In a level 1 Trauma center such as ours, you're always guaranteed a trauma surgical team can be mobilized to the ER within a few minutes, no matter what time it is. To make this possible, there are three Trauma teams that rotate 24-hour shifts of responsibility for all traumatic patients who arrive at the hospital. We do this using a set of pagers that represent the Trauma Team Activation (TTA), and every day at 8AM the Trauma teams meet to pass the pagers onto the next shift. Yesterday was my second day of carrying the Med Student TTA pager for 24 hours. This 24-hour shift, plus a few hours on either side for taking care of our own patients, is what's meant by being "on call."
So although I came in at 6 to write notes on the patients I was following, the day officially started as I came walking through the turnstile of our dining area with a huge tray of the most impressive and soon-to-be satisfying breakfast tray I had assembled from the breakfast bar, and the TTA pager goes off. I watched in horror as my team took their untouched breakfasts and dumped them in the trash and ran towards the ER. Savages. I stuffed what I could in my mouth and headed off past them.
It was a prison inmate who got beat up a week before and collapsed this morning, turned out he was bleeding into his abdomen. Quick trip to the operating room, and after I spent a few minutes scrubbing in, I walked into the OR to take a look at what's going on. As soon as I get there, the attending looks at me and says "Here you go." so I open out my hands to receive this giant bloody slippery purple thing as he hands it to me. You gotta be kidding. So that's what a spleen looks like.
The rest of the day blended into a haze of work and running, with a few hours for class at some point in between. The residents are sleeping when i get back from class, in prep for the storm to come... which doesn't come for long enough for us to head to they mythical gym on the 13th floor. Yeah that's right. The 13th floor, the mythical and mysterious place that only the elevator with the full-time button-pusher leads to, where you need to stand in front of a one-way mirror before another one-way mirror slides open to let you in. But apparently the Jail ward is not only for sick inmates. The wardens need their break room, and what else would they have in there other than a dirty couch in front of a TV/VCR combo, with an entire weight room behind it. No kidding. We had about 10 minutes of building through the skinny scrubs, before one of the residents got a page for a motorcycle crash. All's well and we head up to the call room to watch TV in college dorm style, turning up the computer speakers high among the 2 bunk beds of the tiny room to watch whatever ABC.com has to show us. I try to get some sleep on one of the top bunks, but when the TTA page comes, I jump down and we're all in the elevator in 30 seconds. Some guy got shot right outside our parking lot. It was 10PM. We walk in that area at 10PM. This wasn't another gang shooting in some ghetto somewhere, it's a drive by in our neighborhood. It shakes us all up a bit as we prep to cut into his belly to patch up whatever the bullet hit on its way between the in and out holes. I stay behind in the ICU to put in a Chest Tube on the motorcycle crash, something which 3rd year med students really aren't supposed to do.
This being my first procedure, I'm understandably nervous to learn that this guy has a broken shoulder and can't lift his arm above his head. As you can imagine, sticking an inch-thick tube into somebody's armpit is a lot easier with the arm up. To make things worse, this guy was huge. There'd be a good few inches of fat to get through on my way in between the ribs. We dope him up pretty good, an extra dose of morphene and some versed, but he's still with it enough to make it very clear how much it hurts him. I numb him up a bit and then make my first surgical incision on a live person. And then widen it. And then widen that further. Two inches of permanent scar later, I stick in the clamps to spread the layers of fat by continuously opening up blunt-ended scissors after sticking them inside this guy. I went in 2 inches deep and stuck my finger in and couldn't feel the ribs. I burrowed in another inch and still couldn't feel them. I went in another inch to 4 inches into this guy's side, with him yelping in doped-up agony, and still couldn't feel the ribs. The resident beside me was amazing, in that he let me carry on with this without stepping in to say I was doing everything wrong and killing this person. In fact, he stuck his own finger into this 2 inch hole I'd made, felt around, and said he thought he felt the ribs. I still couldn't feel them. The patient's getting louder.
The TTA pager goes off for both of us underneath our sterile gowns. We look at each other. The other resident and the attending are upstairs operating on the man who got shot outside our parking lot, leaving the two of us as first responders. I ask the resident if he wants to take over and finish it so we get go deal with whatever horribly traumatic dying person is about to get carted into the ER, and to his charity, he asks "are you sure? I don't want to take this from you." What a guy. Yeah I'm sure go show me how the surgeons do it. He reaches his finger all the way in, the guy jumps off the table, but still no ribs. More scissors and more spreading, and still no ribs. How much fat can one man have? He eventually sticks the 8-inch blunt scissors in so all I can see are the rings of them through the resident's knuckles, and then when he thinks he found the ribs, goes over one and pushes as hard as he can. I hold down the patient's knees and I hope that the restraints I put on his arms hold. "YOU GUYS!!!!" the patient screams "It's NOT GOING IN!!!!" "YOU GUYS!!! STOP!!" Finally, there's the loud POP and gush of air that signals the release of air that we're trying to set free with this operation, followed by globs of dark red blood pouring out the hole. I hand the resident the tube to put in, and he sticks it in. And further. And pulls it out. He lost the hole he'd made.
This was a disaster on all fronts. He tries to stick the tube back in, but then takes it back out as he tries to find the hole he'd made. I watch him put the tube onto his sterile towel, only that the patient's kicking and screaming had ruined the flat blue towel that was our sterile field. The bloody sterile tube touched the patient's dirty gown. i had a brief moment of being unsure whether I should say anything or not, maybe I could just pretend it didn't happen and let the resident put that contaminated tube into the guy's chest, let him go off to deal with his TTA, and hope everything's ok? The resident picks up the tube and tries to put it back into the patient just as I snap out of my haze and say "WAIT!" I showed him the bloody line on the gown where the tube had touched it. The poor guy had a minor breakdown of sheer frustration. I wish I hadn't said anything. A nurse is around by this time to take the order to find us another chest tube, only he doesn't know where it is. This being one of my first times of usefulness, I do. I run him over to the area closet where the chest tubes are, point at the one I want, and run back with him. Being clothed in a gown and gloves of sterility, I felt like even more of an ass asking him to do things that were obviously within my own reach. Still, rules being rules he ran back with me and opened up the sterile chest tube into my hands so I could hand it to the resident, who eventually put it into the patient.
When he was done, I asked the resident to run off to the ER while I dress the wound and clean up, not telling him I've never dressed a wound before. I put gauze on the wound, and then wake up to the fact that this guy has two HUGE spots of road rash to the left and right of the wound, and a rediculous amount of chest and back hair above and below it. Gauze needs tape. Tape needs skin, and there's no sterile razor around to shave him. If I don't do this right, this guy could get a life-threatening chest and wound infection. Nobody else is around. Crap. The dressing I end up with is hilarous both in shape and physics, but I manage to patch this guy up without taping over road rash, and I even got whatever tape I had to put over the hair to stick. It's fine.
Turns out the TTA was some Iraq vet who got into a drunken fight with his girlfriend while on the freeway and opened the door and jumped out. All being said and done, he was stable and we left him under close nursing care. By now it was 2AM. The Chest tube's in, the Operation's over, it's time to get some sleep. TTA goes off, back to the ER. False alarm, the ER can handle it on their own. In bed by 3:15 with strict orders to be downstairs at 4:45. TTA at 4:40.
This one's a fighter. Guy's family calls the cops in to take a look at their strange-acting 19 year old, who dives through a second story window, only to get back up and keep running with blood gushing out his arm. Cops tazer him 8 times and stick him into an ambulance. It takes literally 10 of us to hold him down while somebody sticks a needle into his arm to knock him out as he gives the most blood-curdling series of "NOOOOOOOOOOOOOOO! NOOOOOOOO! NOOOOOOOOOOOOOOOOOO!'s" and doesn't let up no matter how many poison darts we stick in him. Finally the call is made to knock him into a coma and have a tube breathe for him. Horrific. He's got a 3 inch hole in his right arm that goes down to the bone, not to mention a slew of body lacerations that apparently happen when you jump through a window.
Now it's 6:30 and time to have seen all our patients already and start rounding with the attending. I hadn't seen a single patient. TTA at 6:45, this one's getting helicoptered in from a rush-hour motorcycle crash somewhere far away, the "real deal" from what the ER docs can tell me. The open bone sticking through his calf is the least of his worries, and the only reason we still think he's alive is because he's got a weak pulse. The base of his skull is cracked (which was a good teaching point because hs's got the characteristic "racoon eyes" that go along with that), and he's got what looks like spinal fluid leaking out his ears. A portion of his rib cage is broken so that it actually goes down into his chest instead of expanding with the chest when he breathes. I'll find out tomorrow if he'll ever regain brain function.
I get out of there shortly after 11, within a half hour of my 30-hour legal work limit, and as much as I think I can complain, the residents are all going to stay there a few hours longer. And they're actually responsible for these people. It's insane. And to think that most of the docs in the hospital had to work an extra 30-40% harder is just plain stupid. So it goes.

I walked out of my first 30-hour workday with the kind of spring in my step you can only get from having stuck your hands into a dying man's chest to pump his heart for him, pulling back half a man's abdomen to watch your teammates remove yards upon yards of dead bowel, and sowing up the deep cuts of two kids that are going to wear the quality of my work as a scar on their chest forever. OK maybe there are other things to give you that spring in your step, but those 30 hours really topped the list of all-nighters I've had, whether all night dancing in a warehouse, or even in the flat desert at Burning Man. Definitely beats spending the night in the library...

I go back on call tomorrow at 5:30AM to come home around noon the next day. During these same hours, 20 of my closest friends will be partying their collective asses off in a mid-size town of 40,000 party-goers and engineers in the Black Rock Desert and for the first time since I started going to the festival 7 years ago, Burning Man is not the only place I want to be during this week of the year. I'll do my best to write what happens...

It's three days into my Trauma Surgery clerkship and I'm already onto the sleeping schedule of an 80 year old. I never had the chance to elaborate in my thoughts of Pediatrics, mostly probably because they were too depressing to write about. A combination of close friends of mine and random new acquaintances had to bear the brunt of those rants, unfortunately for them, leaving little more than a post on big macs here on this blog. Even though I've only been here three days, the gaping hole between the two clerkships is readily apparent. For one, people get better on the Surgery ward. Or the die. Either way, if they die we're probably going to give them a few more hours. Tertiary care pediatrics deals with kids who are really, really messed up to begin with, and all we can ever hope to do is solve their acute problem so they can go home and remain a burden to their family for another few years.
The breakdown is becoming apparent in terms of quality-life-years. Internal medicine is a specialty where great measures are taken for the sake of gaining 5-10 quality life-years for 70 year olds, or 5-10 numb years for 80 year olds. Pediatrics has the goal of possibly adding 50 or so years to a patient's life, but in a tertiary care facility such as the one I was at, the underlying disorder is bad enough to render these years a disaster, leading the primary caregiver down the awful path of convincing herself that keeping this child a live is a good idea in the first place. Trauma surgery, now, deals in terms of Quality Life Years, where all three of these terms are preserved to the utmost degree. A man gets hit by a sewage truck and pinned to the wall. 52 pints of blood and a few extravagant surgeries later, he has a chance for another 40 quality years. Man gets shot in the neck and once in the face. All it takes is an air tube and critical care, and this man can live another 60 good years. Now HERE's a field of medicine we've got down pat. For the first time since I've seen, the state of modern technology is helping save lives. Quality lives. That's something I can get into.
...but I'm three days in. Tomorrow is my call day. 5:30AM Friday 'till noon Saturday of serving on the team to provide the majority of Level 1 Trauma surgery in Los Angeles County on a Friday night. Also my first overnight call night at a hospital (definitely not my last). I'll have to wait 'till after this before I know what I think.