The Right Stuff

We had a meeting this morning for us interns.  It was a kind of “getting ready for second year” meeting/pep-talk that I suspect left most of us more terrified than when we started.  At least at this program, it is a commonly held opinion that our second year and our fourth year are the hardest years.  Our second year is difficult because as an intern nobody really expects you to know anything, or be able to do much of anything alone.  But as a second year, they expect that you’ve learned something from that internship, and they expect you to apply it.  Now you are expected to make some judgements, and do some basic procedures, on your own.  I’ll be starting on a rotation with only three house officers running the entire service.  No cross-cover, no back up residents.  It’s just the three of us managing a service.  And so when I get called in at night to evaluate a patient in the emergency department, it’ll be my judgement alone that determines whether to wake the attending up, or if it can wait until morning.  This and a million other things make second year a daunting one.

As if to call that all into relief, there was an ED thoracotomy today.  I was helping on the periphery for most of it, but I think for the first time I really put myself into the shoes of the people whacking through the ribs, and rummaging around in the patient’s thorax looking for his aorta to cross clamp.  It was pretty intense.  The man hit the door, and to my inexperienced eyes he looked like most other trauma patients.  Unhappy maybe, but not life threatening.  Our department chair was around, and it was impressive watching him work.  He sensed something almost the moment the patient was in the room, that something was wrong.  Like I said, to me he just looked like any other agitated, struggling patient, worked up because it hurt and people were coming at him with pointy needles.  There was nearly no IV access, and the single line the paramedics had put in blew.  The patient continued to struggle, but out chair gabbed a central line kit and I shit you not had the fem line in in less than 20 seconds.  The nurse called out a blood pressure of fifty over palp, and right away our chair was at his side with his knife ready to start the thoracotomy.  I don’t know how he knew the patient was going to head south, but he did and in seconds the patient’s chest was flayed open and they were searching for the bleeding.  I helped one of our chiefs put in a second fem line, and bagged the patient on the way up into the OR (the ED nurses can’t enter the OR with their scubs I guess).  The patient did poorly, and they suspect he had gotten air embolized into his coronaries and the rest of his circulation from the gunshot into his lung.  They shocked him with the internal paddles, and I saw the anesthesiologist give an intra-cardiac shot of epinephrine (the old school needle-into-the-heart craziness).  They went on massaging his heart for maybe 30 minutes, but after that it was obvious things were futile and so they called it.

I don’t know how to describe how impressive it was, seeing arguably our hospital’s best surgeon kick it into high gear.  He knew the patient was going south using senses totally unknown to me.  I guess it’s a gestalt, something a combination of experience and talent lends you.  But thinking about myself, and being in that situation, it staggers me.  Theoretically he is what the program is trying to produce, and the idea of being like that is both amazing and terrifying.  I couldn’t even rouse myself to help put in a central line.  Someone with larger testicles might have actually tried, to see how far you’d get before you got hip checked.  I don’t know.

I hope I’ve got “the right stuff.”  That’s all.

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