Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Outside hospital – ain’t so funny in real life

The Outside Hospital video is great satire – and like all good satire, it shines a very bright light on some uncomfortable truths.  In this case, we’re given some examples of medical hot potato: the patients who do poorly in some God-forsaken outpost before being transferred, with very little useful documentation, to a tertiary care hospital in the Big City.  Sadly, most of us in the trenches of these hospitals have our own memories of being handed a trainwreck with very little back story to help us out.

Mr B was my hot potato.  I was the surgical ICU nights/consults resident, and I got a quick phonecall from the chief resident a couple of hours into my Friday night shift.

“We’ve got a transfer coming in from Outside Hospital, it’s a 78 year old guy who had surgery 3 days ago for gallstones.  Sounds like there might have been some kind of intra-op injury, he’s had a rising white blood cell count and hasn’t gotten better despite antibiotics.  I don’t really know too much else, Dr J [our attending] accepted him and said they sounded like they just gave up.  We’ve requested their scans and notes, but do a history and physical and get some labs when he arrives and give me a call, he should be there around 10pm.”

Phew.  So a potentially very sick old man, and it seemed like we were didn’t have the full story yet.  I’d have to wait it out and piece it together once he arrived.

Sure enough, around 10:30pm, my pager went off. “Mr B is in room 525.”  *groan*  Great.  I had no idea how sick he might be, but he’d scored a bed on a floor that wasn’t used to taking care of anything but the most stable of patients.  I trudged up the stairs, complaining under my breath about this case already.  And that was the last peace I had that night.

I walked into the room, and introduced myself to Mr B’s daughter and wife before turning to say hello to the patient himself.  One look told me all I needed to know at this point.  He was sick, really, really sick, and he didn’t belong on a regular floor – certainly not a floor with no cardiac monitoring.  After saying hello to Mr B and his family, I excused myself and marched right over to the telephone to wrangle with the admissions people.

Me:  Mr B needs to be in a bed with cardiac monitoring.

Admissions:  We only have one regular monitored bed left, and that has to be saved for ER admissions.

Me:  Well, I don’t care where you put him physically, he just needs to be on a cardiac monitor, he’s too sick to be left on level 5.

It went back and forth like this for a few moments, until they agreed to let him have an ICU bed with basic monitoring status.  This was a decision that would serve me well later on.

I went back to the room and finally performed my full history and physical.  I began to have sympathy for vets and pediatricians.  The patient and his family were vague about the details.

Mr B had abdominal pain a few days ago, they went to Outside Hospital and the surgeons told them he needed emergency surgery.  He woke up feeling a little better after the surgery but still had fevers, jaundice, nausea and vomiting 3 days later and then the doctors at Outside Hospital said he needed to come here.  Oh, and his incision was still hurting a little bit.

That was it.  They had no idea which surgery he’d had, no idea why he had it, no idea why the other surgeons thought he wasn’t getting better.  Nada.

I took a deep breath before telling them my plan.  Get labs, start antibiotics, transfer to the ICU, ASAP.  Then I can figure out what the hell’s going on, I thought to myself as walked back to the nurses’ station.  I hoped the notes that came from Outside Hospital would help me.

Ha!  Wishful thinking.  Two hours later in the ICU, I was still sifting through them.  From the reams they’d sent, I had managed to pull out a handful of potentially useful pieces of paper:  two pages of labs (one pre-op and one from that day – stratospheric white count and liver function tests on both); a short typed up history and physical from the ER visit; a barely legible post-op note, from which I could just about tell their diagnosis and operation; and scrawled, completely un-readable notes from the day after surgery.

No operative note to tell us what they’d found or their operative technique, no interval labs or other tests, no discharge summary.  Just a big stack of nursing notes.

At this point, I texted the chief resident with our lab results (high white blood cell count, elevated liver enzymes), and my antibiotic plan, just to keep her in the confused loop.

A couple of hours later, in between taking care of other patients, Mr B’s story was finally beginning to make sense to me.  Then his nurse came over to tell me that he was having some respiratory trouble.  We got some x-rays to make sure he didn’t have a raging pneumonia or heart failure and he perked up for a little while after breathing treatments.  My note was almost done (finally!) when she asked me to take another look.

This time, Mr B had taken a definite turn for the worse, and even from the doorway, I began wondering whether we should intubate him.  After telling the nurse to begin another breathing treatment immediately, I left to ask for a quick second opinion from the medical intensive care attending on call.  Less than 30 seconds later, Mr B went into cardiac arrest.

The usual chaos ensued, and in the midst of the code blue, my mind was racing.  Had I missed something in his history?  Given how little I had to work with, it was possible, but there wasn’t much more I could have done differently that night.  Did I under-treat his respiratory issues?  No, my treatment when he first had breathing trouble had been appropriate.

Did I delay intubation too long?  Well, less than a minute had elapsed between the time I learned of his new breathing trouble and his cardiac arrest.  There was no way that we could have called anesthesia and had him intubated in that time.  But there’s a saying in medicine: if you’re thinking about intubating, you probably should.

By now, I could hear his family wailing in the hallway outside his room.  And in between her sobs, I heard his daughter say something that made me want to punch a wall.

This didn’t happen at the other hospital!

I don’t think I’d ever been that angry with a patient’s family before.

No, no it didn’t.  Of course not.  Because Outside Hospital passed the buck before it could happen.

Outside Hospital

Some humor for the new interns – you’ll discover that it would be funnier if it weren’t true.

Excuse letter to my readers

Dear readers,

Please excuse my absence from the internet for the last few days, as I have been traveling.  I have had limited internet access and excessive physical and mental exercise.  I shall be back to my keyboard by next weekend.

Yours most apologetically,

girlwithaknife

No, really…

I’m not that good.  The lovely Gemma appears to disagree and sent me a completely undeserved “One Lovely Blog” award of appreciation.  It comes with a few rules, but I’m going to be a wet blanket and only observe the first two:

1) Thank the person who nominated you and link them in your post.

Thanks for the recognition!

2) Share seven possibly unknown things about yourself.

Here goes nothin’:

1.  When I started medical school, I had a list of specialties that I didn’t want to go into.  Surgery was number one.

2.  The first time that I first-assisted on a case during med school, I knew I was in trouble.

3.  My alternative career choices for medicine were to be an astronaut or a journalist.

4.  I wanted to be the next Christiane Amanpour but later realized that I would have been a terrible journalist.  I would have quit because the editors messed with my writing too much.

5.  I would have also been a terrible astronaut.  I’m a nervous flyer.

6.  I didn’t eat chicken for a full year after doing a dissection in high school.  We were dissecting a cat and the muscles looked way too similar.

7.  I think Scrubs really is the most accurate medical show.  Not only were the generally quite accurate on the medical facts, they also captured the emotion quite well – the minor victories and losses that we experience in the hospital everyday.  Though I have yet to reenact West Side Story in the halls.

Think I’ll skip that ER, thanks

Do you know what they call alternative medicine that works?

Medicine.

Words (not) to live by

See one, do one, teach one.

It’s an old phrase in medicine, and it embodies a teaching philosophy that has been passed on for decades – observe, practice, then pass on the skill.  During my third year medicine rotation, that expression was turned on its head once or twice.

Do one, see one, teach one.

I was asked to access a chemotherapy portacath – despite not having seen a port or the needles inserted into them.  The intern dictated a list of supplies and told me the requisite steps, along with a couple of technical tips (namely, “it’s a big-ass needle, don’t stick yourself!”).  I scurried off to the supply closet, eager to get started.

In many institutions, physicians are responsible only for placing central access catheters, which go into the large vessels of the neck and chest.  Specialized nurses will place difficult IVs or peripherally inserted central catheters, and they also access ports.  This allows these nurses to gain experience and develop immense skill in a small range of tasks.  They truly become specialists, and they are far more proficient with those tasks than most physicians.  However, this hospital didn’t have an IV therapy team, union contracts prevented nurses from dealing with most vascular access in a timely fashion, and these issues fell to the already overworked house-staff.

So, here I was, a medical student with less than a year of clinical experience.  I was about to stick a large bore needle into a patient’s chest, aiming for a small device that carried silicone tubing straight into the heart.  I had no frame of reference, no prior experience, for what I was doing.  I had some understanding of the potential complications (infection, thrombosis, air embolism), but the intern didn’t review them formally with me.

Yet no one questioned the appropriateness of this situation.

My intern was happy to have another task checked off his seemingly endless to-do list.  The nurse was glad to have vascular access in her patient without doing it herself.  I was excited to actually be allowed to do something, anything (“I get to touch patients!”), though I definitely had some trepidation about the matter.  And the patient was eager to just have the whole ordeal over with.

Of course, I struggled a little.  I improvised a lot.  I kept hearing a voice in the back of my head – “fake it till you make it”.  And, eventually, both the patient and I survived the procedure relatively unscathed.

But would this situation be acceptable to me as a patient?  Absolutely not.  However, the hierarchy of medicine and my eagerness to be helpful prevented me from insisting on more appropriate conditions.  I was too chicken to refuse, for fear of stirring up trouble, delaying patient care, and losing future opportunities.

Every doctor has to learn, and we all start with very little knowledge.  We slowly gain knowledge and experience under supervision, an apprenticeship if you will, before we’re left to our own devices.  But this should happen in a stepwise fashion, with incremental increases in latitude and responsibility.  Instead, all too often, it’s haphazard, and junior trainees are left to sink or swim – along with their patients.

The three hapless amigos

Friday nights are perfect for hanging out with your buddies and partying, maybe going a little nuts.  It’s just innocent goofing off, all fun and games… until someone wraps a car around a lamp post and the three amigos are pulled from the wreckage.

Well, first, there’s the dead one.  He never had a chance.  The impact tossed him around for a few seconds, until he was ejected.  He landed 30 feet from the car.  There was no life left in him to salvage when the cops arrived.

Then there’s the organ donor.  He was driving.  By the time the medics got him out, his body and brain were already giving up.  They kept his body alive long enough to get him to the ER.  Then we were able to keep him alive long enough to gather the family.  Mom, dad, and little brother look shell shocked this morning.  Grandma’s still crying.  There’s about thirty friends with tear-streaked faces loitering about in the hallways.  People are asking each other, “How could this happen?”

Easy peasy, I want to reply,  Take three young men who believe that they’re special immortal snowflakes, add a case of beer, and the keys to dad’s sports car.  Voilà.  Instant wreckage.

Instead, I walk past, head down, in respectful silence.

Finally, there’s the spoilt brat.  There’s always one.  He has a couple of extremity fractures and the delightful attitude of Verruca Salt.   He appears to be doing his best to antagonize the nurses. Periodically, you’ll hear him bellow from across the ward, “Nurse!  I want some water!  Nurse! Where’s my food, I’m hungry!  Nurse!  Gimme my pain meds!”

I wonder if he’s confused and believes that he’s at Burger King.  You don’t get to have it your way in the hospital, buddy.

Perhaps, for now, he thinks he’s the special-est snowflake of them all.  But eventually,  even he will melt into nothingness.

Professional relationships

At a medical convention, a male doctor and a female doctor start checking each other out.  The male doctor asks her to dinner and she accepts.

At the restaurant that evening, she excuses herself to wash her hands once they’ve ordered.  The food, drink, and conversation are enjoyable to both.  After the meal, she goes to wash her hands again.

One thing leads to another and they end up in her hotel room.  Just as things are progressing *ahem* nicely, the woman interrupts and says she has to go and wash her hands.  She returns and things really get hot and heavy.  Afterwards, she gets up and to wash her hands once more.

As she enters the room, the male doctor says, “I bet you’re a surgeon.”

She confirms and asks how he figured it out.  “Easy, you’re always washing your hands.”

She then says, “I bet you’re an anesthesiologist.”

He is stunned,  “Wow, how did you guess?”

“Because I didn’t feel a thing.”

Keeping control

You immediately wonder what actually happened.

She came in with increasing abdominal pain after falling down the stairs 3 days ago.  It’s an isolated splenic injury.  The story doesn’t add up.  The mechanism of injury doesn’t fit.

Why wait so long?  What is she hiding?

Her boyfriend seems off-kilter from the start.  Something about his manner – his eyes, his words, his tone – he reminds you of someone you once knew.  Someone you thought you’d never have to see again.

She barely opens her mouth to speak.

He answers for her.  He controls the conversation.  He becomes her voice.

Her ex-husband and son are with her as well.  They ask to speak to your team after rounds.  They don’t believe her.  They’ve seen what she’s become – a shell of herself.  His plaything.  They know.

He did it.  He’s done it before.  He’ll do it again if – when – she goes home with him.

The next day, he knows he’s been exposed.  He’s far too friendly, too obvious, too familiar with all the women in the room.  He gives you an ingratiating smile.  It’s a calculated greeting, intended to give him the same power over you.

Your stomach turns, and your jaw sets.  You can’t – won’t – refuse to – look him in the eye.  He cannot have that.

She finally goes to the OR when the bleeding won’t stop.  You want to shake her when she wakes up, to make her see sense, to give her the courage she needs – before he sees her, before he can bewitch her again.  Your fists clench, and the flames begin to burn inside you again.  Because you know how this story goes.

But in the end, you realize… this is not your battle.  And she’s not the one you’re really angry with.

The Colorectal Surgeon Song

Workin’ where the sun don’t shine…

Yeah, there’s probably something very wrong with many of us surgeons. :p