ICU: Out in a Blaze of Glory

Last day of ICU! Sarah had seven admits yesterday (three in the morning, three in the evening, and one who died of a hemorrhagic stroke), so rounds were expected to take a while. Other attendings chose to look at CXRs before rounds, but Dr. P liked to look at them in the patient's room. By this time we knew what he expected of us. Within thirty seconds after he entered a room, the lights in the room were on, the charts and rounds reports were in front of him, the CXR was on the computer screen, and someone was ready to write orders. It's interesting the way he said, "Someone needs to be in charge of turning on the lights" as though that was all we're good for. *sigh*

The girl with the bad heart, we learned, had developed the clots in her leg b/c she stopped taking her Coumadin after her mother died about a week ago (too upset to take care of herself, understandably). When Dr. P questioned her on that, she got mad b/c thought he was accusing her of bringing this on herself, and the nurse had to calm her down afterwards. Dr. P, after a disclaimer, said that this girl was "one of God's mistakes." Why, he asked, was she given life when she had heart failure so severe (isolated noncompacted left ventricle is a rare condition) that she will probably die within the year if she doesn't get a heart transplant? No one had an answer for that (or wisely stayed silent), but I think we all agreed that it was horrible for a twenty-year-old girl who should be enjoying life to instead be living on borrowed time.

On a good note, both of my patients have been weaned off the vent and fitted with trach collars, and they were given the green light to transfer out of ICU to the Tele units. The nurses kept pushing at us to discharge our patients to the medicine team b/c at the moment the ICU is packed (and more beds are needed). They will be going to my old medicine team (with Dr. L) and I have a feeling Dr. L is going to hate us for sending him my comatose patient. He made it perfectly clear last year how he felt about rocks, and she's been in the ICU for a whole month with no real improvement. My mediastinal abscess lady, however, is on the road to recovery, and I went to her room specifically to tell her goodbye and wish her well. She has a child waiting for her at home, so hopefully she'll get better and leave the hospital in the next few weeks.

No noon conference for students, so Garrett, Loan, and I had lunch downstairs with a visiting student from A&M, Andrea, who went to college with Garrett's wife. Family medicine programs send invites out early, so Andrea already has several interviews lined up. I just hope to get more invites in the next few weeks now that my chairman's letter has arrived at the Student Affairs office. After lunch Garrett left after saying goodbye to Loan, Heather, and Tony, but I stayed around b/c I had two transfer notes to write on my two patients.

Two of our patients needed thoracenteses. Loan did one, and she suggested that since it's my last day, I should do the other with Tony (who turned 29 today). I never really got to work much with Tony before, but he's an awesome teacher. The patient, a guy from the UTMB federal prison who had tongue cancer, asked (on paper) if I would be doing the procedure b/c he didn't want a collapsed lung. (Gee, thanks). Tony assured him that he would be guiding me the entire time, and in the end the patient gave the ok for us to proceed. The thoracentesis needle is freaking long, but with Tony directing where to push I tapped the fluid collection on the first time. "Now, pull the needle back slightly," he said, but I accidentally pulled back too far and couldn't advance the catheter, so Tony took over briefly. Then, once he was deep in the fluid collection, he let me suction out the fluid (straw-colored) and then hook the catheter to a line that led to one of those huge 1 L collection bottles. Then we waited for the fluid to drain in the bottle (nearly 800 mL in all!) before removing the catheter and putting a Band-Aid on the patient's back (random comment, the patient's back was entirely covered with tattoos, some of the images resembling demonic faces). The patient fared well and wrote "Thank you both" on his notepad to us, and Tony and I thanked him for letting me participate in my first thoracentesis.

As we were writing orders, the nurses nearby asked us where Heather and Loan (the ones on call) were b/c they needed to send our transfer patients out to make way for the new ones (we had four transfers total). They then asked Tony if he could do the transfers instead, and Tony joked, "Why? Those two hos are the ones on call." The nurse said, "What?" and without thinking I repeated what Tony had said. "Ohhhhhh! I'm telling!" the nurse laughed, and Tony said, "Hoser. I called them hosers. Are you trying to get me in trouble?" That last line was for me, of course, but it was all in good humor. Later Tony paged the girls and they said they were coming upstairs, and in the meantime we chatted about my future residency plans. Tony was very supportive of my applying to the two IM programs in Colorado (where he went to med school), saying that both UCHSC and St. Joseph had excellent training (based on the opinions of friends who went there). That all sounds great, if I can get an interview =)

One important event happening in the unit today was that Dr. Hess, an ICU attending who lives out of state but spends several weeks at JPS a year (b/c he used to be here full-time), was back for one week. It was his first time in the new ICU, so the nurses practically gave him a welcome back party (complete with a pair of mesh undies that some patients, wear, hehe). When he heard it was my last day of ICU, he said, "Congratulations, you survived." Heather and Loan both wished me luck for the rest of my year, and we all wished Tony a Happy Birthday and told him to have fun tonight (there's a party in his favor).

Doing an ICU rotation was definitely a great experience. Not only have I become accustomed to seeing patients die (which will undoubtedly prepare me for the hospice portion of my geriatrics rotation), I've learned how to interpret ventilators and have several procedures under my belt so that I won't be a total novice as an intern. Three subclavian lines, one thoracentesis, one attempted paracentesis, and two attempted arterial lines...not too shabby. Garrett one-upped me by getting to do a chest tube insertion, but maybe I'll get to do one of those in ER, who knows? =) I'm just glad to get a weekend off.