Reading this post from an old friend (hi Al!) reminded me of my favorite Mommy Line call ever.

Now, Mommy Line calls tend to vary from stupid to stupider.  Why?  I don’t know – but questions like “Can I drank while pragnint?”  or “I think my water just broke and I’m having contractions, but can I stay home and finish watching Cougar Town?” are a dime a dozen.

One night the good Dr. F was fielding calls, and the conversation transpired as follows:

So, I’m 40 weeks pregnant, and I keep getting this feeling like I have to poop.

Ok, well, sometimes that can be a sign of contractions.  Has your water broken?

No.  When I feel like I have to go poop, I go sit on the toilet, and I do.

Do… what?

Poop.

Ah. Let me get this straight, just so there’s no confusion.  You feel like sometimes you need to poop.  And when you feel that way, you do, in fact, poop.

That is correct.

… you should probably just poop.

She was 70, and her family noticed she wasn’t moving quite right.

By the time she got to the ED, her entire left side was paralyzed and her mental status was poor at best.  The massive, ongoing stroke was getting worse by the minute.  Her pupil was getting progressively more and more dilated.  Gurgling, choking sounds were emanating from her throat – a sure sign that if she hadn’t already swallowed a large volume of stomach juices and oral secretions into her lungs, she would soon.

First and foremost.  ABC: the axiom by which Emergency Medicine doctors live.  A is for Airway, the first and most important part of any emergent case.  She has officially failed to Protect The Airway, and it’s time for me to do it for her.

I’ve just finished my anesthesia rotation and for the rest of my career, I’m officially cleared to intubate when needed.  More importantly, I’ve done enough of these that I feel comfortable handling myself without guidance.

Equipment: check.  Always make sure your equipment works first.  It’ll save your ass when the clock is ticking and you suddenly realize your light doesn’t work.

Drugs: pushed through the IV.  Now she’s sedated and comfortable, and the paralytic quickly starts working.  I give her oxygen with an ambu bag because she can’t breathe for herself.  Completely paralyzed, her life is in my hands – a responsibility not to be taken lightly.

And so.  Scissor the teeth open.  Blade carefully inserted through the open mouth, tongue swept aside for easy visualization.  Vollecula pulled upwards and out.  Momentary pause –  I don’t see vocal cords.  Gentle pressure applied to the throat – ah, there they are – assistant’s hand placed just so to keep them in view.

“Tube please.”

Hands steady, I slide the endotracheal tube gently through the vocal cords.  I inflate the cuff to keep it in place, and hook her up to the ventilator.  Oxygen flows to her lungs.  Immediate crisis averted.  One of the nurses gives me a wink, “Doctor Z, you made that look easy!”

There is a particular satisfaction when you glimpse the beginnings of competency.  A month ago, I wouldn’t have known how to do this.  I’m far from an expert – but it will come.  I’ve got my whole life to practice.

Going back through my dictations today, I found this gem that I dictated at the height of exhaustion in the wee hours:

HISTORY OF PRESENT ILLNESS: This is a 30ish-year-old African American male who apparently was drinking heavily and fell asleep on the train tracks. He awoke when the train ran over his legs yet managed to call 9-1-1. Paramedics on scene report that he had a GCS of 15, was talking well and somehow moving all extremities, although they noted that his legs were not attached to his body.

And suddenly the surgical department realized – we need someone to cover the Surgical/Trauma Intensive Care Unit for the night.

Though some unfortunate planning on my chief’s part I ended up being the one who lost this particular Russian Roulette. I find myself amidst beeping monitors, medication drips, and unfamiliar patients.

Let me back up a moment. Intern year is all about uncomfortable firsts – your first prescription for narcotics, your first lab orders, your first blood transfusion, your first CT scan, your first crashing patient. All of these things are difficult in their own way. That being said, usually the degree of autonomy is matched to skill level.

Unfortunately, a mistake was made in the schedule and nobody was scheduled to run the trauma ICU tonight. Now, I’m on trauma this month, but there is a HUGE distinction between covering the regular floor and the ICU. The floor I can deal with. The ICU I simply do not have the experience to run.

Unfortunately I don’t have much choice, as I find myself here with pager on hip. Currently I have a gentleman on the razor’s edge of dying from his intracranial hemorrhage, another who chose to up and stop breathing about an hour ago, and one woman who is trying her best to grab the famous pink elephant.

I’ve got people I can call if I need to, and so far I’ve been pretty liberal with the phone-a-friend. But even though nothing has happened for the past hour, I’ve been lying wide awake.

If someone dies tonight… is it my fault?

Many of my stories happen at 4:30 in the morning.  Why?  Because that’s when I’m forced to make the choice: my sleep, or my patient?

This was a particularly nice 16 year old who lost control of his car on black ice, careening into a tree at high speed and breaking most of his ribs.  The crash caused his windshield to instantly shatter, giving him a few scattered cuts across his face  and one huge slice through his lip.

Ribs will heal on their own, but the lacerations to his face need sewing.  Now, I’m no plastic surgeon, but I am an ER doc and I sew up a lot of wounds. Importantly, the vermillion border – the demarcation between the lip and the face – is one of the most cosmetically important areas of the face. Even a millimeter of disunion is instantaneously recognizable by the human eye.

And so, 24 hours into my trauma call I was faced with a choice.  Let one of my less experienced colleagues fix his lip in a few hours, or take the time to do it now, myself?  My body was screaming from a difficult call night; 15 or so trauma codes in the last 12 hours, sleep deprived for a month, contorting my back to examine patients in c-spine collars all night long.  I felt the overwhelming, primal need to crawl into a corner and sleep.

I suppose, in the end, it was a false choice.  I went into this profession for a reason – to help people.  Knowing full well that these 30 minutes of my time would directly impact every interaction he has with people for the rest of his life… well, that’s time well spent.  The repair went wonderfully.  He’ll have a barely noticeable whitish scar through his lip.

What I’ve gotten used to in medicine is this:  most patients will never realize how important my small time in their life really was.  A missed diagnosis here, a well-repaired laceration there, a timely intervention when needed.  I think it’s a large part of why I went into emergency medicine – I want to be there for the important stuff.

When he gets out of the hospital, I’ll tell him.  ”Your lip looks great, man.  I’m glad you’re doing better.”  He’ll probably never know why I was more concerned about his lip than his ribs.

I remember all my first deaths.

The very first was our cadaver in medical school.  As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd.  Lying cold, still, aseptic, was our body.  Charlie.   It’s an unsettling feeling, laying hands on a dead body.  There is a quiet dignity about death, a final stillness that is unmistakeable.  I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen.  My hands shook violently as I made the first incision.

The second was the first death I ever witnessed in person.  Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle.  He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him.  His features were barely recognizable with all the damage.  He was intubated, paralyzed, and barely had a pulse on arrival.  CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought.  The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream.  I remember being sorry for him, but not devastated – he was already DOA.

Last night, my patient died.

The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR

I sprinted downstairs and into the trauma room, a sea of faces greeting me.  My favorite nurses, our best physicians, waiting.   These are the most capable people I know.  They were ready –  I prepared myself for the survey.  As the trauma intern, it’s my job to perform the whole physical examination in front of everyone and call out significant findings.  All we knew is that the patient was a 70-ish woman in a car accident.

The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was.  For a second, the only sound was her quiet wailing, “Oh, Lord.  Oh, Lordy, my arm hurts.  Please, my arm hurts so badly…”

The moment ground to a halt.  I remember utter quiet as the seconds ticked by, as long as minutes.  Her forearm had three joints where it should only have two…

Silently, I took in the damage.  Horrific, tenting fracture to the left forearm.  Right wrist splayed off to the side, every bone in her hand likely shattered.  Right ankle sideways.  Left shin with shards of bone sticking out the front.  Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.

So I spoke.

“Airway… is currently intact.”

Time sped up, sounds and colors rushing in to fill the void.  What once was silence and stillness was bedlam and cacophany.  Everyone talking.  Everything moving.  I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her.  But there was too much.

Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing.  For every vein that we accessed, another collapsed.  For every unit of blood given, she bled two more.  I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life.   Grim faces and furrowed brows desperate to help this stranger.  People at their best.

Blood pressure started dropping.  I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness.  I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed.   There was the chill, certain realization that nothing would stop this woman from dying.  My fingers felt her pulse getting weaker.  Slower. Fading.  A few minutes later, she was dead.  Everyone shuffled out of the trauma bay until it was just me and her.  I was struck by how cold she was.   Like Charlie.

And then the page came:  PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR

Off to save a life, this time.

Tomorrow I start trauma surgery.  Gunshot wounds, stabbings, and falls from ladders, oh my!

Stories to come, and lots of them… one thing I’ve never been quite clear on is why all gunshot wounds happen when a patient is “standing on the corner, minding my own business” when “some dude” (or occasionally, “a couple dudes”) just happen to walk up and start firing.

Here’s a warning to everyone in this city for the next month.  Avoid all street corners. Mind someone else’s business, never your own.  Perhaps most importantly, when Some Dude strolls on by, RUN!  You’ll know him when you see him.

“Hey, brotha. I need help. Look, I’m not gonna shit you, I’m an alcoholic. I’m homeless. I’ve got back pain. You can help me, you’re a doctor. I need Ativan so I don’t go into DT’s and some Percocet for my pain.  Please, brotha,  I lay myself at your feet.”

Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air.  His bloodshot eyes track me as I walk over to examine him.

This was my first introduction to Chilly, our resident frequent flier. He’s famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections. He even has a facebook fan page which boasts thousands of “friends”. Among other things, he’s an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).

Unsurprisingly, my exam is unremarkable. It’s freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.

“Chilly, your exam is normal today. I can’t find a reason that your back hurts. I’m sending you home.”

“Fuck you, man. I can already tell, I can’t change your mind. I know your type. Yea, I’ll fuckin’ go. You know how cold it is outside? Yea, I’ll fuckin’ go. I’ll go, you privileged sumbitch. You have no idea what it’s like to be homeless.”

Chilly leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc.  All the same, a small voice in the back of my head wonders if I should have been more compassionate.

The rest of the shift goes uneventfully, and as I drive home, I notice it’s cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.

“You have no idea…”

Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. Chilly was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I’ll break the enamel. I rush inside, the warmth enveloping me like an old friend.

4:55 AM, and I was dragging. My 12th day straight in the hospital, leaving a string of three call nights behind me with one left to go. Twenty patients to see before grand rounds at 7AM.

My knee has been hurting. I suspect it’s from the miles and miles I’ve been putting on my body 14 hours a day, 90 hours a week, running around the hospital. I’ve been taking the stairs everywhere in an attempt to remain in better shape, but this morning it was too much. No coffee yet and too little sleep. I gave in and took the elevator from the 3rd to the 11th floor.

I leaned back in exhaustion against the side of the elevator, eyes closed. It whirred into life, and I let the tug of gravity pull me to the ground. The elevator reached the top floor and *dinged* quietly. I stirred, mentally preparing to start rounds.

And then, the door made a few feeble attempts to open, and quit. Servos whined to a halt. I was stuck in the elevator.

Funny, how things can change. Any other time I would immediately panic. What if I have to go to the bathroom? What if the cable breaks? What if the call button doesn’t work? What if I can never get out?

Instead, pure, unabashed relief washed over me. I couldn’t work while trapped in the elevator.

Zac, why haven’t you finished rounds yet? The situation played out in my mind, There’s so much to do today! We have to get on it!

Sorry sir, I quietly replied, I’m physically trapped in the elevator on the 11th floor, there’s really not much I can do from here.

Well, I suppose you’ve got an excuse then. Take the day off.

I sat there for a few minutes, relishing the solitude. I planned out my entire day of rest, mapping out every delicious hour I would spend in each corner. Perhaps I’d take a nap right in the middle of the floor. I smiled. It was going to be a good day.

Then the elevator *dinged* softly again, and my hopes sank as I traveled back down. The door opened on the third floor. A tech stared at me in surprise, papers stuffed in my pockets, hair askew, sitting on the floor of the elevator.

“You alright, man?” he asked.

“Not really”, I responded. I stood up, knee hurting, as I limped off towards the stairs.

Surgery has been far worse than I expected. It’s actually not the patient care problems; my fears prior to this rotation were (mostly) unfounded. Somewhere in the last month I’ve realized that I am much more capable than I’ve suspected in the past.

Today alone I corrected severe electrolyte imbalances without needing to ask how, transfused a woman with approximately half of her normal blood volume, admitted 7 patients to my service with hardly any guidance from my upper level surgeons, and was told by the nurses on the surgical floor that they want to keep me to themselves, never to return to the ER.

That said, General Surgery is the most difficult, frustrating, and downright unpleasant rotation I have ever done.

The one substantial thing I failed to realize about surgeons – which, looking back on it, is a no brainer – is that they are always in the OR. This means they don’t respond to pages, and it is exceptionally difficult to get in touch with anybody. On top of this, they’re surgeons, and there is a machismo of “do it yourself” that pervades everything they do.

All that you have heard about resident work hour restrictions and duty compliance? Doesn’t apply to surgeons. I’ve worked at least 95 hours each week on service so far, with 32+ hours on call every night with no sleep. Official guidelines state 80 hours/week and 30 maximum on call. Oh, and 10 hours of time off between leaving the hospital and returning in the morning, which is laughable.

I don’t say this to garner pity, because I can hash it for a month. I say it for posterity, and for the sake of my patients who are getting poorer care than I want to give them. There is also no question in my mind that the surgeons are working even harder than I am, which is staggering.

My typical day starts at 5 AM. I need to round on 15 or more patients (our service is absurdly large and understaffed) in the space of 2 hours. This breaks down to approximately 7 minutes per person, most of whom I should spend about twice that much time on.

There are extremes in medicine, as there are in anything. Internal Medicine is known for rounding as a group for hours and hours at a time, spending upwards of 20 minutes on each patient to ensure that every i is dotted and t crossed. Attendings, senior residents, and interns all chat about patients in a formalized, clear fashion. There is a clear demarcation of who is responsible for what.

Our service, on the other hand, does not round at all. In fact, I’m lucky to talk to my senior surgeons for 10 minutes throughout the course of the day, which leaves me – an intern with 3 months of experience as a doctor – to essentially manage all of the problems that occur on the floor while they are operating.

From 7AM until 7PM or so, I respond to every call about the 40+ people on the surgical service. The pagers (I carry 2) go off every 10 minutes or so. Blood pressure too high. Blood pressure too low. Too much fluids. Too little fluids. Patient dying. Patient vomiting. At this point I really only call my upper levels about “patient dying”, as I figure this is a fairly important thing to pass along.

Today is the first day that I got home in time with 9 hours until I need to be back at work. I’ve got an hour to write before I go to sleep.

I suspect this is why surgeons don’t blog very much.