ICU: First Call

I was on call yesterday, and it was one of the longest days ever. Today we rounded with one of the ICU attendings, Dr. ML, who is very smart, very nice, and loves to teach. He does bedside teaching, which means we can spend anywhere from 10 to 30 minutes (or more) with each patient, depending on their pathology. We had a lot of patients this morning and didn't start rounding until almost 9:00 a.m. (we usually start by going over everyone's imaging studies before seeing the patients), and since I only had one patient to present, there was a lot of time just standing around doing nothing. Mike and Jay, as usual, were on top of things and wrote orders whenever they could, and on rare occasions Garrett and I would beat them to the punch and grab the orders folder before they did. Finally, with three patients left to go at 1:30 pm, Dr. ML told us to grab some lunch before the cafeteria closes. As usual, the cafeteria sold the most unhealthy stuff (chicken enchiladas, sausage and rice), but had pretty good desserts. Since Garrett and I were sitting at one end of the table, we began chatting about how we felt about the rotation so far. Garrett liked to do procedures (future anesthesiologist), and he signed up for ICU b/c he was told (as was I) that you get to do a lot of procedures in ICU. Standing around wasting time was not his idea of fun. That's why we've decided to take call on days when it's just the upper level resident on call, so we can do more procedures.

After we saw our last patient, I thought that was the end of the day, but we went to a smaller room to run the list. I chatted with Heather and Eddy about the residency application process and asked how much influence the residents had on whether an applicant is accepted or not. The answer: a lot. At JPS, the applicants are grouped into thirds, and most residents who get accepted made it into the upper third (obviously). Residents are asked for feedback on interviewees (i.e. interviews, dinner or happy hr meetings, etc), so I'll be sure to attend most pre-interview socials if I can just to get my face known. Mike, who has already submitted his ERAS, says he's going to have an interview here at the end of the month (since he won't be back to TX for a while). Jay, like me, hasn't submitted his ERAS yet so he'll have to come back, but he and Mike have already become good friends and act as though they'll definitely be at JPS next year. I hope for their sakes that it works out.

Early in the evening I had nothing going on at first, so I chatted with the ICU attending on call, Dr. O (but Dr. ML was still doing stuff around the unit). Dr. O is extremely nice. He asked me what I was interested in, whether I wanted to specialize, and where I wanted to go. And because there was some downtime, he sat down with me and began teaching me about various ICU topics like acid/base disorders, fluid replacement, and more. Aaron saw us and joked, "What lies are you feeding her?" Then we got a call from the ENT team about a woman coming in with necrotizing fasciitis to the neck. Her CT showed air pockets in her throat (definitely not a good sign) and when we saw her, she was leaning forward to breathe and had what looked like a huge goiter under her chin. Yikes. While that was being drained in the OR, we got another consult in the ER, so we went down two flights of stairs to see what was going on.

Previously, when JPS had proposed having an ER residency, I wasn't impressed with the idea of residents spending 3-4 years in the old JPS ER, which was too small, nasty-looking, and disorganized. But the ER in the new pavilion is large, clean, and much more organized; I easily got lost in there at first. There are some parts of the ER that are starting to smell bad b/c of the patients that come in, but it's still a great improvement from the old ER. A potential ICU patient came to us b/c he had a seizure while driving and crashed into a tree, and despite Aaron's calls to the ER telling the team not to intubate the patient, by the time we got down there he was paralyzed and in the process of getting intubated. Dr. O said that it's not a good idea to intubate seizure patients right off the bat but said that's what they tend to do in the ER. I did notice that the attending was an ER physician that no one seems to respect very much; I've heard surgical residents say negative things about him before, mostly along the lines that he has no clue what he's doing.

When we returned to the floors, I had time to run across the skywalk to the old building to get some food from the cafeteria (namely, a chocolate cheesecake and an apple as snacks) before Dr. O took me to do my first central line. It was on our lady with the neck abscess (I don't want to call it a neck fasc; they also say it might be Ludwig's angina). Dr. O showed me where to place the needle, but he ended up pushing it in b/c I couldn't (kept hitting the clavicle). I did an okay job of feeding the wire in, but it was harder than I thought. I don't think I'll be able to do any of these alone anytime soon, but it was good to at least get the experience. And I found that I still remember how to do one-handed ties, which is great =) Aaron was going to let me do an arterial line on another patient after showing me how to do one (unlike Loan, he barely made a mess), but even while under sedation, the other patient kept tensing and it was hard to stabilize his hand. Aaron came back from writing a note or two thinking I'd set everything up, but when he found out that I did nothing he was visibly annoyed. "I showed you how to do it, you should at least set it up," he said. Great, now he thinks I have no initiative. But later he saw for himself that this patient was not an idea candidate for an art line, so he let me off the hook...for now.

By this time it was past midnight, and with nothing else to do, I was happy to retire to the call room (I managed to get an empty resident room instead of having to share the third year med student room with 2 others) and sleep. I got up at 5:20 to eat and see my patients. On top of my pancreatitis guy (whose condition has been the same for days now), I saw two others, including a guy who was here earlier in the week for a TIA, went to the floors, then came back b/c he was found to have a dissecting aortic aneurysm that originated in the ascending aortic arch. It seems to be beyond any surgeon's ability here to fix, so we're trying to get him to THI in Houston, where there's a surgeon that specializes in aorta repairs.

The rule in ICU is that half of the team takes the day off on Saturday while the other half takes the day off on Sunday. Garrett, Kate, and Eddy were absent, so it was Aaron, Loan, Heather, me, and another 4th year who only did one day of ICU (today). I was able to leave around 11:15. Heather said that if I wanted to stay later to do an arterial line I could. If I weren't post call, I would have stayed, but more importantly, I needed to sleep. But at least I get tomorrow off =D