Code Sepsis

Hospitals got secrets. Where we buy our kidneys, where we hide our bodies, what that drug that starts with an "x" and sounds like "manex" is. It's what all the locked doors and privacy's about. Not personal protection, but cover for a massive, secret effort by the health insurance industry and World Health Organization to put thimerosal in all the tap water and autism in all your children. We're up to something, and let me tell you: it's gonna be big.

One secret I can share without fear of a propofol coma, however, is the color code system which keeps hospital staff informed of impending disasters while simultaneously allowing all our naive and overly trusting patients to continue wandering about the hospital premises. Maybe they'll wander into a fire, maybe an armed assailant, maybe a chemical spill, or maybe all of the above. It's for us to know and everyone else to eventually find out. In this system each conceived of disaster is assigned a color which is then relayed over the hospital intercom. The most common code is the "code blue" for cardiac arrest -- or as it often is at our facility, old man down in the parking lot. Additionally, however, there are "code pinks" for child abduction, "code oranges" for chemical spills, "code greens" for aggressive, angry person, and, most recently added, "code whites" for aggressive, angry person who is now shooting a gun. Many of these codes are adopted across the country with some variation, but there is one that is relatively unique to San Antonio: code sepsis.

"Code sepsis" is the call for the medical intensive care unit (MICU) team to come and evaluate a septic (severe infection) patient for immediate admission to the MICU. Practically speaking, however, it's the call for everyone in the ER to don their crazy hats and go completely out of their minds. Twenty people surround what need only be a 3 or 4 man intervention while central lines and endotracheal tubes fly about in a mad effort to place the patient on minimal ventilator settings and a random dose of dopamine vasopressor. Sometimes the patient will get antibiotics during this time, sometimes a nurse ends up with a femoral catheter in groin. Once this is concluded, typically shortly after the MICU team has arrived, the crowds disperse in a flurry of triumph and indifference while the staff begin the hard work of incessantly pressuring the MICU team to admit the patient to the unit as quickly as possible lest the chupacabra get them. Eventually the orders get in and the insanity returns to normal levels, but not before there is one last self-congratulatory high five.

So it is with my career currently. Somewhere in mid-December the Air Force yelled, "code sepsis!" and all sorts of rip up your bed sheets, fling your poo craziness has ensued. In the course of completing my residency and determining my future station in life I've worked at three different hospitals, flown to two separate fellowship interviews after sending out dozens of separate emails and making dozens of different phone calls, underwent ATLS certification and a week of military field training, had some vacation, had my computer die, got a shot, got an HIV test, got some lunch, filled out an unholy amount of paperwork only to be rewarded with even more illogical sums of paperwork, created and given a lecture, attended a mid-year evaluation meeting, had my already completed research project randomly chosen for quality control review and then had that review canceled, planned for an upcoming medical readiness training exercise (MEDRETE) in the Dominican Republic, and been booted from a base reassignment process entirely without my knowledge. I have not at any given moment been entirely sure of where I am or what time of day it is, nor do I even really know where this all is heading, but I am confident that, in the end, the Air Force will totally be throwing the high fives all around. They'll have done their job of sticking me somewhere, and I will have been successfully stuck somewhere. Good job guys, the chupacabra didn't get me.

Internal Medicine: After Dark

I just finished Night Float. It was crap. It turns out taking care of people with the lights out -- though much like taking care of people with the lights on -- is much less rewarding. I should have seen this coming considering the omens. Within the first five minutes of the first shift my intern lost an eye to the tarp covering the scrub stacks. He was only briefly incapacitated and was left only with a small bruise on his eyeball, but for a short moment I was torn between resuscitation and calling to find his back up.

Anyways, Night Float. Six times the number of supervisors with none of the actual supervision. Plus medicine consults, plus 72-hour consults, plus out of hospital transfers, plus morning report, plus an endless cycle of freetriplescore.com commercials on late night TV. Add to all those new responsibilities a generous supply of next day second guessing and general orneriness from the primary teams, and myeh. Truthfully, I would of rather been kicked in the junk. Now we'd have to haggle over the details, but nevertheless, do it again, kick me in the junk.

The hours themselves weren't that bad mind you; I actually slept rather well. Similarly not knowing what meal to eat at any particular time of day was disorienting but three breakfasts in a row never hurt anyone. My interns were both by and large good, solid citizens, and work load wise we truthfully got off relatively light. It was just the nature of the job, of being subject to a multitude of divergent interests leading to an inability to sufficiently satisfy any which made Night Float a lonely, thankless task. I suppose it developed character, but only if paranoia is a character trait.

It's done and over now, though. May we never do it again.

The Land of Happy People

I forgot what it was like. Being happy sometimes. It turns out in the Emergency Department (ED) they feel this way quite a bit. I am not sure why, whether it's their natural disposition or a combination of poorly regulated and documented narcotics in the trauma bay, but the ER docs are by and large good people. Friendly, happy, good-natured, and not too terribly demanding. Almost makes me want to be an ED physician myself were it not for the fact that I strongly dislike the style of medicine they practice. Nevertheless, this month has been the first month I have had two consecutive smiles and it kind of hurt the corners of my mouth a bit. It has also been the first month that I pulled a rock out of a 4 year old's nose using a pediatric foley catheter and the only month I pulled a shark-tooth shaped piece of glass from its location embedded in a woman's foot, but those are neither here nor there. The point is the ER doctors have reminded me of what it is like to be genuinely, consistently happy and for that I am grateful. I have eaten almost nothing but breakfast for the past month as a result of the wacky hours, but dysgeusia is a small price to pay for that.

Oh, and today the Fighthing Texas Aggies will beat the UConn Huskies in the NCAA tournament. I know this because I have stayed up late at night and had visions. Visions of glory.

It Was a Dark and Stormy Night

It has been a number of months since San Antonio has had a good rain. Yesterday, and today, we finally had one. And then my car battery died.

It is actually not quite the coincidence that it sounds. It turns out that I regularly am in the habit of not turning my lights off when I park my truck when it's raining outside yet still light out. This thing seems to happen about once a year. Nevertheless, usually it is not 12:00 midnight and usually it is not 40 something degrees out and usually I am not stuck on an Air Force base after having being working all evening. Thankfully, after the base's security forces refused to jump me (they apparently have a strict no-helpfulness policy), my dear, good, gracious, reliable friend Beau who happened to be working an overnight shift was there to help me restart my car. It took about 30 minutes to get it all done seeing as the cables were never quite long enough and we had to push my truck out of its parking spot to get closer, but we did it. We were both soaked, Beau was possibly hypothermic, and I had lost faith in my country. (Seriously base police, you cannot give me a jump in the middle of the night in the middle of a storm? Seriously?) On the relatively slow drive home, sometimes it seems like San Antonio was designed specifically with the purpose of flooding in mind, I was treated to one more bit of excitement as getting off the highway I, and the car slightly adjacent of me, disappeared into a sea of water that effectively submerged our vehicles and made me exclaim, "Oh, shi-" right as the cameras cut away. Perhaps it's good that it doesn't rain here too much.

But internship progresses. I am in the ER now. Because last week I was doing evening shifts from 1500 to 2300 and there are not always patients at the ER from 1500 to 2300 thereby leading to my early release some days I have not had a consistent schedule for most of it. I am wholly disoriented. Every day feels like Sunday and every hour like roughly 9 pm. I never know quite what I should be eating, when I should be eating it, and if I am eating enough or too much in a day (not that I likely could eat too much though.) I'd guess the time right now but I'm as likely to be 5 hours off as 1, and it's not like I would know what to do with that information anyway. At least I still know who I am, that I live in San Antonio, and that Ronald Reagan is president.