Healing by Secondary Intention

2004-03-07T22:42:00.000-08:00

Yesterday was a busy call day. One guy was slashed with a butcher knife down his left lateral thorax to the latissimus dorsi and serratus anterior in a fight -- with a lot of blood at the scene (by report). The air ambulance crew thought that it would be a good idea to intubate for flight, and did so at the referring hospital. When the patient's heart rate went up and no breath sounds were detected on the ipsilateral side, they darted. It turned out that the patient was only (right) main-stem intubated and the dart caused a small anterior pneumothorax -- he got his ptx treated by a pigtail catheter today.

Another patient crashed his private plane -- evidently missed the landing on a grassy air strip and throttled up to go around again but did not clear the trees at the end of the airway. He got intubated at the scene -- wasn't following commands and had a big aspiration event -- even though he was reportedly hanging upside down inside the belly-up plane. He has multiple open extremity fractures and bad ARDS (adult respiratory distress syndrome) requiring high-frequency oscillating ventilation. He had some seizure activity initially, and now has high icp's (intracranial pressure) in the mid 20's.

A Slower Service

2004-03-02T07:55:00.000-08:00

My patients are doing well for the most part. We discovered a huge brain tumor in a guy who came in last weekend after rupturing the globe of his eye when he dumped his motorcycle in a turn. He is having a hard time coming to terms with his injuries and this new diagnosis (not surprisingly). Finally, our service has shrunk as we discharged a lot of patients, including some of our bigger (trauma) saves from the last month. It is moderately amazing to see them leave the hospital after their near-death experiences with abdominal compartment syndrome, mesenteric lacerations, aortic injuries, etc...

Having a small inpatient service makes me feel a little unsettled -- waiting for the other shoe to drop. Anything can happen, I guess. At least I do not have any Morbidity or Mortality to report this week. I am getting a little tired of presenting patients every week whilst the other guys blithely report no morbidity or mortality --- though I know their services are full of iatrogenic disasters.

Mainly my thoughts are focused around finding a specialty and a fellowship -- I seem to still be having trouble deciding what to do with my life. Advanced laparoscopy has its advantages (big market, lots of jobs, lucrative) but would seem to mandate doing fat passes ad nauseum for an interminable amount of time, and perhaps some limitations in finding an academic job. Doing a Trauma / Critical Care fellowship appears to have the advantage of allowing one to ask for more clinical research time when shopping for an academic position.

The Beginning

2004-02-29T23:35:00.000-08:00

Today I rounded at 0600 in the ICU, and then went out to see the floor patients, many of whom I have cared for and operated upon over the last month.

The sick and injured have wandered headlong into my world with their fractures, head injuries, limb weakness from spine injuries, renal failure, hernias, stab wounds in the viscera, bullets in the chest, and dead bowel.

Yes, I have immediate and intimate access to people's lives during times of crisis. Through bile, pus, urine, intestinal succous, feces, and blood I reach up between the ribs into the thorax and down though a lower abdominal incision into the pelvis, the ovaries and uterus bouncing against my knuckles as my fingers interrogate the rectum and sigmoid colon.

Sometimes the body fluids seep around the cuff of my gown and I break from the case, tearing off my gown to find my fingers stained with dried blood and smelling putrid. Most of the time I request an impervious surgical gown, but these make me sweat and are just as prone to leaks at the cuff as the lighter ones. Maybe somebody should invent a longer surgical glove.

What truly sucks about becoming a surgeon is the power the process has to mold and modify a person's psychic protoplasm. I keep hoping that maybe, just maybe, I will get my soul back when this is all over, but that is by no means a certainty. Perhaps these years have not effected a fundamental change in my character, but rather, have merely exaggerated and accentuated the blemishes, defects, and malfunctions. -- thus rendereing my pre-residency life partially retrievable.

Sure, I have incredible moments. I suppose that few people know what it is like to fundamentally and directly alter the lives of human beings several times a day in just the way I do. Sometimes these life changing events can be as mundane as building an anus in a baby born without one. Maybe normal people get similar satisfaction from a deep friendship -- at times I seem to have no idea how to do this.

I bark out orders and apply knife to skin...until the cutis yields to fat and thick red blood rolls out of stunned blood vessels. My finger on the blue coag button on the cautery handpiece causes electric current to arc out of the metal tip to the tissues in my forceps producing distinct crackling sounds, smoke and the smell of charred flesh -- a strong smell to be sure, but much sweeter than the aroma of some dead appendage or a putrefying organ mourning the loss of its blood supply.

I cannot even write about my personal relations as they are so confusing.