Monday, March 14, 2011

Night Moves

I'm working nights now. I've actually been enjoying lurking around the hospital in the wee hours of the morning. The place is stripped down to the essentials. People forgo the petty discriminations between the different resident types- ED residents hating on medicine residents who hate on surgery residents who hate on all of the above. I guess there's a camaraderie that builds between those who can commiserate in the chronic exhaustion that comes from the total disregard for the natural circadian cycle. An extra perk to this rotation is that you get your weekends off- Friday AM I am out of the hospital and do not come back until Sunday evening. What scares me is that I have no idea what to do with myself with all that extra time. My social skills are on the decline. I feel like I'm missing something or doing something wrong if I'm out of the hospital for longer than 24 hours. The hospital is beginning to feel more like home to me than my actual home. That scares the hell out of me.

The premise of night float is to be on call for all of the surgical patients in the hospital overnight- two interns care for all the floor surgical patients and the Senior House Officer (a third year resident) takes care of all the ICU patients and oversees all the new surgical consults that happen overnight. One of my closest friends here, LS, is on night float with me right now. Some nights are quiet some are non-stop- you never know what you are going to get. The other night we had a patient that LS was called about for bleeding. The patient was a plastic surgery patient, and I had been in her initial debridement surgery so I came up to see what was going on. She'd had multiple debridements for a sternal wound infection after cardiac surgery. She had been in the ICU for the last several weeks but was now doing well on the floor. Earlier that day, she was doing fine, sitting up in a chair, talking to her children. Now she was acutely decompensating. She went from being responsive, complaining of pain to not responsive to hypotensive. We called anesthesia stat and started taking out the staples and stitches out of her sternal wound. Blood started pouring out. We called a code yellow- a code trauma- it quickly gets the trauma surgeon to wherever you are as well as all the personnel needed to create a mini operating area. Her heart rate went into the twenties, so I started doing chest compressions, while LS kept working at removing the sutures and attempting to find the bleeding. The cardiac and trauma surgeons arrived, as well as the plastic surgeon who had performed her most recent procedure. They were all standing around the woman's bed, trying their best to stop the bleeding and figure out what the hell to do next. With her veins being pumped full of blood and sympathetic drugs, we wheeled her down to the OR. The cardiac and plastic surgeons worked at stopping the blood vessel that was bleeding, while I worked on an arterial line on side of the groin and LS worked on a central line on the other. Finally, the anesthesiologist called it- she had zero blood pressure, zero cardiac output, further attempts at saving her were futile. Time of death was called. The graft had become infected and torn right off the aorta- the cardiac surgeon said the tissue was so far gone, she never would have made it. Everyone stood there in silence over the woman's body, while the remaining ounces of blood continue to pour out of the hole in the woman's aorta. There was nothing more anyone could do. I sewed up the gaping hole in her chest and we cleaned up the blood to make her presentable to her family later.

My heart was still racing. Although I wanted to be right in the middle of that situation so I could learn as much as possible and learn what I could do to act more quickly and effectively next time, I began to feel ashamed. This woman, lying there on the table with her chest wide open, wasn't a science experiment. She wasn't a practice dummy to make me a better surgeon- she was someone's wife, someone's mom, someone's sister. I thought back to when I first walked into the woman's room for her initial consult. I tried to remember the faces of her daughters, the hour I spent with them, telling them that we were going to do a simple debridement, that the infection looked rather superficial, that she was probably going to be ok. Now I looked at the woman on the operating table in front of me- I had lied to them. Not intentionally, but a lie nonetheless. Their mom did not end up alright, and I had been excited at the acuity of the last moments of their mother's life. It's amazing how quickly the humanity leaves and the cold intellectualization sets in during those moments. That scares the hell out of me too.