Me - again!

So today was a good day.

It started with a good (free) breakfast at the cafeteria - just the hot chocolate was a bit too hot in the ten minutes we had before rounds. I put it into the residents' lounge and drank it when I had a bit of time four hours later. Rounds in ED1 were boring as usual, but luckily a patient had decided to have an altercation with his girlfriend and she in turn thought it was a good idea to give him several lacerations to the arm and face with a broken beer bottle. "Have you done sutures before?" - "Sure! (once ..)". See .. it did pay off that I stayed longer in the German ER a few weeks ago. "You're going to suture this guy, get a suture kit". I vaguely remembered they were in the "small surgery room", so I went there and found a box labeled "laceration kit". The resident did stay there to watch me inject the local anesthetic. Then, after some irrigation of the wounds with saline and disinfection with betadine, I put on sterile gloves and started stitching the guy. The resident had left with the words "if you need anything, just tell me". What he forgot to mention was "if you can find me". The place was like a zoo. All day. It really is a wonder these guys don't seriously screw up more often. They hardly ever do one and the same thing for more than ten seconds before getting interrupted with another thing. Anyway I put four stitches into this guy's arm (meanwhile his other arm was handcuffed to the stretcher by an officer), nine stitches into his face and had the attending take a look, she approved of it. Then I put some compressions and bandages on the wounds and he went off with the officer handcuffed. His girlfriend had been treated in the other corner of ED1 by the way.

Another highlight came a bit later, while I was watching another resident trying to get an IV into a nice lady from the Dominican Republic who had spontaneously started getting bruises on her arms two days ago. Just after he failed the second time (granted, her veins really bursted when you looked at them) a code was called coming into bed 1. So the African-American resident who kept reminding me of Eddie Murphy said "come, you're gonna do chest compressions" and shortly thereafter I was doing CPR on a middle-aged woman in full cardiac arrest who had just been brought in by paramedics. From my vantage point in the middle of the scene I could conveniently watch the code team going about their business. We were off-and-on about eight people working on that patient. The attending stood at the foot of the bed, not taking any part in the wild ventilating, perfusing, medicating, sticking into arteries and attaching monitors. Which was good. She certainly had the greatest overview over the scene, while the residents were busy working on their part of resuscitation. Despite the fact that this was the first human I practiced chest compressions on, the BP measured by the cuff was a "steady" 100/50, which was apparently very good so they told me not to stop unless I got exhausted. I didn't, because even though the patient was still warm, her pupils were fixed and dilated and they had maxed out on epinephrine and atropine. The attending called it 15 minutes after the patient had been brought in. This was the first patient that I actually witnessed dying (OK, her chances of survival when being brought in were slim anyway). It was interesting how it took just a few seconds before "my" resident said "allright, let's see about that IV" and walked back over to the previous patient. He did wash his hands first though, so I did the same.

I also witnessed my first pelvic exam on a woman who had miscarried today. Even though I got the examiner's chair while the resident was standing, he did the exam and I got a front-row seat.

A couple of minutes after my shift was officially over, an HIV-positive patient with tracheostomy on a ventilator was brought in. After "Eddie Murphy", a nurse and even an internal medicine resident had been sticking a poor 21-year-old Mexican girl for the past hour or so with absolutely no success, my resident didn't even bother trying to get a normal IV into this HIV-woman. He told me to get one of them pretty yellow gowns, a mask with an eye-protective plastic screen attached to it and sterile gloves for myself, another mask and gloves for him and a central line kit. "Have you done a central line before?" - "No." - "What are the landmarks for the femoral vein?" - "One or two centimeters medial to the femoral artery." - "Or?" - "A bit less than one third of the way between the pubic bone and the upper anterior iliac spine." - "You're doing this central line."

Yay! He told me about three times that he was going to kill me if I stuck myself. But other than that I was lucky and the first try went very smoothly, straight to the vein. He did the Seldinger himself afterwards, unfortunately pulling out the guide wire too far so I had to stick the patient again. This time I hit the artery, her blood pressure wasn't high enough for me to need the screen in front of my eyes though. Well, third one's a charm and that was it for me today.