Yesterday was exciting. At 9am, I sat down in our teaching simulation centre. Every Thursday during the Summer, we are given a topic to research, then locked in a room with a bleeding mannequin and told to "fix it".
Yesterday's topic was Procedural Sedation; that is, giving people drugs in ER to make them drowsy so you can hurt them with minimal distress. I had not done the reading. I stayed up late watching a documentary on Netflix called "Babies", instead.
"Sam, you be the team leader." said my friend/senior Jen.
"This is a 200kg woman who has popped her prosthetic hip out of alignment. It's the third time this happened and she is in a lot of pain. The orthopaedics team is here to do the relocation, what drugs would you like to give?"
I could feel the stress flush creeping up my neck. I couldn't remember any drug names, doses, side effects, nothing... The mannequin started moaning and crying. My team looked at me expectantly. My peers, watching on the other side of the 2-way mirror, tunneled through the glass with their eyes. My armpits steamed up.
I gave propofol and ketamine. Not enough initially, too much eventually. The woman, once her hip was back in place, stopped breathing on her own due to my drugs. We had to help her breathe until they wore off. And my peers, while supportive, judged me with their eyes.
After this intense humiliation, I walked across the street and began my 8 hour ER shift. During this shift, 2 traumas rolled in. A young guy having some sort of seizure and a man who had been pinned under his tractor for many hours. I successfully intubated the young guy, giving the right drugs at the right dose. I scanned the tractor guy's belly using our portable ultrasound and identified some internal bleeding, teeing him up for surgical exploration. I also poked 3 year old with broken clavicles, old men with tummy pain and young women with bleeding in early pregnancy.
It was a good day. I happened to also be on call for the Trauma Team last night, so my pager was by my bedside, waiting to go off all night. When I turned it off at 8am this morning, I fell into a deep sleep.
A woman named Laura (I don't know any Lauras!) with dark hair and an acerbic attitude, was walking with me through the snow. She had talked to all my ex-boyfriends, and took me through all the stupid and humiliating things I've done in previous relationships. "You shouldn't have bothered with the surprise birthday, I'm just saying..." She told me that my enjoyment of my work was a sign that there was something wrong with me. "Sadistic, though?". Mentioned that most people thought I was a loser and breaking up with me was the best thing they ever did. I woke up shaking.
I don't know if my brain was just waiting to remind me of my Sim Lab failures, or if 20 hours of work/stimulation/emotion is too much. I do know I am never going to sleep again.
Friday, August 16, 2013
Wednesday, August 14, 2013
Fear-Based Medicine
Things come in threes. I hesitate to say "good" or "bad" things, but you certainly start to see patterns in the people who walk through the ER doors.
Last week I had 3 people with small bowel obstructions.
The first one I handled delicately, pressing and probing gently on their swollen belly. They got blood tests, lots of xrays and a CT scan before I felt confident about the diagnosis. The second woman got a thoughtful exam, a directed xray and a call to Gen Surg. The third? Slap on the belly and straight to OR.
My latest trend is anaphylaxis.
The first, a week ago, took place at the Urgent Care Centre (eg: not the full ER) and was a bit of a shambles. The nurses didn't realise they should give the epinephrine (epi-pen to y'all) in a muscle, not through a vein. They spent at least 20 minutes looking for a vein in a woman who's throat was closing rapidly. I quickly ordered the epi IM and then spent the next 4 hours shaking with terror at what had almost happened.
The second came in during my night shift. I was stitching up a drunk teenager (one of three!) when I heard my voice being called over the speakers. I ran to the cubicle to find the Staff calmly dispensing orders and monitoring the situation. Epi in the arm, back up drugs through the drip, monitor for 4 hours.
The third was wheeled in on an ambulance stretcher, gasping and flailing her arms. The ambos called "looks like anaphylaxis"! and I grabbed the nearest nurse. "Give her 0.5mg of epi IM stat, please!" It was done.
Then I actually assessed the patient. She did NOT have tongue swelling. She did not have a rash. Her blood pressure was stable. Her heart rate was acceptably fast. She was, not, in fact, anaphylactic.
I spent the next 8 hours watching her, waiting for the effects of the epinephrine to wear off. She was jittery and crazed all night. She settled as the sun came up. I did not.
The rule of threes may apply, but I haven't seen my third anaphylaxis yet. Because I was expecting one, I went ahead and dosed a woman with a drug that can cause cardiac arrest.
I am retreating to cold wine, a soft couch and a documentary about babies.
Last week I had 3 people with small bowel obstructions.
The first one I handled delicately, pressing and probing gently on their swollen belly. They got blood tests, lots of xrays and a CT scan before I felt confident about the diagnosis. The second woman got a thoughtful exam, a directed xray and a call to Gen Surg. The third? Slap on the belly and straight to OR.
My latest trend is anaphylaxis.
The first, a week ago, took place at the Urgent Care Centre (eg: not the full ER) and was a bit of a shambles. The nurses didn't realise they should give the epinephrine (epi-pen to y'all) in a muscle, not through a vein. They spent at least 20 minutes looking for a vein in a woman who's throat was closing rapidly. I quickly ordered the epi IM and then spent the next 4 hours shaking with terror at what had almost happened.
The second came in during my night shift. I was stitching up a drunk teenager (one of three!) when I heard my voice being called over the speakers. I ran to the cubicle to find the Staff calmly dispensing orders and monitoring the situation. Epi in the arm, back up drugs through the drip, monitor for 4 hours.
The third was wheeled in on an ambulance stretcher, gasping and flailing her arms. The ambos called "looks like anaphylaxis"! and I grabbed the nearest nurse. "Give her 0.5mg of epi IM stat, please!" It was done.
Then I actually assessed the patient. She did NOT have tongue swelling. She did not have a rash. Her blood pressure was stable. Her heart rate was acceptably fast. She was, not, in fact, anaphylactic.
I spent the next 8 hours watching her, waiting for the effects of the epinephrine to wear off. She was jittery and crazed all night. She settled as the sun came up. I did not.
The rule of threes may apply, but I haven't seen my third anaphylaxis yet. Because I was expecting one, I went ahead and dosed a woman with a drug that can cause cardiac arrest.
I am retreating to cold wine, a soft couch and a documentary about babies.
Thursday, August 1, 2013
Casting Call
I like it when people break bones.
Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.
However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.
Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.
Folds in the stocking. Folds in the padding. Wrong.
Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.
The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.
My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??
Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.
And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.
Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.
However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.
Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.
Folds in the stocking. Folds in the padding. Wrong.
Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.
The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.
My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??
Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.
And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.
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