After sleeping all day Friday and Saturday, I am nearly recovered from a week of night surgery and it is time to start a two-week trauma rotation. Morning report starts at 6:30 am with M&M (morbidity and mortality).
“Ted,” a burly, soft-spoken 6’4″ 32-year-old PGY4 resident described by Surgeon Sara as a teddy bear, is presenting a trauma case on a MVC (motor vehicle collision) patient in hemorrhagic shock from abdominal bleeding. The case was chosen because the team deployed an aortic balloon to maintain blood flow to the brain before exploratory laparotomy. Ted wants the entire surgery team to be familiar with the proper uses and indications for an aortic balloon. The attendings reduce Teddy to blubbering as they grill him on management of this patient. My former chief comments as we walk up the stairs: “[Teddy] was stumbling, but he was answering all questions right.” After M&M, we head up to the floor to round on our twenty trauma patients, fifteen of which are fractures following falls, ten from alcohol and five from old age.
I am assigned a 21-year-old patient beginning her second in the hospital following an MVC that resulted in an epidural hematoma (bleeding in the skull) and multiple fractures. She was driving back from work at Subway when a drunk driver hit her head-on at about 45 miles per hour. She was ejected from the car. Most of the ICU team did not expect her to recover any brain function. She has become somewhat of a miracle on the floor as she has regained consciousness, primitive motor function, but is cognitively at the level of a 5-year-old. She underwent emergent craniotomy by neurosurgery to release intracranial pressure from the epidural hematoma. She has a wound vac (sponge-packed wound hooked up to a continuous vacuum) on her scalp from the craniotomy site and a tracheostomy tube that can be capped to allow her to speak. The trach does not bother her as much as the spine brace that is needed for several weeks due to her cervical and thoracic vertebra fractures. Her 45-year-old mother stays quiet in the back as we pile into the room.
(The drunk driver was placed in the ICU bed next to her and passed away a few weeks ago.)
Rounds last about two hours as we go room to room for each trauma patient. I meet my 38-year-old attending. At barely 5’4″ she is known to put chills in medical students and residents alike. She is also Jane’s role model in surgery.
(We met her in Year 1, Week 17, starting a meeting of a “women in surgery” interest group:
There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction. Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.
)
Dr. Cruella says that we deal with “bullshit” faux trauma (e.g., drunk person falls and is screened for head injury) rather than transfer patients to the internal medicine service or orthopedic service, as was conventional at the hospital where she trained. Her theory is that this relates to enhanced revenue if a trauma note is dropped into Epic. After rounds, we head to the OR for a rib plating (one plate per broken rib) on a 60-year-old alcoholic who was run over by a car after he passed out in the middle of a road. Eleven ribs were broken, but miraculously he suffered only a mild lung contusion.
Dr. Cruella hasn’t used this brand of rib plates, so the manufacturer’s rep is here to teach her how to use the drill and deploy the plate. After she gets the hang of the equipment, she asks about my background. She describes her experience as a resident. “This old guy in the ‘golden age of surgery’ used to sexually harass every female — med student, intern, resident, nurse, you name it — except the surgical techs. He would never mess with a surgical tech. I was writing a note as a second-year resident and he pulled down my scrub pants in front of the entire OR.”
Had she ever been written up for unprofessional behavior? “I got written up for intimidating the blood bank personnel. I was doing a splenectomy and we needed blood urgently. We kept calling the blood bank and they said they would bring it down. I called two more times, and finally they tell me they need a form, which they could have told me right at the beginning. I had to speak with the Chair and attend anger management.” Like the movie?!? “No, it’s on the phone. Most surgeons have a monthly session.”
What’s the worst thing you’ve seen in the OR? “Well besides getting pantsed by my attending, watching a hotshot surgeon throw a spleen full force at the wall. It exploded with blood everywhere and on everyone’s face. That was pretty bad.” She jokes, “I’ve never done that, but I’ve wanted to!”
Has any surgeon gotten written up by a medical student? “At least once every year. Last year, a medical student wrote a surgeon up for ‘throwing a scalpel at me’. There was no blade on it. Not sure what was going on, but it could have been just him tossing the scalpel to the student.”
The rib plating takes about 2 hours. I assist in retraction of the skin folds while the attending and chief attach the plates between the fractured rib fragments. At the end they allow me to place a chest tube on each side (it will be removed three days later after testing for leaks). Ted patiently teaches me his special “D” suture technique to anchor the tubes in place.
While rolling the patient back to the ICU, a nurse says, “Natural selection, it’s a real thing. You get drunk and pass out in a road, Nature is coming for you.”
The rib plating ends at 1:00 pm. I wait in the medical student lounge for gold alerts, but there aren’t any, and get sent home around 4:00 pm.
The next days are similar. I round on my 21-year-old MVC recovering patient. I also check in on the rib plating, although there is a different service and attending that covers the ICU patients. This can be quite frustrating as many patients that we may do the initial trauma evaluation, and possible surgical intervention, will be transferred to the ICU team for further management until they are ready for downgrade to the PCU (progressive care unit) or “floor” (the most basic level of inpatient care).
Thursday morning: trauma alert for an overweight 28-year-old who fell while running from U.S. Marshalls. He was cornered on top of a two-story building, and decided to jump. Why is he not in handcuffs? “He wasn’t arrested,” explains the EMT. “That’s pretty common. Law enforcement will arrest him after he’s out of the hospital so that the Department of Corrections doesn’t have to pay for the trauma care.”
He arrives on a stretcher. We transfer him to a trauma bay bed, and begin the initial assessment. About 10 people are around him: three trauma nurses, a respiratory therapist, a scribe, an EM resident, a general surgery resident and intern. I grab my valuable trauma shears and cut off his clothes, while the intern evaluates for airway (he can speak), breathing (good air entry into both lungs), and circulation (good peripheral pulses). He has severe pain in both arms. Vitals are stable. We get a chest x-ray to ensure no rib fractures, and a mid humerus x-ray showing a closed, displaced fracture. His right arm has a mid-humerus fracture, and his left shoulder is anteriorly displaced. He also has an anteriorly dislocated shoulder. Ortho tells us via text they will put him on the case list for tomorrow.
Friday morning I pre-round on the patient. He is pensive. He asks, “How old are you?” and then shares some hard-earned lessons. “Make sure you choose the right woman, man. I got two baby girls, and their mom doesn’t care about them or me. But I am going to be a man and take care of them.” It seems that the drug dealing that led to the encounter with U.S. Marshals was motivated by a need to pay court-ordered child support in excess of his legitimately earned income. The orthopedics PGY2 comes into the room and I stay to see his examination. He tries to “reduce” (put back into place) his left dislocated shoulder. After three failed attempts with just a 50 microgram dose of fentanyl, he decides to just do the reduction during the operation while he is sedated. Orthopaedics take him for open reduction, internal fixation. He stays for seven more days working with PT/OT until he has some movement restored in both arms. Arguably disproving his theory that baby mama doesn’t care about him, she was his only visitor during this week.
Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 night. Dinner party with Lanky Luke, Sarcastic Samantha, Jane and me at Put-Together Pete’s apartment. Jane and I successfully made Tres Leche cake.
The rest of the book: http://fifthchance.com/MedicalSchool2020
“It seems that the drug dealing that led to the encounter with U.S. Marshals was motivated by a need to pay court-ordered child support in excess of his legitimately earned income.”
Someone get on the phone to President Biden and tell him that he must hire Philip Greenspun as a policy advisor is he truly wants to reform health care.
> After rounds, we head to the OR for a rib plating (one plate per broken rib) on a 60-year-old alcoholic who was run over by a car after he passed out in the middle of a road. Eleven ribs were broken, but miraculously he suffered only a mild lung contusion.
Unbelievable. It must not have been one of the Sultan of Brunei’s Mercedes S600 V12 B7’s. 2250 pounds per wheel, even spread over the contact patch of an S600’s tires, and it would have been a different story. I think even a Ford F250 would have done him in. He should thank his lucky stars for the people driving Toyota Corollas.
Note to self: “If you’re going to get run over by a car after passing out drunk in the middle of the road, make sure whatever hits you is relatively low-mass.”
What a world we live in.
Given that about 50 mil Americans have IQs under 85, e.g., the military won’t take them because they can’t follow simple instructions, it is not surprising that so many of these situations were avoidable. A friend who is a firefighter in NYC says that most of his work is dealing with people with bad judgment, e.g. people who put the turkey in the oven on broil and pass out drunk on their sofa, picking up people who pass out on the sidewalk because of substance abuse or answering calls where the caller’s “head hurts” and the easiest thing to do is to call 911. You wonder what the hero of this story will think 30 years hence when the novelty of new equipment and techniques has worn off and and it is the same old drudgery of trying to fix people who can’t or won’t behave properly. Sounds in the long run unappealing.
Do we know what the author’s intended / desired specialty is?