Getting Excited!

With my trip just a week away, I can't help but get excited to wear some of my fall favorites for the first time all year.

Thanks to Pinterest for all the inspiraiton!

On The Way Up:

Comfy jeans, simple cardy, and red flats for the ride up to Boston!

Fall Foliage Tour Day #1

Driving through Maine with some good riding boots, jeans, and classic black and white stripes.

Headed to the Mountains

Warming up with some layers...and sticking with riding boots...less to pack!

Driving Back to Boston

Recurring theme of jeans and boots!

Hanging Out in Boston

Easy to pack!

Coming Home

Comfy, cool, and ready for fall back in Texas!

Fall TV

via pinterest

I've seen a number of posts about the fall TV premieres and couldn't help but relay my own TV watching schedule for this fall. My DVR will be busy as usual, seven hours of TV a week is plenty!

Sunday

9pm Pan Am

Monday 

8pm Gossip Girl

9pm Castle

Tuesday

7pm Glee

Wednesday

9pm Revenge

Thursday

8pm Grey's Anatomy

9pm Private Practice

Only one more week until most of the premieres! 

What shows are you most excited about? 

Do you and your friends have certain shows that you get together to watch weekly?

Mmm...fall TV, just another reason I love the season so much!

Pull Yourself Together

Via pinterest

So even though my second year of residency is over and I'm currently not working at the county hospital, life still seems hectic. Just about the time I think I'm all caught up, I realize I've fallen behind in another area. Over the last 12 days, that "area" has obviously been my blog. With crazy hours, bigger cases, and more to read, I'm still not as free as I'd like to be most of the time. I also haven't had a day off that I spent at home trying to get caught up since August sometime. Thankfully, I am off come Monday and can start playing that game of "catch up". While my blog may be lacking, I've accomplished quite a bit over the last couple of weeks...everything from deep cleaning from floors in my house, logging more than a dozen cases, reading for residency, reading through more than 300 blog posts on Google Reader that I had yet to read, perusing more than a dozen catalogs and another dozen magazines, welcoming a best friend's new baby girl, eating brunch with friends, getting back to working out (3 times in one week!), walking the dogs, etc...

Has your September been so productive? 

What in your life are you "caught up" on? 

Do you still need to some "pulling together"?

Keep Fighting

So, I'm going to avoid any HIPAA violations and not mention anything personal about my patient that you've read about for 3 days. But here are the sweet moments of his stay with me.

1. Hugs from the family about a week into everything
2. Being asked for by name by his family members
3. Chocolate chip walnut homemade cookies brought by his family
4. The patient's mom's ensuring my AC gets fixed or else she's sending someone out to do it herself
5. Having the neurosurgeon tell me he's going to wake up, that he can survive
6. Knowing he never even got a whiff of a pressor
7. The bracelets his friends made for support and being provided one to wear proudly myself (see above, they mention his name but that would be poor HIPAA form)
8. When he tolerated tube feeds
9. When he looked me in the eye for the first time
10. When he tried to stop me while I was changing his gastrostomy tube
11. When his grandpa told me "I know you won't bullshit me. But you'll still be upbeat."
12. Making it off the ventilator
13. Fist bumps with his Dad when I had good news, or met goals I had set for us (like his TBili being less than 1.5...it was 1.4 on the day he left)
14. Sweet elbow bumps and waves from them as they walked by when I was working on notes
15. Visits with his family in the waiting room (about my own personal life too)
16. Having an attending stand up for him in conference by saying he wouldn't be a vegetable and that he would wake up (I wasn't the only one that believed!)
17. Presenting him in trauma conference and OWNING him as my patient and being proud of my management
18. Giving updates to the OR staff on his condition/disposition (especially calling to tell them he had been transferred out!)
19. Lingering in his room a bit longer to catch more Looney Tunes while I was working with him

And my most favorite:
The day he was transferred out, I had worn bumble bee earrings. Most of you know, I collect bee things. (Mom and Dad always called me Miss B...which turned into Miss Bee...Dr. Bee...and a love for bee stuff). I hadn't worn bee earrings in at least a month. One of the ICU nurses commented on them, and then Dad's eyes started to well up. Apparently, there is a motivational speaker out there (I couldn't repeat her name even if I tried) that uses the bumble bee analogy that I used for a previous blog post title. She speaks to the fact that aerodynamically speaking, a bumble bee should not be able to fly. Yet, they go on flying anyway. I've always enjoyed that little fact about bees myself. It's part of the reason I've never been hesitant to adopt them as my personal "symbol". On August 30 (the day I put those earrings on for my last call on the rotation), this motivational speaker had called the patient's mom with full knowledge of the situation and to offer support--out of the clear blue. And my precious little Kate Spade bumble bee earrings served as a reminder of that we can overcome things that shouldn't be possible. Maybe my patient shouldn't be alive, but he goes on living anyway. And maybe he shouldn't be doing as well as he is, but he keeps on doing it. That makes me proud. Proud of my patient, and proud to be Dr. Bee.

Sweet Escape

With the help of attendings, ICU nurses and ancillary staff, ICU interns, and the patient's family, he kept improving. He was tolerating more and more tube feeds all the time. His blood pressure was better controlled. We were weaning off pain meds. We were even weaning off the vent, to the point that he didn't even need the ventilator during the day!

We were doing less, and HE was doing more.

Finally, three weeks to the day, my patient was transferred to a skilled nursing facility! Yep, that means he had improved enough that he no longer needed our ICU. He still needed very close monitoring and still has some issues being addressed (but not life-threatening). But he's better, and he's alive, and he's got a long (but likely successful) road ahead!

On August 31, he was discharged. And on August 31, my current rotation at the hospital was over. I had succeeded. HE had succeeded. I had saved a life! I don't think I really took credit for it until I spoke with the accepting physician at the new facility. The day prior to his leaving, I discussed all of his injuries, current treatments, etc with his soon-to-be primary physician.

I had to relinquish care! If you only knew how territorial I had become! I even told my chief when I had my days off to avoid messing with him too much. This was MY patient. My chief never had to see him until four days into his stay, and only saw him a couple more times while he was in our hospital. Otherwise, it was me and the ICU team (attendings, interns, consultants, RTs, RNs, etc) getting this guy through.

After relaying all of his primary injuries and findings during our initial visit to the operating room, her response was "So basically, he should have died?". At that moment, I realized, had we not intervened on time, had my attending not helped me through his first ex lap, had neurosurgery not placed the bolt, had we not watched him like a hawk night and day...he would have died. He could have died. But, the only thing I'll correct about what the new physician said, is that he certainly SHOULDN'T have died. And he didn't. Personally, I count this as MY first big save (obviously not something I could do by myself but you get the gist). I feel proud. Most of all, I'm reminded why I gave up a life in dermatology (working maybe 40 hours a week with minimal call) for surgery (working 60 hours a week plus with frequent, stressful call). It's those moments that your patient's father's eyes well up with tears and all the ICU nurses come by to say their goodbyes as your patient leaves for the next step. That's why I became a surgeon.

Bumble Bees Shouldn't Be Able To Fly, Technically

There he was in the ICU. Pressures good. Heart beating away. On a ventilator. An open belly. And a heart of gold. His drug screen was negative. Not a drop of alcohol in his system. New lab results coming back that I was extremely happy with--considering. So we scanned him. Had we just done a big time surgery to find out he had a devastating head injury?

A list of his injuries:
1. Intraparenchymal cerebral hemorrhages (multiple and terrible looking)
2. Large scalp laceration
3. Left clavicle fracture
4. Bilateral pulmonary contusions
5. Left hemothorax
6. Left diaphragm injury
7. Shattered spleen
8. Grade IV liver laceration
9. Left retroperitoneal hematoma
10. Left acetabulum fracture
11. Left pubic ramus fracture
12. Left sacral ala fracture
13. L1-L4 left transverse process fractures of spine
14. C2 fracture of neck
15. Large amount of pneumomediastinum

Then I spoke to his granddad. Sweetest man ever and obviously aching over his prized grandson. And grandma, the smallest, cutest, and soft spoken woman doing her best to maintain a hopeful smile. And Dad, the most fit middle aged man I've seen, doing his best to act as the backbone for the group when deep down he could use just a moment to have his own breakdown. And Mom, energetic, outgoing, and totally in love with her son. Then the girlfriend, they've been dating for 3 years and this was going to be the biggest growth spurt they could ever take as a couple--you could see she was up for the challenge. And girlfriend's mom who obviously cared for him like her own son. I remember telling Dad, "I just want to meet one mean person in the family. Then I know he'll walk out of here in a week." No such luck.

The next day, his pneumomediastinum appeared to be increasing. So an emergent bedside tracheostomy was placed with significant improvement. Neurosurgery and orthopedics came by. A "bolt" to monitor intracranial pressure was placed. He was started on medications to keep his blood pressure down and to keep fluid off his brain.

A couple days later, he returned to the OR. The sponges were removed and everything appeared ok. No more bleeding. So his belly was closed and he was again sent back to the ICU.

Over the next few days, he remained status quo. Multiple EEGs were done to examine brain function with no devastating (but really not hopeful either) results.

We started tube feeds and the next day we was noted to have what looked like gastric contents coming out from around his trach. More concern for a possible esophageal injury arose. The following day, we took him to the operating again. With a scope, we confirmed that no esophageal injury. We opened his belly again and placed a gastrostomy tube. We placed an IVC filter for prophylaxis, in hopes of avoiding any kind of clot traveling to his lungs. And we closed his belly again.

Over the next few days, he didn't tolerate tube feeds too well. So he stayed on TPN and we watched as his liver function tests and his pancreatic enzymes trended down as his pancreatitis improved. He remained on antibiotics for pneumonia. But otherwise, he wasn't deteriorating but things weren't moving rapidly either.

Then his bolt was removed! No more prongs sticking out of the head making us anxious with roller coaster like numbers. After that, things really started changing. He was overbreathing the vent. He was moving his arms more. Each day, something more happened. His eyes were open wider. He had purposeful movement. He was tracking with his eyes. And on occasion, many of us swear he was following commands. On a number of neurostimulants, he was coming around. Just as I felt he would. With love and age on his side, he was going to get out of here.

To Be Continued...

How to Save a Life

It's not everyday that we get reminders of why we agreed to work 80 hours a week and 30 hour shifts to "someday" have a better paying job with more freedom. Like most residents, I'm pretty jaded. Most days I'm convinced that 75% of our patients are really just a drain on the system rather than real people needing real help. When it comes to trauma, the rule seems to be dealing with jerks who were legally shot by Texas homeowners during attempted break-ins. On top of that, they throw out four letter word after four letter word in the trauma bay and then go on to treat our nurses like another four letter word. It's annoying and disheartening. One easily loses their faith in people. And just when you think these jackasses make residency completely worthless, something amazing happens to reel you back in and convince you to keep going.

On August 10, I was on call. My chief resident and I were in the middle of a case when the trauma pager went off letting us know a Level 1 (the most serious kind of trauma requiring a response from the team within 15 minutes) was coming in the door. My chief looked up and told me to go down to the trauma while he went on with a grueling ventral hernia repair. I scrubbed out and ran downstairs to the ER.

EMS relays the story. This was a young male found down at the scene after a wreck. He had been t-boned on the driver's side and was unresponsive at the scene. EMS intubated him before bringing him to us. He never lost vital signs, but his blood pressure had been persistently low--an ominous sign in trauma. I ran through my ABCs, his endotracheal tube was in good position, confirmed in multiple ways. He had good breath sounds on both sides. His chest xray showed some significant bruising to both lungs and a fracture of his left collar bone. He had a large, deep, bloody scalp laceration on which we placed a gauze dressing. On FAST scan, he had a small amount of fluid around his spleen. He had a small pelvic fracture on xray too. After 2 liters of IV fluids and 2 units of blood, my attending decided if his next blood pressure wasn't more than 100, we were going to the OR. I watched as his belly grew, bloody urine filled his foley catheter tubing, and his reading came back...still in the 90s. More blood was hung on the IV pole and off to the OR we went for an ex lap.

When we got upstairs, my attending and I stopped in OR 8 to tell my chief we were now in OR 12 with the trauma. While putting on our shoe covers, he jokingly asked, "You wanna go scrub him out and finish that ventral hernia so he can come do this?" I laughed and said "Heck no. He can join us later."

Prepped and draped, my attending and I opened him up--a long midline incision from his chest bone down to his pubic bone. Once we got "in", at least four liters of blood poured out. We cleaned up the blood and in typical trauma fashion and packed all four quadrants. Then we went exploring. His spleen was shattered. Out that came. His left side had a large hematoma surrounding his kidney and retroperitoneum that was controlled with more packing. We looked in his pelvis. Thankfully, his pelvic fracture wasn't causing much bleeding. Then we looked at his liver. The capsule was torn in at least 7 places, he had a large hematoma on the left lobe, and two deeper lacerations towards his back. We used the argon laser to help control the bleeding. He continued to ooze so we packed the liver with laparotomy sponges. Still oozing. At this point, I noticed a hole in the left side of his diaphragm. He was somewhat stable at this point, so we repaired that. The bleeding seemed to be controlled for the time being. We placed a wound VAC and got out of the belly. My attending went to the head of the bed and repaired his scalp lac while I put chest tubes in on both sides. Stabilized, we sent him to the ICU. He received 27 units of blood and an additional 37 units of other blood products by the time he got there. And one whopping dose of factor VII. The best part is that anesthesia had done a fantastic job of helping to resuscitate him so he NEVER received one dose of a pressor.

And that's all in the first couple of hours. To be continued...