows and open up the car. Total elapsed time, about 30 minutes. EMS arrives and notes the infant (9 months old) is drenched in sweat and no wet diaper. All the kids get put into the cool back of the ambulance. Dad gets called, but he can't come because he's in surgery. Mom finally shows up and get promptly shown the back of the police car. Auntie, who's also a doctor, gets called and meets the children en route to Children's. All four are seen and evaluated in our ED. CPS (Child protective services) gets called. The four are discharged to the care of their father once he got out of surgery. Will have to hear later what happened to mom.
A woman walks into a bank carrying a year old child. She walks up to another woman and asks if she would please hold the child for a moment while she takes care of something. The second woman agrees. The first woman walks out of the bank and never returns. EMS and police are called and the child is brought to WCHOB for evaluation. Social work and CPS, already there, are brought in to discuss placement of the child who is otherwise healthy. About 5 hours later the mother shows up in the E.D. looking for her child. Buffalo PD is promptly called to escort the woman to a different waiting area. Will have to ask the resident involved what ended up happening with the mom.
I had to call CPS for a case of suspected abuse. A 9 year old "smacked around" by his father causing a bloody nose. I counted and took pictures of all the bruises and lesions he said were inflicted by the father and his new stepmother. He has 3 older brothers and 2 younger step-siblings who are still living in the home. He called his mother for help from an older sibling's cell phone, and she brought him to the emergency department. Seems she is "getting help" and doesn't have custody of the children, their father does. She gets to see her children bi-monthly. She asked if there was any help CPS could give in the custody dispute. I said I didn't think so but I was sure they could connect her with the appropriate resources.
We had another child who fell out of a window and came out the other side looking like they had been thrown into a cement mixer. Head injuries, broken arm, broken ribs. She was being admitted to the PICU.
I worked on a 2 year old riding a motorized ATV who fell off the back and also had a head injury to add to an earlier one suffered when he banged his head on a wooden door. He was going to be admitted as well.
I had a 4 month old that flipped over in their car seat when the transit bus they were on stopped hard. He had bruising all over his face. A head CT did not show any injury to his head. What was interesting is that while I tried to examine the child and talk to the mother, she was more interested in berating the "baby daddy" because he, "wasn't there when his son needed him, he had no interest that his son was injured, why wasn't he a good dad and arranging transportation for them, don't blame me for what happened it was the bus driver's fault, etc."
Sigh.
On a good note, I got to show my final patient her 16 week old baby. She was concerned that she hadn't felt the baby move, and I got to print her a lovely picture of her baby, nice heartbeat, moving all their limbs, a new life ready to enter the world. Hopefully, to a good mother. Hopefully.
This will be a quickie as I should have written last night, and now I am in a rush to get ready for my last shift of this set. Yesterday the flood gates opened and everyone who couldn't wait one more day for their pediatrician's office to open came in. We were full in all 20 rooms and had about 20 people in the waiting room. And, trauma stops for no one.
Everyone was "on their way home" from camping, picnicking, somewhere else, etc. and ended up in the E.D.
The cases I saw:
2 year old with sudden case of vomiting - got IV fluids, drank juice, sent home
15 month old with fever - got tylenol, IV fluids, drank juice, sent home
11 year old with rash - this was a medical mystery ala House style, don't know what she ate, drank, wore, or swam in but she was broken out all over and her face was so swollen she could barely see out of her eyes - she got benadryl, steroids and some pain relief, sent home
38 year old car crash victim - since the hospital has an adult service, we don't see the over age 21 set, except in the case of trauma where they need immediate evaluation, so I was a "consultant" on her case, which basically means I told the adult medicine physician what to order, what to look out for, etc. - she was admitted along with her 8 year old daughter who was also in the vehicle for observation (they were coming home from camping and swerved to avoid a car that cut in front of them going the opposite direction, rolled their vehicle over several times, luckily, they had their seat belts on)
11 year old car crash victim - riding with mom and sister, sitting in back seat, had neck and knee pain, all of the films were negative and she was sent home
15 month old with fever - motrin, drank juice, sent home
4 year old car crash victim - sister to the 11 year old, she wasn't a trauma, so I saw her later on, she will have some bruising on her face but nothing else hurt
2 year old fell out of 2nd story window - supposedly fell off couch near window and fell down to street below, he didn't seem to have any injuries on CT scan but his fall was significant (> 20 feet) so he was kept for observation
6 year old with vomiting - IV medication, drank juice, sent home
and finally 1 year old with fever - given motrin, drank juice, sent home
If you're wondering about the juice, we need to make sure the pedis aren't going to get dehydrated until they can follow up with their primary doctors, so we make sure they can keep fluids down. Everyone gets a P.O. (per oral) challenge prior to leaving the E.D.
Ok, running off to get dressed for what will be another busy shift, I am sure, probably with less traumas since most people are home following the holiday weekend. Will post tonight as tomorrow should be a fun day learning about helicopters!
Oh, the kiddo with the wound under the arm had to go back to the OR because he became so swollen from all of the blood products he needed, they couldn't close his skin after surgery so he was left open and was closed yesterday
The other pedi with the fall down the embankment was doing ok last I heard.
As predicted, we were busier in the E.D. today. At one point we had about 12 patients in the waiting area, and all 20 rooms full. We managed to clean out the waiting area, but then as I was leaving, it started filling up again. And that didn't include the traumas. Traumas take priority, and they go straight to the code room regardless. So you might be busy seeing patients and then have to drop everything to see the trauma.
I think at one point I might have mentioned the triage system which assigns a priority to patients based on how sick they are. In general, the color codes are:
Red - see immediately
Orange - see within 10 minutes
Yellow - see within 15 - 30 minutes
Green - see within 30 - 60 minutes
Blue - see within an hour or two
If you know anything about colors and the color spectrum, you know that blues and greens are cool colors and oranges and reds are warm colors. As an intern, you generally see blues and greens. As you get more comfortable, you venture into the yellow and might actually get to see an orange.
Now, as an unofficial second year, my colors are generally yellows, some oranges, and occasional reds. I do get the occasional green or blue depending on how busy we are, but today especially my attendings physically started handing me orange charts to evaluate, and I was directed into the trauma code room, actually paged once to the code room, where the color is always red.
Also, it makes working more interesting. I don't see as many of the garden variety patients that come into the E.D. I see the sicker kids with more extensive and chronic illnesses. Amoungst my patients tonight I saw a sickle cell patient with chest pain (orange), a cystic fibrosis patient with an exacerbation (orange), vomiting in a 5 day old (yellow), and three traumas (all reds).
The traumas were:
- a 2 year old that fell 15 feet down an embankment and ended up on a concrete landing, to CT and admitted
- a 10 year old who fell off of his bike, onto the street, where a car ran over him, he got discharged with a skin burn on his leg from where the tire scraped his skin
- a year old baby that was sitting on her sister's lap when she fell over backward off of a porch swing, a CT scan showed a head bleed, and as I was leaving they were going to the CT scanner with neurosurgery, she will for sure be admitted to the Pediatric ICU as she was intubated (had a breathing tube in) and seemed to be having seizure-like activity, I'll find out how she did tomorrow
As for the patient with the axillary artery laceration, they ended up being transfused 6 units of blood. Given that the average adult has about 5 - 6 units of blood circulating, they had to replace the patient's entire blood volume and then some. He's still in critical condition in the Peds ICU.
That's it for tonight. Back to the warmth tomorrow.
SUNY Buffalo - South CampusSo, for the last two days I have been in an ATLS (Advance Trauma Life Support) class. Basically, the class teaches the principles of caring for the trauma patient. We had a series of lectures, intermixed with small group learning sessions, a cadaver lab, and then an oral exam and a written exam. It's been a wonderful respite from the geriatric service. For the last two days I have been reviewing a lot of the lessons learned during my surgical residency. As we went through case scenarios, or during particular lectures, my mind would drift back to the patients I had seen or operations I had performed. Several times I had to bring myself back to the current lecture before I lost track of where we were.
One of the funnest parts was the cadaver lab. Suddenly, for just a moment amoungst the familiar smells and sounds, I was back in medical school, excited about pulling back the plastic over the cadaver and beginning to explore and appreciate the gift that someone had given - the ultimate gift of themselves. What was interesting, and just a little eerie, was that one of the participants, an EMT who was auditing the course, actually knew the patient. He said that during his time as an EMT, he had picked up the patient and transported them to the hospital multiple times. We performed various procedures on our body donor. I remember in medical school, on the first day of anatomy lab, my group standing around the shrouded body; staring down, uncomfortable, not liking the smell, trying not to think about the fact that soon we would be meeting our first and most important patient.
Not just that. We all knew that soon one of us was going to have to pick up a scalpel and begin the dissection that would continue throughout the next 4 months of our lives. I have to admit that I was the one that picked up the scalpel and made the first incision; offering a small apology in silence to the body donor. Later, as a third year medical student on my surgery rotation, I remember being allowed to hold the scalpel and make the small incision to remove a small fatty tumor. I remember thinking that the skin was so much more pliable, so much more... alive. Then, during my last rotation of my fourth year (an emergency medicine month if you can imagine) I was allowed to place a chest tube in a patient who had a pneumothorax (collapsed lung.) The surgeon walked me through the procedure. A cut into the skin overlying the 5th rib on the side. Then a deeper cut into the muscle. I then put a Kelly clamp into the muscle layers and started spreading them. Slowly. The surgeon would come over from time to time and check my progress by sticking a finger into the wound. "Keep going. A little faster, I want to go home soon and get some dinner some time tonight," he teased. When I got just above the pleural layer overlying the lung cavity, he told me to spread and push. He was standing at the back of the room joking with the E.D. attending when I broke through the pleura, and there was a sudden, surprising, rush of air. He heard it and said, "What did you just do!!?!?!?" Then he laughed at the startled, and just a little frightened look on my face and said, "Very good. Keep going." I grabbed the chest tube, placed it into the chest cavity, and then he showed me how to sew it in place and place a dressing over it.
I was thankful for that experience as during the first month of my intern year on the cardiothoracic surgery service I placed 13 chest tubes. I've placed many more during the last 5 years. Now, here I was again. A body donor, a scalpel, talking one of the new interns through the steps, showing them some of the tricks I had picked up along the way. At one point I grabbed the scalpel myself and placed a chest tube in less than 30 seconds. Of course, on a real patient there would have been a lot of other things happening, prepping the patient, wearing sterile gowns, giving anesthesia, etc. But, still, there was a certain satisfaction in how far I had come, and how the thought of making that incision no longer frightened me. I miss surgery sometimes, but I know I have made the right choice for this point in my life. And I am happy to have to have spent the last two days, albeit slightly melancholy, reliving a very important time in my life. Tomorrow back to the Geriatric service. Seven more shifts, and it is over. Get me back to the E.D. Back to the trauma and the drama. Back to my new life.
I bought a bunch of these small notebooks when I started this residency. Actually, a total of 6, two in each color. This is the first one, and I have its mate sitting in my white coat out in the car. As a part of our residency program we have to do a "follow up" on a certain number of patients that we see in the emergency department. We want to see "how well we did" in managing their care.
So, I carry my notebook, and every patient I see goes into it. I log down what their presenting complaint was (why they came into the E.D.), what I did (labs, x-rays, etc.), and what their dispo was (dispo = disposition: admitted or discharged.) It's also where I keep track of any procedures I performed: suturing, chest tubes, central lines, intubations, all of my 16 deliveries, etc. We have to have a certain number of procedures to be deemed "certified" and able to perform on our own without supervision.
Usually, I have my little book next to me when I am blogging the past shift's events, but... I left it out in the car, in my white coat, and I am feeling very lazy. So, I thought I would give some general comments about my shift last night:
- again, we were very busy. I think around 3 in the morning, we finally had no patients waiting in triage. Then around 0305 the next patient arrived.
- I am starting to feel like all pediatric thermometers are set at 103.something. I had 2 patients yesterday, and have seen several others, who all had home reported temps > 103 and who had temps of 99, 100, 101 by the time they arrived in triage. Ok, so maybe the Tylenol or Motrin finally kicked in, maybe the fever was at its peak and broke, maybe the trip to the ED in the crisp cool Buffalo air brought the fever down, but still. The kids shouldn't be nice and dry, playful and alert, etc. if they've had that high a fever. Of these two patients, one ended up with a respiratory viral syndrome, and the other I will have to find out about today as I had to sign them out when I left last night.
- I have come to realize that I am no good at math. Everything in pediatrics is mg/kg or ml/kg. Aside fromthe fact we're working in the metric system, and I have to consciously convert Centigrade to Fahrenheit, I just seem to have a mental block when it comes to simple multiplication. Not to mention that I also don't know, off the top of my head, the maximum doses of all of the medications we give (luckily I have my attending and a slew of nurses to remind me). So, it's been quite the challenge when I am called to give a medication order. Which I do, obviously, quite often. Sigh...
- If you're jumped while leaving a bar at 3 in the morning and knocked unconscious, you probably should come into the ED. When your face swells up and looks like Quasimodo's, probably a good time to get that checked out. You shouldn't pop a couple of your buddy's 'pain pills" and then go out to a BBQ with your blurry vision and massive headache. Just not a good idea. Luckily, when his parents finally found out, via an uncle who went to the same BBQ, they made their son come in to be evaluated. Luckily, the CT scan only showed a small fracture in one of the nasal bones, but things could have been much worse. My excitement, of course, was in dealing with something other than vomiting, fever, diarrhea, and, "oh, what's this rash?"
- when you come to the E.D., it is not necessary to bring your "posse" or "entourage" with you. The rooms are small, I am trying to get information, and I don't really need a running commentary or additional information from your supporting cast. There's a rule that only 2 people should accompany any one patient, but somehow others always seem to slip past the front desk, and usually our staff is too busy to notice the comings and goings and exchanges. I don't mind playing to an audience, just not while I am trying to take a history.
- little boys seem to get constipated an awful lot more than girls
- and, finally, there's something about sitting back during those brief moments of "down time" and listening to the "war stories" the nurses exchange with each other. Last night, the comments focused on pregnancy and all of the events that had been witnessed: some funny, some sad, some a testament to my sometimes thoughts that we should adopt a national "contraceptive" vaccine that doesn't allow you to procreate until you've reached a certain age, achieved a passing score on the "baby test" (kinda like your driver'stest, but you're only allowed to fail it once), and passed several rigorous written exams; after which you present with a folder of references and recommendations by others who are nationally certified to procreate. If only...
Ok, off to my last night of being a vampire for a while. We'll see what the evening brings...
I am too tired to do my usual diatribe about the events of the ED. Suffice it to say that the majority of the reports from the EMT's this evening started with the phrase: "Patient went out drinking tonight and then..."
- the patient drove into a tree and crashed headfirst through their front windshield. After all the work-up was complete, the patient was found to have only sustained a bloody nose (refer back to one of my previous posts for rule #1 for drinking and driving: drink enough and you won't get hurt)
- "several unknown assailants" (Two Dudes must be on vacation... again, refer to earlier posts) jumped on several of our patients causing a variety of injuries normally seen on boxers who are on the losing end of the prize match - the patient got into an altercation at a wedding leading to them being stabbed in the stomach, "really, it's just a flesh wound" lead to an exploration, and when 6 inches of the probe disappeared into the belly tissue, the patient was sent for emergency surgery
- the patients went out and rode their motorcycles which they subsequently crashed requiring the services of our Mercy Flight helicopters, the orthopedic surgeons, the neurosurgeons, and admittance into the trauma ICU
and, our favorite of the evening, of which, believe it or not we had two:
- the patient got into an altercation at a local bar, went outside to avoid a further dispute, and tripped off the curb...
what I want you to realize is that this person is lying FLAT on the bed... the two spots you see on the skin just below his pant's line would be just above the front of the ankle if the foot was in the normal position. And, like I said, we had TWO of these injuries tonight.
... that first step is a doozy!
