(almost) flawless victory

Maybe it's a product of being on service for two and a half weeks without a day off, with back to back calls, but everything seemed to come together last night. After struggling with a bedside subdural drain last week (a bedside procedure where you drill a hole into the skull to pass a catheter and evacuate old blood that's been accumulating) I jumped on the opportunity to do the one on Mr. S yesterday. Surgical residency, at least for me, has been an experience of constant self appraisal and validation. Failures can only be redeemed even greater successes in the future. So for my own self esteem and standing within the resident team this procedure was critical to say the least. Oh, and yes of course, we wanted to help the patient.

Despite being fairly elderly, Mr. S required enough sedation to kill a small animal. But eventually he was docile enough to allow me to make a small incision on his scalp and drill down into his skull. I passed the catheter without any difficulty and drew back. Money. The old blood, now degraded into the consistency of CSF, flowed freely. After draining an adequate of fluid to relieve the brain of pressure, we sent him down to the CT scanner. Money again. Awesome placement. Then he came back up and I went to check in on him. There's frank blood in the drain. Poop.

#(*&#$%(*&$

Recomposed.

Another CT scan. Not much blood in the brain. No evidence of acute bleeders. Looks like it's coming from the scalp. I placed a fatty pressure dressing over the incision site and within a few minutes the blood stopped flowing from the drain. I win.

I got a couple hours of sleep before I awoke to a "Critical patient xxxx, subarachnoid hemorrhage." There are few things to get you out of bed in the morning faster than pages like that: coyote ugly, a full bladder, being late for morning rounds, and 'patient is herniating' are amongst the others. I can only imagine what the husband was thinking when I rushed into the room, hair all flat and disheveled from a restless night of inconstant pages, morning breath still lingering, and the look of a person who'd been in the hospital 60 of the past 72 hours. I had glimpsed at the scan on my way into the room and knew the patient needed a ventriculostomy immediately (a catheter placed into the fluid cavities of the brain to drain CSF and blood and monitor intracranial pressures). It's always interesting being the one to raise the level of urgency in a hospital situation. The nurses caught on to the immediacy in my voice as I asked for platelets, ddAVP, a ventriculostomy tray and catheter, and antibiotics STAT. Super STAT guys. Within a few minutes an empty room with a patient and husband became bustling with nurses hanging meds, eager medical students lingering in the background, and me giving this poor woman a terrible hair cut (we shave half the head to place the ventriculostomy).

It was 4:50 when I got down to the ED, 5AM by the time I was shaving hair. But rounds would start in 30 minutes. Luckily my co-resident had come in early that morning. I sent him off to print notes while I got the rest of the meds running and ventriculostomy set up. By the time things were ready for incision he was back. I told him I needed to set up for rounds, gave a quick one-liner "77 year old female, Fisher IV, Hunt Hess III, subarachnoid hemorrhage likely secondary to A-comm aneurysm rupture, pupils reactive, localizing right upper, withdrawing bilateral lowers, needs EVD." He responds "Done. Go take care of rounds."

They told us in the beginning that we three R2s are one person. We each need to know what the other knows regarding the service, and we pick up wherever one person leaves off. That way we can be in 3 places at once, and never lose the seamless control over our service of 30-50 patients.

I made it in time to load images, organize notes, and present for rounds. The lady in the ED got her life stabilizing ventriculostomy, which was in by the time we saw her after film rounds, and she went straight to angio for embolization of her aneurysm (which was successful). Another life saved. No huge screw ups or set backs. Not a bad night.