Today (Monday) our team met Beth, a 4th year from UTSW who's doing a one-week rotation in ICU as part of her FP elective. She seems to have clicked with our team quite well so far. Dr. C rounded with us today, and we finished in time to attend noon conference. It's funny when we round on heavily sedated/comatose patients and Dr. C uses a deep booming voice (which some of us have dubbed "the voice from hell") to try to startle his patients into waking. "I wouldn't want to wake up to a voice like that," Eddy joked. In the afternoon there really wasn't too much going on. We had another patient who needed a cardioversion, and this time Garrett and Beth got to watch. I commented that someone should find Aaron and get him here b/c he'd been wanting to see a cardioversion, and Dr. C said, "Well, looks like he'll miss this one." As it turned out, the guy had to get shocked twice because the first one didn't take. I felt sorry for him b/c it really did look like it hurt; the first time he let out a yell and muttered, "WTF was that?!" For the second one, he asked that we give him lots of stuff to knock him out, and he was given Ativan and fentanyl. The second time he got shocked, he yelled again, but this time it worked and hopefully he was so doped up he won't remember anything. Aaron came in just as the second shock was administered, and he exclaimed, "I missed it again?!" He lamented that there were two cardioversions in two days and he missed them both, but the cardiology nurses assured him that he'll get to do some cardioversions when he does his cards rotation.
We learned that our favorite drunk patient had passed away, and Heather said that she and several people had held a moment of silence in the ER, "where we knew him best." Sometime later I was sent down to the ER to see a new admit: a 53-year-old woman possibly in DKA but with complete heart block and bradycardia (BP 65/40, HR 35-40). She was MR so it was hard to get anything out of her, as she kept saying her side hurt and that she was thirsty. The cardio attending (with Brown in tow) poked his head in briefly and then went on his way, apparently unconcerned. Eddy passed by the cardio team when he came to the ER and asked how the patient was, and the attending said she was fine. When Eddy saw the BP and HR readings he muttered, "That is not fine," and ran after the attending to see what he was thinking. As it turned out, Kindrick was working the day shift at ER, and with him, Brown, and me within feet of each other, I felt like I was back in obgyn. The cardio attending said that since we don't know anything about the woman's history (meds, pmh, etc) he didn't want to jump the gun and put in a pacemaker if it isn't necessary. The patient kept saying she wanted water, so I made a faux pas and gave her a few sips of water, which she threw up several minutes later. When the nurse asked why the patient was throwing up after being given Zofran, I fessed up, and she lightheartedly scolded me for doing so. Fortunately the mother soon came to talk to Eddy and me, and it turned out our patient was on clonidine, propanolol, and verapamil for chronic HTN. That's a lot of BP meds. We then decided that her symptoms were a combination of DKA and too many BP meds, put her on an unsulin drip, gave her some calcium gluconate and sent her to the ICU. When I saw her several hours later, she was calmer, more alert, and smiling. Looks like we fixed her up =)
I then drove to school to meet with the chairman. The meeting was brief; he just asked me a few questions about what I'm looking for in a residency, where I see myself in five years (primary care vs fellowship), and other things. I honestly don't know what he thought about me, but by mannerisms he was fairly reserved. Oh well, at least he said he'll write me a letter. When I drove back to work, I got some dinner and returned to the unit, where I found Aaron on the phone with Kindrick regarding a gastric bleed patient down in the ER. He then told me to go see the patient and told Kindrick, "I'm sending down my student." Aaron wasn't on call tonight; he was covering for Eddy until 7:30 pm b/c Eddy had to attend his son's soccer game.
When I went down to the ER around 7:00 pm, I found another dad (Kindrick) eager to get home and see his kids. "Hey kiddo," he said when he saw me, and when he asked where I was this month I said, "ICU." "No, not for long," he said, and it took me a few seconds to realize he had turned "ICU" into "I see you," which was, obviously, a joke. He told me a bit about my gastric bleed patient and said to look out for tachycardia or hypotension, and he said the patient badly needed a central line. He asked some nearby interns if they wanted to do a central line, but they hadn't done one before. "Why doesn't the third year stick around to teach us how to do one?" asked one intern, and he replied, "The third year wants to see his kids before they go to bed!" He seemed a bit hesitant about leaving things not taken care of, but the nurses and I told him to go home. My patient had just returned from an EGD (that revealed actively bleeding gastric varices secondary to alcoholism) and was sleeping soundly (there was a basin full of bloody emesis nearby that was pretty gross though), so at the moment he was stable. I couldn't get too much out of him, but as I watched his BP drop from 90/60 to 81/55 (yet his HR never went above 90), I wondered if I should worry. Dr. ML said no, that we would get a central line in him once he got to the unit and take care of him from there.
Back on the unit, Eddy went off to do a few lines on his own while I stuck close to Dr. ML. He let me attempt a paracentesis on a lady with a possible SBP (also a Jehovah's witness so she can't get blood products; her lab draws had to be done in pedi tubes), but we couldn't get any fluid. I then asked if I could do a central line on the gastric bleed patient, and Dr. ML asked which route I wanted to take. I said subclavian since that was most common (I thought), and Dr. ML said okay, but commented that he prefers the IJ route. The procedure went pretty well; after hitting the clavicle with the needle a few times, I got the vein in one stick. Dr. ML watched me almost the entire time; when all that was left were the sutures he said, "Nice work" and left. Umm, what? How could he just leave me there? What if I didn't know how to suture? At any rate, I don't know how good my sutures were and hope that my patient won't get an infection. It was hard to stick the Tegraderm on there b/c his wound kept bleeding, but fortunately the nurse, who could tell I was a newbie, helped me out. I also found out where to print procedure notes so that whenever Eddy does a procedure, I can modify it and print it out so all he needs to do is sign. That'll save a little bit of time. We didn't get a chance to rest until well after midnight (about 12:45 a.m), and Eddy said I could go to sleep if I wanted to. So I did, but was awakened at 2:30 by someone talking next door. Gee, thanks.
Our attending in the morning was Dr. O, and once again we had to adjust to a new attending and his ways. Dr. O, like Dr. ML, does teaching rounds, but he also wants a lot more detail about our patients than what we're used to. He asked us to calculate ideal body weights for all our patients, which means we need to know their heights (which we don't), so that we can write our own TPN orders (something I never remembered from surgery). Dang. With my patients, it wasn't enough that one was in a coma; he asked me the GCS score and asked how she responded to painful stimuli (which I hadn't been checking). And all this while I was post-call and brain-dead! If that wasn't enough, I couldn't finish seeing my patients until close to 12:30 pm b/c Heather had clinic in the afternoon and had to present her patients before mine. I suppose I could have been a real prat and insisted on seeing my patients before hers so I could go home early, but she's a resident so her needs come before a med student's. At least I was able to grab some lunch at noon conference before going home.
Tuesday, September 16, 2008
Sunday, September 14, 2008
ICU: Thank goodness I'm not post-call...
Last night Aaron had seven new admits, and only got one hour of sleep. If I'd been on call with him, I undoubtedly would have suffered the same fate (though I didn't sleep much better; I only got about 4-5 hrs of sleep b/c I had trouble falling asleep). Needless to say we were all relieved when we found that we'd be rounding with Dr. C (who rounds at lightning speed) instead of Dr. ML. Even still, because we had 15 patients to see, we didn't get done until shortly before noon. My longterm patient finally went to an L-tach yesterday, so I no longer have any established patients (saw two patients for Garrett and Aaron today). I'll have to ask Aaron to for some of his patients tomorrow.
We had two problem patients today: one was a man from IPA with a bad case of A-fib, and another was a septic patient we've had for over a week (coincidentally, he was also in IPA before he coded and had to be brought up to ICU) who, according to Dr. ML, was finally succeeding in dying after trying for many days (more on that later). Aaron was all excited about seeing a possible cardioversion on our A-fib guy ("Mr. Red"), but was so busy making phone calls and other things that he missed it. Mr. Red was sedated, the pads placed on his chest, everyone clear, then BZZT! His eyes flew open and he gasped, but the shocks did the trick; his heart resumed a normal sinus rhythm. We thought that was the worst of it, but suddenly he developed very bad SOB, and even with the oxygen turned on full blast he was still only sating at 80% or worse b/c he kept coughing and gasping. At one point he coughed up some frothy red stuff, and the nurse, afraid that he would need to be intubated, called Dr. C over the intercom. Dr. C hurried over to see what was going on and suggested giving Mr. Red some Ativan to calm him down, then put in a Foley (which he'd originally refused) and some Lasix to treat what was most likely flash pulmonary edema secondary to pneumonia (he had infiltrates on CXR). The Ativan helped a lot, and with the Lasix and Foley he ended up making a lot of urine. Let's hope that'll help with his flash pulmonary edema; of all our patients, we got paged the most regarding his care.
Our other IPA patient was "actively dying," but I still have no idea what that means. His blood pressure held steady in the 70s-80s/50s, and he was completely dependent on the ventilator (his sats were about 70%), but I'd expected "active dying" to be a quick, noticeable decline, the way little AJ's heart rate dropped to zero in a matter of minutes back at Driscoll. I took a closer look at him and saw that there were tears in his eyes. That made me sad. =(
Loan and Heather were on call today, and I ended up hanging out with Loan. She told me that I should take call with her sometime, since she and Heather operate independently of each other. Sounds tempting, but I think I'll stick to working with Eddy for a while. Unless another fourth year comes along, then I may give up my spot (and Garrett will think I'm being too nice again). Speaking of fourth years, apparently Mafruha didn't make a favorable impression on some of the residents last week. Of course, it's hard to live up to Mike and Jay's standards (those two were on top of everything and Jay chatted with Dr. C when he was in the ICU during his medicine rotation). In addition to being on call tomorrow, I'm also meeting with the chairman of IM at our school to get a rec letter. Hopefully I'll make a favorable impression on him.
We had two problem patients today: one was a man from IPA with a bad case of A-fib, and another was a septic patient we've had for over a week (coincidentally, he was also in IPA before he coded and had to be brought up to ICU) who, according to Dr. ML, was finally succeeding in dying after trying for many days (more on that later). Aaron was all excited about seeing a possible cardioversion on our A-fib guy ("Mr. Red"), but was so busy making phone calls and other things that he missed it. Mr. Red was sedated, the pads placed on his chest, everyone clear, then BZZT! His eyes flew open and he gasped, but the shocks did the trick; his heart resumed a normal sinus rhythm. We thought that was the worst of it, but suddenly he developed very bad SOB, and even with the oxygen turned on full blast he was still only sating at 80% or worse b/c he kept coughing and gasping. At one point he coughed up some frothy red stuff, and the nurse, afraid that he would need to be intubated, called Dr. C over the intercom. Dr. C hurried over to see what was going on and suggested giving Mr. Red some Ativan to calm him down, then put in a Foley (which he'd originally refused) and some Lasix to treat what was most likely flash pulmonary edema secondary to pneumonia (he had infiltrates on CXR). The Ativan helped a lot, and with the Lasix and Foley he ended up making a lot of urine. Let's hope that'll help with his flash pulmonary edema; of all our patients, we got paged the most regarding his care.
Our other IPA patient was "actively dying," but I still have no idea what that means. His blood pressure held steady in the 70s-80s/50s, and he was completely dependent on the ventilator (his sats were about 70%), but I'd expected "active dying" to be a quick, noticeable decline, the way little AJ's heart rate dropped to zero in a matter of minutes back at Driscoll. I took a closer look at him and saw that there were tears in his eyes. That made me sad. =(
Loan and Heather were on call today, and I ended up hanging out with Loan. She told me that I should take call with her sometime, since she and Heather operate independently of each other. Sounds tempting, but I think I'll stick to working with Eddy for a while. Unless another fourth year comes along, then I may give up my spot (and Garrett will think I'm being too nice again). Speaking of fourth years, apparently Mafruha didn't make a favorable impression on some of the residents last week. Of course, it's hard to live up to Mike and Jay's standards (those two were on top of everything and Jay chatted with Dr. C when he was in the ICU during his medicine rotation). In addition to being on call tomorrow, I'm also meeting with the chairman of IM at our school to get a rec letter. Hopefully I'll make a favorable impression on him.
Saturday, September 13, 2008
ICU: Switcharound
I was prepared to take call today (took the day off yesterday in anticipation of working through the weekend), but then Garrett asked me if I wanted to take call on Monday instead so that I could work with Eddy and he could work with Aaron for the next two weeks. That meant there would be no students working with Aaron today. When I told Aaron what was going on, he just shrugged and said, "Do whatever you want to." I couldn't tell if he was annoyed or flat out didn't care, but it's most likely the latter. In a way, Garrett and I are both relieved to be switching residents. Aaron, being a third year, knows his stuff and has no problems doing procedures by himself, but he's hard to read and sometimes gives the impression that you're insignificant. Eddy is more friendly, more approachable, but he's still learning and as such, doesn't always have the answers to our questions (he didn't do an IJ central line until today). So the tradeoff seems like a good thing for now. In some respects, this ICU rotation has been a letdown as far as students are involved. There have been times when Dr. ML doesn't wait for Garrett or me to present or ask questions before going to see the patient. Maybe it's the attending, b/c I know Dr. C encourages students to do procedures and Dr. O is always available for questions.
Our local alcoholic-turned-septic patient is now receiving end of life care. He has refused all other treatment and is DNR. I remember how when I first saw him back in May, Jordan had pointed him out and said, "That's a train wreck waiting to happen." It was true. This year, he came to the hospital almost every day for a warm bed to sleep in, but not before getting totally wasted on alcohol. (I've seen him standing in street corners and have to wonder where he got all the money to supply his alcohol) Nurses have shared stories about how he used to unhook his IV, leave the hospital, and then come back 2 hrs later drunk as a skunk. Never mind how when he was drunk, he'd become belligerent and cuss people out, throwing F bombs left and right. Not many people will miss him when he passes, but at least he'll be in a warm bed and not out on the streets. The daughter and husband off another of our patients who had a stroke and is now in a coma got "the talk" from Dr. ML, saying they could take her off life support or else do a trach and PEG to make her more comfortable. The husband kept asking why they couldn't just keep her on the vent if she was stable, and he couldn't quite understand when Dr. ML said the trach would only cause more problems if left in the throat beyond 10 days. Dr. ML was careful to address mainly the daughter, who has the medical power of attorney, to keep her informed in case her father tried to convince her to do something she didn't agree with. We'll see what happens then.
Our local alcoholic-turned-septic patient is now receiving end of life care. He has refused all other treatment and is DNR. I remember how when I first saw him back in May, Jordan had pointed him out and said, "That's a train wreck waiting to happen." It was true. This year, he came to the hospital almost every day for a warm bed to sleep in, but not before getting totally wasted on alcohol. (I've seen him standing in street corners and have to wonder where he got all the money to supply his alcohol) Nurses have shared stories about how he used to unhook his IV, leave the hospital, and then come back 2 hrs later drunk as a skunk. Never mind how when he was drunk, he'd become belligerent and cuss people out, throwing F bombs left and right. Not many people will miss him when he passes, but at least he'll be in a warm bed and not out on the streets. The daughter and husband off another of our patients who had a stroke and is now in a coma got "the talk" from Dr. ML, saying they could take her off life support or else do a trach and PEG to make her more comfortable. The husband kept asking why they couldn't just keep her on the vent if she was stable, and he couldn't quite understand when Dr. ML said the trach would only cause more problems if left in the throat beyond 10 days. Dr. ML was careful to address mainly the daughter, who has the medical power of attorney, to keep her informed in case her father tried to convince her to do something she didn't agree with. We'll see what happens then.
Thursday, September 11, 2008
ICU: A lesson in organ donation
I came to work today to find that the patient I'd helped admit early yesterday morning had officially been declared brain dead after she lost her cough and gag reflex (and failed her apnea test). She was still in her room, but LifeGift (the people in charge of arranging organ donations) was taking care of her now, keeping her condition stable until her organs were ready to be recovered. Right before I went home this afternoon, I talked to my patient's LifeGift nurse to ask about the "harvesting" process. He said that the organs are viable in the first twenty-four hours after brain death is declared, and those twenty-four hours are spent contacting organ donation companies and doing crosstyping and HLA typing across a registry to find the closest matches. Then, after matches have been found and the surgical team is ready, the organs are recovered and then flown to other hospitals for the recipients. In order for the organs to be in top shape, they must be removed within one hour of all support being turned off, assuming the patient stops breathing and flatlines within that hour. If not, then the organs are essentially useless and cannot be donated. That happened to our other lady with a stroke from several days ago. She still had some breathing function, so she wasn't totally brain dead when life support was removed. Her O2 sat remained at 60% and her BP was fairly stable for about 6 hours before her circulatory system collapsed, and by then, of course, her organs were in no shape to be transplanted (even though her family had given consent). Too bad. The LifeGift nurse said that I could watch the surgery if I wanted to, and though I was tempted, I declined. I have no idea what the new ORs look like or where I can find which room the surgery is in, and on top of that, they didn't know what time they'd be doing the surgery yet. The question was asked whether the LifeGift nurse had trouble getting patients' families to allow organ donation, and he said the harder part was just waiting for a qualified donor to come along (usually brain deaths). He said there was no age limit to donation (newborn to 90s; in older adults, the liver is most viable b/c it regenerates), and I asked if teenagers ever get middle-aged organs. He said it's happened, and on the other spectrum, older adults have received teenage organs only to pass away within ten years. *sigh*
We only had nine patients to see this morning, and we finished with enough time for Dr. ML to give us a lecture on mechanical ventilation that was actually very helpful. Then we got our first crisis after lunch: AG, our septic patient who treated JPS like his home between drunken binges, was transferred to Tele but his BP began dropping soon afterwards (we're talking 50s/30s) and he had to be moved back to the ICU. Eddy kept muttering about how he couldn't believe this was happening, and when we got to the ICU, Dr. ML said that I could do the art line. The problem: AG was infamous for having bad veins and pulses (I remember this tidbit from my medicine rotation), and I couldn't find a pulse. "We'll have to go in blind," said Dr. ML, and we each took an arm and attempted to do an art line. Needless to say I failed, but Dr. ML was able to get a stick. And the blood that came out did not look like blood at all: it was bright red and watery, almost like Kool-Aid (not my idea). His H&H turned out to be 7.7/25, so orders were immediately written for blood transfusions. On another patient, Garrett got to put in a chest tube, which looks like a painful procedure (thankfully the patient got lots of lidocaine; he never flinched even though he was conscious). I think he liked that; anesthesiologists are more hands-on people.
We only had nine patients to see this morning, and we finished with enough time for Dr. ML to give us a lecture on mechanical ventilation that was actually very helpful. Then we got our first crisis after lunch: AG, our septic patient who treated JPS like his home between drunken binges, was transferred to Tele but his BP began dropping soon afterwards (we're talking 50s/30s) and he had to be moved back to the ICU. Eddy kept muttering about how he couldn't believe this was happening, and when we got to the ICU, Dr. ML said that I could do the art line. The problem: AG was infamous for having bad veins and pulses (I remember this tidbit from my medicine rotation), and I couldn't find a pulse. "We'll have to go in blind," said Dr. ML, and we each took an arm and attempted to do an art line. Needless to say I failed, but Dr. ML was able to get a stick. And the blood that came out did not look like blood at all: it was bright red and watery, almost like Kool-Aid (not my idea). His H&H turned out to be 7.7/25, so orders were immediately written for blood transfusions. On another patient, Garrett got to put in a chest tube, which looks like a painful procedure (thankfully the patient got lots of lidocaine; he never flinched even though he was conscious). I think he liked that; anesthesiologists are more hands-on people.
Wednesday, September 10, 2008
ICU: Death and Dying
Once again, I was on call yesterday, and the day did not start off on a good note. One of Kate's new admissions was a woman who was sitting on the porch with her husband when she suddenly fell back and lost consciousness. It turned out she had a ruptured berry aneurysm (subarachnoid hemorrhage), and on CT it was really bad. "You know the bleed is bad when you can see the Circle of Willis," said Dr. ML. He was right; we really could see the circle of Willis outlined on the CT. Clinically, the woman was brain dead. We were all in the room prepared to do the apnea test (if the patient can't breathe on his/her own, it's a confirmatory sign of brain death) when the husband came in; when Dr. ML tried to break the bad news to him, he stiffened and said to us, "Can you all get out?" All the residents and students except Kate left the room immediately, and we stood outside the room wondering what happened next. Soon more family members came, and later Kate left the room in tears. "They started wailing, and I couldn't help it," she said, saying that seeing others cry makes HER cry too. The woman's son was sobbing as he called his siblings on the phone saying, "She's gone." And that made us feel awful.
Several doors down was another crying family. The patient, a heavyset Hispanic man, had fallen to the ground in front of witnesses, yet no CPR was done on him until the paramedics arrived 15 minutes later. And now he, too, is brain-dead because of anoxic injury to the brain. I remember JB, my chief surgery resident, telling me once that only 10% of patients who go into cardiac arrest outside of a hospital setting survive with the proper resuscitation techniques, but it makes me mad to think that maybe this man had a chance of living. He'd failed his apnea test, so clinically, he's brain dead. Not so with the first woman; when we did the apnea test on her (basically turned off the vent), she started breathing on her own. Clearly there's still some function in her brainstem, and when Dr. ML told her children that, her son looked furious. "You just said she was dead," he accused. "That's why I called everyone up here!" Dr. ML said that the prognosis doesn't change, that sooner or later, the patient will die, but that for now, she cannot be classified as brain dead. *sigh* At least it buys the patient's family some time to be with her and say their goodbyes (though I can't imagine it'd be any easier)
Mafruha (the DMU 4th year) asked me when I'd be on call, and she seemed a bit annoyed when I told her that Garrett and I were on call whenever Eddy and Aaron were by themselves. Maybe it was Garrett's influence but I wanted to remind that I was doing an ICU rotation and she was just rotating through. At any rate, she said that she'll probably experience call next week when she does a week of medicine. There was nothing to do in the afternoon so Garrett and Mafruha were quick to leave. As for me, Aaron and I went back to the Commons area where I proceeded to work on ERAS some more. There was even time to eat a long dinner, and I ran into the ortho team in the lounge the same time as me. Lindsay, one of my interns from medicine (she's a 2nd year ortho resident), was there; I asked her about one of our problem patients from medicine and she said she got him to the VA. Whew. Aaron said that it was not a typical call night to have nothing to do, but we took advantage of it.
When nothing happened by 10 pm, I lay down to go to bed, but never really fell asleep completely. The ICU walkie-talkie woke me up shortly after midnight for "stroke team to the ER," and when I left the room, I saw Aaron in the hallway, apparently ready to knock on my door. He wasn't going to the stroke in the ER though; he had another case, a hemorrhagic stroke case in the ER. The two of us went to the ER, where I said hi to Asuka (she was working the evening shift) and went to see what was going on. The patient was an African American woman whom Aaron had to intubate, and when I saw her CT later, it was bad. The left ventricle was almost completely filled with blood. Later, when she was brought to the ICU, Aaron let me to an art line on her. Sadly I was unable to draw any blood (artery kept rolling away from me), so Aaron did it. He then proceeded to insert both the central line and the femoral line while I went to the waiting room to interview the family. The story was classic; the patient had been fine the evening before but around 11 pm she suddenly became limp, her speech became slurred, and she complained of a headache before losing the ability to speak altogether. At any rate I think I wrote a pretty good H&P (doing a sub-I in Austin sure gave me practice), and Aaron said he'd let me present to Dr. ML in the morning. Of course, by the time we finished with her it was almost 4 a.m., and we weren't done yet. Someone in the ER needed a central line.
I thought I'd be doing at least one procedure tonight, so I was surprised when Aaron sought out an intern named Matt (who's on call for surgery) to do the central line. *sigh* Brushed aside again. Aaron started setting up and said that if Matt didn't show up soon, he was going to do it himself (we were all desperate to get at least one hour of sleep). So I hunted Matt down in the ER and told him to get to the room. I made myself useful by holding the patient's hand (he was awake, only got local sedation, which is probably why Aaron didn't let me do this one). The patient was fairly cooperative, but then there were times when he'd squirm and we'd have to tell him not to move. Matt, fortunately, didn't have a lot of difficulty with it, and Aaron said that next time, he expected Matt to be able to do a central line alone, without an R3 supervising him. Matt did give me some tips with doing a central line though (namely, how to avoid pricking myself with the needle), and recommended that I learn how to do an IJ line from Dr. ML. We'll see if I'm that lucky.
It was 4:40 a.m. when I trudged back to the commons area and ran into Lindsay in the bathroom (don't think she slept at all). She said she's working for the next 20 days straight, which doesn't bode well for Casey (her 4th year med student from UTHSCSA), who works when she works. I lay down for about an hour or so (don't think I really slept) before getting up, eating a big breakfast, and grabbing some coffee to stay awake. I got to present my patient, but Dr. ML had some tough questions for me ("Why did she bleed easily? What does DDAVP do?") and the others weren't much help. The chaplain went to see the family and by the time we went in there, they were all crying. Later when I turned in my note, I saw a teenage boy who had to be her son come in, and it was heartbreaking. There was a time in high school when I feared what would happen if I lost my parents, and now this boy has lost his mother. But even as the relatives cried, there was one woman praying aloud to keep everyone together. =/ I don't think I can ever get used to death and dying on the job.
On a humorous note, Dr. ML said ____ was the sasquatch of ICU, and Kate asked what a sasquatch was. "It's Bigfoot," said Heather, and Kate asked, "Who's Bigfoot?" Dr. ML said, "You never heard of Bigfoot?" and Kate said, "I didn't grow up here!" (she's from NY). Everyone exclaimed, "It doesn't matter!" LOL.
Several doors down was another crying family. The patient, a heavyset Hispanic man, had fallen to the ground in front of witnesses, yet no CPR was done on him until the paramedics arrived 15 minutes later. And now he, too, is brain-dead because of anoxic injury to the brain. I remember JB, my chief surgery resident, telling me once that only 10% of patients who go into cardiac arrest outside of a hospital setting survive with the proper resuscitation techniques, but it makes me mad to think that maybe this man had a chance of living. He'd failed his apnea test, so clinically, he's brain dead. Not so with the first woman; when we did the apnea test on her (basically turned off the vent), she started breathing on her own. Clearly there's still some function in her brainstem, and when Dr. ML told her children that, her son looked furious. "You just said she was dead," he accused. "That's why I called everyone up here!" Dr. ML said that the prognosis doesn't change, that sooner or later, the patient will die, but that for now, she cannot be classified as brain dead. *sigh* At least it buys the patient's family some time to be with her and say their goodbyes (though I can't imagine it'd be any easier)
Mafruha (the DMU 4th year) asked me when I'd be on call, and she seemed a bit annoyed when I told her that Garrett and I were on call whenever Eddy and Aaron were by themselves. Maybe it was Garrett's influence but I wanted to remind that I was doing an ICU rotation and she was just rotating through. At any rate, she said that she'll probably experience call next week when she does a week of medicine. There was nothing to do in the afternoon so Garrett and Mafruha were quick to leave. As for me, Aaron and I went back to the Commons area where I proceeded to work on ERAS some more. There was even time to eat a long dinner, and I ran into the ortho team in the lounge the same time as me. Lindsay, one of my interns from medicine (she's a 2nd year ortho resident), was there; I asked her about one of our problem patients from medicine and she said she got him to the VA. Whew. Aaron said that it was not a typical call night to have nothing to do, but we took advantage of it.
When nothing happened by 10 pm, I lay down to go to bed, but never really fell asleep completely. The ICU walkie-talkie woke me up shortly after midnight for "stroke team to the ER," and when I left the room, I saw Aaron in the hallway, apparently ready to knock on my door. He wasn't going to the stroke in the ER though; he had another case, a hemorrhagic stroke case in the ER. The two of us went to the ER, where I said hi to Asuka (she was working the evening shift) and went to see what was going on. The patient was an African American woman whom Aaron had to intubate, and when I saw her CT later, it was bad. The left ventricle was almost completely filled with blood. Later, when she was brought to the ICU, Aaron let me to an art line on her. Sadly I was unable to draw any blood (artery kept rolling away from me), so Aaron did it. He then proceeded to insert both the central line and the femoral line while I went to the waiting room to interview the family. The story was classic; the patient had been fine the evening before but around 11 pm she suddenly became limp, her speech became slurred, and she complained of a headache before losing the ability to speak altogether. At any rate I think I wrote a pretty good H&P (doing a sub-I in Austin sure gave me practice), and Aaron said he'd let me present to Dr. ML in the morning. Of course, by the time we finished with her it was almost 4 a.m., and we weren't done yet. Someone in the ER needed a central line.
I thought I'd be doing at least one procedure tonight, so I was surprised when Aaron sought out an intern named Matt (who's on call for surgery) to do the central line. *sigh* Brushed aside again. Aaron started setting up and said that if Matt didn't show up soon, he was going to do it himself (we were all desperate to get at least one hour of sleep). So I hunted Matt down in the ER and told him to get to the room. I made myself useful by holding the patient's hand (he was awake, only got local sedation, which is probably why Aaron didn't let me do this one). The patient was fairly cooperative, but then there were times when he'd squirm and we'd have to tell him not to move. Matt, fortunately, didn't have a lot of difficulty with it, and Aaron said that next time, he expected Matt to be able to do a central line alone, without an R3 supervising him. Matt did give me some tips with doing a central line though (namely, how to avoid pricking myself with the needle), and recommended that I learn how to do an IJ line from Dr. ML. We'll see if I'm that lucky.
It was 4:40 a.m. when I trudged back to the commons area and ran into Lindsay in the bathroom (don't think she slept at all). She said she's working for the next 20 days straight, which doesn't bode well for Casey (her 4th year med student from UTHSCSA), who works when she works. I lay down for about an hour or so (don't think I really slept) before getting up, eating a big breakfast, and grabbing some coffee to stay awake. I got to present my patient, but Dr. ML had some tough questions for me ("Why did she bleed easily? What does DDAVP do?") and the others weren't much help. The chaplain went to see the family and by the time we went in there, they were all crying. Later when I turned in my note, I saw a teenage boy who had to be her son come in, and it was heartbreaking. There was a time in high school when I feared what would happen if I lost my parents, and now this boy has lost his mother. But even as the relatives cried, there was one woman praying aloud to keep everyone together. =/ I don't think I can ever get used to death and dying on the job.
On a humorous note, Dr. ML said ____ was the sasquatch of ICU, and Kate asked what a sasquatch was. "It's Bigfoot," said Heather, and Kate asked, "Who's Bigfoot?" Dr. ML said, "You never heard of Bigfoot?" and Kate said, "I didn't grow up here!" (she's from NY). Everyone exclaimed, "It doesn't matter!" LOL.
Monday, September 8, 2008
ICU: Crazy Code Day
After having a relaxing day off yesterday, it was back to work this morning. I saw my two patients (pancreatitis man and dissecting aneurysm man), who are the same as usual. Another 4th year interested in the FP program here joined us today; she's from DMU and wants to go to residency in FW b/c her parents have moved here. I originally offered to let her be on call tomorrow with Aaron, but Garrett told me to take it back. "She's just an FP student," he said. "We're here for the whole month. We're already second to three interns (I corrected him saying that Loan was a second year and not an intern, but technically she's still learning and not at Aaron's level), and the only time to learn anything is on call." So later I told the girl that I'll be taking call tomorrow after all, and she said it was fine. I told Garrett that I have a tendency to be too nice (which people have taken advantage of, I'm sure), and he reminded me that I'm learning, too, so I shouldn't have to give up good learning opportunities to others.
We had barely begun to see our first patient when we heard a Code Blue from Tower 6 over the walkie talkies. Kate (who's on call) and Garrett immediately headed over there to see what was going on while Aaron called Tower 6 to see what happened. All we got was that a woman with metastatic breast cancer had coded and that she was being intubated as we speak. When Kate and Garrett returned, I asked Garrett if the woman was alive. He said yes, and she was soon brought to our unit. All thoughts of rounding forgotten, Dr. ML immediately went to her room and said he needed someone to do a femoral line, another to do an IJ (intrajugular line). Heather started on the femoral line while Kate did the IJ. A nurse put a Foley in the woman and I saw some blood come out of the Foley; it made me wonder if it was possible to puncture the bladder if the Foley is pushed in too hard. Not too long afterwards, the woman coded again, and everyone immediately began feeling for a pulse. One nurse started compressions and then asked for someone to take over, so Garrett jumped in. I told Garrett to switch with me if he got tired, but I had the feeling he wouldn't get tired anytime soon.
A few thready pulses were felt once in a while, but in the end, it was decided that there was nothing that could be done and Dr. ML told Aaron to bring the husband into the room. As the chest compressions continued, the patient's remarkably calm husband entered the room and Dr. ML explained what was going on and asked the husband if he wanted them to stop the code. His reason for bringing the husband into the room was so that the husband could actually see what we were doing to keep his wife alive (pounding her chest, bagging her, etc.); many families have some false idea that we keep patients live by injecting them with drugs, nothing physically demanding like CPR. The husband told us to stop the code, and time of death was listed as 9:35 a.m. And yet when I looked at the monitor, she was still breathing on her own and her heart was still beating, albeit erratically. Why were they calling time of death so soon?
All tubes were removed, and the husband went to his wife's side and held her hand. Her eyes were open, and even though he tried to close them, they stayed open for a while. I kept an eye on the monitor and watched her HR drop from 80 to 70, then 65, then 40, then 35, then 0, then back to 30, then 0 again. Her breathing eventually flatlined, and soon, so did her HR, not to beat again. The husband never once lost his composure; maybe he prepared for this a long time ago. Dr. ML murmured some words of condolence as he left the room, and one by one we left too, leaving only the husband, the patient, and the chaplain. I did look back in the room once, and I noticed that the patient's eyes had finally closed.
Needless to say this reminded me of the death of little AJ back in Corpus Christi over a year ago. Back then, they didn't call time of death until his heart had stopped beating, and we had to listen to the screams of his brokenhearted mother throughout the code. But in the end she, like this patient's husband, knew not to prolong their loved one's suffering, and was willing to let them go peacefully.
After our patient passed away (Garrett left the room early and didn't realize she'd passed until later), rounds resumed as though nothing had happened. Then we had another emergency; our patient from IPA had somehow extubated himself (even though he was in restraints; maybe he coughed up the tube?) and needed an emergency trach. Kate got to do the intubation, and she struggled a bit, too, but she got it in. That's part of the learning experience. I also saw another familiar name on our patient list: the name of a homeless man familiar to the ER whom I met on my first day at JPS in medicine. Back then he came to the ER almost every night after getting drunk as a skunk for a place to sleep off the alcohol, and I specifically remember him calling me a "f***ing p***y." Aaron, too, asked if he'd been admitted to the hospital for being drunk or if he developed sepsis (his reason for being in the ICU) later. "Looks like he finally got sick for real this time," I commented, and Dr. O agreed. Someone made a semi-joke about how maybe he liked our new ER and ICU so much that he decided to figure out a way to stay here long term. It's not worth his while though; he's suspected of having TB and had to get a trach. My pancreatitis patient got a trach, too; hopefully he'll be more comfortable now.
There were lots of procedures going on this afternoon (3-4 trachs, 1 bronchoscopy, one core biopsy of the breast), but because I had to write a transfer note, I missed out on the trachs (though I did get to see part of one). Hopefully I'll be able to do more on call. Heather commented that when she was a 4th year, taking call was optional. It still is, but if you think about it, the only time I really learn anything is when I'm on call, and q4 isn't too bad as long as there are no codes during the night. Garrett said he got 6 hrs of sleep last night (lucky him). We'll see how things go for me.
We had barely begun to see our first patient when we heard a Code Blue from Tower 6 over the walkie talkies. Kate (who's on call) and Garrett immediately headed over there to see what was going on while Aaron called Tower 6 to see what happened. All we got was that a woman with metastatic breast cancer had coded and that she was being intubated as we speak. When Kate and Garrett returned, I asked Garrett if the woman was alive. He said yes, and she was soon brought to our unit. All thoughts of rounding forgotten, Dr. ML immediately went to her room and said he needed someone to do a femoral line, another to do an IJ (intrajugular line). Heather started on the femoral line while Kate did the IJ. A nurse put a Foley in the woman and I saw some blood come out of the Foley; it made me wonder if it was possible to puncture the bladder if the Foley is pushed in too hard. Not too long afterwards, the woman coded again, and everyone immediately began feeling for a pulse. One nurse started compressions and then asked for someone to take over, so Garrett jumped in. I told Garrett to switch with me if he got tired, but I had the feeling he wouldn't get tired anytime soon.
A few thready pulses were felt once in a while, but in the end, it was decided that there was nothing that could be done and Dr. ML told Aaron to bring the husband into the room. As the chest compressions continued, the patient's remarkably calm husband entered the room and Dr. ML explained what was going on and asked the husband if he wanted them to stop the code. His reason for bringing the husband into the room was so that the husband could actually see what we were doing to keep his wife alive (pounding her chest, bagging her, etc.); many families have some false idea that we keep patients live by injecting them with drugs, nothing physically demanding like CPR. The husband told us to stop the code, and time of death was listed as 9:35 a.m. And yet when I looked at the monitor, she was still breathing on her own and her heart was still beating, albeit erratically. Why were they calling time of death so soon?
All tubes were removed, and the husband went to his wife's side and held her hand. Her eyes were open, and even though he tried to close them, they stayed open for a while. I kept an eye on the monitor and watched her HR drop from 80 to 70, then 65, then 40, then 35, then 0, then back to 30, then 0 again. Her breathing eventually flatlined, and soon, so did her HR, not to beat again. The husband never once lost his composure; maybe he prepared for this a long time ago. Dr. ML murmured some words of condolence as he left the room, and one by one we left too, leaving only the husband, the patient, and the chaplain. I did look back in the room once, and I noticed that the patient's eyes had finally closed.
Needless to say this reminded me of the death of little AJ back in Corpus Christi over a year ago. Back then, they didn't call time of death until his heart had stopped beating, and we had to listen to the screams of his brokenhearted mother throughout the code. But in the end she, like this patient's husband, knew not to prolong their loved one's suffering, and was willing to let them go peacefully.
After our patient passed away (Garrett left the room early and didn't realize she'd passed until later), rounds resumed as though nothing had happened. Then we had another emergency; our patient from IPA had somehow extubated himself (even though he was in restraints; maybe he coughed up the tube?) and needed an emergency trach. Kate got to do the intubation, and she struggled a bit, too, but she got it in. That's part of the learning experience. I also saw another familiar name on our patient list: the name of a homeless man familiar to the ER whom I met on my first day at JPS in medicine. Back then he came to the ER almost every night after getting drunk as a skunk for a place to sleep off the alcohol, and I specifically remember him calling me a "f***ing p***y." Aaron, too, asked if he'd been admitted to the hospital for being drunk or if he developed sepsis (his reason for being in the ICU) later. "Looks like he finally got sick for real this time," I commented, and Dr. O agreed. Someone made a semi-joke about how maybe he liked our new ER and ICU so much that he decided to figure out a way to stay here long term. It's not worth his while though; he's suspected of having TB and had to get a trach. My pancreatitis patient got a trach, too; hopefully he'll be more comfortable now.
There were lots of procedures going on this afternoon (3-4 trachs, 1 bronchoscopy, one core biopsy of the breast), but because I had to write a transfer note, I missed out on the trachs (though I did get to see part of one). Hopefully I'll be able to do more on call. Heather commented that when she was a 4th year, taking call was optional. It still is, but if you think about it, the only time I really learn anything is when I'm on call, and q4 isn't too bad as long as there are no codes during the night. Garrett said he got 6 hrs of sleep last night (lucky him). We'll see how things go for me.
Saturday, September 6, 2008
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
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
Thursday, September 4, 2008
ICU: A long non-call day
This morning I saw my one patient, an elderly man who initially came with pancreatitis and then developed respiratory failure. When I talked to him and examined him this morning, there were times where he'd try to speak and then become agitated because he can't, and his hands are in restraints to keep him from yanking out the tube. He's also been NPO for several days now, so we got a nutritionist to see him today for TPN purposes. Dr. C spent a lot of time on a sepsis patient, discussing different types of sepsis and what pressors are good to use in certain situations. I'll say one thing for the ICU attendings, they all love to teach. The four med students took turns writing orders; I got to write 2 and there were times when I wasn't paying attention and Heather (intern) would nudge me to get my attention. *sigh* Mike and Jay, of course, are usually on top of everything (to impress Dr. C); Mike even stayed past 11 am even though he was post call b/c there was stuff going on.
After rounds I went with Loan, Garrett, and Mike to SNF to see a 48-year-old patient (new ICU admit) with systemic fungemia. Her story was a sad case; about a year ago, her son died unexpectedly and she was so immersed in grief that she did nothing but lie in bed all day. Eventually she developed bed sores that turned into osteomyelitis (which still haven't healed properly), and somehow this turned into fungemia. Her tongue was completely covered with creamy Candida, her extremities were swollen with peeling skin, and she was barely conscious. One thing everyone noticed was her appearance; even though her records say she was 48, she looked ten to fifteen years older. Her face looked very wrinkled, and when Dr. C left the room, he shook his head and said, "Forty-eight?!" One of the residents had a theory that she could be here illegally and using a false ID, but even if that were true, it was ridiculous.
Because Loan, Garrett, and I had nothing to do before noon conference, we went to morning report. I nearly fell asleep, and Garrett said, "Okay, don't lie, how many hours of sleep did you get last night?" I answered, "Between 5 and 6," which is because I don't get to bed until after 11 and I have to get up earlier than usual to drive to JPS. I know I need more sleep; heck, Dr. R at TSH called me on my sleepiness during one of her first lectures. And since I'll be on call tomorrow, I'm determined to go to bed at least one hour earlier tonight. The internet is usually the reason why I sleep so late, what with researching residency programs, chatting online with friends, or watching videos on YT. *sigh* I need to get my priorities straight.
Sadly there was a lot of downtime in the afternoon. We did get to see one man get a burr hole drilled into his skull b/c he had a chronic head bleed that was shifting his brain past the midline. Jay got to hold the bulb, and the neurosurgeon told him, "So you'll be here for another month? You'll get to do another of these." Hmm, that all sounds nice, but what about me and Garrett, who are actually the ones doing an ICU rotation? Later our fungemia patient was transferred to the ICU from SNF, and we all prepared to do an arterial line and central line on her. Sadly, there were a lot of delays so that it took about 2-3 hrs to get everything done. First, Loan was unable to get a good reading on her first attempt at the arterial line. The second time, her sutures were "off" so Dr. L (the other ICU doc, NOT the same Dr. L as my medicine attending) made her redo the entire line (yikes). Fortunately the third one worked. Garrett and I had the job of holding the patient's arm and leg still b/c she sometimes struggled against us (despite getting fentanyl). Spilled blood was everywhere and Dr. L (when he first came in) scolded Loan for not putting chux on the floor and bed to minimize the mess. When a Code Blue was called in IPA, Garrett seemed all too glad to accompany Dr. C to IPA while I stayed and waited for the central line to be put in. It took forever for them to find the equipment, and in the meantime the patient's breathing was getting worse so we had to intubate her. Loan and Dr. L decided that I should do the intubation, and even though I had no trouble intubating dead patients in our anatomy lab, I did struggle with this woman. Her mouth was full of yeast (eww) and I couldn't find her vocal cords. On top of that I selected a laryngoscope with a straight blade instead of a curved blade (didn't know which one was easier), which Dr. L said made things more difficult (note to self: choose a curved blade next time). Finally Dr. L took over and, once he isolated the vocal cords, gave me the honors of pushing the breathing tube into position. So that was my first real intubation, and hopefully my next one will go more smoothly.
That wasn't the end. The central line kit finally arrived, but Loan accidentally put the line in the artery instead of the vein, so once again that had to be reinserted. The nurses also needed to put in a Foley (this lady was obese), and they asked me to wipe her down before they inserted the catheter. So yeah, since I had nothing else to do, I cleaned her up. With all the fungemia, blood, and what not, one of the nurses said she was going to take a shower as soon as she got home. Good idea. It was about 5:45 pm when I left, and the central line still needed to be sutured to the neck. *sigh* For someone who's not even on call, I sure did stay a long time.
After rounds I went with Loan, Garrett, and Mike to SNF to see a 48-year-old patient (new ICU admit) with systemic fungemia. Her story was a sad case; about a year ago, her son died unexpectedly and she was so immersed in grief that she did nothing but lie in bed all day. Eventually she developed bed sores that turned into osteomyelitis (which still haven't healed properly), and somehow this turned into fungemia. Her tongue was completely covered with creamy Candida, her extremities were swollen with peeling skin, and she was barely conscious. One thing everyone noticed was her appearance; even though her records say she was 48, she looked ten to fifteen years older. Her face looked very wrinkled, and when Dr. C left the room, he shook his head and said, "Forty-eight?!" One of the residents had a theory that she could be here illegally and using a false ID, but even if that were true, it was ridiculous.
Because Loan, Garrett, and I had nothing to do before noon conference, we went to morning report. I nearly fell asleep, and Garrett said, "Okay, don't lie, how many hours of sleep did you get last night?" I answered, "Between 5 and 6," which is because I don't get to bed until after 11 and I have to get up earlier than usual to drive to JPS. I know I need more sleep; heck, Dr. R at TSH called me on my sleepiness during one of her first lectures. And since I'll be on call tomorrow, I'm determined to go to bed at least one hour earlier tonight. The internet is usually the reason why I sleep so late, what with researching residency programs, chatting online with friends, or watching videos on YT. *sigh* I need to get my priorities straight.
Sadly there was a lot of downtime in the afternoon. We did get to see one man get a burr hole drilled into his skull b/c he had a chronic head bleed that was shifting his brain past the midline. Jay got to hold the bulb, and the neurosurgeon told him, "So you'll be here for another month? You'll get to do another of these." Hmm, that all sounds nice, but what about me and Garrett, who are actually the ones doing an ICU rotation? Later our fungemia patient was transferred to the ICU from SNF, and we all prepared to do an arterial line and central line on her. Sadly, there were a lot of delays so that it took about 2-3 hrs to get everything done. First, Loan was unable to get a good reading on her first attempt at the arterial line. The second time, her sutures were "off" so Dr. L (the other ICU doc, NOT the same Dr. L as my medicine attending) made her redo the entire line (yikes). Fortunately the third one worked. Garrett and I had the job of holding the patient's arm and leg still b/c she sometimes struggled against us (despite getting fentanyl). Spilled blood was everywhere and Dr. L (when he first came in) scolded Loan for not putting chux on the floor and bed to minimize the mess. When a Code Blue was called in IPA, Garrett seemed all too glad to accompany Dr. C to IPA while I stayed and waited for the central line to be put in. It took forever for them to find the equipment, and in the meantime the patient's breathing was getting worse so we had to intubate her. Loan and Dr. L decided that I should do the intubation, and even though I had no trouble intubating dead patients in our anatomy lab, I did struggle with this woman. Her mouth was full of yeast (eww) and I couldn't find her vocal cords. On top of that I selected a laryngoscope with a straight blade instead of a curved blade (didn't know which one was easier), which Dr. L said made things more difficult (note to self: choose a curved blade next time). Finally Dr. L took over and, once he isolated the vocal cords, gave me the honors of pushing the breathing tube into position. So that was my first real intubation, and hopefully my next one will go more smoothly.
That wasn't the end. The central line kit finally arrived, but Loan accidentally put the line in the artery instead of the vein, so once again that had to be reinserted. The nurses also needed to put in a Foley (this lady was obese), and they asked me to wipe her down before they inserted the catheter. So yeah, since I had nothing else to do, I cleaned her up. With all the fungemia, blood, and what not, one of the nurses said she was going to take a shower as soon as she got home. Good idea. It was about 5:45 pm when I left, and the central line still needed to be sutured to the neck. *sigh* For someone who's not even on call, I sure did stay a long time.
Wednesday, September 3, 2008
ICU: Too Many Med Students
Our current ICU team is huge. Aside from three upper level residents and two interns, there are four 4th year medical students. And while the residents are happy about it (less patients for them to see), I am not, and neither is Garrett. Jay, Garrett, and I were joined by Mike, the 4th year from KCUMB, whom we met yesterday while waiting in line for IDs to be made. Mike and Jay are both interested in the family practice residency program at JPS, and it just so happens that the program director is Dr. C, our current ICU attending. As a result, Jay and Mike have been doing their best to make themselves well-known to Dr. C (writing orders, hanging out with the residents, etc) and leave Garrett and me with absolutely nothing to do even though we're the ones doing ICU for an entire month. 4th years rotating through family medicine do everything in one-week blocks, so next week Mike and Jay will be somewhere else, but that also means other 4th years doing a month of family medicine (I know of at least two others) may also do an ICU week, leaving us hanging again. Even still, I have nothing against Mike and Jay; they're both nice guys and I like working with them. And who can blame them for wanting to do their best in a program they're interested in? At least only one student is on call at a time; if an emergency LP or central line needs to be done after hours, we'll get first dibs when we're on call. Mike got "suckered" into being on call with Eddy today (b/c Eddy has no interns to help him tonight), and I think Garrett is on call tomorrow, so I'll take call on Friday. That's another thing with ICU: too much freedom among the students regarding call and days off. We have to work with each other to make sure not everyone takes call or vacation the same day.
I think I did a pretty good job presenting my cardiac arrest patient today; later I wrote an ICU transfer note for her to go to Medicine B (Manov's team), so I had to pick up another patient at the end of the day. Another patient with miliary TB got an LP, and Mike immediately went in to observe. That left me, Jay, and Garrett hanging around outside, so Garrett (who had done an anesthesiology rotation at UTSW) gave me a few pointers on doing an LP so that when I get to do my first one, I'll be more prepared. Inevitably our conversation went to ERAS; Mike and Garrett submitted their apps yesterday. And here I'm still working on my PS and deciding what programs to apply to. *sigh* Oh well. My rec letter from Dr. C in Austin should be arriving later in the week, and when that happens hopefully I'll have almost everything finished.
I think I did a pretty good job presenting my cardiac arrest patient today; later I wrote an ICU transfer note for her to go to Medicine B (Manov's team), so I had to pick up another patient at the end of the day. Another patient with miliary TB got an LP, and Mike immediately went in to observe. That left me, Jay, and Garrett hanging around outside, so Garrett (who had done an anesthesiology rotation at UTSW) gave me a few pointers on doing an LP so that when I get to do my first one, I'll be more prepared. Inevitably our conversation went to ERAS; Mike and Garrett submitted their apps yesterday. And here I'm still working on my PS and deciding what programs to apply to. *sigh* Oh well. My rec letter from Dr. C in Austin should be arriving later in the week, and when that happens hopefully I'll have almost everything finished.
Tuesday, September 2, 2008
ICU: First Day
Today was my first day of ICU at JPS. I ran into Garrett on the bus and found out that he'd be doing ICU with me. There were even MORE familiar faces (Andrew, Asuka, Jon, Rachel, Lydia, Mani) once we got to orientation with Margie, and a few unfamiliar ones, too. There were a few fourth years visiting from OU, KCUMB, UT-HSC, and UTHSCSA, to name a few; they were doing rotations in ortho, ob-gyn, and FP. Garrett and I soon found out that the ICU has been relocated across the street to the "Pavilion" along with the Tele units, ER, and surgery, and after calling Eddy, our 2nd year resident, we headed across the walkway to the Pavilion. (Oh yeah, the cafeteria is STILL not open) 
Compared to the old ICU (smelly waiting rooms, old rooms), the new ICU (and the Pavilion in general) was amazing. The rooms were larger, with hardwood floors; most patients had their own room. We soon found the rest of the team: Dr. C, 2nd years Eddy and Loan, and interns Kate and Heather. There's also another fourth year, Jay, from MUSC (South Carolina) who actually started working yesterday, so he knows a little bit more than Garrett and I do about how the ICU works. Since there's so many of us, each person has about 1-2 patients to see; Garrett and I each took one of Heather's patients b/c she's on call tonight along with Loan. Eddy said that we could take call only if we wanted to, which to me didn't make much sense. You either take call or don't. I think I'll try and do one call a week, because hey, at least it's not q3. But I also want to know when I can take a day off. Maybe I'll ask Eddy later.
Rounds went by quickly, but there was still a lot of downtime where Garrett and I stood around talking about ERAS. Dr. C told us to follow Loan and Heather to admit a patient from SNF, so we did. This lady suddenly became unresponsive (previous hx of TIA, if I remember correctly), and when we examined her, she had fluid in her right lung and her pupils were dilated and not really responsive to light. We then talked to another ICU doctor, Dr. L, who LOVES to teach. He spent a great deal of time going over distinguishing shunts from dead space, characteristics of SIRS, and more. The only downside: we spent so much time talking that we weren't able to get lunch until 3:30 pm. Dr. C saw me reading through my patient's chart in the ICU and commented that I must have had a lot of reading to do. Yup.
Compared to the old ICU (smelly waiting rooms, old rooms), the new ICU (and the Pavilion in general) was amazing. The rooms were larger, with hardwood floors; most patients had their own room. We soon found the rest of the team: Dr. C, 2nd years Eddy and Loan, and interns Kate and Heather. There's also another fourth year, Jay, from MUSC (South Carolina) who actually started working yesterday, so he knows a little bit more than Garrett and I do about how the ICU works. Since there's so many of us, each person has about 1-2 patients to see; Garrett and I each took one of Heather's patients b/c she's on call tonight along with Loan. Eddy said that we could take call only if we wanted to, which to me didn't make much sense. You either take call or don't. I think I'll try and do one call a week, because hey, at least it's not q3. But I also want to know when I can take a day off. Maybe I'll ask Eddy later.
Rounds went by quickly, but there was still a lot of downtime where Garrett and I stood around talking about ERAS. Dr. C told us to follow Loan and Heather to admit a patient from SNF, so we did. This lady suddenly became unresponsive (previous hx of TIA, if I remember correctly), and when we examined her, she had fluid in her right lung and her pupils were dilated and not really responsive to light. We then talked to another ICU doctor, Dr. L, who LOVES to teach. He spent a great deal of time going over distinguishing shunts from dead space, characteristics of SIRS, and more. The only downside: we spent so much time talking that we weren't able to get lunch until 3:30 pm. Dr. C saw me reading through my patient's chart in the ICU and commented that I must have had a lot of reading to do. Yup.
Subscribe to:
Posts (Atom)