Workings of the Mind

As I wrote before, for the last 3 weeks I have been on an elective in Neurosurgery.  It's been a heady (hee hee) experience being back in the OR.  Learning SO much about neuroanatomy.  Since the beginning of the month, we have been on-call for spine, so I've also been getting quite the education about spinal lesions and learning how to read MRI's.

We've been rather busy due to "trauma season," and at times have affectionately nicknamed the Trauma ICU as "Turban City" since 90% of the patients are ours and have their heads wrapped following surgery or ventriculostomies.

During the last several weeks I've come to realize a few things:

 - drunk anything is bad.  It makes you drive carelessly and hit 70 year old grandmas who then bleed into their brains.  It makes you jump on the hood of a car that then drives away, and you fall and fracture your skull and then bleed into your brain.  It makes you jump off a porch causing you to break several bones in your spine which leave you with weakened legs and needing a urine bag because your bladder no longer works properly.

 - you can be hurt by the ones you love.  The guy whose name you tattooed on your shoulder can shoot you in the head and dump you by the side of the road.  The family of your boyfriend can object to your relationship and cause broken bones in your face and head.  Your drunk husband can roll over the car causing you to have massive brain injury and leaving you as helpless as your two young toddlers.

 - walking down the street is dangerous.  You can get shot at, run over, mugged, or just trip and fall.  All of which can land you on our service.  So is riding your bicycle, driving in a car, or flying in a plane.

 - I like opening and closing surgical cases more than the actual procedure.  I know, weird.  But there's something very satisfying about gaining the exposure, identifying the lesion, then trying to cosmetically close the wound.  While drilling and plating is interesting, once I've seen the anatomy I'm satisfied.  I know, weird.

 One more week then it's back to the E.D. for my final 11 shifts.  We're on a countdown of 30 more days until I move from coast to coast... I've got to start thinking of new names for my blog...

Under the Pale Moon Light...

So, this month, I am on-call with one of our neurosurgeons.  Since I am going to a place with no neurosurgery back-up, I thought I would take the initiative and find out what I would need to know to be able to manage any patient that came into the E.D. that would need to be stabilized before transporting them several hours away to a University facility.  Plus I get to spend some time in the O.R.and learn other procedures so that is a bonus as well.

Last night I was awoken from my sleep and drove to the hospital in the middle of the night under a full moon for this....

Let me explain... this is a CAT scan of someone's skull.  The shiny thing at the bottom of the screen is what is left of the bullet that struck this person's head.  In the upper left, you can see the hole the bullet made, and the small white pieces that are scattered just to the right of the hole are pieces of bone that entered the brain when the bullet came through.  We spent the first part of the surgery clearing out the clot that had formed.  We spent the next part of the surgery clearing out many of those pieces of bone.  We spent the final part of the surgery getting "the heck out of Dodge" as the patient was bleeding profusely and needed to be stabilized in the Trauma ICU.

When we arrived in the TICU, we put in an ICP monitor at the bedside.  This will measure the pressure inside of the skull (IntraCranial Pressure - ICP).  High pressure is bad because there's a certain pressure above which the brain doesn't get any blood flow.

I'll post photos as I can during the next month... hopefully there will be some happy endings as well to talk about.

Isn't Sunday a Day of Rest...?

So I knew things were going to be bad when I woke up late for work this morning.  I was able to grab a pair of clean scrubs and run out the door.  All I could think about was getting sign out from the night team and heading downstairs to get a cup of coffee.  Little did I know...  I rushed to get to work quickly.  Made it in the door just at 0700, change of shift.  Before I even had a chance to take off my coat, the senior from the night shift told me that there were three victims from a house fire coming in;  one was a child and unresponsive and the other was an adult in respiratory distress.

I quickly took off my outer coat, grabbed my lab coat and stethoscope, figured out who my junior resident was going to be and got ready.  We got the adult patient first.  They were not responding coherently, so the decision was made to put a breathing tube in.  I left my junior resident to handle that while I took off to the next room as the child was being brought in.

She was brought in barely conscious but breathing.  She had soot around her nose, and we knew she probably had inhalation injuries.  We quickly made the decision to intubate her, and I put a breathing tube in.  We got her stabilized and started arranging transport to Children's Hospital.  We had no names for either of the patients, so we would just have to wait to name our little Jane Doe.

About this time, a third victim from the fire was brought in.  We asked if they had a little girl.  They immediately started crying but could not give us a name.  Carbon monoxide poisoning from a fire can make you goofy and delirious which they were.  They became argumentative and refusing treatment, but it quickly became apparent that they were not breathing well and would quickly be needing to be intubated.

After a quick sign-out from the night team that had patiently waited while we stabilized the fire victims, I talked to the patient who was starting to complain of a sore throat.  I told them what I was about to do and got some feeling that they understood.  We sedated the patient and placed the breathing tube... three patients intubated and it wasn't even 0930.

Somewhere around here time started to speed up.  I know from time to time I asked if it was Sunday and was anyone going downstairs for coffee.  Seriously, it was a cold snowy day.  A Sunday.  Why were we so busy?

Things that also happened during my shift, sometimes at the same time or right after each other:

 - alcoholic who vomited a liter and half of blood and needed a blood transfusion and admission to the ICU

  - a patient who heard voiced telling them to stab themselves in the chest, so they did, and then ate kitty litter in an attempt to kill themselves, they also needed a breathing tube

 - a possible stroke that turned out to be worsening heart and kidney failure

 - a teenager shot while driving with a friend "minding their own business" who initially went to Children's and then needed to be transfered to us

 - a teenager who decided to drink and drive and had a head-on collision with another vehicle;  they and their passenger forgot to wear their seatbelts and both had head injuries

 - an older driver who should have known better and drove while under the influence.  They had a head-on collision too, with a tree.  Again, no seatbelt.  Again, major face trauma

 - a very sick elderly patient that was transferred from another hospital and brought in by the helicopter.  I'll have to see if they're still alive when I go in tomorrow

 - another patient "minding their own business" who was stopping at a convenience store and was shot;  they came in just at the end of my shift which just about rounded out my day.  I will find out in the morning what the extent of their injuries were.

Wow.  What a Sunday.  And, tomorrow is Monday;  traditionally the busiest day of the week.  I better get to sleep early and double set my alarms... I think being late starts the day off on the wrong foot... yeah, we'll blame it on that!

Blood on My Scrubs

I can't say I've honestly thought about what happens to my scrubs throughout the course of my medical career. Until last night. I don't know why I had this surreal moment in the middle of a trauma code. I was handing a chest tube to one of the surgery residents to place in this patient's chest, and I looked down to step back as a puddle of blood had formed on the floor.

I noticed the blood spattered on my scrubs, and my first thought was, "Darn, I don't have a clean pair and it's the middle of the shift." Then, I started thinking about all the bloody, vomited on, amniotic-fluid covered scrubs I have worn during my medical training.

In medical school, most of the scrubs worn in the anatomy labs were new, bought excitedly in anticipation of starting your medical training. By the end of the year, we had a mass burning of these soiled clothes that had spent countless hours, literally elbow-deep at times, working to understand and learn the intricacies of the human body. I threw my shoes out too.

In your third year when you start your clinical rotation, you grabbed scrubs whenever you could. The residents had access to the scrubs machines and some hospitals had a general pile. We didn't have access to the machines so you stocked up when you could. Sometimes your scrubs got soiled midshift, and you had to have some kind of backup. I kept an extra pair in my "on-call bag." So, by the end of your medical school training you had this mixed bag of scrubs sporting the "not to leave the premises" or "property of" imprinting from the various hospitals.

These became a badge of honor in a way when I started my internship. You'd go to work in your home scrubs some nights on call. Everyone would look at your scrubs and say, "Oh, you worked there?" or "Oh, do you know so and so at that hospital?" We had access to the scrub machines there when we had to go to the OR, but you were only allotted 3 sets at a time. Sometimes you just didn't have time to run to the machine (or most likely the machine was empty), so it was more convenient to always have a pile of scrubs in your locker. We learned ingenious ways of getting more scrubs (including timing your visit to the locker room when the filler of the scrub machine was loading the machine... "Geesh, I don't have my card right now and I've got to get to the OR, can you help me out?") so that you had quite the surplus too by the end of the year.

Of course, the bloody, messed up ones went into the dirty bin. So all the scrubs you kept were nice and clean. At this point in my life, I have a pile of scrubs from all the places I've been. Most of them are blue in some shade or other. Some are what I call OR green. I have a cool teal green pair from a hospital in Rhode Island where we went on a transplant run while I was in Boston. We had to wear their scrubs to go to the OR for the harvest, and we didn't change out on our way home since time is of the essence in transplants.

But, when I became an Emergency Medicine resident, we didn't get scrubs. So we all had to go back to grabbing them when we could while on other off-service rotations.

Last year, our residency bought us these cool black "Ninja" scrubs. I don't like to think about what collection of body fluids accumulates on my shoes and the bottom of my scrubs by the end of the night. And, like last night, you can't help but get something on you.

Because we got a limited amount, they go right in the dirty bin when I get home. They get washed with the super-extra strength detergent after an Oxy-Clean soak. You just don't know what's hiding on them....

Hot in the City

We've had a lot of shootings over the last several days. I have been working the night shift, so it's always very difficult to post because I am often too tired in the morning when I get home, and then I am usually in a rush out the door when I head off for the next shift. I do manage to sneak in a quick post from time to time.

Anyway, onto the shootings. I worked the overnight shift at the county hospital on Tuesday night, and we had three unrelated shootings, plus a couple of stabbings, plus the token rollover... and a whole lot of drunks. I was in the middle of dealing with several different patients that I received on sign-out (some things are never what they seem) when a patient comes running in the door saying "I got shot in the face, don't let me die."

I took a look and saw the wound on his face. A larger caliber round and his face would have been an empty hole. A couple of inches further back, and I wouldn't been seeing this patient as they would have been either an organ donor or in the morgue. He was the lucky one that night. The bullet scratched just under his eye and ended up stopping and breaking his nose. Oh yeah, the bullet fragments are still there. He's going to need to have those removed at some point. That night, though, just some fancy stitching by the facial trauma resident and a referral to specialty clinic to fix his nose.

While I was finishing getting him settled I was told by the charge nurse that another shooting victim was coming in. This time, multiple wounds in the extremities and torso. We got the trauma team notified and I waited in the room as they were brought in. He lost his pulse as he was brought in the door. There was no saving him. I had to tell his family members. I worried about retaliatory shootings.

I kept working the shift. In the early morning hours we got another victim. This one had multiple bullet holes and a fracture in an arm and a leg. Not to mention the bullets that went into their abdomen. They went to the O.R. They survived.

Thursday night I went back to work at the General, and there was a large security presence in the area in front of the E.D. Now, at the county when there's a shooting, we get a strong police presence, so it's no big deal to see the ambulance ramp shut down to traffic. Just not used to seeing it at the General. But, that evening there had been a shooting that resulted in a death of a member of the community. Their family along with many neighbors were all there and had just gotten news of the death when I pulled up trying to get in for my shift.

I made my way through the crying, screaming people holding onto one another and demanding to be let into the E.D. to be with their loved one. Security let me through as several people tried to push their way through. They were held back.

Today I worked a day shift. I had a GSW (gun shot wound) to the legs in the morning, and a GSW to the abdomen in the evening. Kinda like book ends. Both were in the process of an attempted robbery. Both were taken to surgery. Both will most likely survive.

Some say people are going a little crazy from the heat. The heat wave is supposed to continue through the weekend. I wonder what tomorrow's going to bring...

Last Night at the County

Some of the cases from last night's revelry:

OD's - My two of the half dozen or so OD's we got last night were of unknown substances. One we think was methadone the other is a complete mystery.

GSW's - we got one last night but one shot was all it took to take the life of an 18 year old

Stabbings - mostly superficial wounds on the patients, but my patient's assailant decided stabbing wasn't enough. He was going to run over him with the car too. I think he's going to be lucky and wind up with some relatively minor injuries

Motorcycle crash - again, please don't take drugs and then think you can control a motorcycle. You'll end up with lots of broken bones in the trauma icu and the police placing you under arrest.

All this plus the chest pains, the abdominal pains, the shortness of breaths, and the eight or so patients signed out to me last night.

Have a great and safe Fourth! Stay out of the ED!! I don't want to meet you under those circumstances...

A Shot in the Dark

So, I just spent the last two hours sewing together a hand which had gone through a glass window. It wasn't the first time this drunken patient had done this. It was their third.

As I did so, I listened to the exchange between my patient and their spouse. They got married when they were 18 and she was pregnant. They had a son. They separated a year later when she says she stopped loving him romantically. He now lives with his girlfriend and their daughter. She lives with her boyfriend of 9 years.

They see each other daily because of their shared child. She says she loves him, and that they are still "family." She says they won't get divorced because he won't divorce her, and it would cost her too much money to divorce him. So, they live this way and everyone is in agreement and happy. If only he would stop drinking and punching things harder than his hand.

Wow. As for me, I am on my last shift before heading out to a national conference. I put up the gun picture because during the prior two shifts I had not one, but two patients shot in the arm that had broken bones. Both patients were "walking down the street minding my own business" when shots rang out. Both had what looked to be entrance and exit wounds with no severe damage. Both had broken bones that needed setting. Both could have been brothers. Both handled things in very different ways.

The first patient I can only describe as "a real jerk." The kind of patient that cusses out everyone, moves around screaming for pain medication while you are trying to do an exam, and who finally settles down when security gets called and stands outside the door. He told the police that showed up where they could "(*^&!" themselves. He tried to sass the nurse who showed him and told him in no uncertain terms who the boss was now. We cleaned out his wounds and splinted his arm. He was admitted and taken to the OR that morning. He's now got a metal rod where his radius bone used to be.

The second patient was very polite; asked questions about taking care of his wounds. Asked about his medications and how he should take his antibiotics. He was concerned about how his mother was going to take the news and if he should worry her or not. He needed cleaning and a cast. His bone will heal without surgery. He said "thank you" as I was giving him his follow-up instructions.

So now I am counting down the last 2 hours before the end of my shift. A couple of more hours, and I will be on a plane. Hopefully, that hand is the last torn flesh I will see until next week. Pics, etc. when I get back!