Agraphia Medical Tragicomedy

3Sep/09Off

Priorities

At 4:45 AM I sat, head in my hands, trying to figure out who I needed to call first: Vascular Surgery for the bullet in my patient's calf, Trauma Surgery for the girl who nearly sliced her thigh in two on a plate-glass window, Orthopedic Surgery for the guy with the infected tendon from the cat bite, or OB/GYN for my 40-something who was hemorrhaging out of her nether regions.

It was too much for me. Tired, confused, nervous; with far too much on my plate for an intern with 2 month's experience at playing doctor. Decisions that are clear and simple in hindsight were insurmountable obstacles in the wee hours of the morning.

What transpired was this: I spent 30 minutes running around like a chicken with its head cut off, filling patients' requests for pain medications while trying to decide who I needed to take care of first. I was scared. I knew none of my patients were trying to die on me, but all needed emergent care.

Surprisingly, I have never seen a "vag bleed" in the ED before. Insulated from this common complaint during medical school by well-meaning residents, I had no idea how to work her up. She was terrified that she was hemorrhaging out of her vagina. One quick look at all the blood and I was terrified too.

I've also never been responsible for working up a gunshot wound; fragments of the bullet were clearly present on the XRay, although fortunately for him it missed the bone. There was a lot of blood, and he was in a lot of pain.

Fearful of the unknown, I spent the next hour fretting over the gunshot and the vaginal bleed.

Knowing what I do now, I should have flipped my priorities. The vaginal bleed had stable blood pressures and heart rates, with normal hemoglobin. Urgent OB/GYN followup, but discharge home. The gunshot wound, although impressive (mo'fucka SHOT me, doc! It HURTS!) had normal neurologic and vascular exams - no major structures hit by the bullet - and also went home. The surgery to remove bullet fragments is more dangerous than keeping them in.

The thigh wound and cat bite, by contrast, both needed admission to the hospital and truly STAT treatment. The infection from the cat bite was rapidly advancing up the patient's arm. Luckily the nurse had asked me for antibiotic orders when she first saw him... I can't thank her enough. I shudder to think what the several hour delay in treatment could have meant otherwise.

The thigh wound, as I suspected, required a trip to the OR. However, with a large, open wound like she had, the sooner the better. She'll be fine with plenty of operative cleaning and antibiotics, but I got a scolding from the trauma surgeon for not calling them earlier.

It's amazing how far removed from book learning reality in the Emergency Department is. Do I have the cojones to send a dude with a bullet through the thigh home, just based on an article I read? I sure don't. At least not until someone who has seen it 50 times says I can.

This marks 1/50 for me. Give it time.

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  1. Yeah, flexor tenosynovitis – especially with a cat bite – is a surgical emergency.

    As for GSWs… is there an indication for debridement of nonviable tissue? This is more for the high-energy bullets, but still. Leaving nonviable necrotic stuff with a tract to the air is not my idea of fun.

  2. I think you’re right; high-energy may be a different story. This was actually a through-and-through .22 cal bullet tract with clear entrance and exit wounds. Nothing really to do but irrigate and d/c home with percocet and a tetanus shot.


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