Saturday, March 18. 2006
Match Day on TV
Queens NY here I come!
Until someone figures out how to save this video, here's a link to the local news story on our match day...
www.wavy.com (click on the EVMS story on the right)
Friday, March 10. 2006
Life Experience
58 year old Caucasian male, found in a parking lot at the side of his car... complained of difficulty breathing, some epigastic pain. has become unresponsive en route and tachycardic to the one forties... blood pressure is ninety over palpable... ETA to MTA is 5 minutes.
Understood, awaiting your arrival. Ten-four.
Status update... the patient is deteriorating, no longer has a pulse and we cannot get a BP reading... we are starting CPR. ETA 2 minutes.
The patient comes in on a stretcher, with one emergency medical technician (EMT) doing rescue breathing with a bag mask and another doing chest compressions - desperate measures to keep that vital oxygen flowing to his brain when his heart and lungs have all but given up. They rush the patient into bay 11, and our staff start to take over. We hear that he was on the way to the bank, and that he has metastatic colon cancer. The patient's head and shoulders are already visibly blue. My resident has all his intubation equipment ready, and he gives the order to stop CPR. He attempts to slip the tube into the patient's trachea. No good, restart CPR. I grab a bigger tongue blade and a better handle, and again he tries. The tube slips in gently, and we start feeding him air through the tube. We give ever more fluids. We give epinephrine. Atropine had already been given in the ambulance, so that's no option. We give more epinephrine. Still no good.
We are now 20-25 minutes from when he first crashed in the ambulance, and a quick ultrasound exam shows no cardiac activity whatsoever. The heart simply refuses to beat, despite the electrical rhythm displayed on the monitor. My attending decides that the effort is futile, and over.
Time of death, 10:31 am.
And that was it. The first time I've ever seen a man die in front of me. Sure, I've had patients of mine die (only twice though), but it was always something I heard about the next morning, or later after I've left rotation. It was a strange experience. I wasn't broken up nor did I want to break down or something. Why should I? I did not know this man, and although he was on the young side, his odds were certainly stacked against him. I had suspected he would die before he even arrived, I figured he had a 10% chance of seeing tomorrow. Still, there he was, blue and cold and still as can be, with a plastic tube coming out of his mouth. Still, life went on in the ER, people going back to work and joking around as they always did, seemingly unfazed. Who knows how many they've seen die. Heck, I'm sure some friends of mine are surprised it took me this long to see someone die.
I was fazed. My next patient clearly was not dying, and I started getting annoyed by his babbling on about his problems. When I realized this, I had to tell myself that he was no less needing or deserving of our help, just because he was not critically ill. I was there for him. That wasn't all though. I was just a little more jumpy the rest of the day. Every other patient looked sick to me, and I more often than not grabbed my resident to have him evaluate the patient first, just in case. Funny, I guess I do fear death, after all. Also funny, that feeling that my problems are trivial compared to that of the man I met in the ER today, the man who woke up today planning to wake up tomorrow and the day after. It's not true, of course; if anything, he's the one that has no problems now. Certainly up until now his life has been tougher than mine; a battle with metastatic cancer is no easy thing on one's life or psyche. And it's a terrible thing to die so tragically and unexpectedly. Still, I suspect it's a gut instinct to feel the way I felt, I guess part of what makes us human.
I dunno. I guess we do all have to go sometime. I just wish this guy could've not died today.
Thursday, March 2. 2006
Emergencies
No photo today, sorry folks. So I haven't posted in a while, I think the last time I did I was still in California. I've just finished up my month on Radiology, and I suppose now I can read a chest x-ray better than before. Certainly better, but still not quite up to par. I just don't know why those darn things are so difficult.
So I'm on Emergency Medicine now, and of course they started me off with a solid 8 days in a row, 3 evening shifts followed by 5 graveyard shifts. Ugh. I don't know if I like this hectic, fast paced type of medicine, with patients flowing in just a tad faster than I can see them. I like a little downtime in my day, a chance to breathe... In the ER, though, there are always more people in the waiting room, and it's expected for my resident to be juggling 5-6 patients at once. Which means, thankfully, I'm only juggling 2-3. Crazy stuff.
So last night, 'round eight, the ambulance pulls up and in comes the cutest 7-year-old girl sitting on a stretcher. Strapped to her (via seatbelt) is a massive metal bedframe, made of colorful pipes welded to each other. In a tiny hole on the side of one of the pipes (who know's what it's for) is stuck her middle finger. She was very amused as a mass of doctors and nurses surrounded her, and my attending chats with her with a smile as he pours a generous amount of lubricant around her finger. Doesn't work, she's still quite stuck.
Now the picture isn't quite right already - I can see there's small smears of blood on her pajamas. She's gotten cuts around her finger already where it's inserted in the hole, which apparently was quite sharp and she's already tried to free herself. Her finger is presumably pretty swollen on the inside. So it's off to the pipe shop. Pipe shop? I didn't even know our hospital had a pipe shop. I wonder what they do there during the day? Tonight, however, they were going to cut that bedframe to pieces.
Of course, once I get over there (along with a very dedicated nurse and ER tech), the pipe folks (plumbers?) have their own lubricant to try - some sort of silicone grease (quite different from our stuff) - but it doesn't work either. So we do our best to comfort the child while they tear the bed apart before our eyes. The first few cuts are easy, using circumfrential cutters to debulk the massive thing. The small pipes welded on come apart easily, but her finger is stuck in a huge pipe (2.5" diameter maybe?) , which requires a powersaw to go through. We do our best to brace her hand and the pipe in a vice. As we get closer, the nurse and I put our fingers in the way of her fingers, so if the saw missed, we'd get maimed first. His idea, not mine. Are all ER nurses so brave? I was pretty scared.
Slowly her charming demeanor melted away with the increasing pain. Each further cut got worse and worse, as the pipe started to bend and pinch her finger. We finally cut enough of the pipe to fully expose her finger, a horribly swollen mess covered in blood and grease. Any further cutting simply bent the pipe too much, she would cry out in pain. We attempted to use teflon tape to squeeze the edematous fluid out of the proximal part of the trapped finger, hoping to squeeze it through bit by bit, similarly to how we remove swollen rings from fingers using dental floss. It didn't work. (btw, unless you're trained in it, I would not recommend trying to remove your own stuck rings this way - go to the ER!)
"Do you have any ideas, doctor?" they ask me for the 5th time in 2 hours. Me? I'm no surgeon! "I think she needs to be sedated. This is causing too much stress and we can't get good access here." Or something like that. The nurse recommends I go talk to my attending. He demands of me, "Why sedation? Is she no longer cooperative? Has her condition deteriorated to the point where she simply can't take it anymore?" No, and no. Or no and maybe. I'm not sure. I suggest we might be able to get to her finger with a hacksaw - I'm simply not comfortable with using any more powertools at this point. He agrees - one more try with the hacksaw, and if it doesn't work, the patient comes back to the ER for reevaluation.
I tell the nurse the plan, and he agrees. We clamp what's left of the pipe wall, and go to work. We simply can't hold the pipe still enough (it's really only half a pipe now - meaning it's only half the circle and so has no structural integrity). The girl cries in pain from every single movement of the saw, and we were barely able to make a centimeter of progress before we decide it's just unsafe. Back to the ER. By this time the pipe guy had already called in several his maintenance friends, and they all are sad to see her go. More so, I think they were truly disappointed they weren't able to save the day and free her finger, and I'm sure they were all wondering what more they could do.
We get back to the ER, and my attending comes over and looks at the poor finger, still stuck inside the remnant of bedframe. He begins to try the dental floss trick, but the nurse convinces him we've already tried that. Okay. Time to call the hand surgeon. The nurse starts an IV on her, something they could easily do in the operating room, but I think he too wanted to do something for her, despite everything he's already done. I finish up all my paperwork on her - what else can I do? I'd like to follow her to the OR at the next door children's hospital, and through to the next day and round on her, but seeing as I'm on ER, I can't quite do that.
My resident calls me over to sew someone's laceration closed. It's been a long time since I've done stitches, but somehow they come out looking pretty nice. I guess I learned something these past few years. And then on to the next patient...
Friday, November 18. 2005
Champagne Tap
Sorry, no picture today. I haven't really had the inspiration to take any photos lately, hence my lack of posts... Anyways, life is speeding along as always. I finished up my month at CHOC, and I'm still pretty happy with the idea of becoming a pediatric cardiologist. I'm working at UCI now, doing a sub-internship in pediatric ward medicine. UCI's pediatric program is mostly based at Miller's Children Hospital, and interns really only spend one or two months at UCI Medical Center (where I am). As such, it's a very low-key rotation, and I don't follow a lot of patients. Things were very frustrating at first: it took some 30 phone calls to get access to the computer system, they refused to give me a pager so I had to buy my own, and lots of small things like the way they do their discharge summaries infuriated me. But I settled in and now I'm enjoying myself quite a bit. Phew!
Which brings me to the title of this post. To cap off the first week and my first night on call, I got woken up by a page in the early morning because one of my kids had broken yet another fever. The kid needed a lumbar puncture (aka spinal tap), and I had to do it. I got a little scared, imagining the horror of sticking a needle into the spine of a 4-month-old baby and somehow wrecking the spinal cord or something, paralyzing him for life. Which of course couldn't happen if I even barely knew what I was doing, since really the most serious complication would be an infection or maybe an allergic reaction to lidocaine. I wouldn't be poking around where the spinal cord lies, just where the fluid collects.
So I went over the procedure with my senior resident, and we got the baby ready. With the parents just outside the treatment room all teary-eyed and the baby crying inconsolably, I put on my sterile gloves and got to work. Finding the right spot was tricky at first, but I figured it out. I broke sterility. Oops. I changed gloves, and finally put in the needle. I pushed forward in a gentle motion, staying straight as I could, and I felt the pop I was told to expect. I pulled back the stylus, and badabang! CLEAR AS WATER! No blood at all, just pure, pure sweet cerebrospinal fluid (brain urine). A champagne tap! On my first try!
Now I know I was lucky (there are so many variables), but hey, that was still awesome. Bwa! And no, I didn't paralyze the baby. I checked in on him about 30 minutes later, and he was just as happy as he could be. (He was being fed.)
Sunday, November 6. 2005
Birthday number three
Had dinner with a bunch of family tonight, it was my cousin's third birthday. This was about the best photo I could take, I was shooting somewhat blind and had slow exposure. To explain how blind this shot was, I thought there was a birthday cake in front of her. Turns out they had moved it.
For some reason, I still can't get my flash to fire independently of my meter, something my old camera could do... grr. I think I'm just doing it wrong. As you can see, she's a cutie, although her movements seem to have given her a black eye in this photo. Weird.
Click here for a larger version.