VACATION!

I am on vacation starting NOW! No updates for a bit.

Back in the Habit

I am back on the adult side. Today there was suturing, splinting, and another CHEST TUBE! Woohoo! Goodbye fever and diarrhea-land!

Screw Job

I worked late on Friday night, but now I have until Monday evening off. This is the first time I've had two days off in a row all month.

My weekend didn't exactly start off the way I wanted it to. Saturday, I rolled out of bed and went to open the blinds on one of the windows in my bedroom. I was surprised to see that some of the siding of the house was hanging off in the breeze! There had been a pretty rough storm the day before. Several trees lost some limbs on my street, but I didn't think it would tear part of the house off!

Luckily, I could reach the section by hanging out the window without having to climb out onto the roof. I could just picture myself falling off the roof and having to go into the ER-- definitely not how I wanted to spend my day off. I hammered the section back in, adding a few extra nails. However, it wasn't flush with the wall.

I decided to find the longest screws I had and drill through the siding into the old wooden stuff beneath. Unfortunately, this meant a trip to the hardware store for pilot point drill bits as the "all-purpose" set I had wasn't meeting my purpose. The new bits went through the aluminum like butter, and I bought some all-purpose caulking as there was still a gap between the siding and the window ledge.

This is where my project went downhill.

I squeezed and squeezed on the caulking tube and got nothing. So finally, I used both hands, only to have the back end pop off and the stuff started to ooze out the back of the tube! Then I tried spackling the stuff onto the side of the house (mind you, I was upside-down hanging out the window doing this), but it wasn't working. Finally, I just started sticking my bare fingers in the tube and slathering it on like frosting. It sort of worked, and luckily, since it is clear and high up, I don't think it is too noticeable. I wouldn't recommend this "technique" though, as I'm not exactly sure that caulking is non-toxic.

The gap definitely needed to be fixed though, as I have old plaster walls in my 82 year-old house. Just under that window the wall kind of bows out and I put my knee through it when I was cleaning the window a few months ago. Maybe with the siding water-proofed there it will stay dry and when I get around to patching the wall it will stay nice and smooth. Finally, because I'm a girl and care about such things, I put some clear nail polish over the screw heads so that they won't start rusting later. Pretty resourceful, eh? Or I guess I could have just used better screws.

Last night I was over at my buddy's for a movie and a few beers. He was impressed, right up until the finger-painting part. He said, "Why didn't you just use a caulk gun?" This is the part where my head spun around and I said, "WHAT?" Apparently, the back end of those tubes is designed to slide forward, which is why the stupid thing popped open when I squeezed it. I thought it was just supposed to work like a large tube of toothpaste! I have another tube to redo the mildewy part around my bathtub, but luckily I hadn't gotten into that yet.

I guess part of the problem is that I have all of these home improvement books, but I don't technically look up things before I do them. I just do them and am then later shocked to discover that there's a better way to go about it. Apparently, J isn't as clueless as he likes to pretend to be. I may have to start enlisting his help around here.

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Today's mishap was in the kitchen. I am trying to do more cooking around here, as I basically use my stove to heat up frozen pizzas. I am smart enough to not attempt new dishes for other people, and am first trying things out on myself. Tonight's attempt was at stuffed peppers. One of the peppers split open down the side. I briefly thought about suturing it back together. It turned out that it didn't even matter, as the stuffing only filled four of the COLLOSSAL bell peppers I had rather than the six the recipe called for.

Other than trashing my kitchen , I thought that things were going well until I saw this:


Here's a closer look in case you missed it:


That would be a tupperware lid, melted on one of my burners. Luckily, the thing peeled off in one piece once it cooled down.


The peppers actually didn't turn out too bad:


I was too full to eat more than half of it though, as I also made some Beer-Cheese soup which was quite tasty... and it didn't involve harming any innocent tupperware!

Glad I Am Not an Early Bird...

I think that working in the medical field, I may have some phobias that are different than the average person. As an EMT, I was horrified to learn about rectal prolapse. We were talking about this very subject with a neighbor during a hockey game the other week, and he said something along the lines of, "What do you mean my ass can fall out of my butt?" Comedic gold, let me tell you!

I am not afraid of having a heart attack. It's all the little weird things like anal fistulas and necrotizing fasciitis that freak me out. I know that I am not alone in this. I had an instructor in medical school who said that he was always afraid of the produce section at the supermarket. Whenever the automatic misters would come on to spray the fruit and vegetables, he said he would take off running. There is a somewhat rare bacteria that can inhabit irrigation systems and he didn't want to get Legionnaire's disease. It's kind of funny when you think about a grown man racing out of the grocery store, but I guess we all have our little quirks.

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Anyway, back to my point: the other night a child came in with a complaint of worms. It turned out that she had pinworms. Not a big deal-- easy to treat, but kind of gross! I never really expected to encounter them as in med school they tell you that the worms typically only come out at night. If you suspect a patient has them, you place scotch tape over the patient's anus and by morning, there will be worms stuck to the tape. These worms weren't even bashful... they were easy to see! Fortunately, the child was young enough that she wasn't even aware that they were there.

Seeing them reminded me of this song that one of my little friends taught me in grade school:

Did you ever think, as a hearse goes by,
That you might be the next to die?
They wrap you up in a big white sheet,
And bury you down about six feet deep

They put you in a big black box,
And cover you up with dirt and rocks,
And all goes well, for about a week,
And then the coffin begins to leak!

The worms crawl in, the worms crawl out,
The worms play pinochle on your snout.
They eat your eyes, they eat your nose,
They eat the jelly between your toes.

A great big worm with rolling eyes,
Crawls in your stomach and out your eyes,
Your stomach turns a slimy green,
And pus pours out like whipping cream.

You spread it on a slice of bread,
And that's what worms eat when you're dead.

So I discovered that pinworms are just like scabies and lice. Once you see them, you are doomed to a shift of compulsive hand washing and just can't shake that itchy feeling until after a good night's sleep.

The Short of It

On Saturday I ran a 5K. This one was for breast cancer and there were about 7000 participants. No medals for me this time! This one was much fancier, with bands playing at a few intervals along the sidelines. And there was a chip for runners to tie to their shoelaces, so that they could get their times. However, the time was when the gun fired at the start to when one crossed the finish line. There were so many people ahead of us and the walkers were mixed in with the runners that it took several minutes to get away from the crowd. I came in 839th if I recall properly, with a time of 33:41 minutes. I think I probably did better and was under a 10:30 mile but the slow start messed me up.

My friends, who are much more seasoned runners, said that usually there is a starting strip and an ending strip when one runs with a chip so that the times are more accurate. The guy that came in first ran a 15:40 time. I thought they were being over ambitious when there was a starting point for people averaging a 5-minute mile, but I guess not!

After that, I took a quick nap and then joined the gang for a barbeque before working the 5pm-2am shift. I pushed it a bit too much, as I just felt feverish and out of it the whole night.

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On Sunday, a group of us met up for a game of Ultimate Frisbee. I thought I would be much better at it than last fall, given all of the running. However, it's more of a sprinting game. There was a med student there that kept smoking me, so I ended up just doggedly running after him the whole game. One of the other residents sprained her knee, but other than that there were no casualties.

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On Monday, a group of movers came and removed the playhouse from my backyard. I have been wanting to get rid of this thing because it sits right in the middle of my grass since I moved in. Fortunately, one of the other interns has a 4 year-old that wanted it desperately, so she was willing to pay a crew to come pick it up. It took 6 men over an hour to maneuver it down my driveway, and they still ended up banging into the roof over the side door!

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Today, I met up with a friend to start studying for boards. I will be taking the last part of my licensing exam in July (hopefully only once), and I am trying to make myself just do a little bit every night. Step 3 is not supposed to be as bad as the first two parts, but I have a friend who failed it, and the stupid thing costs over $600, so I am not at all interested in repeating it!

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Only 8 more days left until my vacation! I haven't had time off since September, so I can't wait! A lot of the impetus behind all of this running is for a big upcoming hike with "The Phoenix". Just the thought of not setting foot in the hospital for 9 days has me excited.

Automatic Electric Chair?

This kind of stuff is why I can't do pediatrics.

No Complaints

Because I do a lot of complaining, here is an entry in which I do not.

Last night was perfect. We had a great combination of residents. Everyone picked up charts as soon as they were in the rack, so the patients didn't have any wait time. The "Big Guy" was on, and he is notorious for flying through patients, so people actually got seen, evaluated, and discharged home in a timely fashion.

I am still working on the pediatric side, and every patient I saw had some combination of fever, vomiting, abdominal pain, and/or diarrhea. It was like directing traffic: go home, go home, go home, and you-- you have to stay.


I was supposed to stay until 2 am, but by then, things were so under control that the attending was letting one of the senior residents leave early. There were a group of residents heading out for a drink from the adult side, and my buddy came over and asked the attending if there was "anyone else he wanted to get rid of." So I got to leave, too.

So I really can't top a night of efficiency, followed by an early release, and social hour with my buddies. I think I was long overdue for a shift without problems after some of the stuff I have been dealing with lately.

Thunderstorms

Outside it is thundering. There are occasional flashes of light here and there, but nothing like the cracking streaks of light that race across the sky like during monsoon season back home.

Work has been somewhat stormy lately. In med school, one of my friends once likened me to a grizzly bear. She said I was normally independent and peaceful, but when backed into a corner, I would be a "force to be reckoned with." I guess I have been doing a lot more growling at work lately.

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A couple of weeks ago I ran a trauma in which a child had been struck by a car. Reportedly, he was unresponsive on scene and bystanders had to do CPR. When he rolled into our department he was talking, but in a lot of pain. His breath sounds were unequal, and his chest x-ray showed several broken ribs and a huge lung contusion. His oxygen sats were dropping, so I ended up intubating him.

Traumas are always somewhat of a mess. There are often too many people in the room and people get focused on starting IVs and whatnot, and it's hard to get through the most important thing, which is thoroughly examining the patient, looking for injuries. I have learned quickly to be VERY assertive, so I can get in and get through my exam without getting distracted. There's still a lot to learn and improve on, but I'm holding my ground.

This case was somewhat frustrating to me as a resident on another service strolled right in and started talking to my patient when she had no business being there. She introduced herself and then had the audacity to tell him she would hold his hand until his mother arrived. I told her she wasn't needed and had to leave because we were about to do some x-rays. She had the nerve to say she was going to stay and get exposed to the radiation as she was not fertile anyway! I glared at her and kicked her out. I don't have any tolerance for bullshit, particularly in stressful situations. Plus, I already had good rapport with the patient, she didn't ask if I needed help, and it was condescending for her to just waltz in and act like she was there to save the day.

Shortly after that, I intubated the kid and he went up to the ICU on a ventilator for a few days. It turned out he had a head bleed. He just got discharged a few days ago.

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Today, I had another kid that was hit by a car. This one was a complete mess. For some reason, his friends dumped him off bleeding in our parking lot, where a paramedic team happened to come across him on the way out of the hospital. We weren't expecting him, so the charge nurse had him taken to a regular room, rather than a more spacious trauma room.

Tonight the problems arose with a consulting service calling another service without our knowledge and canceling our orders and putting in some requested by a person who had never even laid eyes on the patient. This is a big no-no. While in the ER, we are ultimately in charge of the patient. A consult is technically there to make recommendations, and is not running the show.

Basically, this all came to a head when an x-ray tech called me and asked me cancel some of my own orders because another resident told her they weren't necessary. This ended up causing numerous phone calls and conversations about why orders weren't being carried out. I ended up canceling their unnecessary tests and re-ordering everything all over again. I was fuming, and unfortunately the whole mess caused so much delay in getting the testing done, that by sign-out time, everything was still pending for the oncoming resident.

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Like I said, there has been a lot of growling lately.

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On a lighter note, Ruthie has answered my 5 questions.

Bringing Home the Gold

So yesterday was race day. I was not off to the best of starts. Fortunately, my ability to breathe through my nose was back to normal, but there were still phlegmy remnants of my cold. The location ended up being pretty obscure and over an hour's drive away. I only went for a run once this past week and quit after 4 miles, so I wasn't sure what kind of day I was in for.

There were about 130 people registered, but the majority of them did the 5K. My friends and I took off at a snail's pace. There were times when I wanted to walk, but we just kept plodding along. There were several hills along the route, but just when I wanted to stop, we would start to descend and I would be able to build my energy back up. By the halfway point, we had all split off at our own paces.

I didn't bring my iPod, so it was just me and the countryside. Just the sounds of my own rhythmic breathing. Mile 4 was by a cow pasture. That was an incentive to speed it up a bit! That was also the point when I decided I could do this thing, without walking. The only breaks I took were to grab a dixie cup at the water stands and the 15 seconds or so it took of walking for me to gulp the cool liquid down.

The plan was to speed it up for the last quarter mile, but by the time I got there, there wasn't enough reserve left. I ended up running out the last 100 meters or so. My last steps were woozy, but I made it!

I ran my bib number: 1:07, which means I averaged a 10:45 minute mile. That's pretty darn slow!

We stuck around for the door prize drawings at the end and were surprised to find that we all took home medals. The majority of the 10K runners were 40+ and they smoked us! The best time of the day was 47 minutes. I ended up with first place for women 20-29 years. There were only two of us in the bracket, and my friend got the silver. My other friends took gold and silver for the 30-39 year brackets. The guy that won for the 70+ bracket was amazing-- he looked like he was in his 50's! There was this older guy in a yellow shirt that I wanted to catch up to the whole race, but he stayed about a quarter-mile ahead the whole way!

Overall, I am pretty pleased with myself. I have never run even 5 miles continuously. If I keep at it, I am sure I will get faster, but I surprised myself by not having to stop for any breaks!


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The night before the race, I went out with a couple of friends to a new sushi restaurant in town. It was pretty cool because it was remodeled inside to look like a diner. At the counter, there was a long conveyer belt, and the cooks (Are they still called cooks when the fish is raw?) just kept putting out dishes and you picked up whatever looked good as it went by. The plates were color-coded by price. Pretty trendy for not being in the Big City!

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P.S. Call yo' mama today!

This One's for the Children...

Give 'em all a hand folks, those little $&#*@#! have struck again. Halfway through my shift I noticed my throat was on fire, then my ears started popping, and then the sniffles hit in waves every time I tried to dictate a chart.

I guess given all the "viral syndromes" I have diagnosed in the past week I had it coming.

And just so you know, nothing makes me crankier than seeing patients who are obviously less sick than I am. Where's MY Lortab Elixir? Where's MY excuse from work? No one is handing ME popsicles and stroking my hair!

Considering the gastroenteritis and pink eye from my peds month on the wards, I think it is clear who is winning.

Children: 3 Kate: 0

More Spring

Things are starting to look a little bit better around here. I went for a run around the lake yesterday, and actually got a bit of a sunburn! The flower beds in the front yard are looking good, but almost nothing is growing in the backyard.

Five Questions

Chris agreed to be interviewed by another blogger a little while ago and upped the ante by challenging his readers to answer any five questions of his choosing.

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1. Do you feel like you are treated differently by the general public, for good or bad, when people find out that you are a doctor?

Well, no one exactly rolls out the red carpet for me, if that's what you mean. I once got upgraded to first class on an airline, but that was before I graduated from medical school and more due to the low-cut top I was wearing at the time!

I usually don't tell people openly what I do for a living. Occasionally, when people have asked, they act like they don't believe me. At work, I typically get called a nurse by my patients, even after introducing myself as Dr. ______. I don't have a problem with that, but it looks bad when later they tell people that they love our nurses, but were never seen by an actual doctor!

And then, there was the one time this guy walked across Barnes & Noble to chat me up. I was wearing my scrubs as it was just after a shift, and he asked me if I was a nurse. When I told him I was a doctor, he just turned around and walked right off! The resident/intern thing is a confusing thing to try to explain to people, too.

2. What were you like as a teenager?

As a teenager, I remember being frustrated all of the time. I did not ever feel like I fit in with anyone. Most of my friends I had maybe one or two things in common with, but I never really felt close to anyone. During high school, I tended to over-involve myself in all sorts of activities, clubs, and sports. I think that partly stemmed from being bored and trying to find myself. My hometown is kind of bizarre in that it is so small, there weren't really any cliques. I tended to just float from person to person, and never really felt like I fit in. I did a lot of stupid, stupid things to try and please other people that luckily didn't end disastrously. And I didn't date. It was also the kind of environment where everyone knew everyone else's business and I was always too scared to share my feelings.

3. What is the most recent dream that you can remember?

Most recently, I dreamt that a patient was telling me that he had been bitten by a shark. There were bite marks up and down his legs. He denied going to the ocean and said he had been swimming in one of our local lakes. I kept telling him that there was no way that a shark could be in the lake, but he wouldn't believe me. In the dream, I was talking about the patient to an attending and they kept telling me I had to find out the truth. I woke up pretty frustrated from that one.

4. When you run and “get into the zone”, are you a “thinker” or do you just let your mind go blank?

Blank. I like the calm that comes with not being distracted by all of the usual worries and background thoughts that are bouncing around.

5. Tell us something that you have done, that you would not have thought you would have done in a million years.

This is a difficult one for me as most of my recent life has about getting to where I planned to be. To be honest, the move here was difficult for me. It wasn't what I planned on. It certainly wasn't where I expected to be. I am lucky to have supporting friends and family, but I am truly alone here. In many ways, I think that I have grown a lot confidence-wise, and I guess I needed some of that, but it hasn't been easy. I am fortunate to be at a program where I am treated very well, but it is all the other stuff like developing friendships outside of work that has been difficult. If you had asked me 10 years, 5 years, or even 2 years ago, where I would be now, it would never have been here.

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Also copied from Chris:

If you are brave enough to play.... Leave me a comment saying, “Interview me.” I will respond by asking you five questions. I get to pick the questions.You will update your weblog with the answers to the questions.You will include this explanation and an offer to interview someone else in the same post.When others comment asking to be interviewed, you will ask them five questions.

Play Ball!

I just got back from playing softball. We have a team composed of residents, department nurses, and spouses. And we are horrible. The game got called in the fifth inning because the other team was so far ahead. I did manage to bat a run in, and the other time I struck out. I ended up being the catcher, a position that I find scary since we don't have masks or helmets. Our original catcher got clocked in the face by a over-aggressive runner and ended up with a cut below her eye. She probably will have a nasty bruise tomorrow. The good thing about being a catcher is all of the squatting probably is a good butt workout. The bad thing is that you get hit in the shins by bouncing softballs a lot. At least I do.

A few hours before the game I went for a 4-mile run... and rewarded myself with a sundae for dinner. With all of the night shifts lately and weekend activities my running has kind of fallen by the wayside. This is unfortunate as that 10K is rapidly approaching. It most definitely will be a run/walk event for me.

Twenty-Nine

Yesterday I turned 29. It was a good thing, I think. Today was my first day back to work after a 3-day weekend. I probably should have used the time more wisely, but somehow when it comes down to having a day off, I just want to enjoy it.

On Saturday, I went on a Wine and Herb tour with some friends. We got there later than planned, and had to leave early as one of us had to work that evening, but it was fun. We made it to 9 of the 16 wineries. This time I went more with reds rather than whites. At each stop, they gave us a small herb in a container, a snack, and a recipe utilizing their featured herb. I came home with two kinds of tomatoes, basil, chives, pepper plants, and several other things I can't remember. I guess now I can really dress up those Lean Cuisines I nuke every night in the microwave!

On Sunday, I went to see "300" with a friend. It's about a small group of Spartans trying to hold back Xerxes (spelling?) in his quest to conquer Greece. It was very bloody, but the nice thing about the Spartans is that they don't wear pants... and they have incredibly fit bodies! After that, my friends treated me to a fancy dinner and drinks.

On Monday, I went out to lunch with some friends, mowed the lawn for the first time this year, and did some shopping.

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Today I went back to work. The bad thing about long weekends is that it's so annoying to have to go back. I survived, but the day was INCREDIBLY long.

Patient Art

This was given to me by a patient the other night. It looks like it should be a tattoo.

Closing Time

I went out for a quick drink with a couple of people after work last night.

I don't know that it's necessarily a good thing to show up to a bar in scrubs, but whatever. My bartender friend was there and he was just as clever and eccentric as ever.

Being tired + a shot of very fine whiskey = a numb nose for several hours.

Spit It Out

Chris asked the other day what grosses me out, so here goes:

I can't stand spit.

I can't watch people cough up phlegm, and spit it out with a gleaming string of drool hanging from their lips.

Even worse are the drunk, or near passed-out ones that end up with globs of mucus slipping and running down their cheek like raw eggs.

It makes me nauseous and start gagging. Luckily, I've never actually puked from seeing someone hawk up a loogie. And I don't know what's worse, watching them spit it out or swallow it back down.

You can reach for the suction tubing and try to get rid of all of that stuff, but the gurgling sound of the spit getting sucked up grosses me out also.

And I don't like sticking my hands in people's mouths, either. There's nothing worse than peering intently at someone's rotten away molars and having them breathe in your face. I don't know how dentists do it. If I worked in a dental office, I would require patients to gargle with mouthwash before I saw them.

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Feet are not my favorite either. Especially, when you peel off someone's sweaty socks and large flakes of skin go flying into the air. You try and time your breathing, but it's impossible. Somewhere in your nasal passages, some foot flakes get stuck, and the memory of the smell will be stuck in your head all night.

The other day I saw this guy with nasty trenchfoot... as in George Washington's soldiers marching barefoot through snow, trenchfoot. The bottoms of his feet were slimy and yellow, with thick, soggy skin. The tops were swollen, red, and ulcerated. Luckily, there were no maggots. That I actually haven't seen... yet.

Old, twisted, thick with fungus toenails creep me out, too.

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So there you have it: dental hygienists and pedicurists are people who in my mind cannot be paid enough.

Crocus

2nd Chance

The tulips I planted last fall aren't anywhere near blooming, but these ones are keeping me happy in the mean time.

Last night I got another chance at intubating. A woman came in who was unresponsive, jerking her arms and legs all over the place. She was fighting against everyone and randomly coughing and spitting. Her husband was there, but he said that she was very secretive about her medications and he had no idea what she had taken, just that she was acting bizarre all day and kept falling throughout the day. We tried calming her down with some benzodiazepines, but that did nothing, and didn't help her tremors. She seemed to be having a lot of trouble breathing and controlling her secretions, so intubating was an easy decision.

I once again had a full audience as prior to intubating her, it took five people to hold her down. This time I got it! It took two tries because she had a tight airway and the first tube I tried was too large. Things also got a little hairy as she started dropping her heart rate and oxygen saturation after the medication was given, but that all corrected with intubation.

Since we weren't sure if she had overdosed, was going through some sort of withdrawl, or had a brain injury, she got a pretty extensive workup. When everything came back essentially normal, I called the neurology resident who proceeded to yell at me for intubating her and literally hung up on me. Then he snuck in and saw her without talking to anyone. He basically copied my notes off the chart and wrote that he didn't think it was a seizure and that she needed to be seen by a psychiatrist when she got extubated. I am really getting tired of that service. We wanted her to get an EEG, but those unfortunately have to be ordered by the neurology team. I realize that her being sedated kind of messes up his ability to examine her, but I couldn't very well wait until she aspirated on her saliva and stopped breathing. I also didn't have time to wait for him to come down and see her before securing her airway.

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My other "big case" of the night was a 25 year-old with two seizures earlier that day. He had been seen at another hospital, and sent home. I was waiting for the report from that other hospital to decide what all we needed to do for him. My attending said that as he had another seizure since being evaluated there, we needed to do the whole workup. That turned out to be a very wise decision. I was sitting at the computer reviewing all of my patient's results when I pulled up his CT scan. It hadn't been read by the radiologist yet, but clearly there was a huge problem. I saw what looked to me like a tumor, and he had some sort of blockage (obstructive hydrocephalus) that was causing the CSF to accumulate on one side of his head and compress the brain tissue. It wasn't good, and just seeing it made me nauseous.

I pulled my attending away from what he was doing and told him he had to see this scan. I think he thought I was crazy at first. Then I went over the images with the radiologist, talked to neurosurgery, and ophthalmology. Then I had to talk with the patient and his entire family about the findings. I tried to explain it as best I could, but in the end, I ended up showing his mother his head CT. I don't know how to explain the other hospital's decision to send him home, but when I left he was going to get an MRI and he may need surgery right away.

Last night I had a hard time getting to sleep. Two traumas came in at 5 minutes before sign-out and I stayed late doing some dictations, but I was still wide awake at 3 am when I got home. It was snowing hard on my drive home. I just kept thinking about that patient. If it had been up to me, I would have just repeated his labs and not his head scan. This scan was so abnormal that staff from across the room noticed it and kept asking who it was. We never did get the report from that other hospital. Everything else was faxed over, but they said there wouldn't be a typed report until during the week. That's the sort of thing that terrifies me. Forgetting to check one lab or study could be crucial.

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.

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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.

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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.

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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.

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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.