Medical School 2020, Year 3, Week 3

How should one prepare for a week of nights on surgery? Class president: “I drank a pot of coffee, and stayed up as late I could on Friday.” Adrenaline Andrew: “I went out to bars on Friday. Kept me up later than if I had stayed in. Worked quite well in fact. If you’re trying to stay up as late as possible come out with us.” I elect to go out with several classmates to a few bars, get to bed at 2:00 am and sleep until 10:00 am. In retrospect, bar hopping was a mistake…

We start on Saturday at 5:30 pm in the surgeon’s lounge for handoff from the day teams, which include separate groups for colon, liver, plastics, urology, orthopaedics, cardiothoracic, ENT (maxillofacial), etc.. All of these groups’ patients will become the responsibility of the night team, which can decide to call a specialist back in for anything urgent. The night team also consults as necessary with the ED and other units, such as oncology.

Our team consists of a critical care fellowship-trained attending (“trauma surgeon”), a senior resident (PGY4-5), a mid-level (PGY2-3), an intern, my classmate Surgeon Sara and myself. The senior resident is a calm 31-year-old aspiring to follow in his father’s footsteps providing medicine in developing countries. Navy Nate, the PGY2 mid-level, is a snarky, brilliant 36-year-old who steered a desk for 9 years. “I should’ve probably should’ve stayed for another 11 years to retire with a pension. But medicine was my calling. I just couldn’t think of doing anything else except surgery. It’s the thrill.” His wife is a family medicine resident. Pregnant Patricia is the intern who immediately speeds off after handoff to run the “floor,” i.e., every floor in hospital with postoperative patients. The chief and I head down to the ED trauma room to wait for consults, while the attending, a 46-year-old tall pensive former philosophy major with a unkempt beard, slips away to his call room.

Our first ED consult is at 6:00 pm. Navy Nate sends Sara and me to interview the patient: “Hey, you have ten minutes to report back. Don’t look at the chart. What is the problem? Is this surgical or not? Ten minutes.”

Surgeon Sara and I struggle to navigate the packed ED, looking for “Bed 4”. The rooms have filled up and patients are on beds in the hallways. A 27-year-old nulliparous female is lying on a hallway bed curled up with her boyfriend, whose family is in the hospital for an MI (myocardial infarction). The energetic female presented for worsening abdominal pain over the past 5 days. She has a family history of Crohn disease (named for gastroenterologist Burrill Bernard Crohn). On physical exam she has significant tenderness on light touch in the lower abdominal quadrants.

After a discussion while walking back to the trauma bay, we present our findings. Sara does the HPI (history of present illness) and PMH (past medical history), while I present the physical exam and A/P (assessment and plan). “It’s unlikely to be appendicitis or ovarian torsion. The timeline does not fit. It could be PID or inflammatory bowel disease although she has no diarrhea.” The ED had ordered a CT, which Navy Nate studies. The radiologist report is in Epic: “Cannot rule out appendicitis” given the mild edema around the appendix. Nate: “Radiologists can be so useless sometimes, but this is a pretty unimpressive appendix. I agree the timeline does not fit with appendicitis.” As we look through her CT we begin to see other involvement of the gut, including striations in the rectum and small bowel. We admitted her for serial exams to see if she worsens, and put in inflammatory labs for IBD. 

(Appendicitis usually presents over 48 hours. Umbilical or epigastric abdominal pain transitions to nausea and vomiting followed by localized pain over “McBurney’s Point” (halfway between the umbilicus and the anterior superior iliac spine of the hip. The key is that after 48 hours, the patient becomes acute (fever, peritonitis) with either a free rupture or abscess formation.)

Trauma Alerts text messages pop up on our personal phones starting around 8:00 pm. First a 23-year-old MVA (motor vehicle accident). He is talking and does not appear to have any significant injuries, but 10 hospital workers will do a complete trauma evaluation nonetheless. There is a primary survey for airway, breathing, cardiac activity, active bleeding, then a secondary survey for spine fractures, and finally a trip to the CT scanner for a “Panscan”. 

Trauma Alert at 11 pm: 20-year-old African-American with multiple gunshot wounds and a tourniquet placed by the EMTs. He is having trouble breathing and blood pressure is dropping. A CXR shows a massive hemothorax (collection of blood in the space between the chest wall and the lung) in the right side. The intern places a chest tube guided by the attending. Immediately the patient improves, and we consult plastics for reconstruction of the median nerve.

The chief and I see a patient stabilized in a rural hospital and then flown to us for treatment of septic shock from decubitus ulcer. The 22-year-old was in a MVA three years ago resulting in a T10 transection. He cannot feel anything below his belly button. He is cared for by his aunt.  The senior resident and I help him rotate to his left side so we can see the pressure sore. I shine an iPhone light onto the wound. Pus oozes out of the necrotic tissue. I see spongy red bone of the ischial tuberosity. The wound grows every kind of bad bug: KPC, MRSA, VRE. We begin stabilization. “This how paraplegics die. It’s a slow nasty death. We’ll probably clear this episode up but we’ll never get ride of the underlying deep infection. And he’ll just develop another one. It’s sad to say, but this is what eventually happens to most paraplegics.”

Surgeon Sara and I all head to a consult for an 45-year-old 250 lb. male with RUQ (right upper quadrant) pain, tachycardia (rapid heart beat) with stable BP and O2 saturations.  When we report back, the Chief, midlevel, and attending are poring over the patient’s CT scan and labs. “How’s he doing?” “Bad, he has rebound tenderness, intense pain.” Labs showed slightly elevated bilirubin, but normal liver enzymes and Alk phosphate. We quickly got hooked on cholangitis even though the liver enzymes were not elevated. The attending arrives from his call room. The chief asks the attending, “See that inflammation around the entire duodenum, not just the gallbladder.” “Yep, that’s why I came down. Let’s get him to surgery.” (We still don’t know what is wrong with this buy, but it is time to explore.)

Sara: “I am surprised how much the surgeons use imaging before the radiologist gives the final report.”

We learn he is a habitual cocaine user and, in fact, had used cocaine just a few hours earlier. He has an acute angioedema attack requiring rapid intubation in the ED and a 10-minute trip upstairs to the OR. The resident opens him up. The belly is a mess, with damage that was not visible on the CT. The gastric juices was eroding away at the tissue in the belly. The attending and resident pass the bowel back forth (“running the mesentery”) to look for any perforations in the bowel blood supply. This all happens so fast, I have no idea what is happening. They then identify maybe a five millimeter hole in the stomach from a gastric ulcer perforation. Attending: “Probably from the cocaine. Not his lucky day. Angioedema and a perfed ulcer.”

Navy Nate: “I need you do a med reconciliation on this patient [a 35-year-old female who came in for a rule-out on appendicitis]. Her chart says she takes 30 medicines.” Sara and I have to hold back laughing as we go through each medication. I ask if she takes X dose for X medicaition X times a day and Sara would write down the answer. It takes us at least 35 minutes because she wouldn’t stop about her experience in nursing school.  By the time we finish, it’s time for morning handoff. We leave the hospital around 7:00 am.

Wednesday night is memorable. Around 9:00 pm, we get consulted for a 73-year-old Army combat (Vietnam) veteran with a six-month history of worsening fatigue, melanotic stools, anemia and a 15 lb weight loss . He presents to the ED this evening because of an acute abdomen. The ED places him on two pressors for unstable vitals and fentanyl.  When we arrive he appears quite comfortable, accompanied by his wife and daughter. Sara asks, “Have you gotten a colonoscopy.” He responds: “No I never thought it worth it to get colonoscopies. I am so active.” We get a CT that reveals a large mass in the colon with distal metastases to the liver and lung. 

I call the VA to request his medical records. The attending instructs me to request only H&Ps, labs and imaging, “No progress notes.” 100 pages come out of the fax machine. We find that he has gotten a “CT ab” (abdominal CT scan) with follow-up needle biopsies of the mass about two weeks ago, pathology results still pending. Our patient doesn’t know why he got the biopsy and is unaware that colon cancer was the most likely diagnosis.

We go into his alcove in the ED and meet his wife, daughter, and 12-year-old granddaughter. The attending explains that the cancer has grown large enough that it is obstructing the small bowel. The recent onset of pain is most likely from a small perforation in the bowel. The attending explains there are two options. We could take him back to the OR and try to repair the perforation. “It’s unlikely that will work because the bowel around it is also invaded with cancer. It will be difficult to find good bowel to close.” He emphasizes that this is not a long-term treatment. “You are going to die from this cancer. The other option is palliative care.” We tell them to think about the options and go back to the OR lounge to look more carefully at the imaging.

“There is no way we can operate on him,” the attending tells us. “He is unstable and the chance of success is so low. Everyone says they are a fighter. Well if you were a fighter you would have gotten a colonoscopy. No one is a fighter. It’s the disease. I had an uncle who died suddenly, my whole family was so shocked but I see this every day. No one knows what they would do if given three months to live. No one knows what they find meaningful in their life until life runs out.”

Surgeon Sara: “I am calling my parents first thing in the morning to tell my parents to get a colonoscopy. My mom has been hesitant, saying she eats a good diet.” I also call my parents to encourage them to get their colonoscopy. Sara and I still have an hour before a required lecture on postoperative management at 8:00 am. We visit the 73-year-old veteran. “We’re here not to answer questions, but to give you some questions to ask the colon specialist on the day team.”

He confides in us: “I’ve done everything on my own. I didn’t depend on anyone. What’s the word… Pride, that’s the word. Pride. I wont have no pride if I am a vegetable. Just last year I was building a foundation in my backyard, lifting 50 lb bags of concrete. I was so active less than a year ago. How can this be?”

Jane and I are two ships in the night. I get home around 9:00 am and she is already gone for her psychiatry clerkship at the state mental asylum. I call her as I walk back to the car. She’s had a rough week. She walks around with a massive keychain.. Every door, to hallways, stairs, etc. is locked and requires a physical key. Her first patient: “You’re going to die tonight”. She believes that she will unconsciously kill everyone around her. “Get away from me,” she tells Jane. Jane relates that “I asked her to ‘tell me more,’ but wanted to say, ‘I”ll just be outside if you need anything.”

Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: none. By the time you get adjusted for night schedule, my time is up.

The rest of the book: http://fifthchance.com/MedicalSchool2020