Wednesday, June 15, 2011

It seemed okay until I said it out loud

So after spending a half hour staring at the same two sentences of a manuscript without actually comprehending their meaning, I concluded I was too tired to do anything useful. Which I didn't really understand - I do stuff while tired all the time, so why am I extra whiny today? I didn't really do anything out of the ordinary yesterday - just office work by day and an ED shift in the evening, left around midnight. Back early this morning, but big deal - it's just sleep. What gives?

I was pondering this mystery when my friend Julianne asked me how my day was yesterday. The poor woman - for some reason, I took it into my head to actually answer her. And here is what came out of my mouth:

My last patient of the night was a cardiac arrest. She arrested at home, came in bleeding like crazy out of her airway, impossible to ventilate. All kinds of air in her neck and chest, almost certainly a collapsed lung, which we decompressed successfully. Even after expanding her lung, securing her airway, giving her CPR, multiple shocks, and lots of drugs, we couldn't get her back. This happens. Unfortunately, her family was somehow completely unprepared for this - usually families know the score on some deep level when they see a loved one collapse, but not this family. My news hit them like an atomic bomb. There were stoic tears of desperation (husband), wailing tears of rage (son), obscenities, chair throwing and wall punching (other son), and - my personal favorite - shrieking accusations that I didn't care and I didn't even try to save her and that I could go fuck myself (daughter, egged on by helpful granddaughter).

When my cardiac arrest patient came in, I was pulled away from working on IV access for a septic patient with an infected dialysis catheter. This young woman (my age, for the record) has congestive heart failure, no dialysis for a week, crazy anemic, labs all jacked-up, low blood pressure, and no veins. Agonized about putting in a central line, but do I really want a new line sitting right next to the old gnarly infected one? Should I pull the old one? She doesn't have alternate dialysis access - what if they can't get a new catheter in? Should I give her fluid to support blood pressure? How much? Will blood help? Am I going to put her into pulmonary edema? Sorry, non-medical friends - the flavor here is that there is a high probability of screwing things up no matter what you do. It's like when you shock the monkey for everything it does: eventually it will give up and stop trying to do things. Apparently it will just blog about them instead.

Of course, the IV access on the lady above had already been delayed by my earlier trip to critical care where I met a randy old gentleman in ventricular tachycardia (for the non-medical: crazy fast dangerous heart rhythm). He was stable enough, and quite amusing, but nonetheless very much in V-tach. He had an internal defibrillator, but it wasn't set to fire until his heart rate got above 160, and he was reliably at 156. Julianne suggested that I should have flashed him - she is a genius, as this likely would have raised his heart rate just enough to solve our problem. As it is, I kept my shirt on and we ended up getting cardiology to come and do overdrive pacing. This ended in a shock, which the patient did not enjoy, but at least it restored his normal heart rhythm, so all's well that ends well I guess.

Before my tachycardic friend arrived, I spent a good hour in critical care with an elderly gentleman in a deep coma. For no discernible reason. He had been hanging out on the porch, doing fine, then sort of slumped over. When family couldn't wake him, 911 was called. Usually these things are not particularly mysterious, but we could not find a thing wrong with this man. We checked every lab under the sun, head CT, brain MRI, X-rays, tox screen, all normal. Why in hell does a healthy man just slump over and go comatose? I felt like a brand new med student, searching in textbooks for the differential diagnosis, coming up empty. At least the rest of the team was stumped too, so I guess I'm no more of a doofus than anybody else. This is cold comfort, but I suppose it's comfort nonetheless.

Those are the highlights. Of course interspersed with all this, I had the usual complement of asthma, heart attacks, abdominal pain, sore throats, broken jaws, etc. I worked as hard and fast as I could, fielded countless questions and phone calls, tried to sneak in some tidbits of teaching, wrote semi-coherent notes, did my best to keep my wits about me, and endeavored (with variable success) to remain polite and pleasant.

When I actually said all this to another human, I realized how crazy it sounded. And crazier still is the fact that this was not a particularly epic shift. Sure it was busy, and people were sick - what else is new? It's just my job. But saying it out loud gave me a new perspective: I have a really crazy job.

This, of course, is probably not news to you, and I'm sure you are wondering why it's news to me. But working daily in this environment, it's become normal to me. Last night, I left work stressed out and unhappy because I felt like things were out of control, and I had failed in my quest to restore order. The waiting room was full, there were patients I hadn't seen, i's left undotted and t's uncrossed. What the hell is wrong with me that after 10 years in practice, I can't nail this stuff cold? In truth, I'm tired today because I spent precious sleep hours last night pondering my inadequacy.

But taking this rare opportunity to see my job through the eyes of a rational human, I realize that my expectations are not entirely, well, rational. Maybe I would be a saner person if I indulged myself in a few reflections about what I actually accomplish each day. Like many shifts do, last night stabbed me right in the ego. But the truth is that I saw all the patients I could, treated each with respect and compassion, didn't harm any, arguably benefitted a few, and juggled everything else with as much grace as I could muster. Is that so bad?

Maybe I should say stuff out loud more often. Wait - isn't that called therapy?

Saturday, June 11, 2011

On eggs.

If you have babies and the babies are still in eggs, and the eggs have been laid, then the only way to carry your babies is in your mouth.

Thus is the wisdom of Jack, after discovering a robin's nest containing three beautiful blue eggs in our plum tree.

And FYI, you know who lays the biggest eggs? Ostriches, that's who. We have yet to find an ostrich nest in out yard, but we are looking.

Location:Our plum tree