Estoy cuidando por los higados, y sus receptores.

This is a story about a liver.  Just one liver, and three people.  I am not one of those three people.  The role I play in this story is rather insignificant.  In fact if they were to make this story into a movie my role would be what they call a ‘cameo appearance.’  Well…I guess one would have to first be famous or important for it to be a ‘cameo,’ so not even that.  Just ‘appearance’ then.  An appearance that would get credited as ‘random hospital resident’ or ‘H&P taker.’  But now I’ve jumped all the way to the credits of the story and only talked about myself….not the best start for this liver’s story.

The story starts with a death.  The death of Person A.  This was the liver’s first human, the one who had grown and nurtured him since birth.  We don’t know how Person A met their doom, but it is of little consequence to this story since the liver is our center piece.  Not the human.  Unbeknownst to the liver, prior to death, Person A, had signed the papers donating him. And this is where Person B comes into our story.

I arrived to work one night, and getting sign out from the day teams, was told about Person B.  I was told that Person B was already in the hospital, currently getting a liver transplant, and would probably go to the Surgical Intensive Care Unit post operatively.  In other words, good to know about Person B, but nothing really for me to specifically do in terms of his care.  Shortly thereafter sign out was interrupted by a text message from the transplant fellow.  Informing me of a new patient in the hospital, there for a liver transplant, could I do the History & Physical?  Very surprised that they would be doing two transplants the same night I responded, it would be no problem, would it be for that night or the next day.  His response, ‘tonight, 8pm.  Same liver. New recipient.’ Apparently while on the operating table, Person B had gone into Ventricular Tachycardia and then Atrial Fibrillation.  Case was cancelled.  Enter Person C. 

All the while the clock is ticking for the liver. Hence the need for urgency.  Person C was called up and told a liver was waiting, time was of the essence and get to the hospital 5 minutes ago. Time for my ‘appearance’ in the story.  The transplant fellow is entering orders into the computer.  Anesthesia is in the room interviewing the patient.  Nursing is in the room getting the patient ready according to the pre-op orders. And amidst all of that I sneak in, ask the appropriate questions etc, and sneak out again to enter my H&P into the computer.  And thus my ‘appearance’ ended. The liver was still waiting.

Person C is taken to the OR and the liver transplant commences.  At one point during the night a problem arises with another post-op transplant patient on the floor.  I attempt calling into the OR to talk with the transplant fellow and get turned away at the phone by the nurse saying very hushed that it just wasn’t a good time as hands were moving very rapidly.  Found out later that the patient’s portal vein had ruptured intra-op.  In the end however, Person C made it okay, liver securely transplanted, and transferred to the SICU post-operatively to recover.  And recover they do, both Person C and the liver recover from the transplant beautifully.

Don’t worry.  That isn’t the end of the story.  Not yet.  

I come into work the following night, to once again have sign out interrupted by this liver.  Person C had suddenly and dramatically died in the SICU.  Was doing absolutely beautifully, and after a simple, standard routine procedure started bleeding.  Within seconds heartrate had dropped, and within 2 minutes had flat lined.

And that’s it.  The end of the liver.  A crazy story of one liver and three people expanding no more than 48 hours total. Person B the only survivor….still waiting for a liver transplant.

I could go into much more detail about just what that simple standard routine procedure was and possible reasons behind Person C’s mystifying rapid demise.  But in the end, all would be, at best, nothing more than educated conclusions.

Much Love.

Estoy levantando cajas.

Not only was he still there when I got to the hospital that night, but he was there the following night as well.  How do I put this nicely?..... It is very unfortunate, the tremendous use of resources used by those noncompliant and yet unwilling to leave the hospital.  On more than one occasion I’ve seen a resident burst into our little conference room uttering some expression along the lines of “This is NOT a Hotel!” 

Remember that box analogy I used before?  I’m going to use it again.  The night started off with a box sitting waiting to be picked up. If it could talk, it was basically begging to be picked up.  However, interesting thing about this box was that it was already scheduled to be picked up in the morning.  And therefore during sign out I could tell that the primary team was trying to ignore it until the morning.  Easy for them to do…they weren’t there.  On the other hand, I was there, and it was impossible to ignore it.  It went from begging to demanding to be picked up.  So I assessed the box and called my senior.  He came but like the primary team, concluded that it’ll get picked up in the morning, no need to rush things.  I felt reassured.  However, as the night wore on the box kept getting angrier and angrier.  Eventually, to the point where I finally decided to myself that the box needed to be picked up NOW…not in the morning (which was only a few hours away at that point). I called up the chain again. 4^th year came, was unsure so called in the Chief.  Conclusion was still that it could wait until the appointed time of pick-up.  I was not reassured this time, but did feel better that even the Chief had at least assessed the box.  I wasn’t at the hospital when the box was finally picked up.  But I got the story when I came in the following night.  The bottom had basically fallen out, rotted through. It’s still a box now…but it’ll never again be the same. I guess it’s not one person’s fault, and the fact that I had called multiple times to have it picked up throughout the night in a way protects me.  If I’m honest with myself though I may have a bit of a chip on my shoulder against that primary care team now.  That they had seen the box, acknowledged the box and then tried to ignore the box in the first place.  Chip won’t stay for long, but for the moment it’s there.

Much Love.

Estoy leyendo.

When a friend visits, you don't question the possibility of seeing them. You just know you'll make it happen...somehow.  Even if that means sleep gets sacrificed. Some people are worth it.  Amber M. and Donna F. were visiting in Rockville last weekend. Left after I got off work Saturday morning and didn't leave to return until after church on Sunday just in time that I could get back to work on time.

 Amber and I

I've been making more of an active effort to get through my To Do List for the month of October.  I have this list specifically for this month because as I am working nights I have days that I could potentially use.  Went to the dentist yesterday.  I didn't think there was a problem, but at the same time, it's been many years since I've last had a dentist look at my teeth.  I just wanted to be reassured I guess.  Found my way into the Bronx to this little hole in the wall dentist office.  It didn't take long.  And he didn't really tell me anything, probably wouldn't have said anything either had I not asked him questions.  Made me miss Dr. Proesel and the thorough job they do at the dentist office in Gridley.  But at least now I've been reassured.  Good to go for another couple of years now! ;)

For the past couple of weeks there has been a liver transplant recipient in the hospital. For a while he was in the ICU, everyone thought he was going to die.  But then he was transferred to the floor. And yesterday he was told he's finally ready for recovery outside of the hospital.  He was to be discharged today.  Unfortunately, this patient does not want to be discharged. And last night he took a great big yank on his nephrostomy tube.  A tube placed percutaneously into his kidney to drain his urine. As his usual, this guy walks around with his nephrostomy bag trailing behind him anyways, but now with it halfway yanked out he was draining all over instead of just into his bag.  I patched it up best I could to get him through the rest of the night.  I'm interested to find out if he was actually discharged today as planned or if his nephrostomy is going to delay that. 

Much Love.

Estoy avanzando en el agua.

Sufficiently transitioned to the schedule of night float.  Never had trouble sleeping during the day this time, but staying awake through the night proved difficult at first.  Now I can say we are good to go for the rest of the month.

The least fun part of night float I've encountered so far are direct admits to the floor that no one knows anything about.  If I'm lucky I get a call from the nurse manager to let me know Mr. So-and-So will be arriving soon.  So I have at least some time to try and figure out who Mr. So-and-So is, why he's coming, and what I'm supposed to do with him when he does arrive.  If I'm not so lucky I get a call from the nurse manager to let me know that Mr. So-and-So is here....already....in his bed.  Leaving me with no time to figure out the who, why, and what.  I was unaware that clairvoyance was a necessity in this job. And it makes me wonder if such horrible lack of communication exists across the board....or if we are just extra special at WMC.

The most frustrating part of night float I've encountered so far is the expectation that I handle everything on the floors overnight, and yet without the independence to do just that. To put it in a picture.  It's like someone telling you to go pick up boxes, but oh wait, they first tie your hands behind your back. So really what they're saying is 'when you see a box, call someone to come pick it up.' Trouble I've encountered with this method of picking up boxes, is that No. One. Comes. Seriously, I had a patient who had a heart attack, the most I immediately could do on my own was order the labs and studies proving that he was in fact having a heart attack and then call Cardiology.  But actual treatment.....it took 6 hours before I could get my seniors to get back to me with the okay to order it. In the meantime, I had sufficiently lost my patience and gone ahead and ordered it at one point....which my senior than made me cancel.....so that he could then tell me to reorder it hours later when he finally conceded that yes, perhaps we should treat. Worse part about this 6 hour delay. None of my seniors actually physically came to the floor to see the patient. 

Overall, night float is not bad.  I'm learning how to deal with a lot of stuff.  Kind of like learning how to swim by throwing you in the water without the floaties.  Your head goes under a couple of times. Swallow a mouthful of water. And come up each time coughing and sputtering. Not the nicest way to learn, but perhaps the fastest way.

Much Love.

Estoy seguir siguiendo.

The sun was beautiful in New England this past Sunday morning.  God had really outdone himself.  The combination of feeling fresh and rested, smelling breakfast and that view was enough to make me forget all worries.  And for a moment, remember what it was like to not have a care in the world. 

It’s rejuvenating to be reminded that I am cared for in such an unearned simple manner, by the Creator of the universe.  And that He will have work for me to do no matter where I am.  There will always be people.  Those people for the time being happen to be the community that lives and works WMC.  Will it be the same a year from now?   I give a shrug, because for the time being I get to work one more day.  And I’m right where I’m supposed to be, for such a time as this.  

I realize I’m making myself sound very nonchalant about where God will be taking me next.  And I think I’ll leave it as such.  It’s how I’d like to think of myself; the picture I’d like to paint of myself. When in reality, I don’t think nonchalant is included in my genome. 

I believe that if you give God limits, whether consciously or subconsciously, that He will respect those limits.  Until you’re ready to take those limits away he’ll use you within the bounds.  But that’s just the problem, within the bounds, always in the comfort zone. 

…..I can feel myself wanting to pull out a soapbox and start droning on and on, so I’ll stop.  …pause… And now I feel like I haven’t really said anything despite letters being strung together in grammatically accepted patterns.  

Hmmmm, a moment.  That was my original point. Always wonderful to have those God-blessed moments that remind us anew of what is true, honest, just, pure, lovely and of good report. 

Much Love.

Estoy aqui en medio.

Another month.

Spent a lot of time on the phone tonight signing out all of our trauma patients to the two interns who will be taking up the trauma mantel. We are handing them a list roughly half the length of the list we received a month ago. Is it okay to feel some pride about that?  I know....probably not.

My conclusion about trauma: No. Not for me.
Granted this is an initial conclusion and subject to change as I gain more experience.
But....I was not the kind of doctor that I want to be this past month.
I'll go even further, I am ashamed of the kind of doctor I was this past month.

I could pass an entire day without seeing a patient.  The patient still got cared for.  The work was done.  If they needed studies, ordered and sent.  If they needed consults, called and seen. Plan clarified and seen through.  But, all without myself physically laying eyes on the patient. This wasn't a common happening, but....it wasn't rare either.

I rarely said goodbye.  Once I clicked that 'discharge' button....I immediately took out my paper list and wrote 'bedcheck' next to that patient's name. And in my mind I had already moved on to the pressing needs of those still 'admitted.'  Before I knew it, time had passed and they were long gone.  No goodbye.
Towards the end of the month there were a two goodbyes I made. Both had been patients since before my time. Really bad trauma cases.  Many many surgeries required for each. And despite the fact that both were young individuals with a long road of recovery in front of them...both were cheerful, pleasant individuals.
I got to spend some time one afternoon taking a bunch of complicated sutures out of her abdomen. She had been going to school to be a cop.  But not anymore.  Now.  Now she wants to be a surgeon.
And him.  His insurance kept denying his placement.  Let me tell you, talking with insurance companies is the absolute pits.  I'd so much rather deal with the government than with insurance companies.  But we got it eventually. And....he didn't look happy.  Truth be told, he was nervous. I told him he would be fine.  And he will, he'll be just fine.  I told him, I'd love to be there when he walks again.  He choked up.  "Seems like that would be a miracle," he said.  I said, "I believe in miracles."

I do kind of regret, that I don't take the time to tell stories more often.  You get some of the craziest stuff on trauma. And there's no way I'll be able to remember it all. But I'll be back for more soon enough.

I'm on Night Float for the month of October.  The night float intern takes signout from all of the surgery teams on the floor.  There's three floor teams. So one person carries three lists of patients through the night......and tries to not let any of them die, until morning when he/she can sign them back out again to their respective primary teams. Things I'm looking forward to about Night Float.  No daily progress note writing!  And no discharges, meaning no discharge dictations to do!  Except for the random crazy patient who decides to leave AMA at 2am I suppose. ;)

Trying to stay up late tonight....so I can sleep late tomorrow....so I can stay up all night tomorrow night!

Much Love.