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.

Well, after an absurdly long hiatus, it is my pleasure to announce that Agraphia is back!  She may not look like much right now, but I’ll be piecing together all the old posts, comments, and site structure over the next few days.

Apparently I got hit by a hacker, and was in the process of selling crude oil to some Afghani prince when Google stepped in and red-flagged my entire domain.  Still not sure what all that was about, but either way, I’m pretty sure I’m being audited by the IRS this year.

Long story short, a complete computer reformat and a complete website reformat later, I’m now running Windows 7 and the newest and hottest version of Wordpress, and I’m ready to do some typing.  I’ve really missed being able to post on this blog… didn’t realize how much it meant to me until it was gone. Posts to come!  I’ve got 2 or 3 that I wrote while I was waiting for the detritus to settle.

-Zac

P.S. Anybody who has needs 50,000 gallons of crude oil on the d/l… you know who to ask.

P.P.S. RSS feeds are officially:

http://feeds.feedburner.com/agraphia for the main rss/atom feed (for all you google feedreaders out there), and

http://feeds.feedburner.com/agraphia_comments for the shiny, brand new COMMENTS feed (I know you asked for it!).   Pretty Web 2.0 buttons to follow.

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.

Tomorrow I start my general surgery month, on call at 5 in the morning. I’m nervous, for many reasons.

Apologies for the pity post. I’m allowed to do that once in a while, right? Cheer me up by forwarding this blog to your favorite friend and/or leave me a comment :)

Faceless children throng through the doors of the Peds ER; parents, illnesses, charts all flowing into one feverish, runny-nosed amalgamation.

The waiting room is full of these kids. Anyone who didn’t have the flu before, does now. It takes 7 hours to be seen, plenty of time for snotty hands to wipe all over the tables, the chairs, the playthings.

I vaguely listen to my voice on autopilot, droning on about the benefits of motrin and tyenol for fevers. I’m surprised to hear myself lose patience with a particularly insistent mother who wants her daughter hospitalized for a fever of 101.3 and a cough. Her kid is fine. She won’t take no for an answer. We get security to escort her out.

This isn’t fun. At one point I see 8 children in a row who I diagnose with the cold. The monotony is broken by a child with a cut on his finger, but he starts screaming the second I enter the room. We have to sedate him before I can sew it up. He hates me for it, and his mom judges my repair every step of the way. I look too young, she explains. My next 5 patients all have the cold. Nothing about this is enjoyable or fulfilling.

The shift ends with a whimper, as we finally clear out the waiting room 15 minutes before I’m scheduled to leave. My last patient is a kid with a cough. I send him home with tylenol for the fevers. The parents can’t believe they waited eight hours for me to tell them that. I can’t believe they did either.

Working the pediatric ED overnight, I got called to a room for an urgent transfer. An attending physician at another institution had decided this child was beyond his scope of care, and sent the kid by ambulance to us for further workup.

The story as I got it: Previously healthy 5 year old boy with a retropharyngeal abscess so big it was starting to swell out the back of the neck. Feverish, lethargic, sick looking kid. The other doctor had started him on very hefty IV antibiotics, drawn blood cultures, loaded him with fluids, and shipped him to us as quickly as possible. This child needed ICU monitoring and surgery for the abscess.

I walked in the room and was immediately struck by how wrong the other doc was. Even to my fairly untrained eye, I could tell this “abscess out the back of his neck” was just a lymph node.

Odd, because only two diseases commonly cause enlarged lymph nodes on the back of the neck. The first is HIV (much less likely in this particular 5 year old)… and the second is mononucleosis, colloquially known as the kissing disease, requiring only lots of TLC and chicken soup.

So, instead of sending him to the PICU with urgent surgical consult like the transferring doctor wanted, I ordered only one test – a confirmation for mononucleosis. 20 minutes later it came back positive.

I was walking on a cloud for the rest of the night.

And just like that, I felt like it was my first day of internship all over again.

The patient was a middle-aged, obese, ill-appearing diabetic woman in chronic kidney failure. Thrice-weekly dialysis was all that was keeping her from spilling so much water into her lungs that she drowned in her own fluids.

I walked in the room and realized I had no idea what to do with this woman. “That damn dialysis ain’t workin’ no more, doctor.” she said, “and them fluids, they jest keep buildin’ up. Jest buildin’ on up.”

To my best exam, there was not much wrong with her except some soggy-sounding lungs, and possibly a swollen ankle from where she had sprained it a few days before. Even with her extensive medical history, I couldn’t make a good case for a heart attack or lung clot causing her breathing difficulties.

So, I sent her off for an X-ray and some basic lab work. An hour and a half later the tests came back stone cold normal – except the aforementioned soggy lungs. I called the kidney doctor who regularly dialyzes her, to see if we could get her in that night for an extra treatment. He called back 30 minutes later. I had interrupted dinner with his family.

“Well, she’s scheduled for dialysis at 6:30AM tomorrow morning. Didn’t you bother to check? Can’t she just wait until then?” He was not happy with me.

I paused. She could probably wait until morning, I thought. I apologized, and told him I’d call back after I asked my attending.

It was another 30 minutes before I got a chance. My attending, an impeccably brilliant man, asked me a few pertinent questions… and came to the conclusion that there were many plausible explanations for her progressive shortness of breath. Including a heart attack or lung clot.

Her emergency department stay ballooned into 6+ hours, what with the leg ultrasound and the cardiac lab studies tacked on after the fact. All negative, of course. She was admitted to the hospital anyway.

I suspect, in the end, that she’s right. Her dialysis “jest don’t work no more”. People aren’t meant to function without kidneys. But that horrible feeling that I made a mistake today, and overlooked something potentially life-threatening… that doesn’t sit well with me.

She’ll die soon… I wonder if she knows? Once you start failing dialysis it’s pretty much end-game, and she’s not a candidate for a kidney transplant. She just wanted me to help her. I had nothing to offer.

Frustrating patient. Frustrating workup. Frustrating day.

Sirens screaming, we ran the red light. Cars stopped, necks craning, pedestrians waving, all watching the ambulance with sirens at full blast tear through the intersection. The EMT flipped the siren switch on and off to alert that we were coming through.

The call: “Ambulance 33 to Charlie Alert, we have an 11 year old with an unknown cause for acute change in mental status”.

The two EMT’s and I, joking around at a fire station only a moment before, were now grimly trying to figure out the fastest way to the house. Sick children bring out a protective response in everyone.

Arriving on scene, a fire truck and 2 squad cars were already parked outside, lights flashing. Neighbors peeked their heads through windows, the streets eerily devoid of onlookers. Two muscular, salt-and-pepper haired firemen stood outside the door, looking decidedly nervous… incongruous for these men who looked capable of handling anything.

The girl was floppy and almost unresponsive. Eyes closed, head lolling to the side. Sternal rub barely able to wake her. The EMT looked over at me and said “honestly, doc, since I’ve got you here… do you want to handle this?”

And so, I did. Airway intact, as long as she stayed awake enough. Breath sounds equal bilaterally. Pulses good, heart rate normal. Physical exam unremarkable except for some nystagmus in her eyes. Family hysterical, wanting to know if she was going to be ok. She had just come back from a friend’s house. He’s a 13 year old in the neighborhood who was grounded last week for drinking his mom’s tequila.

And suddenly, I knew what to do.

I put my nose close to her mouth. The acetic tang of barely metabolized alcohol washed over me. I’ve seen enough drunks in the hallway beds – and smelled them – to know exactly what this was.

I pulled one of the police officers aside, and asked him to give her a breathalyzer before we left for the hospital. She blew a .16, twice the legal limit for an adult.

Smiling to myself, I asked her if the world was spinning in front of her eyes. “It’s like there’s two of you,” she responded, and then promptly threw up all over the inside of the ambulance. The EMT and I rode back with her all the way to the hospital, chuckling at her drunken ramblings.

She’s gonna have one hell of a lot of explaining to do when she sobers up.