Puella cum Cultello

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

Tag: absurdity

One track mind…

Orthopods have a certain reputation.  This video embodies it.  Hey, at least they’re focused!

Welcome to Ringling Bros. Hospital – here, have an umbrella!

continued from here

sigh.

“Code alert” in the ICU?  There was only one possible culprit.  If the cardiac surgery attending called back, he’d miss my explanation, but I’d have to update him now anyway.  I left the call room and made my way to the ICU.

Wait a second, fire alarms?  Funny, I don’t remember hearing a “code red” being called.  Wait – no, there’s no way that Mr. T could have started a fire this quickly…  Could he?  Nah, he’s probably just pulled the fire alarm station or something.  I hope.

As I walked down the long hallway leading into the unit, I could tell that something was off.  For a start, it looked like someone had dumped half a linen closet on the floor.  Why were there so many blankets all over the place?  As I got closer, I could see that they were mostly clumped in front of one room.  And outside this room was one of our respiratory therapists, Jimmy.  But I’d never seen him like this before.

Jimmy was standing with one foot on the ground, the other planted on the wall, pulling closed the door to a patient room with all his might, and looking more than a little agitated.  “Uh, Jimmy, what the he-”  And at that moment, I looked through the window, into the room.

Oh…  Oh!  Um… what?!

I shook my head in disbelief.  My eyes had to be deceiving me.  Mr. T was standing alone in the room, on the other side of the bed.  He was also stark naked, looking absolutely incensed, with water pouring out of a sprinkler unit and directly on his head.  One look at Jimmy’s face told me this wasn’t a bad dream.  I looked back at Mr. T.

But, but… this doesn’t happen in real life!  This is like an episode of ER!

I got the rest of the story from Jimmy pretty quickly.  While the “code brown” from the earlier incident was being cleaned up, Mr. T managed to get away from his nurses.  He found another impromptu weapon and chased them, screaming in terror, out of the room.  He then proceeded to smash up two windows, his cardiac monitor, and the TV.  At some point, he also jumped onto the bed, ripping the smoke detector out of the ceiling with his bare hands and setting off the sprinkler.

And that’s how we ended up with two hysterical nurses, Mr. T in danger of drowning or slipping, Jimmy functioning as a sentry, and, by now, water seeping into neighboring patient rooms.  And those damn fire alarms – I couldn’t hear myself think!

I tried to find Dr. G to come up with some plan about how to tackle this.  He was preoccupied with trying to figure out how to keep the rest of the patients, several of whom were on ventilators, safe.

I headed back to Mr. T’s room, where the water was almost mid-calf by now.  Which meant that it we were only a few more inches from water reaching the electrical outlets.  Awesome.  So, instead of drowning, Mr. T might actually be electrocuted – along with the rest of us, since the blankets were proving a poor match for the rapidly escaping water.

“Anyone know where the circuit breakers or water shutoff valve are?  Anyone?”  Of course not.  Oh well, it was worth a try.  Dr. G walked by and I stopped him.

“You!  You realize this is all your fault?!”

His eyes grew wide. “My fault?!  How could this be my fault?  He’s your patient!”

“And who was complaining about it being too quiet earlier?!”

He just shook his head and chuckled quietly before walking off.

By this time, the local fire department had made an appearance.  Oh good, we finally had a hope of getting somewhere.  The evacuation was starting to move along too.  One by one Dr. G would take patients off their ventilators, and their nurses would hand-ventilate them during transport.  Well, they were being moved, until the firefighters refused to let the nurses use the elevators for the evacuation.  Because the fire alarms were still going off.

:facepalm:

Thankfully, a few moments later, we had the first sign of success – the sprinkler was shut off.  Hallelujah, praise the Lord!  Just in time too, because Mr. T and the rest of us were only a couple of minutes from getting the shock of our lives.

And oh look… The boys in blue were back again.  This time, I didn’t even bother giving my “please be gentle” speech.  They stood in front of Mr. T’s room, hands on hips.  The standoff lasted less than a minute before Mr. T put down his weapon and waded over to the door.

Gush.  Hundreds of gallons of rusty water flowed everywhere.  Lovely.

He walked out calmly, allowing the officers to grip each of his arms firmly and lead him down the hallway to an empty (and drier) room.  Here, he was immediately restrained, and given an extra dose of Haldol.  Once he was settled in, and I felt reasonably sure that he wasn’t about to attempt to kill another staff member, I turned to leave and find a place to document the heck out of this.

Not so fast.

“Doctor, I need to have a word with you.”  It was a police lieutenant…  How could I refuse?  “I understand that you weren’t very happy with how the situation earlier was handled.  Why did you call us back?”

Seriously?!

“Um… well.  Ahem.  Well… I didn’t actually call you back…  I’m not sure who did, but we’re glad you came.  We actually appreciated your people coming earlier too.  I just became a little concerned when they sat on my post-op day 5 patient and smushed his chest!  He’s just had major surgery and even though he looks pretty strong, his body is actually quite vulnerable, so we were just concerned for his safety.”

A few moments of grumbling later, I was finally free to go.  I slouched over to  the nurses station and collapsed in a chair.  This was insane.  How was I supposed to explain it in the morning?!  I started to write my note, detailing the events of the night.  At some point, I wondered whether I should also write a letter of resignation.  I soldiered on, and after a while, Dr. G wandered over and sat down next to me, holding his face in his hands.

girlwithaknife… what the #$@& just happened?”

I giggled, probably sounding about as deranged as I felt by now.  “I don’t know, Dr. G, I don’t know.  Hopefully, we can look back and laugh about this one day.”

Then I frowned at my own words.  “Just… maybe not today.”

Welcome to Ringling Bros. Hospital, enjoy your stay!

While most people are familiar with the idea of a “code blue” for communicating a medical emergency inside a hospital, they may not know about the many other codes we use.  Some are intuitive, such as “code red” for a fire.  Others are convenient ways for staff to communicate without embarrassing a patient who needs to be cleaned up – “code yellow” for urinary accidents, “code brown” for incidents of a fecal nature.  My least favorite is probably “code alert,” denoting a combative patient.  They seem to follow me around like a black cloud.  I joke that I have to dodge at least one punch per year.

Hmm…  That might be funnier if it weren’t actually true…

One incident is particularly memorable.  I was on call on a weekend night, hoping that things would remain calm.  While doing some quick rounds in the ICU, I started chatting with Dr. G, the medical intensive care attending.  Neither of us were especially busy, and he sounded almost disappointed – “It’s been kind of quiet around here for a few days.”

Famous last words.

I was in my call room when I heard “code alert” on the overhead speakers.  I don’t usually go to those – we’re more liable to end up in the way, and the nurses call if they need us.  But this one was one the cardiac floor, which meant that a surgical patient might be involved.  I decided to head over since I wasn’t otherwise occupied.

I arrived to find that security had established a perimeter around a patient who was talking rapidly into a phone.  He was brandishing a 10lb hole punch at anyone who approached him and rambling that people were trying to hurt him.  Despite multiple efforts to calm him, his agitation wasn’t improving at all.  The situation definitely had the potential to turn physical, so I pulled the security guards aside.  They’re pretty good with patients, but they needed to know a few things about this particular one, Mr. T:

“Guys, this patient had his chest cracked a few days ago for heart surgery.  The only things holding his heart and lungs inside his body right now are a few little steel wires.  If you have to take him down, please be careful, he’s not supposed to do any weight-bearing with his arms, and he shouldn’t get any pressure on his chest.”

“No worries Doc, we don’t take patients down.”

Phew!

My relief was short-lived because a few minutes later, a couple of the boys in blue showed up.  I made a bee-line for them and gave the same spiel.  They looked me over and responded with a dismissive “yeah, yeah…” before walking away.

The next few seconds unfolded as though in slow motion.  As they approached him, Mr. T was already moving to raise his hands in surrender.  I gasped as I noticed one officer reaching for his taser – Don’t tase him bro!  I don’t want to run a “code blue” in the hallway when his heart stops!  But I didn’t have time to say anything.  As Mr. T was moving to kneel, the officers had each grabbed an arm and twisted it behind his back.  What happened to being careful?!  Crap!  And now he was face-down on the floor with both arms behind him and two knees in his back, both officers almost sitting on him.  So much for sternal precautions!

By now, I was freaking out internally, but one of our nurses was freaking out audibly, screaming at the officers to be gentle.  I moved closer to the scene to try to calm things down.  My plan didn’t quite work, because then I was near enough to see that Mr. T’s face was quickly turning blue.  Instead of getting the nurse to stop yelling at the police, I joined in.

“Can’t you see, his lips are turning blue!  You need to get off him!  Right!  Now!  He can’t breathe!  He’s hypoxic, we need oxygen, where’s the code cart?  I want an ABG!  Who has the O2? – Get! Off! Him!  Move!  Get him on his back!”

Eventually the officers got out of the way, and we were able to begin treating Mr. T before putting him onto a gurney.  The “code blue” team had arrived, and since I had some major concerns about Mr. T’s physical condition, Dr. G agreed with my decision to move him to the ICU for the night.  He’d have closer nursing supervision, plus we could assess for any potential injuries from this little adventure.

I soon noticed that there had also been a “code brown” in the midst of this chaos.  Wonderful.  I picked my way around the mess and went back to my call room to put in some orders.

Haldol, to calm him down.  Stat!

Chest x-ray, to make sure his sternal wires were still intact.  Stat!

EKG, to make sure we hadn’t knocked his heart rhythm out of whack.  Stat!

Perhaps some Haldol to calm me down…

I had just finished sending a page to the cardiac surgery attending telling him about this incident when the overhead speakers went off again.

“Code alert, ICU.  Code alert, ICU.  Code alert, ICU.”

I looked heavenward with a sigh.

Somebody up there must really hate me.

to be continued….

The Art of Surgery

Much has been written about the art of medicine and how important the humanities are to our work.  Abraham Varghese has a TED talk in which he explores the art of the doctor-patient relationship far more eloquently than I could.  I’d encourage everyone to watch if they can.  I’ll stick to what I know instead – surgery.

Much of the vernacular of surgery seems dramatic in origin.  It’s no accident that operating rooms were originally called “theaters”.  In Thomas Eakins’ oil painting The Agnew Clinic, the good surgeon and his entourage occupy center stage with their patient.  They are surrounded by rows of seated observers, an audience of medical students whose expressions range from curious to horrified to bored.  Dr. Agnew, dressed in his surgical whites rather than street clothes, has just performed a mastectomy.  He’s no doubt pontificating to the students while his assistants finish the case.

Perhaps we surgeons are just performance artists?  Well, we no longer operate in theaters, though observation opportunities do still exist.  Let’s consider a hypothetical case.

The patient has been prepared in the peri-operative area – he has signed the consent, changed from his own clothes into a hospital issued gown, and an IV line has been placed.  He’s subject and audience of this play – he’s bought his ticket, changed into his costume, and been through the prosthetics department.  Now he’s about to leave the wings.

He’s wheeled into the operating theatre  room and positioned in the center of the OR, under a canopy of dimmed lights.  The anesthesiologist guides him to the twilight zone, where he will remain unconscious, paralyzed, amnesic.  The surgeon and her assistants then position him – an arm tucked here, legs propped up there,  a pillow under the head, as though he is a sculptor’s flaccid model.

Their subject positioned, the surgeons leave temporarily to complete their scrubbing, allowing the nurse to clean the patient’s skin.  The nurse and tech cover him  in blue drapes, marking out the sterile zone, exposing only what is necessary.  The lights are turned on and focused onto the operative field.  The patient is no longer visible, he’s been reduced to a slab of exposed abdomen.

By now, the surgeons have marched back into the room.  They form a line, with the attending surgeon first, followed by a senior resident, then a lowly intern.  Once their hands are dry, the scrub tech helps dress the lead surgeon for her performance, first one arm, then the other, finally tossing the rest of the gown over her shoulders.  The resident surgeons are left to gown themselves.  As the nurse ties their gowns from behind, the scrub tech helps each surgeon with their gloves.   “Shall we dance?” asks the attending, before pirouetting with the nurse to complete the wrapping of her gown.

The surgeons approach the patient, a troop of masked players, anonymous except for their eyes.  They adjust the lights while the scrub tech brings his table full of props closer.  There’s a brief pause to review the plan, spelling out the program for the day.

“Knife please.”  And with a flourish of the scalpel, the performance finally begins.

OK, perhaps I’m being overly dramatic.  We accept that for a successful, clean operation, patients need to be anesthetized, positioned, cleaned, and draped before an operation, while their surgeons must scrub, gown, and glove.  But do these rituals serve a need beyond their technical purposes?  While a well-established routine certainly helps us to remember all these steps, I would argue that it also prepares us for the bizarre acts that are to follow.

If you were to see a surgeon walking down the street, would you know?  After all, this is someone who enjoys using potentially lethal instruments to disassemble and reassemble other people’s bodies on a daily basis – the bodies of patients who have willingly agreed to allow strangers to drug and cut them.  What happens in an operating room everyday is far from normal.  In any setting outside healthcare, it might constitute assault and battery at best, torture at worst.  How could anyone willingly participate in this?

The ritual, being “on stage” and performing in costume, allows us to assume roles outside our ordinary selves, overcoming the limits of what we see as natural or normal.

The patient dresses for his part and becomes a willing subject.  He’s about to allow strangers to make him lose consciousness before they break his skin – but it’s OK, the rites of preparing for surgery have marked him as a patient rather than a victim.  In a hospital gown and with an IV in his arm, he’s here to be cured, not killed.

Once scrubbed, gowned and gloved, I’m no longer girlwithaknife,  I’m now Dr. girlwithaknife.  I’m no evil torturer, I’m the surgeon to whom this patient has entrusted his health and given his permission to operate.  I can allow myself to press a scalpel into another living person’s skin without fear, because he needs my skill.

So, we may not be performance artists – but for a surgery to succeed, every person in the room needs to fill a role that goes far beyond the ordinary.  And perhaps our funny costumes help us do that.

That awkward moment…

… when the evening news and your work collide, causing your parents to freak out.  I was talking with my dad on the phone one evening.  Of course, being far away, he often worries about my safety.

Dad: Have you been hiking lately?
Me: Nope, not recently, haven’t had time.
Dad: Good.  Stop doing that.
Me: … Wait, what?  Why?!
Dad: There was a bear attack near you a couple of days ago, the poor person-
Me: sighing Dad-
Dad: was out in the woods and out of nowhere-
Me: Dad!
Dad: rising panic this bear came and attacked them and they were horribly injured! It was all over the news and-
Me: Dad!  I know.
Dad: Oh good.  It sounds like it was terrible, and-
Me: That’s one of my patients…
Dad: … Oh… sternly So you’re never going hiking again are you?
Me: 

 

I’m pretty safety conscious anyway, perhaps even a little too cautious.  But if I worried about every type of injury I’ve seen, I’d tell you breathing is dangerous – you might choke!