When somebody is crashing, you don’t see anyone screaming to call the pediatric endocrinologists. They call the surgeons.
Part of this passage was written by me back in August of 2017, and the latter half by me in late 2018. The verb tenses and tones will give it away.
It had been a crazy two months. Turns out residency is more insane than I imagined. I’ve got a lot to say, but let’s start at the beginning.
I’m what you might call a “corn-fed Indiana boy” who was beyond comfortable with life in Indiana. I hadn’t had a big moment of being out on my own. What is normally a “see the world” moment for young adults is the whole going off to college thing. For me, this was me and most of my best friends (and 350 of my high school class) heading off 90 miles to Indiana University. That was hardly a drastic change. Needless to say, moving to St. Louis to begin my surgery residency was a bit of a big transition. While it’s not that far from home, which is a mere 4 hour drive (3 or 5 if you account for the sorcery of time zones. I mean that’s not how time zones really work, but you get what I mean), it was intimidating to move out where I knew nobody. I knew one of my future co-interns because he was the first person I met on the interview trail, where we had an awkward-white-boy-party by being way too early to the pre-interview dinner. That stemmed from me not knowing that St. Louis was on Central Time. Whoops.
I squeezed a whole bunch of stuff into a U-Haul and shipped out to Missouri. I never got around to writing about saying goodbye, most likely because I didn’t want to acknowledge it. That and the fact that none of the goodbyes I said to my friends felt…permanent. The people I’ve become really close with are people I’m convinced I will see again, even if that comes a year or ten from now. I’m going to miss (and have already missed) my beloved Bloomington med school family and my goofball of a roommate (whom I’ve lived with for 5 years), because those are the people I went to battle with over the past 4 years. We have scattered pretty far across the U.S. and holy crap do I miss you all. We are all slogging through residency together, and the stories we share through our group text (that will likely be going until the day we die) make me feel like we will never miss a beat.
As I arrived in St. Louis…I wasn’t sure what to feel. With my family camped out for a few days, it didn’t feel like it was really happening. It was here that I was introduced to the wonderful world of IKEA (and proceeded to buy nearly all of my furniture from, short of the 15+ year old couches that have followed me since leaving for college), went to see a Cardinals game, and went through the tiring exercise of deciding, “Now, where should I hang this weird picture of squares?”
The moment they left me, it set in. I was now living truly alone for the first time in my life. I never had to wear pants again! Okay, at least not in the comfort of my own apartment. Not like I really wore pants last year at home anyway. I digress. I’ve got a pretty dope little balcony, from which I’m currently typing this post. It’s so dope that conveniently the view allows for people to somehow stare directly into my bathroom from the street outside. IKEA shades were purchased immediately to remedy this. I can say that it’s pretty weird living alone. Not like I have that much time to contemplate it, because I barely spend any time here that isn’t spent sleeping. It’s in a pretty cool little neighborhood, at least from what I can tell when I’m out for runs. Most importantly, it’s so close to the hospital that I can get there in 5 minutes. Minimizing commuting time was a pretty important factor.
The moment my family left, I sped off to meet three of my new co-interns for the year. I’m not going to go out and say I already craved human interaction (my cactus is a good listener, but turns out I crave human interaction – EDIT from 2018 Brandon – This cactus was either dead when I got it or died along the way. It didn’t make it to 2018), but I craved human interaction. I distinctly remember freaking out what to wear that would say, “I’m here to chill, do work, and make friends, and I’m all out of work”. Instead, what it ended up saying was, “I have a sweating problem from the waist on down”. We had a great time in the gigantic Forest Park, and I came home with a pretty good sense that I was going to be working, living, and attempting to survive with a great group of people. Pretty soon, it was off to 2 weeks of orientation: the last buffer between us and having to be real doctors.
Fast forward to orientation, where I met the remainder of my fellow general surgery interns. We had to play the, “We haven’t met in real life, but I stalked your Facebook so I basically know everything about you, but so as to not be too awkward, let’s pretend we both didn’t do that” game. There is something to be said about similar personality types going into the same specialty, and it took all of 5 minutes for me to become 100% certain these were my peeps. Once we had secured our little general surgery group, we proceeded to become really social and located all the other surgeons-to-be in our gigantic orientation. We proceeded to become even more social by immediately segregating ourselves from the medicine specialties and only talking to each other. 10/10 points on inclusiveness were awarded to the surgery interns that day. As one of my co-interns put it, “Are y’all self-segregating again?” Yes, yes we were. In such a gigantic group of future interns, it made sense to flock to the 20 or so like-minded people in the room.
Orientation was filled with a few things that were useful, a few that were not, and a few that might one day be useful but we didn’t yet have the knowledge to know that. The talk about things we can do to keep the hospital coders (aka the people who read through charts for billing purposes) off our backs by including the appropriate magic words that keep them happy…was something that went in one ear and out the other. And oh boy, was orientation filled with laughs. If you look really closely at my hospital ID badge, I was crying from laughing so hard in the moments before that photo was taken. We had to take these weird photos with our chest puffed out and in some weird POWER STANCE that made everyone look super awkward. Good times were had. We talked about things like life insurance, how we were going to get paid (OH MY GOD I’M GOING TO MAKE MONEY FOR THE FIRST TIME SINCE MY OFFICE DEPOT DAYS!), and more. The second week we no longer had to self-segregate, as we had surgery specific orientation. The segregation was done for us.
We took these days to spend as much time together as a surgery cohort as we could. As it turns out, the Lou (I have no idea why I called it that. I think this is the first and probably last time I ever will. Maybe. Who knows) has a gigantic football-sized hole where the Rams used to be. That and it is a baseball city, so we naturally went to a Cardinals game, which they obviously lost because we were there. We enjoyed food around the city and got acquainted with life. We even got invited to the graduation of the leaving chiefs, where we got to meet the rest of the residents and enjoyed a beautiful night on a rooftop with some live music.
It had barely been two weeks and I felt I had known these people for years. These were the residents I would go to battle with out in this strange new world of being a doctor; they were the people who would have my back through the challenging days ahead. We joked, we bonded, we expressed surprise at seeing the letters MD after our names, and freaked out on a group level about what was to come. The level of anxiety in my life had started as some dull roar in the background and had reached a fever pitch. The day was here.
July First, Two Thousand-Seventeen
It was dark. It was midnight. I was awake. The clock had just ushered in July 1st. While my colleagues were sleeping and would be arriving at the hospital in a few hours, I was struggling to stay alert. I had found out a few weeks prior that I was starting on one of our night rotations: Trauma Nights. What little I knew about this rotation put fear in the darkest parts of both my heart and colon. When I had mentioned what rotation I was starting on to the residents, they always had that kind of puckered up “oooooh” expression and recoiled a bit. It was said more than once that if I could survive that, I could survive anything. I found out that not only was I covering the floor trauma service and all of the new trauma patients that came in during the night, but I was also the intern responsible for the floor patients on the vascular, cardiac, and thoracic surgery services. Pretty sure I developed an arrhythmia just thinking about the responsibilities this rotation entailed. (Quick side note for those not in medicine: the “floor” patients are the patients who are more stable and generally more healthy, those are the ones I covered. The other patients are the Intensive Care Unit (ICU) patients, which one 2nd year surgical resident covers all of the ICU surgical patients during the night. You will meet him later in this story).
While I normally had no trouble staying up past normal people hours, the past two weeks of being on a normal person schedule (i.e. waking up before noon – something I don’t particularly like doing) during orientation had taken its toll. I found myself zoning out at my computer, trying to find another video game to keep me awake. Even my anxiety was overpowered by fatigue; after I fell asleep on my desk at 3AM, I decided it was time to call it quits.
I jolted awake at 2PM. It was here: my first day of residency. I thought of my colleagues who had been up for hours, fighting through day 1 of doctordom. Here I was having not experienced any of that. I got out of bed, heated up my skillet, and cooked my oddly-timed breakfast. I had so many thoughts, worries, and fears crashing through my mind…my anxiety had gone so far overboard that it had hit an 404 error and reset to zero. I threw on the scrubs I had grabbed the day before, loaded a dozen protein bars into my bag, walked out to my car, and drove to the hospital. Luckily I had shadowed the trauma rotation a few days prior, so I at least knew where to show up to, but that was it. I didn’t know where the bathroom was. Turns out that wouldn’t be a problem because there wouldn’t be time for basic bodily functions. FORESHADOWING – CHECK.
Our surgery teams operate on a 5 to 5 “shift” (I use that word very, very loosely. All the people who say residency is now shiftwork and blah blah are very off base), so I got there at around 3:30PM (or rather, 1500. Military time is exceedingly useful in hospitals because things are as likely to happen at 3am as 3pm, so shifting your life towards thinking on military time will help greatly. There’s my tip for you future residents. That and the fact that it’s a lot harder to set your alarm for the wrong time). I sat down at a computer, made sure my Epic login worked, and attempted to re-familiarize myself with the EMR (electronic medical record: AKA computers now run the world and all the medical records are digital). Luckily I had used Epic before, so I was at least somewhat familiar with its features, but it was a whole different world. I tried to customize my settings, find a note template or two, and spent probably 15 minutes deciding what color I wanted my background to be (I went with “cells”. It has this pretty sweet green color and little cells everywhere. I later switched to Carbon, which is more boring but a sleek black. The galaxy one is great for a change of pace). It was nervous fidgeting to pass the time. I drew up a whole “to do” list for the events on call that night (which, despite being taught to me by one of my favorite residents from medical school, turned out to be a garbage system for me that I scrapped about a week into the rotation), made sure I had two working pens (always have more than one pen), and sat waiting. I grabbed my stethoscope for the sole purpose that it made me feel like a slightly better sham of a doctor. At least I looked the part.
The day trauma team began to file in sporadically, including the interns, the nurse practitioners, and the students. One of my fellow interns was about ready to pull her hair out (which became a common theme every time I saw her at the end of her day), and got to frantically working on a computer. She easily became one of my best friends in residency (A bond built on a mutual love of It’s Always Sunny in Philadelphia is a strong one), and we had joked the week prior that we would be seeing each other at our worst throughout this month. We were right. The clock slowly ticked towards 5pm as the team prepared their sign-out.
Sign-out, hand-off, transfer of care, “Please take the bomb” (our loving nickname for the pager. Don’t come after me, FBI), whatever you call it, it is the process of transitioning a patients care from the day team to the night/on call team (or any other team, really) in a way that both teams can do their job and take the best care of the patient. It is a doctor to doctor exchange that allows us to talk about what has happened to a patient, what needs to be done, and what kind of impending disasters loom on the horizon. It also allows the ability for us to occasionally go home. Call it what you want, but for us it was one thing: a haphazard disaster. A controlled one, but a disaster nonetheless. We were the blind leading the blind, we still winced at hearing the words “Dr. _____” when someone addressed us, so you can bet your bottom dollar we had no idea what was important to discuss in sign-out. For the first of many times, we proceeded to do something having no idea what we were doing.
The clock tolled 5. Residents from four teams swarmed at me, eager to pass off their bombs. Pagers are called “the bomb” because they’re always blowing up. Ha, get it?! I’m on a watch list now. The trauma list was near 30 patients long, with another 10 from vascular, 4 from thoracic, and 6 or 7 from cardiac. I got a brief story about each patient, what brought them to the hospital, what issues were going on, and what I had to do during the night. I wrote and wrote until I could no longer write, and looked at what I had written. My hand had already cramped and I had nothing but illegible word vomit all over nearly a dozen sheets of paper. I was handed 4 pagers (on top of my personal pager), a portable ASCOM phone, four lists of patients, and the weight of four surgical teams. Where during the day there had stood seven full surgical teams with 20+ residents: Trauma, vascular, thoracic, cardiac, surgical oncology, transplant, and acute care/general surgery, there now stood four surgical residents between the doors of the hospital and the doors to the morgue.
Okay I’m being a drama queen, but thinking a little bit about it, it was true. For any and all surgical disasters that happened throughout the night, we were the first response. The only surgery attending in-house was the trauma surgery attending, and that was for the big disasters that needed immediate attention. Our team included a fourth year trauma chief, a second year surgery ICU resident, a general surgery intern (who covers acute care surgery, transplant, colorectal, breast, and surgical oncology) and the trauma intern (me). We were the first line of defense against anything the city of St. Louis could throw at us. Little did I know that my new city was a fully automatic trebuchet aimed squarely at SLU hospital.
Here is where 2018 Brandon begins writing. I got up until this last paragraph during my first year
I quickly realized I was the rate limiting step in my colleagues going home (or rather sitting for 2 hours after work finishing their notes or other miscellaneous work. I didn’t quite grasp how inefficient we were at the time). If their work was done (big IF there, folks), them giving me sign-out was their last step before walking out the door. Four pagers and one of me made it so that they had to take turns. That first day, the thoracic resident came in first, handed me a paper riddled with patient names and information. There isn’t an intern on the thoracic service, and as a fourth year, he already knew the drill. He handed me the dilapidated pager held together by shreds of silk tape and said, “They’re all ICU patients, you don’t have anyone to worry about. Have a good night.” One of four down, that was easy. I didn’t take care of the Intensive Care Unit (ICU) patients at all. At a place like SLU, which is a tertiary care center, those patients are the sickest of the sick. A second year resident handled all things ICU. My soul was spared.
My medical students sat in a corner across the room, intently listening to the things said by the interns, scribbling away. I’d like to think I came up with a clever nickname for them since they both had names that started with J, but the best my pea-brain could come up with is “Jimmy John’s” or J², but that would require too much effort on formatting. As I glanced over, I felt this weird wave of some emotion that didn’t resemble anxiety for the first time in 24 hours. It might have been…pride? Joy? Unsure. They were my first medical students, my little children/babies?/ohmygodi’mresponsibleforthem. I started thinking of the things I was going to teach them, of all the things I wanted to be as a resident in the eyes of students, and how crazy it was that I was now the teacher. My pride was quickly replaced by fear, feelings of imposter syndrome, and the realization that they were my lifeline for the rest of the night. I didn’t even know where the bathrooms are. I silently prayed they would carry me through the next 12 hours.
“Brandon, are you listening?!”
I snapped out of my trance.
“This guy is going to be the problem for the night. He’s agitated and had 5 code grays already tonight. We’ve given him everything under the sun and consulted psych, but they really haven’t told us much of anything else. We’ve tried ativan and seroquel but it only seems to be making him worse.”
Great, a psych disaster, I thought. There’s no way this can possibly go wrong. (Narrator: “It goes wrong”). This would become a common story on the trauma service: agitated patients going buck-wild in the middle of the night. During sign-out, there were patients very unlikely to cause problems and might as well not have been on my list. There were those about which I was forewarned that were either angry, sick, or likely to be unstable throughout the night. These were who I needed to watch for.
Sign out had finished. The trauma day interns went back to their work, as they still had dozens of unwritten notes for the day (every patient in the hospital needs a written progress note each and every day that documents a lot of things about how the patient did over the past day, what their exam was, their labs, and what the team’s plan was for the day. I had learned in medical school about the mountains of documenting that physicians have to do, but turns out that was only the tip of the iceberg).
I stared at my patient lists, my separate “to do” and “pages” list, and my waistline, which was now filled with a bunch of pagers. The picture above details all of the things on my body at any given time. I took a look at my medical students, who we affectionately call “studs” (studmuffins if you’re feeling extra saucy that day), and just kind of stared. I’m not sure if they sensed the fear within me, but the thousand yard stare gave it away. I’m going to call them J&J from here on out. They would be my saviors in the coming days. They had barely been third year medical students, maybe a few weeks tops, and they brought the poise to those nights that I had left some hundreds of miles away in Indiana.
“Well, let’s do this”.
Not even 30 seconds later, a shrill sound erupted from my iliac crest. It was the first page of the night. A trauma. “30something year old male MVC unrestrained…..”
I woke up from my blackout. It was some 15 hours later. It might have been 39 hours later, I honestly can’t remember. I was sitting at Kingside diner in St. Louis, a local diner that specializes in being open early for the night-shifters, especially those of us in healthcare. It sits in close proximity to Washington University’s hospital, and employs a morning happy hour that puts Budweiser (the headquarters of Anheiser-Busch is located in St. Louis) and many other drinks at prices that can almost take the edge off a night on call. I was sitting across from my trauma chief and the trauma ICU resident, two tall, dark, and handsome gentlemen with very, very similar names. It was to the point that two weeks ago, when I went to our first residency event with them, I knew that one was good friends with one of my med school buddies. I went up to the 4th year resident (who has more letters in his name) and started asking him how he knew my friend and kept talking while he just stared at me…turns out I had switched up the two, and it was his shorter-named counterpart that in fact knew my friend. Fail. I digress.
I was sipping on a Budweiser, staring at the half-eaten mess of eggs, sausage, and deliciousness in front of me, trying to remember where I was and what happened over the past hours or days. All I remember is that I felt like I got picked up in a tornado where I couldn’t tell which way was up, and violently thrown down after what could have been hours, days, or months. I took another bite of food and stared across the table, where they did their best to include me, a new intern, in their discussion and feel like part of the three man resident team against the world of trauma. Their gesture of inviting me out with them, making me feel included, and showing me that I had their support helped me get a sliver of confidence that I could survive this…
From the moment that first page went off on July first, it was a storm. We rushed down to the trauma bay (pretty sure I ended up out of breath. A rule that I learned from my seniors was clear in that moment: NEVER run anywhere. You get there marginally faster and out of breath. It’s pretty hard to appear calm and collected, much less think straight, while you’re out of breath), and donned our protective gowns and gloves. If the trauma was going to be severe based on the info we received, we’d often put on masks, gigantic shoe covers, and hair nets in case we had to do a procedure. We then waited for the ambulance to show up with our patient. This is when I learned that the ETA (estimated time of arrival) on those pages would have been more accurate if we pulled the number out of a hat. Five minutes could mean thirty, ten could mean one. In that moment, those minutes weren’t long enough. I was racking my brain trying to remember the steps for what I was supposed to do during a trauma, which we had learned some two days ago in our ATLS class – Advanced Trauma and Life Support.
The intern’s responsibility was the “Primary Survey”, which consists of the primary examination of the patient to identify any life-threatening problems and all obvious injuries, at which point if there is something urgent, it is addressed. For all of my brainpower, the idiot-proof “ABCDE” algorithm for the primary survey didn’t seem so idiot proof anymore, as I could barely remember it. It stands for Airway, Breathing, Circulation, Disability, Exposure. My mind was swirling with the possibilities of what problems the patient could have, the ways to treat those problems, and what I needed to do to make sure I got all the steps. My mind then promptly flushed all of that down my spinal cord the moment that patient rolled into our trauma bay. I presume those ideas went out my splanchnic nerves straight into my bowels, which due to my occasional explosive bowel dysfunction when I get really stressed, I was less than comfortable in that moment than I had ever been.
As the patient hit the stretcher, I reverted to the very basic form of ATLS that I had been practicing exactly for the moment everything else failed.
Step 1: SIR/MA’AM, WHAT IS YOUR NAME? – If patient responds, their airway is at least intact enough they aren’t dying. If gasping for breath, fix problem, repeat step 1.
Step 2: TAKE DEEP BREATHS FOR ME – Listen to lungs. If breath sounds exist equally on both sides, life threatening lung problem is unlikely.
Step 3: PALPATE PERIPHERAL PULSES/LOOK FOR BIG BLEEDING – If the patient has the feeling of beating drums in their arteries of arms/legs, and aren’t bleeding everywhere, they are probably fine.
Step 4: SQUEEZE MY FINGERS, WIGGLE YOUR TOES, OPEN YOUR EYES – If the patient can follow commands and move all their extremities, these things are good. If their leg is snapped in half, or they all of a sudden can’t move their legs, that’s a bit more of a problem.
Step 5: STRIP PATIENT OF ALL CLOTHES – Yes, down to their birthday suit.
Step 6: LOOK FOR OBVIOUS THINGS – Gunshot wounds and large chunks of missing flesh/broken bones are pretty evident here.
Step 7: ROLL PATIENT, PRESS ON BACK, AND PROBABLY A RECTAL EXAM – This is to make sure their spine is in (relatively) one piece and that they have rectal tone. I used to say “you’ll feel some pressure” for a rectal exam. One of my attendings told me that was ridiculous and vague. I converted to saying “You’re getting a finger up your bottom!” It’s crass, but gets the point across better.
That is ACLS for dummies in a nutshell. I was so afraid that I would be the only one to have to identify these life-threatening injuries during the primary survey, when in reality there are a dozen people around the bed assessing the patient. Not to mention that my chief, standing calmly at the foot of the bed, was already ten steps ahead of me. That was something I wouldn’t realize until much later.
I can’t remember what our first trauma was, statistically a patient in a motor vehicle collision (not “motor vehicle accident”. As one of our attendings says – nothing is an accident) who had minimal injuries. To me, it felt like every patient was life or death. It was a flurry of activity during a trauma. I would be calling out injuries, the medical students writing down every detail, nurses drawing blood, hooking up the monitors, getting IV access and grabbing supplies, the emergency medicine physicians at the head of the bed assessing the head and the airway, and so on. This choreographed dance would repeat itself anywhere from four to five to over a dozen times per night, involving a whole slew of specialties: the orthopedic surgery residents assessing fractures, the neurosurgery resident performing a neurologic exam on a patient with a head injury, the vascular surgery chief assessing a leg with compromised blood flow, and that was just the beginning. After we completed our assessment, more often than not, it was off to the CT scanner. It was in that truth booth that we found the extent of the patient’s injuries.
In this manner, each patient was effectively reduced to a list of their injuries. While you don’t want to forget that there is a person beneath the sometimes mess of a trauma in front of us, we had to compartmentalize each and every injury with plans for each. With this system, each aspect of a patient’s care was appropriately dealt with and not forgotten. A list of a patient’s injuries on my piece of paper might look something like this (although written in nearly illegible writing and probably smeared with blood, ketchup, or both):
Right subdural hemorrhage (SDH) – NSGY consult (neurosurgery), 1u platelets for abnormal TEG
Right PTX (pneumothorax) – CT (chest tube) to suction
L 2-6th rib fx (fracture), R 1-5th – Pulm toilet, pain control
Right open tib/fib (tibia/fibula) fx – Ortho consult, bedside reduction, plan for OR
Concern for small bowel injury – serial abdominal exams, NPO, IVF
My job, as the intern, was to document these injuries in an H&P (History and physical) in the computer which included the plan on each of these injuries, call any consults, put in the orders for admitting the patient, and perform small procedures as needed. My first night, I believe we had something like 8 or 9 new “traumas” – patients who came in needing to be evaluated. Each time the pager went off, I could feel the weight of the workload of another patient being thrown onto my back. I felt trapped in a spiral of electronic medical record documentation, endless rectal exams (there are only two reasons to not do a rectal exam: 1. No finger 2. No rectum) and the despair of barely being able to keep afloat. In those moments, my chief was there to lift me up: to put in orders, to handle calling the consults, and do everything I had to do in a quarter of the time with one tenth of the effort. Something so simple as giving someone Tylenol took more brainpower than calculus in those times (sometimes, I yearned to go back to math class. At least there, the numbers weren’t in danger of dying at my hands). Luckily, he made it look so easy.
While those eight new patients that night often needed more attention than I could provide, they were often only half of my responsibilities for the night. Remember when I mentioned earlier that I covered four different surgical services? I had some 30-50 patients scattered throughout the dimly lit corridors in the floors above that I was also responsible for. A large majority of them were trauma patients who were admitted to the hospital after their respective incidents. If there were any issues, whether it be explosive diarrhea (that somehow ALWAYS got on the walls. HOW?!), a patient trying to punch the nurses (and occasionally succeeding), to a sore throat….these issues became mine. I was the first person of contact, the dam holding back the lake of chaos. Good thing I hadn’t lost the 30 pounds I would lose by nearly a year later, so I had a little more fat to plug the hole.
These complaints ranged in severity from “The pt in 515 has a sore throat” to “630 is in afib with RVR and they are becoming hypotensive (an irregular heart rhythm that makes it so the heart doesn’t pump enough blood to sustain the body’s needs. This, my friends, is bad. At that time as an intern, it felt so scary I could no longer process emotions). For anything that goes “BEEP” in the night (I’m looking at you, wound vacs) to “BURP” – the patient now profusely vomiting, to “THUMP” – the patient who ends up face first on the floor because they are so delirious they don’t know where they are, these were the terrors of the night.
On top of that, any new consults (a new patient to be evaluated, i.e. if a patient needs to be evaluated by vascular surgery) were also me. That led to the hilarious thing where if a trauma patient came in with an arterial injury, I had to consult myself as vascular surgery, then call the vascular surgery chief resident about that patient. These consults could include new patients in the emergency department, patients admitted to the floor, or the classic patient that shows up as a “direct admit” (transferred from another hospital directly to a room in our hospital, without going through the emergency department) to one of the services I covered. 11 times out of 10, I had no idea these patients were coming. Those were my favorite 1am calls from the nurses. “Mr. Johnson has just arrived and needs orders”……Mr. Johnson Who???!!?
July 4, 2017
This was the night that would baptize me into residency. We’re not talking the kind of baptism where a priest gets some cup of water and sprinkles it on the baby…we’re talking the kind that have you thinking, “Oh my God did he just drown that child?!” The kind where that little nugget gets dunked so deep and so vigorously that it’s probably the scariest moment of that kid’s life. Think about some gigantic being that’s 40 feet tall grabbing you in its oversized hands and dragging you through a swimming pool at 100mph. That’s the kind of perspective that makes you realize how terrifying that is.
Anyway, the night had arrived. By 3 days in, I had managed to find the bathroom reliably (whenever I actually had the time to use one. There’s nothing like going 14 hours and thinking “I haven’t urinated once today. I’m sure this is fine”), but that was the extent of my ability as a resident. I heard rumblings about how bad this night would be, and on top of my baseline level of scared, there was a new level of anxiety as I walked into the hospital that evening. I walked to the trauma team room, dropped my bag, pulled out my roll of Starburst (which had quickly become my comfort food), and sat down for sign out. This progressed in the usual amount of chaos as it had the past few days, but it felt like somewhat comfortable chaos. Or at least predictable chaos. The night kicked off with the normal slew (or SLU, haha) of phone calls and random tasks. We had a few minor traumas, but nobody that sick. The hours rolled into the late night…and that’s when the city of St. Louis went up in flames.
Our first level 1 trauma of the night was paged out. The screeching of the trauma pagers erupted throughout our team room. I don’t remember what the page exactly said, but the chain of events that followed will forever be burned into my memory. At our institution, we have level 1 and level 2 traumas. Level 2’s are the not-so-sick people. These people can mostly talk to us and may have injuries, but are not usually life threatening. Level 1’s are the sick people…the ones who have severe problems from the get go. These are the gunshots, the stabbings, the patients for whom the clock is ticking from the minute their incident occurred. While some are more severe than others, these are the pages that perked us up more than usual. If there is going to be a dance with death over the life of a critically ill patient, it would be during a level 1. For these, our attending surgeon has to come down to the trauma bay. On level 2’s, the residents often handle them initially and then discuss them with our trauma attending.
***20-SOMETHING YEAR OLD MALE MULTIPLE GSW TO ABDOMEN AND CHEST ETA 3 MIN***
The page went something like that. We knew he was going to be sick. A skill you learn as a resident is immediately identifying the patients who are SICK. There are relatively healthy patients, sick, and SICK patients. This guy fell into the latter category. He was barely responsive and had multiple visible penetrating wounds to the abdomen and chest. It doesn’t take a doctor to realize that wasn’t good. We quickly transferred him to our trauma bed and began assessing him. He needed about 10 things done at once, and our team quickly set to work getting blood to transfuse, preparing to intubate him and put in a chest tube, as he had wounds to the chest. This guy needed the operating room immediately if he was going to live. My chief called the OR. Our attending came down and jumped into the fray. I saw the detached look on the patient’s face…he was in shock from blood loss. The simplest definition of shock is “piss poor perfusion” as per one of my medical school instructors. His abdomen felt firm and distended. Those bullets had done some major damage, and we weren’t going to know the extent until we put a scalpel to his skin. We were about to roll him to look at his back when something didn’t seem right. In all the noise and activity, something was missing. Something that had been there the whole time. A particularly noisy machine had stopped chirping it’s metronome-like tone. We turned to the monitor.
His pulse was gone.
Our best laid plans, while they were made of cardboard at that moment, went up in flames. My attending yelled for our open chest tray. I stared at the monitor, then stared at the patient. That vacant look was gone, replaced by the blank face of unconsciousness. One of the nurses jumped on a step and started performing CPR. Being the uninitiated resident I was, having never done a trauma rotation as a medical student, I didn’t understand the gravity of what was about to happen.
When faced with penetrating trauma and a patient losing their pulse in front of our eyes, thus going into cardiac arrest, you have to act quickly. While there are a number of things that can cause someone’s heart to stop, in trauma, it is usually a “empty gas tank” type of problem…the “tank” being your heart, arteries, and veins. Having massive blood loss, there becomes a point where there is no longer enough blood to support life. We needed to get control of the bleeding…and do it fast. When your body is in a SHTF (Shit Hits The Fan) type of situation, if you had to pick two organs to get blood flow, what would you pick?
The liver and spleen? Kidney and lungs? No way. Those can do without their share of blood flow for the immediate future. 1. Brain. 2. Heart. That’s it.
We were about to perform a resuscitative thoracotomy in order to give this guy a shot at life. While the success rate of this procedure is abysmal, the outcome of not performing this is certain death. Desperate times call for desperate measures. This involves slicing open the chest on the side, spreading the ribs apart, moving the lung aside, and putting a gigantic clamp on the descending aorta. The aorta is the largest blood vessel in your body that carries the blood from your heart to everywhere else. By putting this clamp in the chest, you effectively turn the blood flow off to every part of the body below the clamp. That means everything below the ribs no longer gets any blood. This allows what little blood remains to go to the brain and heart, which tend to throw the biggest fit when they don’t have blood flow. Selfish, they are. You can open the entire chest, plug a bleeding hole in the heart or lung, and perform other maneuvers to try to save their life. See…I didn’t know that was about to happen….so I was along for this wild ride.
My attending and chief grabbed the cart, threw on gowns and gloves, and took a scalpel to the patient’s left chest while the CPR was going on. They entered the chest with speed that I had never seen, cranking open the ribs to allow for the large clamp they placed on the aorta. My chief yelled to me to throw on a sterile gown and gloves and to come to the chest. I stared at my hands and realized until that moment I hadn’t moved from that spot for the past 2 minutes, despite the chaos around me. I quickly gowned and gloved myself and stepped up.
“Pump the heart against the back of the sternum. See, like this? Okay, GO!”
I followed their commands blindly and placed my hands around this man’s heart and started punching it against his sternum, performing the job his heart was no longer able to do. What the hell, I’m performing CPR from the INSIDE OF THIS DUDE’S CHEST. WHAT IS GOING ON. That was the only thought my brain could muster in that moment. Ah, ah, ah ah, staying alive, staying alive. I sang that song in my head, trying to stay on the beat of 100 beats per minute instead of the 1,000 beats per minute the adrenaline had my body moving at.
Through the magic of blood and resuscitation, and maybe a bit from my boxing match versus his heart, we looked at the monitor during a pulse check a few minutes later…he had signs of life! A pulse! The beeping, it’s back! That meant time for the OR. On our exploration of the chest, we had yet to find the source of his bleeding, so we knew it had to be his abdomen. We quickly packed up all the lines, drains, tubes, and blood products and rushed up to the operating room. My utility belt of pagers and phone had been going off like crazy throughout this. I ignored them.
I had never seen an OR move that fast. We threw him to the table as fast as we could, smattered a sterile prep on what seemed like his whole body, and within two minutes my attending and chief were cutting into his abdomen. I threw my pagers in the corner. Everything else could wait. Upon entry, they were greeted with what was probably two liters of blood. Well, that would explain why he died earlier. I donned my gown and gloves and stepped up to the table. I might not know how to do much, but 4 years of medical school and $200,000+ of debt taught me how to hold the suction. They worked quickly, evacuating the blood and packing the abdomen with surgical-grade “lap sponges” (See: expensive sterile rags) in an attempt to stifle the bleeding and figure out where it was coming from. While our move of clamping the aorta earlier had bought us some time and prevented us from diving headfirst into a geyser of blood, it hadn’t stopped all of the bleeding. Something big had a hole in it that wasn’t supposed to. And we had limited time to fix it.
From the moment that patient entered the door, the clock was ticking. We had caused the clock to tick faster in our efforts to save him. The clamp on the aorta, while allowing us to resuscitate him, was also cutting off blood flow to everything in his abdomen and below. Leave the clamp on too short – he dies, leave it on too long – he also dies. The physiologic toll of losing that blood flow mounted with every minute. Even if we fixed everything and stopped all the bleeding, he could still die from either the lack of blood flow or the injury from returning blood flow to a place that didn’t have it before. This is called reperfusion injury, and can be more lethal than the lack of blood flow in the first place. We were performing surgery on the edge of a knife. Granted, these thoughts all came to me in retrospect…because what I was actually thinking about…
OH MY GOD THERE IS SO MUCH BLOOD
Where is this all coming from. This is bad. I’m just going to jam this suction right there. It’s impossible to miss when you’re suctioning in a lake. Great? Great. What do I do with my hands. Am I helpful……I don’t think I’m helpful. I’m going to grab onto this retractor and put some amount of pressure on it that looks like I’m helping, but doesn’t actually do anything. Sick, great job Brandon.
Meanwhile, my chief and attending had packed off the abdomen, but blood was welling up from somewhere much deeper. There were gunshot wounds to a variety of organs, but they didn’t explain his massive blood loss. They performed a Mattox maneuver, also known as a left medial visceral rotation, in order to expose the abdominal aorta. This revealed what we were after. I’m not much of a doctor…but I think that’s not supposed to be there, I thought to myself. I’m a tall guy, so just over the edge of the abdomen I could see blood coming out of what looked like his aorta. After my attending jammed the suction there and dried it off, we could see his aorta was….shredded…for lack of a better word. It looked like someone had set off a pipe bomb in the body’s biggest blood pipe. The entire front portion of the aorta was no longer there, and maybe 40% of the back part of it remained. This wasn’t good. My senior and attending went into quick thinking mode, attempting to deal with the injury in the fastest way possible. This wasn’t a time to do some pretty repair, as every minute was invaluable.
Meanwhile, the anesthesia team was fighting their own battle. What was going on behind the other half of the “blood-brain barrier” (Guess which side is which…I’ll give you a hint, the name was coined by anesthesia as a friendly jest against their barber counterparts) was as important as what we were doing. They were pumping blood, vasopressor agents, and a myriad of medication in order to attempt to get the patient’s body out of the physiologic crater it was in. The resuscitation is an attempt to keep up with blood loss to give the body just enough to function. If they fall behind, our surgical efforts would be useless. If we couldn’t get control of the bleeding, their battle would equally fail. What I recognize now, in retrospect, was that we were already losing that battle by this point, if not lost it.
An attempt at placing a shunt over the portion of the aorta failed, and we attempted a Hail Mary of options, including a large hemostatic patch, to no avail. The patient had gone in and out of cardiac arrest multiple times, requiring me to intermittently pump the heart while they worked. A few minutes had passed, my attending looked up to the patient’s liver and put down his instruments as the beeping signifying asystole droned in the background.
“He’s bleeding saline”
The “blood” coming from…well…everywhere was more water than blood. I came later to recognize that the diffuse oozing of blood from everywhere within our surgical field was severe coagulopathy (AKA the body’s clotting system stops working), a part of the Lethal Triad of physiologic derangements that often spells death. No amount of fixing his aorta would be able to fix that. The war was lost.
“We’re done here”
At that point, I stopped squeezing his heart, anesthesia turned off the blood transfusions, and the room took a collective sigh. My attending broke scrub and stepped away from the table. We sat for a minute, exhausted. BEEP BEEP, BEEP BEEP BEEP, BEEP BEEP BEEP. A pager went off in the corner of the room. It was ignored. My senior told me to step around to the other side of the table across from him.
“You know how to run a baseball stitch” Yes. No. What is…stitch. How did someone let me be a doctor.
“Uhhh, I think so” I replied.
“Close him up. We just need it closed to get him to the morgue”.
The scrub tech handed me a needle driver loaded with a big needle. My senior scrubbed out to attend to whatever disasters had been brewing while we were in the operating room. I don’t remember if any new traumas came in while we were there, all I knew was that I wasn’t there for them. The scrub tech knew more about how to close this patient’s abdomen than I did, and he kindly guided me through it. Three stitches in, I became acutely aware of how numb I was. Sure, I’d seen a patient or two die before…but nothing like this. Who knows who or what this patient was….he was young, had so much time ahead of him. We didn’t know the circumstances or much else about him. No name, no age, nothing. None of that mattered. Nothing changed what laid in front of me…the lifeless body of a person that some hours before was still laughing, breathing, and talking just like anyone else. Now…nothing. I finished closing his belly with what was likely the ugliest stitch of all time. We tried to clean off all the blood from his body to attempt to move him to a clean stretcher. I found myself wiping over areas that were already clean, lost in thought. And by thought, I meant blank thoughts. I wanted to get every drop of blood off of him, as if that would somehow cleanse my own sins and make him come back to life. I was grasping at something to control. The scrub tech tapped me on the shoulder, I stopped, and we moved him over to the other stretcher and into a body bag.
Minutes later, I stepped out into the OR hallway. What just happened….What did I get myself into. Dead. That patient….person…human being…is dead. Someone shot him. Why? And all of that work and we failed. He died. My senior walked by and patted me on the back, sensing that I was a little shell-shocked.
“How do we do this…?” I asked with a flat affect.
“We think about it later. No time for it now, we’ve got work to do. Come on, we’ve got to get down to the ED.”
I decided I would process later. My students came up to me and told me I had some ungodly amount of pages to answer. Off we went.
I checked my watch, it was around 3AM. I was in the emergency department. We already had another patient dead on arrival, where the trauma activation ended in less than 2 minutes after it was determined to be futile. We had patients with new gunshot wounds in each of our trauma bays, and as I was walking back over, there was screaming and a stampede of people from outside our emergency department doors. Sharp snapping sounds came from the distance. The paramedics and people who rushed inside were panicked, saying someone had driven by the road by the front entrance to our hospital, firing guns. Luckily, nobody had been hit.
A drive-by. A freaking…DRIVE. BY. OUTSIDE OF OUR HOSPITAL. WHAT THE HELL IS WRONG WITH THE WORLD.
I received a call from our trauma ICU resident then. He asked if I was okay and needed help. He tells the story to this day about this phone call. My reply was “Yeah dude, I’m fine, are you okay? Do you need help?” It sounded peppy and upbeat in my mind, but he says that when he heard my reply, I sounded completely delirious and lost. I was laughing in a lost-my-mind kind of way. As he finishes telling the story, he says, laughing, “And I called Wojcik and ask him if he’s okay and needs help. Dude is getting crushed, and he laughs and asks if I’m okay and needs help. If I’m okay? He’s asking if I’m okay? He sounded delirious. We’d had over a dozen traumas at that point, they had been getting slaughtered, and this dude is asking if I am okay. That’s when I knew he was f*cked.”
What seemed like a week-long night finally came to a close. My fellow interns were late in finding me in the morning to re-cap the night’s events. Turns out the hospital was on lockdown after the drive-by that morning, so they had to sneak in side doors and beg to be let in, despite, you know, being the doctors that worked there. The parade of interns from my 4 services came and went, and I sat down to finish my backlog of notes from that night. Turns out when you’re running around, you don’t have time for paperwork. I left, exhausted, around 9am that morning (our sign-out time was 5am, for reference). There was no time for our post-work ritual of breakfast and happy hour, which had long passed. I don’t remember getting in the door of my apartment. I turned the key to my door, took one step, and then woke up to the sound of my alarm at 4PM later that day.
Back to it.
Despite being at this for a week, this is how I often felt during traumas. I could at least fake my way through things. There’s also something to be said for establishing a system; a semi-rigid set of steps performed every single time that builds a framework of reference. The ABCDE of ACLS, and thus the primary and and secondary assessment, are built so that we have something to fall back on when the stool is launched at the rotating cooling device. It’s the same way that martial artists, athletes, soldiers, or anyone in high pressure situations are trained to have a failsafe system to run through in stressful situations. I began to find comfort in ACLS, and while I didn’t have the grasp of floors 1-100 of the building of trauma care, I at least felt like I knew my way around the basement.
If you have eyes, you might have noticed the pretty ridiculous picture at the top of this page. Since I was 12 or 13 years old, I had a short, buzzed haircut. From the ages of 16 onward, I usually had someone else who helped cut my hair. However, since being alone in a new city, I didn’t exactly have someone to help. I had done it before without too much of an issue. I woke up a little bit early that day and decided I wanted a nice, fresh haircut to start the new week. I picked up my razor (which by then was fairly old), and buzzed my hair with a “2” – which is about a half inch. I looked in the mirror afterward and thought something was off, but I couldn’t quite put my finger on what it was. Regardless, it didn’t matter, as I had to be at work in 20 minutes and promptly left.
When I arrived at the hospital, some other interns asked me if I got my hair cut, to which I replied I did. However they looked at me a little sideways….in a one-eyebrow raised type of way. I was clueless about why they were doing this, but got through sign out and started out on the floor to deal with my first phone calls of the night. The nurses, although at that point they had known me only a week, had gotten to know me pretty well. They all looked at me a little funny and asked about my haircut and what went wrong. I turned to my studs, who finally spilled the beans.
“Brandon, there’s something wrong with the back of your head”.
I don’t think they meant it’s odd shape. I went back to the resident room, where one of our third year residents took the picture you now see. Turns out my hair clipper blades on the attachment had separated when I pressed too hard, giving me a stripe that was cut shorter than the others. It. Looked. AWFUL. And. HILARIOUS. Some of the nurses asked if it was intentional that I shaved some design in the back of my head…I think I could have shaved it better if I had spastic paralysis. It was pretty much the talk of the floors that night, and boy did everyone get a laugh out of it, me included. It must have been so ridiculous when I walked out of a patient’s room and they saw that it looked like I was mauled by a bear. I even resorted to wearing one of the super ugly bouffant caps to hide the back of my head, which arguably made me look more ridiculous. The next night, I shaved my head almost bare in order to get rid of the stripe. It was in that moment that I decided I was going to grow up and get a real haircut (Cue nearly 5 months of hair growth/looking unkempt until halfway through my intern year, when I finally got a big boy haircut).
My first day off on the rotation, while glorious, seemed all too short. We average 1/7 days off for the month, so that meant once per week. It was pretty awkward being off during the middle of the night, and I’m pretty sure most of what I did that day was sleep, sleep, and more sleep. But there was one other thing I did that helped set me up for success….
The relationship between residents and nurses is something that deserves probably an entire book, or at least an entire post worth. It is especially complicated for new residents, as we were “in charge” in the hospital in the sense that the nurses are supposed to do what we tell them to do as far as caring for patients. However, there often exists a massive gap in experience between the nurses and day 1 residents. Every resident remembers when a nurse calls them about an issue, we have no clue what to do, and try to save face by saying, “Well, what do you usually do for this?” – AKA: Help, I have no clue what I’m doing because I can barely walk and chew gum at the same time right now.
The power dynamic of now being the superior to nurses that have sometimes been practicing since before we started medical school, college, or even high school, is a dangerous maze to navigate. Combine that with being stressed out, in a foreign situation as a new physician, the long hours and lack of sleep/food, and trying to resolve conflicts, and you get something that is really, really difficult to get right. However, if you follow the rule of Bill and Ted’s Excellent adventure and Be Excellent to Each Other, you’ll do okay. I always heard the way to a nurse’s heart was chocolate, so I baked some chocolate chip cookies and took them with me the next night to work.
After getting sign out, I grabbed a container of cookies and walked to the surgical floors, asking if anybody wanted cookies. I gave them to nurses, care partners (basically nurse assistants), other residents, and more. I wanted to get off on the right foot as a resident, because if you work with people you like and who like you, it makes everything easier. And a little bribery in the form of treats is never a bad thing. I wanted those nurses to know that not only was I a person who could bake edible things, but that I had their back. Because Lord knows, I needed them to have mine. In the trenches of the hospital, you want people on your side. I tried to learn as many nurse names as I could (despite forgetting them probably a dozen times before getting it right), and in moments of frustration to remind myself that we were all on the same team. I’d like to think it worked. Those nurses not only raised me as a resident through some pretty difficult times, but 6 months later, they were still talking about me being the resident that brought them cookies. I call that a win.
I remember one particular incident on the most popular floor for trauma patients, 6 North, where there was a patient who was being very rude to nurses. And not just any nurses…my nurses. I remember the very frank and stern conversation I had with that patient (and many others since them) where I flatly, with a very grave tone stated that nobody messes with my nurses, and that they would respect them from now on. While the lack of respect made me feel some pretty fiery anger, I was able to channel that into a chilling talk that often set patients right. They had my back, you can bet I had theirs.
I started my second year of my residency on nights as well, and saw many of the same nurses who I credit with raising me as a resident. Many of them had moved into the ICU or to other floors, but it felt good to still see them and let them see how I’d grown as a resident.
If you’re in medicine and haven’t read The House of God…I’d recommend doing this right away. It is a fictional book that, while being ridiculous, hits the spectrum of medicine in a way that seldom other sources of media can (The show Scrubs is also an excellent example of this). In the book, the main character is Roy G. Basch, a fresh medical intern, and the book is about his journey through his year as an intern. In it, there is a character known as The Fat Man, or Fats. Fats is his senior resident, and is portrayed as a kind of genius medical wizard who shows up, fixes Roy’s problems, and disappears in a snap.
My chief resident was the type of chief that I hope to one day be like. Calm, cool, collected, and had a grace both in and out of the operating room that exuded confidence and poise. Plus, he’s a genuinely great guy to be around and is excellent to everyone he meets. However, he wasn’t my Fat Man. My Fat Man for that month was our second year resident in the Intensive Care Unit. Proportional to his body size, I should probably call him The Slim Man. That’s going to be his nickname for the remainder of this story. Slim looks like a tall, dark, and handsome GQ model or something. Well, short of the scraggly mess of hair he had over those two months (the ICU nights rotation – two straight months of working in the ICU at night covering ALL surgical ICU patients on 8 different surgery teams – has a special way of both creating incredible growth of both a resident’s skill and their overall level of being disheveled), he had a unique kind of charm and slightly insane level of being a genius of patient care. This is the type of quality that made him like the Fat Man from the book.
While he helped me feel at home and part of the team of Trauma from day one, he continued to do so during the nights. He would just call to ask if I was okay in the middle of getting crushed, and would come to my aid whenever I needed him. He showed me how to do a bronchoscopy, where to find the peanut butter and graham crackers (a staple in any resident’s diet), and introduced me to a plethora of incredible ICU nurses who would help get me through that same rotation one year later. He seemed to be friends with everyone, know everyone’s names from the nurses to the janitors, worked tirelessly, and would go above and beyond to take care of his patients.
One night, during some kind of stupor at 3AM, I was walking through the ICU when he stopped me, handed me a carton of juice and graham crackers, and made me sit down. He asked me if I had eaten or drank anything that night…which I hadn’t…and said, “Man, we’ve been getting crushed, haven’t we?” It was true. It felt like we had anywhere from 8-12 trauma activations per night. Those that were the sickest of the sick went up to the ICU, where I never saw them again, but Slim was the one-man army taking care of patients with the worst problems in the hospital. Often times I would see him running between critically ill patients, and the sounds of “Code Blue, 9ICU” paged overhead (most often the code was on one of his patients). This was all too common
I’ll never forget one of the many nights he saved me. You want to scare a new surgery intern? Give them an EKG of a patient who is having a cardiac issue and ask them what to do. Oh, and perhaps make that a patient who just had open heart surgery. And make that intern have to directly call the cardiac surgery attending with that issue, because there was no senior resident to call. That happened to me the second week. That pager was the one I feared most…the cardiac surgery pager. Heart surgery was something I had no experience with, and there was a very real possibility that someone with all new coronary arteries or a new valve could very easily decompensate. It wasn’t like abdominal surgery, where if a connection between two pieces of intestines broke down, the patient would become sick over a period of hours. With cardiac surgery, if something broke down, it often meant a cardiac arrest or a severe hemodynamic problem.
Until this point, I had rarely gotten any cardiac surgery pages. However, I got one stating that a patient who just had a CABG (Coronary Artery Bypass Graft – the procedure to help resolve severe heart disease) was having an unusual finding on their EKG. I rushed to the nurse’s station, fearing the worst. I stared at the EKG…powerless. I don’t think there’s a heart attack here. I don’t think there’s a heart attack here. Is there a heart attack here?! What does this mean? DOES THAT SQUIGGLY LINE MEAN THEY ARE DYING?! I rushed to the patient’s bedside, sweating, out of breath, and entirely stressed out after 60 seconds of looking at an EKG. She was staring at me as if I had two heads…make that three. She looked fine. I examined her from head to toe, got another set of vitals, and proceeded to be more confused. I rushed back to the nurse’s station. I thought that whatever small squiggle on her EKG meant her heart was going to explode any minute. I called Slim.
He came sauntering out of the ICU and proceeded to work his magic. He ordered labs, called cardiology to look at the EKG, took a look at it himself and read about what the findings would mean, told me exactly what to say when I called the cardiac surgery attending….and disappeared in a flash, back to deal with whatever fresh disaster was brewing in the ICU. It was the scariest phone call I’d ever made in my life….aaaaaaaaand it turned out the issue was nothing. Absolutely nothing. As I hung up the phone call, I felt a sigh of relief. I might have been stupid, but at least the patient was okay. That was one of the many times that Slim saved me, especially on cardiac surgery patients, even though that wasn’t his responsibility. This was when I first learned that no matter what, the program at SLU was a team game. If I was in a bind, someone would always be willing to help, even if they weren’t on that service, in that building, or even working that day. Slim showed me that the bond of SLUGS knew no bounds.
While I had conquered many technical skills over that month, including fixing wound vacs, writing orders, finding the bathroom, remembering to use the bathroom, carrying 5 pagers, and how to close a wound, none was quite as memorable as my first arterial line. An “art line”, for short, allows us to continuously monitor blood pressure, and often goes in the wrist. Three weeks in, when I finally started to feel like I got the hang of things, Slim called me to the ICU on an unusually slow night. He asked me if I had put in an art line before. In fact, I had as a medical student, somehow getting it on the first try in what proved to have been a stroke of pure luck. He said there was a trauma patient down the way that needed one, and that I should go do it. When I asked him what I needed, having never put in an art line before, he told me “Figure it out, man.” Learning to be self-sufficient as a resident was a valuable skill…he introduced me to the patient’s nurse and walked away. I looked her in the eyes, said “Help….?” She laughed and proceeded to ask me my glove size, and turned up 3 minutes later with everything I needed to put in an art line. Score.
I entered the patient’s room. Lucky for me, the patient was intubated and sedated, meaning he wouldn’t feel or remember how much or little I was about to torture him over what should have been the next 10 minutes…which was instead the next hour and a half. What ensued was a battle between me, the ultrasound machine, and this man’s radial arteries. I went through about ten arterial line kits, had successful sticks that became unsuccessful when I tried to thread the wire, and kept getting the ultrasound machine in my way. My frustration mounted with each failed attempt, questioning my technical ability (Can you even be a surgeon if you can’t put in a freaking arterial line? Come on, man…), my self worth, and everything in between. What I should have done after a few failed attempts was call Slim for help, but at that point I was too deep. Too. Far. Gone. I was going to get that arterial line come hell, high water, or the sunrise.
The nurse came in intermittently to check on me, laughed at me muttering obscenities under my breath, and brought me extra supplies when I needed it. She was a great sport about it, poking a little bit of fun at me as I was berating myself, while simultaneously offering little bits of encouragement. At long last, I stuck the artery, saw the pulsation, and slid the catheter into place over the wire, securing it with a suture. I practically screamed down the hall for the nurse to come back quickly to connect the tubing to the monitor and calibrate it, lest I somehow failed this late in the game. She came in, hooked it up, and a wavy red line traced across the screen. Beautiful. I sighed a deep sigh of relief. As occasionally happens at important moments, I somehow went without a single page or phone call during that time.
That was one of the moments that I was victorious over the challenge in front of me. There are moments as a resident where you have to call for help, and others where you are given just enough space to figure it out for yourself. The task is not within your comfort zone, but it’s not that far out of reach, either. Those are the moments in which I have grown the most in the shortest time. Now, some year and change later, I could have put in six arterial lines in that time, but back then, that was the point I was at. And that’s okay. Those frustrating moments, sitting with catheter in hand, about to scream so loud it would wake up the sedated patients, were the ones that paved the way for success later. I smiled at the nurse, she patted me on the shoulder, and I walked out, feeling good about myself. Slim asked me if I had managed to put arterial lines in all the patients with how long it took me. I laughed and walked out of the ICU, back to my world of the floor. I wasn’t ready for the ICU yet. For the many times I had lost that month, for that one line, I had won.
Sometimes, the answer is a cry for help and reaching for the hand of those above you. Others, it is an abusive determination to succeed above all else. It’s like when a basketball player shoots a reckless shot from near half court and it somehow goes in. Was my 90 minute half court shot worth it only because it went in? Was it even a smart idea in the first place? All I knew was that I didn’t care.
That art line went out in less than 24 hours and he needed another one.
It was a Monday, the 31st. The end of the month. Slim, my chief, and I were sitting outside at another night-shift favorite, Hammerstone’s, on that beautiful, sunny morning. We were laughing, surrounded by some of the cardiac ICU nurses who helped Slim make it through the tough times during the night (who would later be the fantastic nurses to do the same for me one year later). The Budweiser never tasted so good that morning, washed down with a delicious egg and sausage slinger. I had somehow survived the remainder of that month. I had put in my first (and second, and third) chest tubes, been a part of 100+ trauma activations, learned how to order Tylenol, and survived the first month of residency. The thrill of the night-to-night chaos, brief moments of feeling like a real, somewhat competent doctor followed by long moments of being reminded just how dumb I was, had been a roller coaster I wasn’t prepared for. Survive and advance, that was the goal.
That morning, we laughed, we reminisced, and I was the happiest I had been that month. I felt like I was exactly where I needed to be in that moment. To tell the truth, I was sad to see it end…I had grown to embrace the chaos. The prospect of starting a new rotation the next day, with the responsibility to round (What?!), write daily notes (WAT?!), and deal with the plethora of issues that aren’t even an afterthought on nights (such as the logistics of discharging a patient from the hospital) was daunting. I didn’t want to leave the small bubble of security I had found, the small bit of this residency life that I knew. Again, such is residency, the moment you get comfortable, you are whisked off to something else.
We said our goodbyes, overjoyed that we had survived the insanity of summer trauma during the first month of the residency year. I might not have felt like much of a doctor, but I finally felt like a resident. As I laid down to sleep with the sun shining through my evidently poorly placed “blackout” shades (Thanks, IKEA…), I put on my rose colored glasses and forgot about all of the pain of the last month, thankful and proud of myself for surviving month 1. Being a doctor was pretty badass after all.
This piece was started some 14 months or so ago, and sat unfinished and untouched for a long time. Writing was something that went on the backburner for me, and intern year was a battle like none other. In this piece are parts of intern me, as well as parts of intern me seen in a retrospective fashion through the eyes of second-year me. While it’s only one year, that one year feels like a decade. As one of my med school classmates once said, “In medicine, the days are long but the years are short.” It’s a fitting saying. I feel like I wasn’t stable as a person until after my intern year, and while there is so much more growth to be had (there’s a reason residency is 5 years for surgeons), it felt like intern year was a gigantic leap in my life.
I hope you enjoyed reading this, and that if you’re about to be an intern, are an intern, or aren’t even in medicine, that you got a glimpse into the life of a surgery intern. I’ll end with music, as I always do. Back in that month, here are a few songs I listened to frequently:
My recent new artist is Sickick, who is an incredible producer/vocalist that does some disgusting mashups like this one of Sean Paul
Or one of his originals – No Games
Feel free to email me at the email address located in one of the site tabs at the top with any questions/comments.