patients you want to strangle

i worked my first full 12 hour shift, I must say better than being on call but still a very long time. My first patient was a woman who spoke zero English and for whom I had to struggle to get anything out of a translator. Atleast she smiled and was cooperative. My second patient - was a homeless man who apparently came in for chronic back pain. When i went in he was sleeping (even though he had just arrived.) I tapped his arm and attemped to rouse hiim. He briefly fluttered his eyes at me and then quickly closed them again. It was like pulling teeth, begging, pleading please Mr you need to answer my questions, we cant help you unless we know whats going on, you need to wake up, you need to answer this, if you answer my questions i'll leave you alone and you can sleep, i know you are sleepy but i need to get t his information from you in order to help make you feel better. He would whisper his answers, and i would repeat myself to speak louder. Then he would grouchily shout his answer, annoyed that I had asked so many times. I felt my tone getting angrier and angrier. Finally I just skipped to the physical exam. Possibly still frustrated from trying to take his history I about gagged when i had to lean over him and listen to his heart, as i could smell his scent, his odor, his energy. There is nothing i hate more than hot breath breathing down on me. I hated this poor patient, who was feverish, likely intoxicated, and as it turns out positive for cocaine and benzos. My resident finally took over and maybe because he is a man was able to get the patient to cooperate - atleast more than he was with me. this patient made me feel like not helping him and we are not supposed to feel that way about any patient.

on being a guide

I stepped into the Peds ER, was asked to bandage an ankle. And before I knew the two quiet latinas sitting at their sons bedside were asking me all the questions in the world. does he need follow-up, what is this medicine the doctor prescribed, can he get a note for school to use the elevator, is he going to be ok and some. Move to the next bed to find a mom with a chronically ill son who is monolingual spanish and is dealing with complicated seizure medications, who calls me over to ask what fluticasone is. they prescribed it to her son and she uses it, but she didn't know what it was for. Flash to walking to lunch out on the quad, atleast two people ask me for directions, everyday, anytime. My classmate turns to me and says, wow people always ask you for stuff? how do they know you can help? Guess its these pretty brown eyes, tanned skin, unkept curly hair and approachable face.

procedures

It was a better night, I got to write up one of the new admits - vaginal bleeding. Not too complicated. I don't know where all the time went becuase reall did nothing else but sit and wait for her labs and US to come back. During that time my resident told me I could get a chance to do a Lumbar puncture on a woman with a suspected subarachnoid hemorrahage. He asked if I'd like to watch or just do it. Attempting to break free of the timid shroud that overcomes me, I said yes i'd like to try.
two hours later I was gowned up, wearing sterile gloves and a huge mask shield. My resident positioned the patient, betadined it all. I layed out the sterile field and then he gave me the needle to anesthesize the area. I injected all of the lidocaine. Then I got the lp syringe and slowly guided it through checking for csf after about 3cm. I repeated this over and over, removing the needle then reentering. At times my resident was engaged inanother conversation not even looking at what I was doing. I thought I hit bone and my resident checked it, and indeed it was not bone, I had got it. He handed me the manometer and we measured the pressure. At this point i started to feel nauseous and light headed. I struggled to hold the manometer straight as I felt I was going to keel over. Got throught it and he handed me the vile to collect the csf fluid, drop by drop. At this point I could no longer take it, I told him I felt sick and he said go ahead and step back get some fresh air. Which I did. I felt my body gettign extremely hot and then cold sweat. I stepped out, pulled off the gown and went to splash water on my face in the bathroom. I wasn't scared, I wasn't grossed out, I wasn't nervous - I don't know what came over me at that moment. I stepped back into the room and even the patients daughter asked me if I was ok. I did it. The resident said good job. hopefully the next time will be easier

night shift#2

either I'm lazy or I keep getting residents who think I'm lazy, or residents who are lazy and don't want to deal with having a medstudent. in either case I finally got my own patient to talk to - but my resident decided it better he write everything down - as if i can't write or i might write the wrong thing. ugh. While talking to my patient the nurse informed me of all the other traumas going on - my resident didn't even tell me. one motor vehicle accident vs pedestrian, one bar fight, and one 15 ft fall after removing xmas lights. I felt so awkward as everyone seems to have a purpose and you are just there. and in everyone else's defense its not like they have time to tell you what your role is. later i asked my resident and he just said, he's some scissors you can cut their clothes off. ok. oh and bring warm blankets. so thats what i did. cut shirts off if the patient had a c-spine collar. That and paced around the 12 room circle, looking around, peeking into rooms behind curtains. Checking on my patient, making sure she was comfortable, makign sure someone was doing something for her. All she wanted to do was eat her food. But we had to wait for labs, Cxr etc and determine what might be causing her problem before we let her eat in case we were going to do "something." what i have no idea. finally after 4 hours in being in the ER we let her eat. And finally after being in the ER for 4 hours my resident went in to listen to her lungs. and even then she never got his full attention. neither did I. i hope to get more procedures next time. atleast a foley for petes sake. its almost a disadvantage being a fourth year becuase everyone thinks you just want to skip out and go home. and no! i just want to learn something, have some responsibility, before I become an intern and have no idea at all.

Night shift #1

Well truly not as bad as I had thought. I only worked 4 hrs. And it was busy - but slow for me. I just stood around and ended up talking to the three patients my resident was caring for. There was one nurse assigned to those three - who was just almost frantic all the time, and had his preceptor nurse looking over him, correcting him, grilling him. My resident is a tall skinny latino guy with glasses. He was so busy and yet i have no idea what was so time consuming. i swear to you he was pacing around, making phone calls, writing stuff down on the papers, ordering the nurses around, breathing coffee breath down on me, and he kept on tell the patient, "sorry sir, i'm going to get to you soon." Craziest part is, there is a waiting list of 100 or more waiting to be seen. Some have been waiting for 12 hours for their turn to come in to one of the rooms and be seen. Depending on acuity they will be seen sooner or later. The guy that got in was an older man in his sixties with a rare condition acquired after a sting from a yellow-fish in the Alaskan waters where he worked as a fisherman. The venom caused him to get Endocarditis - this is extremely rare, and the last documentation of such an occurrence from this fish was in 1958. As a result this poor man has received three consecutive aortic valve replacements. The first was from a cow and somehow fell out, causing him to go into immedicate congestive heart failure. The second was porcine and somehow became ineffective over time and was replaced with a mosaic porcine valve. today this man was presenting with acute stabbing, squeezing pain at the precordium, radiating to his jaw and left shoulder and occurred during exertion, with diaphoresis, nausea. The pain was 8/10 and lasted for an hour until the paramedics arrived and gave him some aspirin. In the ED he was given nitro, serial EKGs, and troponins. The EKGs were negative for ST elevations (meaning no ST Elevation MI) but the Tn returned as .14. Nitro drip was started and teh cards team consulted - calling it Non ST elevation MI. The poor guy was homeless on his way to see his daughter here in LA. We took his boots off to look at his feet and feel his pulses - and boy did those feet stink! the room just reeked. pobrecito.
The other patient we had was not too interesting, latino guy with 9 days of watery diarrhea and three days of RLQ pain, here to rule out appendicitis. What was the most interesting was his phone conversation to his mom that I overheard. He called his mom and said, "Ama pues aqui estoy. todavia no me atiendan. Pero me toco un doctor chicano y una chicanita." Pretty awesome. Doesn't happen very often. He told me he thought the white doctors treated him worse, he said he felt like they didn't care, they would send him home with pain killers y ya. they never tried to figure out what was really wrong with him.
ANyways, most of my night was spent chopping it up with these two guys. About life, diarrhea, and fishing in Alaska.

reflections on thanksgivings past

I will never forget my Thanksgiving on trauma as a 3rd year. I was on call for thanksgiving day. I was really mad too cuz I wanted to be with my family. Lucky for me though, my family came to LA and we had thanksgiving the day after. Anyways the day of thanksgiving there were a lot of car accidents. There was the elderly asian couple that crashed into a young latino guy. Forunatly everyone was ok. Just a long night in the ER. Another couple was riding home on their motorcycle. The guy ended up very badly injured, with the c collar and his girlfriend a little scratched looking on him. Her parents arrived very concerned. But by far the worst of the accidents. A 50 year old African-American man who was changing the tire on his van on the side of the freeway. He was changing the rear tire on the side with the railings when another car side swiped his van leaving his legs trapped between the railing and his van resulting in mangling of both of his legs. When he arrived to the ER he was conscous and completely unaware of the state of his legs. Everyone assumed their places around the beg checking airway, breathing circulation. THey FAST scanned his abdomen. Stripped off his clothes. And tried to get his name. All this as blood oozed of the table and his legs lay in a dissarray - sideways straight curved twisted, mangled like strips of ground beef and bone. "Can you feel your legs, sir?" He said that he could. Well quite obviously there is no way he could feel it. They quickly morphined him up and knocked him out. Vascular and ortho were called to determine if there was any intact circulation. In these situations they use the MES score (Mangled Extremity Score), who knew? I just kept thinking why do these people keep calling his legs a mess? Thats so mean. Unfortunatly for this man there was no intact circulation and both of his legs had to be amputated above the knee. I didn't see him the day after but I can't imagine how he felt when he woke up and realized he no longer had legs. So this Thanksgiving I am thankful for my legs and good health. You never know when they'll be taken away from you.

Goethe

A wise attending quoted Goethe today, he said, "we can only see what we know how to see." or something along those lines. Essentially what I learned is that don't take every opinion. Question always. Don't accept. We had a patient for which we were considering CABG vs Stent placement for a very bad heart. The CT surgeons, interventional radiologist, and whichever cardiologist was the attending of the moment agreed that CABG was not an option. My attending said - well how do you know they were right? are u sure? this could dramatically change the number of years this man has to live. Certainly as a medstudent my opinion doesn't ever matter much, and i personally really had no idea, but I never stopped to question the opinion of these experts. Maybe the experts were right - but what if they weren't. The worst part is that we as a team never stopped to consider that maybe they were wrong. I guess its true what they say in medicine - you can never trust anyone but yourself. this is why you double check labs, findings, make sure you wrote your orders correctly, review and review to make sure you dont' miss something and if someone tells you something you go back and check it again for your self. And it goes the same for any expert opinion you ask for. always do your own research. always push for more answers, i mean it could be your only family members life on the line.