Peds ER: O.M.G.!!!!

Okay so today is my day off (ha!) in which I have to attend lectures/grand rounds for ER residents. So I listened to a few good lectures then i was told we were going to attend trauma lab (dun dun dun!).

We were lead down a labyrinth of hallways lined with pipes and broken 70s tile. The woman pointed to a stack of paper gowns, hats, booties, and other surgical coverings and told us to 'gear up'. We were then divided into teams of 3 and lead into a sterile room with two steel slabs. There are two human-sized, hairy pigs laying upside down tied down with a tube coming out of their mouth.

A dorky, gangling guy in bright blue scrubs, who I assume is in charge, walks into the middle of the room. "These pigs are anesthetized." Without hesitation he leans over grabs a large cleaver and stabs one pig in the chest 4 times and then grabs a bat and smashes the other pig a couple times as hard as he can.

I fight off this wave of nausea and suddenly got really sweaty under my green latex gloves. I am trying not to think about the crunching noise of the pigs ribs or the twitching of his legs. I am thinking don't get sick, don't get sick.

"What are you doing standing around? SAVE YOUR PATIENTS!" The guy yells pointing at the injured pigs.

Suddenly the room lurches into motion and everyone swarms around the pigs. I don't even realize what's going on, but I am moving without thinking- standing beside the stabbed pig. Its' blood is throbbing and spurting out the stab wounds, its obvious the heart and lung was punctured.  I look up because this girl is handing me a scalpel to do a thoracocentesis (pop a hole in the chest wall to release the air that is preventing the lung from inflating). I'm kinda nervous because its not like I've ever done this procedure or seen one or even really paid attention to reading about it.  The other team is frantically moving about and my team members are splitting open the chest to try to stop the bleeding from the heart (which we have to visualize). So I take a deep breath, find the intercostal space and make the incision. The muscle twitches and warm blood trickles down to pool on the tray. I shove my finger in the hole trying to find the appropriate space to get through the muscle. I put a hemostat in the warm muscle with my finger and spread them apart hoping that this is the appropriate technique. The girls are now shouting because they are pulling apart the rib cage on the other side of the pig- the hole is smaller than we thought, which makes it harder to plug up. They need me to hold some things open.  I shove a plastic tube in the hole I've made and wait for the barely audible rush of air before i struggle to throw a few stitches around the hole i've made so the tube doesn't slip out. I then rush to wrench the metal contraption that is holding the ribcage open. The purple red heart is pulsing furiously, the phrenic nerve is beautiful!  They insert a foley and inflate it to stopper up the heart temporarily. She says we need to establish an airway since the heartbeat and become unstable. So they hand me the equipment and keep calling me Crystal which I don't really correct at the time.

The man in blue scrubs comes to observe our table and shouts at me "to get it together." And i try to insert the tube down the pigs throat. In the meantime, one of the interns at the other table shrieks while a spurt of blood shoots at the ceiling and narrowly misses my paper cap. And I slipped, the tube enters the esophagus and I have to pull it out and retry.  I try to ignore the fuss happening at the other table as they urgently buzz from one side of the table to the other. The intern at our tables also began to yell as blood began to seep past the seal. I didn't see what exactly went wrong but soon the blood began spurting and I failed intubating a third time. I attempted a cricoidotomy but failed just as the last of the seal broke off. The blood was flowing freely now and had stopped spurting so much as oozing. We realize that we are in deep here and somebody shoves me outta the way and fixes the airway. They ask me to help on a femoral line to get a pacemaker in but before I am able to get the equipment the man in blue scrubs demanded we call it.

He promptly berated us and demanded we discuss what went wrong. He demonstrated the use of a transcutaneous pacemaker on the quivering heart that still oozed despite the lack of fluid pumping through its walls.

It was only at this point I explained I didn't know who Crystal was and that I was only a third year student. The man in blue scrubs was the third year resident and he said we did alright considering. The pig was given some extra drugs to make sure he would never wake up.

I stayed afterward and sewed him up. I wanted to give what thanks I could for the life he gave. I truely hope he didn't feel out botched central line attempt or our interosseus femoral line or any of it. Plus it was good suturing practice. So thanks piggy.

So a bit of of history.... (because i had to ask.)
I found out this has been done one time a month since the 70s. They used to use dogs, but pigs are more anatomically similar to humans. This activity is approved by the animal rights people. I was told that we justify it by knowing that as future physicians in this scenario we will use this information and would rather practice on a pig rather than a real human.

Peds ER: day 1

so. today is the first day of pediatric ER. It is different than internal med. Somehow I don't feel quite so overwhelmed as I did there. It still wasn't easy-- but it was more comfortable.

So i get to work with one doc, two residents, and a nurse. There are only 8 beds and its attached to the main ER.  Its only open at nights because most parents don't bring kids in till after school anyway.

It was an ER just like any other-- lots of kids are sick or hurt-- fingers need stitches,etc.   I only saw about 6 patients or so where I got to do much... i know i didn't really impress the doc, but i wasn't totally retarded I hope. I have lots of hope for this rotation.

IM: presentation

so today we were getting pimped on stuff and me and my fellow student disagreed with the attending on a particular point that we had read on the night before.  He was like "oh well, why don't you do a presentation for me in 3 days?"  So it was about Proton Pump Inhibitor Side effects (things like pneumonia, C. diff, and fractures).

So we did all this research on studies done about it. And put together a powerpoint and then the doc was all, well i forgot about your presentation so why don't you just present it tomorrow in front of the ENTIRE hospital at grand rounds. Besides peeing our pants, we were surprised. So we presented this in front of the entire hospital. We had print outs of the studies and out powerpoint and we had NO IDEA what we were supposed to say.  But I guess everyone was impressed. Residents came up to us after and said we did a really good job and the program director for IM said he wanted to write a letter to our dean. He actually wrote that letter and recommeded me for honors! Which is totally awesome!! YAY.

IM: a week summary

So I'm surprised to say this-- but I definitely like internal medicine. I was walking around the floor with the interns and still unable to answer questions and still not the favorite and-- i felt relaxed anyway. I felt like the team I was with was good and I liked what I was doing. It wasn't thrilling, but it definitely made me think internal med could be an option.

IM gives you time to think about your patient and research it. There is something to be said about time to think. There is something to be said about constantly thinking about your patient, seeing them several days and googling things. The residents had time to cancel their stat orders or reorder wrong tests. It takes a bit of the stress off.

Anyhow, I don't know if i'm learning as much I should be. I have two patients everyday and I follow the interns around. I probably ask too many questions, but I do it anyway. I think they got used to it because several of them asked me to hang out outside of work.  One I even went to dinner with at this amazing jazz club bar.   But I wish I was getting pimped more questions and going through more ways to diagnose. I should be reading more instead of doing these stupid presentations for lazy doctors who don't want to read the new studies they use the medical students to do it and then present the important stuff. Genius really. I should be reading more though.

I've noticed that the doctors linger more at the nice people's room. The little old lady with the fecal impaction gets tons of attention while the guy with pancreatitis who screams in pain we only go in for about 5 minutes. And what's worse.... I think i'm starting to do it too.  I spent over 3 hours reviewing her chart and about 20 minutes researching pancreatitis.  I have to be careful of falling into the trap like so many doctors do.

This week I also witnessed my first death note. The patient died on the floor and we had to come in and declare them dead. Had to do all the reflexes and listen to heart and lungs and all the legal stuff. The lady was 40 and starting to go into rigor mortis already. She was very waxy and just staring at the wall with her eyes open.  Even though I knew she was dead before going into the room, seeing her like that made me instinctually back out of the room and my veins fill with adrenaline.  I have no idea why, i've seen plenty of dead people-- but this lady just freaked me out.  Turns out death notes are really important if a legal case gets brought up. There is a particular way to do them and its so unlike SOAP format.  You have to state not just time of death and reflexes but also discuss organ donation, funeral arrangements, things for the mortician, you have to list every device or line on the body (including IVs and foleys which you can't remove).  It was educational.

I have to go to bed now.... but more cases to come.

IM: new eyes

Yesterday, we had a new chief resident. She swept in and organized everything. Patient lists and defined our roles and what we can and cannot do... It was amazing! What a difference it made.

Today, we got the new interns. The senior resident always changes first so they can get a handle on what has been done so they know where to go.  We have the best possible team.  One black guy who really likes to teach, one OB resident who doesn't know what she's doing but is confident she can learn and help us learn, and one indian resident girl who doesn't know what she is doing but knows enough to recognize it and let us help.  I am floored by the difference this made in the day.

To top it off, we were long call today, which means our team admits patients from the ER until the night team takes over. So i was chilling in the ER. We had about 4 admits. I only got to see one, but the important part wasn't even witnessing the admissions. It was having the interns, who had down time, take the time to teach us HOW to think about the case.  The black intern is really good, he took me step by step through what i should do, questions i should ask, and how i should think about the answers. It's probably all stuff that other people know or figure out. But since I'm slow or something, I benefitted from being told.

Doing rounds with this new team and watching how they make decisions I suddenly understand much more about what IM at least is about.  We don't have to research and understand the entire picture of the patient like i was trying to do earlier. Its more about preventing any complications and simply treating them to be stable enough to leave the hospital. You don't have to fix them, you can't even if you wanted to.  You just get them stabilized enough that they can go back to their lives.  That may sound harsh, but its the only way we can handle our 20 patients a day.

Let me give an example of JJ- he was my patient the second day. The one I said I couldn't finish even in 4 hours.  He's an 82 y.o. african american male who was admitted because of a 66lb weight loss, unexplained. He said he didn't want to eat for the past 4 months. He gave me several reasons why over the past 4 days (because i've followed up with him) 1- he was afraid to swallow because he choked 2-because he wanted to die 3- because he couldn't swallow.  Now while these seem like tiny differences and some ppl might say this discrepancy is because I asked the same question for 3 days in a row, each answer points to different causes- drastically different.  Psych, cancer, and muscle spasm.  The worst part is because he's so old and he's also sick with (to name a few)  COPD, diabetes, hx of cancer and now has malnutrition symptoms it could be any of the three possibilities.  This makes how we treat him, what tests we do, and what questions we ask change everyday (maddening, i know).

I've been following JJ for awhile now and then one day in front of the new attending he gave drastically different answers(making me look like an idiot)- which made the doc think of several more tests to run. Then there was a big hulla-bullo because his family said do the test but they aren't going to treat him for anything. So we ran the test- He has a hiatal hernia, which explains his weight loss. But the doctors weren't happy about it. Its an easy fix and would increase his quality of life. So the family doesn't show up for 2 days.  But there is something else that is going on because his blood pressure keeps dropping suddenly now. We keep having to call a code purple on him-- that's get the paddles ready he's failing.  And the docs are getting frustrated. Several days ago he was fine- we were sitting at his bed laughing about his son and how i had to ask him these silly questions everyday. Then the family comes back and says we never said that fix our dude! So now we're trying to fix the guy who we've let tank almost too far. Nobody knows what to think about his case now. We were going to send the guy home, but now... now we're admitting him to the ICU.  He may have been a thin man before, hadn't eaten really in 4 months, but now he was near unrecognizable. The jutting cheekbones and the fact that you knew he didn't have any teeth before he opened his mouth made him look like an alien. He can now barely talk. ANd i still don't understand why he changes his story everyday or what we could have done differently.

His story makes me understand why we round everyday. IM is simply about keeping the patient alive for another day. IM isn't about cures or diagnosis. Its about staying one step ahead of the complications and of things getting worse.  Which i still don't feel capable of doing-- but even though I still feel overwhelmed everyday I feel like I have a better grip on what is happening. At least for now.