Sunday, April 15, 2007

Just Another Day in the Department

Last night was a Traumafest. So far, traumas haven't really meant all that much to me because the second-year residents run them. So while they are busy assessing patients and getting to do cool procedures, I'm off in the back of the department talking with Mrs. Smith about just exactly where her belly pain is and getting her to describe her vomitus. Last night my favorite attending was on. This guy just has such a great attitude. Even when he's stressed out, he's still really good-natured and great at supervising.

A trauma came in that the second-year had taken a radio call about. I was free, so I went and helped assess the patient. His breath sounds were good, but when you pressed on the lower left part of his chest there was a crunching sensation and it was quite painful for him. Sure enough, the chest x-rays showed a lot free air was trapped under the skin and several of his ribs were broken. His lungs were both inflated so we ordered a CT scan to get a better view. The CT scan showed a pneumothorax (dropped lung) and the surgery team started talking about putting in a chest tube.

The third-year resident looked at me and said, "You're doing this tube." I was happy about this, but also somewhat concerned about screwing over the second-year resident as it was technically her patient. To get certified in procedures we have to do so many under supervision and get signed off on them. There have been instances in which interns have been given procedures when a second-year still needed them and has less time to get them done because they are closer to graduating. To me, it wasn't worth gaining an angry co-worker for the next year. I gingerly approached the second-year and made sure that she had all of her chest tubes. Luckily she did, so the chest tube was mine!

Now the heart starts beating faster and the anxiety starts kicking in.

For an emergency medicine resident, putting a chest tube in is about the closest that we get to performing surgery. Technically, post-mortem cesarean sections (yikes) and thoracotomies (cutting open the chest to directly get to the aorta to clamp it) are more difficult, but those procedures are so few and far between that I most likely won't do them on real patients during my training.

My attending asked me to get everything set up. I hadn't done a chest tube since September. And, while the patient was stable enough that I had time to get him to sign consent forms, order the medications, and talk to his family first, I didn't have enough time to read over the procedure first. So, I wasn't as prepared as I could have been.

To make things more high stakes, there was a fourth-year medical student, a psychiatry intern, and an internal medicine resident that wanted to watch. The third-year and attending were supervising me, the second-year was going to perform the sedation (which made her happy as she still ended up with a procedure), and the patient's nurse was present, as were a couple of techs.

There were certainly a lot of eyeballs focused on me now, while I tried to run through the procedure in my head. I gowned up with a mask, booties, sterile gloves, and the sweating started. I had to be helped prepping the chest with betadine as I had forgotten to do this before getting sterile. Luckily, the patient was sleeping soundly, so I was free to take my time.

My attending and senior coached me through the procedure. After numbing him up, I cut into the chest with my scalpel and felt for the next higher rib. My hemostat found its way to the parietal pleura (rubbery-like layer of tissue that encases the lungs). By this time, everyone was pressed up against the bed, and air was bubbling up through the blood because of all of the pockets of air that were trapped in the layers of skin. I traced the path of the hemostat with my finger and made sure I was right where I wanted to be.

With a quick plunge, I shoved the hemostat up over the top of the rib and into the thorax.

Air gushed out at me. I widened the hole with my finger and my attending checked my position. This chest tube was different than the other ones I had done because the lungs were mainly still inflated. You could feel their rubbery fullness. I guided the chest tube into place and then closed my incision. An x-ray confirmed it to be in the right place.

I couldn't have asked for a better scenario. The patient was stable, and my supervisors were patient. I was rusty enough on the procedure that my confidence was somewhat shaky. Now I feel much more prepared. If an unstable patient comes in tonight needing a chest tube, I am sure that I can get one in much more quickly.


Then there was the asthmatic that came in very combative and in respiratory failure. My attending took a radio call saying that they were 2 minutes out, and told me to get the room ready. This time I redeemed myself by having the suction, laryngoscope, and endotracheal tube prepped and ready, with backup tubes and blades if needed. The rapid-sequence intubation (use of a sedating agent and a paralytic) went smoothly with the exception that I couldn't see the vocal cords, so my attending had to help out and reposition. The patient got switched over to the ventilator and sent up to the ICU for management.


By this time of night, the second-year resident had left. Another car accident came in, and that meant I was running the trauma. It was a young guy, and he was a lot more stable. I was able to take my time and systematically look him over from head to toe. X-rays and labs didn't turn up anything, and I ended up turning him over at sign-out with a nearly-completed negative workup.


Another cool thing I got to do was trephinate a toenail. This lady had dropped something heavy on her foot and there was blood trapped under the nail. So, we grabbed an electrocautery tool and basically shoved a red, hot poker into her toenail... after numbing her up with a nerve block first. It wasn't very satisfying though, as the injury was old, so there wasn't a whole lot of blood released.


All in all, I don't think I could have asked for a better shift. I was carrying a crazy amount of patients because the senior basically acts as a supervisor and doesn't see his own. Also, the off-service interns typically don't handle more than a couple of patients at a time. For my other patients, it took a little bit longer for me to get them taken care of, but by the end of the night things were pretty well cleaned up. Now I just have about 90 minutes of dictations to do, and an hour of review reading to keep up with myself.

1 comment:

Chris said...

Traumafest? That sounds like a punk rock festival or something:)

You call that a great night? I'm exhausted just reading about it all. Air gushing at you and caulerizing toe nail-beds? Yuck-o.

Is there anything that really grosses you out? If so, what?