General Surgery: Sunday Call

Whew, thank goodness I got Saturday off; I really needed the break. Sunday morning started out the usual; we rounded on patients, then went to the ER to see any traumas that needed to be seen. One of the first guys who came in had a stab wound beneath his ribs; BR probed it with a cotton swab and found it to be about 4 cm deep. CT didn't show any peritoneal penetration, but it couldn't be ruled out so arrangements for an exploratory laparoscopy were soon underway. BB would be doing the exp lap since JB was out of town (he didn't come back until 4:00 pm).

Then a fresh trauma was called in: victim with GSW to the head, ETA 9 minutes. This sounded like a case we saw last week, so we all gowned up and got ready. When the paramedics brought the patient in, however, I was caught off guard when I saw that it was a young female in her twenties. There was blood all through her hair and her left eye looked completely swollen. The police had the story: apparently the girl's boyfriend shot her through the eye in a fit of rage before turning the gun on himself (and did the job properly) By the time she got to the ER, she had PEA (pulseless electrical activity) from all the blood lost; we couldn't palpate a pulse anywhere. Sometimes after CPR we'd feel little blips of pulse, but it was rarely followed by another one. Her hands and feet were pale and cold (all the remaining blood had gone to the internal organs), and a blood transfusion did nothing to improve her volume. A doppler was used to find her heart, and while her heart was visibly twitching, the attending (who also happened to be Corey's preceptor) pointed out that her heart muscles themselves were not contracting. Time of death, 13:51. *sigh* This was a sad case, even worse when she was rolled over and I saw that the sheets and the backboard she was riding on were completely soaked with her blood. I had to put her clothes in a paper bag to accompany her body to the ME's office and hold the backboard while the nurses scrubbed it down. Later I found tiny specks of blood on my sleeve, but it was nothing a wet paper towel couldn't take care of. Still, it was unnerving.

Corey was waiting outside when I came out (he didn't see the trauma), so I filled him in on what was going on. He said he was going to see the exp lap on the stab patient with his attending, so I took that to mean I wouldn't be able to watch. While BB went to surgery, I followed BR and RB to McDonalds for lunch and then ate in the Commons (lounge) b/c the guys wanted to watch football. There was a Cowboys vs Giants game later in the afternoon, and my interns were hoping no traumas would come in so they could watch the game. Sadly, that was not to be. RB had to put a central line in a preeclampic patient in L&D (never thought I'd have to see the inside of that place again), but after 3-4 tries he couldn't do it (the girl had a bad case of generalized edema; poor girl was in a lot of discomfort) so I paged BR to come help him out. To our surprise, JB came with him (he finally made it back to town). BR couldn't get the line in either, but JB got it in easily. Later he (nicely) reprimanded me for contaminating the sterile field by putting a syringe down on the blue sheet; I don't even remember if I apologized =(

The guys managed to catch a play or two of the Cowboys game (the OB residents were watching it in an empty room) before we had to go back down to the ER. More MVCs rolled in, and one patient (a nurse, it turns out) was flown to the ER after she got drunk and fell off a scaffolding. She kept yelling that there was nothing wrong with her and threatening to pull out her IVs; BR had to go in and get her to cool down. I then went to see a patient who had an unsuccessful I&D on an abscess on her butt; apparently whoever did it told her to leave the wound packing inside the wound for a week, instead of changing it twice a day, and the stuff was oozing pus. Really gross. It really hurt, too; she wanted to hit RB after he tried to peel the scab off to see how deep the incision was. At one point the Short Stay nurses tackled RB and tried to get him to see a patient who'd been waiting for about 8 hrs, so I was sent to talk to him before the ER attending handed me another chart. This man had a huge swelling around a hernia incision site that was non tender to palpation (rule out abscess?); JB later stuck a syringe in there and drew out blood. It was a huge hematoma. By this time the football game was over and both doctors and nurses were griping about how they couldn't watch the game and how it sucked the Cowboys lost.

I followed BB and JB on rounds, and in the ICU, JB asked me what the point of a Swan-Ganz catheter was. I forgot (I just remembered one prof's story about "floating a swan"), and I proceeded to get pimped on the different types of shock, CVP, PCWP, preload, afterload, etc. Some I knew, others I didn't. "You got to know all these well for medicine," said JB. "All right, that's enough midnight teaching." Whew. JB and BB retired to their room around midnight so I did the same (even though BR suggested I watch RB drain the "butt pus" I was exhausted) Because I don't have a trauma pager, I felt bad about sleeping through the night, so I set my alarm for 2 a.m. My timing couldn't have been more perfect; a patient was brought in after he slit his own throat 2-3 times (he owed someone money and needed a way out). BR said that he was originally going to wake me but let me sleep in, so it's a good thing I woke myself up. There was a police chaperone not far away as RB and BR cleaned the patient's neck and prepared to sew him up. They did the deep stitches while I did some of the surface sutures. There was also a burning smell in the ER b/c the nurses burned a bag of popcorn. At 4:30 a.m. we all went back to the lounge. I slept until 6:15, but the two interns barely had a chance to lie down before getting paged again. The morning went by in a blur but finally at 10:40 we were free to leave.