Bill's annual fishing trip would certainly be ruined without some sort of immediate intervention. My advice was for Bill to mosey on up to the local ER for evaluation and treatment. However, since he had no health insurance and the possibility of hospital admission would put the kibosh on his fly-fishing trip, the answer was simple. I, the young resident in training and this man's best friend, was going to have to take control of this situation and either fix him up or possibly f%ck him up.
As we all know, a little knowledge is a dangerous thing. I was contemplating how I had just enough knowledge to be lethal when I decided to examine my best friend of over twenty years. It's one thing to ask a total stranger to drop ‘em and bend over, but it's another totally disgusting thing to ask a middle-aged friend who is semi-toxic from alcohol and bacteria to assume “the position.”
We found a quiet place and Bill bared his generous, sweaty, infected bottom to my semi-trained eyes.
Yes, there definitely was problem here. I was almost sure of it.
Bill had a large, swollen, shiny, tender erythe-matous mass covering his entire perineum. It was not clear at first if this was a scrotal hernia gone south, a femoral artery aneurysm ready to blow, a perirectal abscess with vigor, a tumor, or maybe just an alien. With considerable deliberation I decided that this was likely an abscess - or maybe the alien.
I had several flashbacks come to me from those surgical lectures I had in med school. Our instructor was a crusty, weathered old surgeon who always will be remembered for his unique approach to dealing with abscesses. His rules were “Never let the sun go down on an abscess” and “When you cut one open, be sure to cut a hole big enough for a prairie dog to jump through.” And of course, “Cold steel cures.”
It was time to move, so Bill and I made the drive into the clinic at the hospital. Being Sunday it was luckily closed and no one was around to get me in trouble for treating a patient on the side. The problem was that when we snuck into the procedure room, we found all the surgical instruments, including anesthetics, drapes, gauze, and packing were locked up tight. I went to my cubicle and found a sterile #11 blade as well as some betadine, 4 × 4's and sterile dressing. I had Bill assume the position once more and explained everything to him this way: “I have some good news and some bad news. The good news is that I have located enough sterile equipment to get the job done. The bad news is that I don't have any topical anesthetic to apply to the area!”
He groaned and stated that he didn't give a rat's ass! He also mentioned to
Hurry thefu#k up!
With this reassurance, I quickly prepped the area and found some CHUX (absorbent medical pads) for the mess. Without hesitation (okay, a lot of hesitation), I carefully made a linear incision “big enough for a prairie dog” along the long axis of this enormous abscess.
Immediately I jumped back. Wow! Right up side my head I was hit with the foulest smell I can ever remember. It seemed to be a cross between vomit, necrotic tissue, and toe jam.
Bill had immediate relief of his pain and in fact, he seemed to be almost orgasmic. Here I am turning blue and this guy was euphoric on some kind of sadomasochistic acid trip. His pain was gone and his nausea subsided shortly thereafter. Bill went on his remote fishing trip without incident. I spent the rest of the day cleaning my sneakers. Bill loves to tell this story at family gatherings and parties and I squirm a little when he does. I think about being a resident and how medical training demands that you operate out of your comfort zone on a daily basis - and do it without error.
I also think about the strange relationship doctors have with their families and friends. On one hand, we are asked medical questions and opinions regularly, which the family (usually my wife) will either embrace or ignore depending on their own perceived diagnosis, prognosis, or whim. I think most physicians cringe at the thought of the saying …
“Is there a doctor in the house?”
I suppose this is the cross we bear for the rights and the responsibilities of our profession. There may never be a limit to this role, but if there ever was one, it would be dealing with an angry-looking rectum with a bulging abscess - or an alien.
A Sticky Situation
After finishing medical school, I still wasn't sure what I wanted to do. I had a number of relatives who were surgeons and thought this might be a good area of specialization for me. Fortunately, I was able to get a rotating internship in a large city hospital in the East where I could concentrate on the surgical specialties.
During my general surgery rotation I worked the usual long hours with little sleep and poor eating habits, which was the norm in those days.
We had a patient, Lester,
who had a long-standing ulcer of the stomach with frequent vomiting which was due to a complete obstruction. Despite his malnourished state, our hands were forced and he had to have a 90 percent gastrectomy by our very aggressive third-year surgical resident.
As an intern on service, I got to spend long hours with Lester pre-op and post-op. Following surgery,
he didn't do much better in the vomiting department
and this didn't help with his incision's healing. In fact, late every afternoon, the unfortunate fellow would have vigorous emesis which resulted in daily wound dehiscence during the first post-op week. We maintained Lester on needed transfusions and IV fluids, but he eventually “ran out of veins” and we had just one remaining site,
his right jugular vein in his neck.
Unfortunately the need for a new IV site occurred right at supper time. I was getting hypoglycemic so I popped a couple of sticks of Juicy Fruit gum into my mouth and got the patient ready for the procedure. Since this was an emergency, Lester had to have his neck “cut down” at the bedside.
I made the incision and started to carefully dissect for that “last vein.” The resident (did I mention he was very aggressive) couldn't stand to wait so he took over pretty quickly.
How's that for instilling confidence in your intern?
At this point things got really tense. The vein was very tiny and we both were concentrating very hard not to lose it. The first couple of ties slipped off. The light was poor and it was stuffy on the ward and we were both sweating up a storm. As I opened up my mouth to say something encouraging, the piece of Juicy Fruit fell right into the incision.
The angry resident made only one comment, “Get that Goddamned thing out of there!!!!”
I could not have been more embarrassed. Luckily things turned out all right for everybody. Lester recovered and was discharged after a long stay with us. I rethought my choice of specialties and decided that my Juicy Fruit and I might be better attuned to Internal Medicine.
As for the very aggressive resident
… actually, who cares?
It was the first day of my surgical residency in a large Midwestern hospital. I started on the trauma service which was a grueling rotation. As luck would have it, I was on-call the first night. I couldn't wait to get started. Literally, I couldn't wait because before we could even finish morning rounds, the calls started to come in.
The first patient had ascending cholangitis and went into respiratory arrest. The crash cart was summoned and the second-year surgical resident adeptly inserted an endotracheal tube into the patient's lungs. As I watched, I saw the patient cough up a large, yellowish-green mucous honker which hung so grotesquely from the ET tube that I wanted to puke.
“Where's the ambu bag?” the resident asked the nurse. The nurse who had brought the crash cart couldn't find one. “Isn't someone goingflllBto to ventilate the patient?” m she asked as she glanced at me with an attitude. Shielding my incompetence (and not letting an intern do something stupid), the second-year resident replied “You ventilate the patient” to the nurse. With that she grasped the gravity of the situation and ran from the patient's room to find an ambu bag. The rest of us left to go on rounds except the second-year resident, who stayed to enjoy his time with the patient (and the nurse).
This was g
oing to be fun, I thought.
By the time we reached the stairwell to move onto the next floor, seven pagers went off at once like something out of a Sci-Fi movie.
“Trauma Alert. Trauma Alert. Three minutes.”
It was surreal and the whole progression stopped in its tracks. The beauty was that I had no idea what a trauma alert was. It is a good thing they gave me the responsibility of holding on to the pager.
With a blink of an eye, most of the group whisked off to the ER to treat the first of many stabbing victims that would come in that day. I was one of the few left to finish rounds. One by one our group was being “picked off” and I was praying all along not to be left alone. Fortunately, it didn't happen.
The day continued with a treat from our senior resident. He wanted to look in on an autopsy of a patient who had died from necrotizing fasciitis.
The “flesh-eating” bacteria pervaded the room with such a stench that it was almost unbearable. I've known some bad smells but this was the worst.
As an intern, you are at the senior resident's whim. As he chatted with his buddy, the pathologist, I was trapped there breathing in death.
A little later, the pagers started up again. The first one was an ENT (Ear, Nose, and Throat) resident wanting me to come to the recovery room to put chest tubes in one of his patients. The guy had bilateral tension pneumothoraces after his tracheostomy Remind me never to have a tra-cheostomy July 1st at a teaching hospital By the time I told him it was my first day he was already paging the third-year resident. I went to see how things were going and the third-year was already there with tubes in place. He directed me to the radiographic viewbox to see the most collapsed lung nubbins I had ever seen (actually I had never seen any).
Thank goodness he was there to help or else this patient would have been left with me. My chance to shine that day came with a nursing home patient who had a fever and abdominal pain. On rounds, the senior resident wanted me to do the rectal exam after everyone left. Sure enough, the lady had a rectal mass. I was a hero.
I waited until the afternoon rounds to disclose my findings. I told the group that I had felt rectal cancer before (bluffing), but this was different. It was rock hard, but smooth and oddly shaped. We moved on and the senior resident came back with me to do a complete pelvic exam. Our patient didn't have rectal cancer but a foul-smelling pessary that had eroded through the vaginal wall. I was humbled. I didn't even know what a pessary was.
Now I do, and it's not cancer.
My first day concluded with my feet killing me and my pride hurting even worse. I am sure I wasn't the first to go through this initiation or trial by fire. It still didn't make it any easier. I am wiser now. I am more experienced now. As I sit back and write about trauma, chest tubes, smells and pessaries I realize how glad I am to be done with it all and laugh because I know some schmuck somewhere is now going through the same thing.
interns skate through their internship and residency without the pain, hardship, and emotional scars that all physicians endure in training. The wounds run deep ‘ and are quickly opened up even 20 or 30 years later. No physician should escape that horror, all must run the gauntlet (flashback to the movie Apocalypse Now where Marlon Brando discusses “The horror, the horror” shortly before his death).
Cases admitted overnight (known as hits) were presented at sit-down rounds the next morning complete with EKGs, X-rays, labs, etc. This was the resident's chance to sink or swim and the senior resident rarely presented cases at rounds (they paid their dues as an intern). The attendings seemed to enjoy sit-down rounds, it was their chance to drink coffee, discuss fascinating medical cases, and conduct their own twisted version of The Weakest Link with the housestaff. After taking your licks at rounds, the night crew would stagger home, depressed from sleep deprivation, exhaustion, ego assassination, and bad hair. They would then try to get some sleep with the sun beaming in their window, only to be woken up by the friggin’ alarm and begin their night all over again (like a bad Groundhog Day movie). Frequently the night crew fought with one another as well as with the nurses, other residents, ER attendings, RNs, and our own attendings who don't want to get out of bed in the middle of the night (remember, they paid their dues too).
TRADITION IS A FUNNY THING.
Tradition is alive and well in academic medicine.
All of us agree that overworked, depressed, and borderline psychotic interns are a danger to themselves and all patients with whom they come in contact. On the other hand … few of us want to see these
The case that sticks out in my mind occurred on my FIRST NIGHT of Medicine rotation in my internship year. I was excited and somewhat nervous about starting the night shift. It was billed as a tremendous learning experience and a chance to fly solo, run some codes, and practice real medicine. I was teamed up with Sandy, a third-year resident who was very bright and upbeat. I considered myself lucky to be working with Sandy since I had lots to learn. We were getting coffee when the beeper went off. Something about a “GI bleeder” was all Sandy said. I was pumped! A real medicine case! Not some “namby pamby” 90-year-old dehydrated, demented, incontinent nursing home horror show who was sent over so her covering nurse could have some respite. The ER doctor gave us the bullet presentation and did the ceremonious passing of the chart to me (it was like handing over the keys to a car that was on fire). “Her pressure is kind of soft and her labs aren't back yet.” My naiveté was suddenly exposed as I watched the senior resident's eyebrows twitch at the word “soft.”
Our patient was in the critical care section of the ER. She was sitting on her gurney, all 275 pounds of her. She was inebriated, reeking of alcohol, the NG (nasogastric) tube was stuck in her nose and her face and mouth were covered with charcoal. A very pretty picture. She was a suspected polysubstance f abuser and subsequently now 1; had a GI bleed. She was a frequent flyer and the ER staff was on a first-name basis with her and knew her life story (with intimate details).
As I approached the gurney Sandy threw a yellow smock, a face shield, and gloves at me. “Put these on … you'll need ‘em.” I interviewed the patient after reviewing her previous 12 charts in the ER. I learned nothing new from the interview with the patient that was not already well documented in her history except for the two things she said to me, “You suck” and “I'm leaving.”
Her labs starting coming back and we found out that her alcohol levels were high and her blood counts were low. Her toxicology screens were positive for benzodiazapenes and cannabis (“Party on Wayne, party on Garth”). Just as the nurse was handing me a fresh set of vital signs, both our code beepers went off. Sandy moved fast. “It's in the ICU, I'll go … you stay here!” Sounded like a good idea.
As Sandy was taking off her smock and face shield the patient sat up, looked directly at Sandy and in slow motion projectile vomited one warm fresh quart of blood, alcohol, bile, and charcoal all over Sandy's face, chest, and arms. “Motherf cker!” Sandy ran out of the ER to her code and did not have time to shower off her new look.
The ER nurse started yelling out numbers at me “70 systolic over palp, what do you want to do?” … Let's see, I've never managed a GI bleed or for that matter a critical care case and I have now just sh#t me pants. Hmm, ahh, let's ahhmmm. Give blood, yes lots of blood!
Bold move, Einstein! The patient began to vomit bright red blood at an alarming rate; she filled a large basin on her lap. The nurses guessed about 5 to 6 liters. The experienced ER nurses started smelling panic and fear; I needed to do something substantial. What I really thought was “How else can I stall until Sandy gets back?” As quickly as the nurses pumped in the blood through two large bore needles, it came back out. I decided to call the gastroenterologist on-call. Yeah, that's if he'll help me. At 2 a.m. most attendings don't answer the pager on the first page. Twenty minutes and two pages later, I got a hold of Dr. Letmesleep on the horn. “Yeah, that sounds bad, why don't you get the patient stable in the ICU and I'll see her –” CLICK. Wait a minute,
need help now, please, I beg of you! I then called the surgeon on-call for his opinion. Again I gave my 30-second history hoping he would bite. He didn't. “Sounds like she's going to die –” and “Call Gastro –” CLICK. I felt like the “newbies” in the movie Platoon, going out for an all-night ambush expecting a firefight with the enemy and placing the most inexperienced, greenest soldiers at the point position – the point most likely to confront the enemy. Why, do you ask, would they do this?
A NIGHT I WOULD RATHER FORGET
TRADITION!
(I could just picture myself presenting this case at rounds the next morning. “You are the weakest link, good bye!”) I got out my Ferris’ manual and flipped to GI bleeds. The nurses began to roll their eyes; they fully understood the gravity of the situation. By the way, nurses do hate interns. Why? Because technically an intern is a doctor, but he/she is a special kind of doctor, the kind that doesn't know squat!
I finally realized Sandy wasn't coming back anytime soon. It looked like esophageal varices or possibly a Mallory-Weiss tear. I blurted out an order to give vasopressin using the most confident reassuring voice I could muster. I believed in my heart that the administration of this obscure medication (which I read about but never even prescribed before) would have no effect on the patient's condition. The nurses smirked and ran to get the medicine. Like magic, the medicine stopped the bleeding immediately and the patient's blood pressure rebounded.
What odds! Had I won the lottery?
How did this end? The patient lived to drink and drug another day. Me? After some sleep, I got pimped unmercifully at rounds the next morning on the 900 causes of upper GI bleeds. Oh yeah, the gastroenterologist who saw the bleeder the next morning in the ICU confirmed that she did in fact have esophageal varices and said, “You might want to try octreotide next time, it's a new somatostatin analog with an improved side effect profile over vasopressin.”
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 8