Life in Triage

Since the second years are all in the throes of taking that infamous exam and I’m supposed to be studying for my pediatrics shelf exam, I thought I’d take a second to reflect on the studying (or lack thereof) I’ve done since June 17, 2007.

Quite honestly, I think I may have blown some kind of a study fuse while studying for the boards. Since that day last year, I think I’ve put in about 4 or 5 honest days of studying. I’m simply incapable of it any more. I find it tiring, boring, and simply useless. This has been proven by my scores on the various exams. Some I studied MUCH more for than others, yet my grades on most of them have been within 3 points of all the others.

So, here I sit, a book in front of me, doing anything but reading it. This is the last exam of third year, and I’m honestly a little bit terrified that I’m going to fail it. And yet, I’m not scared enough to really buckle down and study for it. Because I don’t give a flying crap about developmental milestones. I just don’t care enough to learn things in which I’m not interested anymore.

I haven’t written anything here in a while. In fact, that last post was saved as a draft after I forgot to put it on here for almost a month. I’m gonna get back to this.

I saw my first death a few days ago.

Going through medical school, of course, you see your share of dead bodies. Heck, I spent an entire semester in a large room filled with about 100 of them. Dead bodies are old news. This was the first time, however, I witnessed someone transition from being alive to being dead. It was strange, but in the complete opposite way that I expected. The oddity was in its complete nonchalance, even from me.

She came in with a ruptured thoracic aortic aneurysm, already a grim diagnosis. Most people don’t even make it to the hospital, and even then the majority of those that do don’t survive. Already under general anesthesia when I first saw her, she was never a real person to me, I suppose. They laid her on the table, turned her halfway on her side, and flayed her open. Dr. Safi works incredibly fast, and in under 5 minutes we had been through skin, fat, and fascia, cut out 2 ribs, incised the pleura, retracted the lung and found it…the 2-3cm hole in a tube that was about to kill this woman.

We operated for about 45 minutes. About 15 minutes in, the EEG went flat. Due to the massive infusion of IV fluids she was getting, she developed some problems with her potassium and her heart began to fibrillate. I’ll never forget how it looked. First, the heart was beating like any other heart, then it looked as if it were a bag filled up with small worms. It writhed and writhed, producing some crazy patterns on the EKG. Paddles were brought over to shock the heart back into a rhythm, only to have it begin to fibrillate again 2 or 3 beats later.

Both surgeons were sewing with alacrity, but it was (apparently) all in vain. Suddenly, without any warning, Dr. Safi threw his needle driver and pickups down, and shouted: “Case over! Call time of death.” Anesthesia was dissatisfied with this. “Give me 5 more minutes,” he asked Safi, who had already scrubbed out and was beginning to write. “Fine, fine” he replied. Dr. Estrera kept operating for a few minutes, then the anesthesiologist was satisfied. “Ok, case over. Time of death 10:15.”

And that was it. No trumpets, no grim reaper, no…nothing. Anesthesia was still keeping her body functioning for the moment, so there was no real change in her physiology. But she was, for medical purposes, alive one minute and dead the next. Over the course of the next few minutes, as anesthesia began to remove their supports and we began to close, I watched the heart begin to writhe slower and slower. We had closed up the cavity before it completely stopped. We closed the wound roughly, it was just going to be opened again by the coroner. Even after that, it wasn’t much different than dealing with a live anesthetized patient. We cleaned the blood off her chest, undid the drapes, and put blankets on her.

The only difference was, this time there was one covering her face.

Surgery lesson of the week:

Be careful where you put your pecker.

I watched a three month old baby get operated on this afternoon.

At his age, he has already spent more time in the hospital as a patient than I have in my 25 years.

Life just plain isn’t fair sometimes.

I think I’m going to be a surgeon.

I say that with an unbelievable amount of fear, and without one bit of assurance that it is the correct decision.

That being said, I’ve never been happier in the hospital than I have been for the past week. Yes, the hours are incredibly long, but they pass at a rate that was completely unexpected. This is what medicine was supposed to be about. Gone are the tedious hours of taking long, drawn-out histories, listening to endless complaints that have nothing to do with the current hospitalization, and meaningless notes that don’t change anything.

Those things will be replaced with many a 4:30 morning, sore knees and ankles, and constant fear of my superiors.

I’m scared, but comfortable.

I will, as long as I live, never forget my first guiac.

For those of you that don’t know, a guiac is a test for tiny amounts of blood in the stool. One must glove up, lube a finger, insert it, get a “sample,” rub this sample on a card, then put a developer on the card and see if the test is positive. Sounds so wonderfully simple in concept, doesn’t it?

 My first guaic was done on the same 44 year old hispanic man mentioned in my previous post. Considering my already complex feelings toward this particular patient, I definitely cringed a bit when I was asked to do this at around 9pm (I was supposed to leave at 7).

So, my intern and I enter the room, I with much trepidation. Keep in mind, my intern is a very nice Indian dude, but only this year came to our great country…meaning he has no concept of the Spanish language whatsoever. So I’m left to attempt to communicate to this guy what it is that I’m about to do to him. He starts off relatively unpleasant, but then, as if he had been punched in the groin by some invisible force, realization washes over his face. He knows I’m about to stick my latex-clad finger in his rectum, and he’s not at all happy about it.

So, I get to work. I lube up. I turn him on his side. I hold my breath….and in I go.

Its hairy. I miss a couple times. And then…guiac. I won’t go any further than that. The whole thing lasts about 45 seconds, but he is swearing in Spanish the entire time. Loudly. Simultaneously I, like some apologetic robot, just keep repeating “Lo siento, senior, lo siento.”

And I am sorry, Mr. H. I’m sorry.

Goodness knows I hate nothing more than people who drone on endlessly about politics, And I dont really mean to cause any sort of debate or even any
discussion about this, but I feel it needs to be said.
So, as part of an initial history and physical in the hospital, we ask
you questions concerning your social status, including alcohol,
tobacco and drug use, as well as living conditions and employment
status.

Most of our patients are uninsured, which leads to many interesting
answers to these questions. Let me give you a common conversation
between myself and a patient who we will call Mr H. He is a 44 year
old Hispanic male who I was seeing recently. He is in good health
overall, coming in with probable pneumonia. He binge drinks and uses
cocaine about once every 2 weeks.

Scott: “So, Mr. H, what do you do for work?”
Mr H: “What do you mean?”
Scott: “As in, a job”
Mr. H: “I don’t work. I’m on welfare.”
Scott: “oh…ok.”

This man has no reason he is unable to work, he simply chooses to not.
He simply sits around and waits for his government check to arrive. I
had this overwhelming desire to grab him by his neck and shout “What
the hell do you do all day??”

Sadly, this story is shockingly common amongst the patients I have
encountered. More often than not, my uninsured patients
simply choose not to work because the government will give them money
even if they don’t.

Now, we get to the cost of his health care. For his 3 day hospital
stay, I’m estimating the total cost to the health care system was
around $10,000. Who pays for that? Certainly not Mr. H. He hasn’t
worked to make a dime in years. No, the people paying for it are you
and I, and even moreso our parents.

For every 3 hours my father works, he works two of them to provide for
his family, and one of them to pay for Mr. H’s health care and his
monthly paycheck from the government, which he uses to buy alcohol and
cocaine, only to get sick again and come drain the health care system
again.

Frankly, that flat out pisses me off. No, I dont know how to fix it.
Its a moral stalemate and I simply hate it.

Wow…third year is half over. Through the sleepless nights, endless call days, and patients, it really did fly by. Studying for the boards feels like yesterday…and also a lifetime ago. Every day seems to last a year, but then months melt away as if they never happened. I feel like this year is intellectual and emotional puberty for me; I’m finally growing up. I work real person hours, have actual responsibilities (albeit few), and stuff I do really matters sometimes. I fell in and out of love, and have the scars to show for it now. I’ve learned some hard lessons this year, and made some big changes in my life. I guess its time, I’ve been putting it off for the better part of a decade.

It is, above all else, about other people. Narcissism comes so seductively, almost gracefully. But what is a physician without his pride? Its a balance, I guess.

In our industry, which when boiled down is a service industry, what place is there for a self-aggrandizing servant? We who  are in turn slave to our diagnostic machines, what then are we? The nurses provide the personal care, the machines the diagnoses and treatments. Are we nothing more than glorified middle men? Just a point of contact to tell people what the machines tell us?