January 23rd, 2004

White Coat

We never stick our fingers in holes people made...

I was going to write to you last night, O Best Beloved. I had the very best of intentions to write to you. But I got home post-call at 10 and woke up when the Code 77 test went off at 5. And then I spent a while fighting to get into Michel's character. He's such a subtle bastard of a man, and I don't want to overplay him. And then it was 10 PM and I went back to bed. So now it's Friday morning, off to a questionable start as all the other students looked good, got labs, and had ICU vitals before rounds, while I came in right when we were supposed to meet, saw them leaving, and paged Joerg to a phone which didn't ring back, and thus wasn't in on the vital-sign-getting and was also 5 minutes late for rounds. I almost cried for frustration this morning, O Best Beloved, feeling totally useless.
It got a little better as I wrote a note and had some late labs, but am still worried that my residents think I suck. This is the story of my life, O Best Beloved; I'm terrified that secretly I suck and nobody will tell me that I'm resented for my incompetence.
On top of the slow start, I'm in lecture until 1300, so I really am useless today. And it's the last day of the residents' rotation, to boot. I hate surgery. I can't wait until it's over. I am not a surgeon, and I'm so glad other people are.
It's not all bad, O Best Beloved, please don't think that it is. My on-call night was fun. I'm just not a surgeon. And I'm no good at the surgery mindset. I want to treat everything that's wrong with my patient.

And that's quite enough whining about surgery; the block ends in a week and I'll go on to Internal Medicine. In Medicine (they call Internal Medicine Medicine, o Best Beloved, as if it weren't all Medicine) we treat all sorts of things, all day. I'll be expected to write my nice long notes and not truncate them. I'll get to do a real physical exam. I can't friggin' wait, but at the same time I'm terrified that I'll suck.

"Pericardial tamponade," he says to us. "It's exciting. You see a hole in the heart, you fix it. Blood everywhere. It's very exciting. Sort of like sex, but not really." Trauma staff is so weird. He has some good stories, like the person with a cribriform plate fracture who wound up with an NG tube in his brain. But he's weird.

So last night. O Best Beloved. We were doing so well until we came off diversion. We had time to bitch and moan about how Medicine called us at 1730 for a patient who'd been there for a day and a half and had a foot ulcer. Why, AE says, did they need a consult right now? It's not an emergency, just wait for the primary team to come back in the morning. We even had dinner with staff (TGI Fridays', he paid ) and watched South Park before going back to Detention to do a post-op check. And then, on the way back to Detention our pagers went off. It's a 50-something man, found down outside a bar with a respiratory rate of 6 or so. He had a blown pupil - one eye where his pupil was about 6 mm and not responding to light, and once the EMS got oxygen on him, he not only started to breathe again, he started to turn combative. He came in tied to the stretcher, head bound down to an immobilizer board, swearing and demanding we take the c-collar off. He wouldn't cooperate with us at all. He wouldn't hold still, he wouldn't give us any information, and he kept fighting us with everything he did. The room reeked of alcohol. We tried to reason with him. He could not be reasoned with. So we pushed some succinylcholine and put him to sleep, got Anesthesia to put a tube down his throat, and did our survey on a compliant patient. I got to put the Foley in, excitingly, and to go running through the ER in scrubs and no jacket to get warm saline for CT. Everyone got out of my way, pronto. It was sort of cool.
We took the elevator down to CT, and as we were getting in, a half-dozen people if you count the unconscious drunk on the cart, pushing a portable vent and blood everywhere still, we pass the woman in a wheelchair coming back from US. We let them by, wheel the cart into the elevator as this woman's head swivels all the way around to watch as pass, and as the doors close we hear a horrified "Oh, my God..." from behind. I wonder what she went home and told her friends she saw.
Spent forever in CT scan, because we had to scan him head to toe, and it's a good thing we did. His only injured area was his head. He has a bleed in his brain, basilar skull fractures, air in his sinuses, and a broken eye. Spent a good ten minutes in radiology, spent some Quality Time with the resident, came back and reported. Just as we were getting him settled back from CT, our pagers went off again.
This time it was a 20-something kid who'd gotten drunk and run his truck into the back of a semi at high speed. He was only a little more cooperative - just enough that you could get him to hold still and cooperate with the exam. But he was so drunk he told us he wasn't in pain despite his gigantic arm laceration.
He was awake and alert, alert enough to fell us to f* off and leave him alone a good three times a minute. He didn't remember why he was at the hospital, and the first thing he asked when we reminded him he'd been in a car wreck - the only thing he wanted to know - was if he'd totaled his car. He had - the fire/EMS who cut him out of it brought pictures. It was a nice truck, but now the engine is in the passenger's seat and the driver was in our tender hands. We surveyed him, shot films and established he wasn't in danger of dying, then we logrolled him and checked his spine and rectum.
I will admit, O Best Beloved, that there was a rare sort of vicious satisfaction to doing a rectal exam on a patient who'd been such a jerk to us the whole time. We explained to him what we were going to do, but he didn't connect "check your butt" to "digital rectal exam" and he screamed all sorts of obscenities when I did it. Then, when he heard me give report - No gross blood, great rectal tone - he screamed even louder. And got sulky about how "some lady stuck her finger in my shitter." I do my best to treat all patients equally, but you do resent the ones who treat you like crap. You don't want a tube or a finger or a scope in every orifice God gave you? Don't get drunk and run your truck into a semi. And don't cuss out the trauma team. Don't friggin' cuss out the trauma team.
I cleaned up his wounds later, once he was out of the shock room. He had to know everything I did, asked me ten times what I was washing his arm with. He watched me use the same bottle of normal saline to wash his arm and his forehead, had to know what I'd put on the gauze I gave him to wipe the blood off his lips with. He wouldn't let me touch his left hand, not even to clean it off. I don't think he connected me and my doctor voice - soft and trying to be reassuring - with my trauma team voice - much less soft and much more brusque. I'm sure he would've said something if he had. He was pretty calm, if a little paranoid, by then.
He went home the next morning, after he'd sobered up. He was a very lucky jerk. He was also, according to BW, "still an asshole in the morning." The other gentleman has a long hospital course ahead of him. We're going to wean him off the vent today, and Neurosurgery (whom we called out of bed to see the CT scan, something AE pointed out to me as an appropriate reason for a consult after hours) will follow him.

And that was last night's story. I think I've probably given you enough eyestrain for now, O Best Beloved, so I'll leave you be. Tonight is my residents' meeting for drinks at the Rathskeller, followed by a working dinner at the Adams Mark for the Board of Trustees of the IAFP, doesn't that sound exciting? I feel so important. I wish it didn't keep me from Angel, though.
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