26 December 2006

Christmas at the Hospital

Christmas comes to the hospital in a manner far different from the shopping malls. Usually the patient census is lower because most attending physicians want to get their patients home for the holidays. It is a well-known fact that people heal much faster at home among familiar surroundings than in the hospital. Exceptions to this rule would be people who are incapable of caring for themselves or those who have no one at home to help with their convalescence. Sending any patient home to an empty house where they have no groceries or means of even preparing meals is not going to assist in their recovery. That being said, most people are happy to get home ,holiday or not, to their familiar routines.

I usually volunteer to work on Christmas. My family has a huge celebration to welcome in the New Year so Christmas generally takes second place to the New Year's celebration. I also LIKE being in the hospital on Christmas. There are decorations and most people are in a festive mood even if they are hospitalized. Rooms are usually decked with little Christmas trees and and cards with loads of red and green. The staff is generally upbeat because by Christmas Day, one is over the grumbling and disappointments of not being home for the holiday. I have found that the folks who work the evening and night shifts have little disruption to their holiday activities. The folks who are working during the day shift are usually younger and have plans for the evening and night anyway. Christmas is a pretty nice day in the hospital.

In our departement on Christmas, or any holiday for that matter, the chiefs and one intern will take care of their services. We round on the patients and get needs taken care of. Since the operating room is only taking care of emergency cases, we can generally get most things done and get home unless we are on call. If there is an emergency case, the call team will take care of it. Most of the time, it's something like an appendectomy or an occasional strangulated hernia that the patient has been trying to ignore over the holiday. On a couple of occasions, I have had things like a ruptured abdominal aortic aneurysm roll in though the door. All in all, you are not going to be operating unless something needs to be done in a hurry.

The Operating Room staff will make plans for brunch or dinner on Christmas. Usually one of the attending surgeons will have some food sent in for the folks who are working on Christmas. They are happy to share their food with the resident staff, which is a nice thing to do. Many of the larger surgical or medical practices will have sent gift baskets and fruit baskets to various floors in appreciation for the work that the nursing staff does. One of our thoracic surgeons has a catered party for all shifts on the floor that takes care of his patients. It's pretty nice for the staff. Even as an intern, I was always invited to "share the chow" with the nurses. Usually, I wanted to rest in bed because the night might get busy and being rested was a good thing.

The week preceding Christmas was generally a time of holiday vacation for most of the clinic staff too. Patients were not scheduled unless they needed something that couldn't wait. Usually there would be a party after we had seen a couple of patients that needed treatments on a regular basis. The week after Christmas would be brutal but some of the wiser office managers had developed the practice of making the schedule after Christmas a bit lighter and the week before Christmas a bit heavier. In either event, working the clinics around Christmas wasn't bad. Some of the regular patients would drop off chocolate, which made the days even more pleasant.

Some of my colleagues started their annual "grumble" from Thanksgiving to Christmas. They wanted to go home (California or overseas) for the holidays and a week just wasn't enought time for this kind of travel. Our program director was pretty flexible about time off around the holidays as long as services were covered. If someone wanted to take a couple of extra days, we worked out a schedule where we could accomodate everyone. Still, there are folks who would complain that the schedule is "unfair". Again, I always volunteered for Christmas Day or Christmas Eve and was happy to be off New Years Eve and New Year's Day. By my third year of residency, the holidays were a welcome break in my routine and I would "go with the flow".

Our department would have an elaborate Christmas party. This would be held off hospital grounds (read alcoholic beverages involved) and would be a "dress-up" affair. It gave some of us a welcome change from the scrubs and minimialist atmosphere of our everyday life. It was also an opportunity to meet some of the spouses and significant others of my colleagues. Sometimes this affair turned into the "coming out party" for some of the couples that had developed from July to December. One of my favorite tasks was taking bets on who would last through New Year's Day. Many times, the week off during the holidays took care of the relationships that had been so feverish right after residency started.

Christmas was not an especially heavy time for traumas. If the weather was bad (ice storm or heavy rains), we would get an occasional motor vehicle collision victim but most of the time, people stayed home and the bars were closed. I remember an very sad Christmas night when a family was returning home for a day trip. The father was driving and feel asleep at the wheel of the car. The mother ended up being declared brain dead and all three of the children were killed. Only the father survived. One of the children and the mother became organ donors so that many people were helped that Christmas by the generosity of this grieving father who had lost his entire family. It was't weather or alcohol that had caused this collision, it was extreme fatigue. Christmas can be a day of tragedy sometimes too.

I remember one quiet Christmas evening. I was resting in my call room (half watching the Food Channel) with my eyes closed. I had told the charge nurse in the Intensive Care Unit that I was going to take a nap so just call into the room instead of paging (faster anyway). She would also make sure that her staff didn't page for trivial things that could wait until I finished napping. When I am the ICU resident, I always round every four hours and take care of loose ends. Most of the nursing staff will keep a "scut sheet" at the bedside for things that they need or for things that they want to bring to my attention. I also check vitals, lab values and make sure that all of my orders are up to date too. This makes signout in the morning and round much faster.

On this quite evening, I napped for about 30 minutes and then got up to make my rounds. I got a call from the chief resident that he was bringing up a very unstable patient that was a ruptured thoracic aortic aneurysm. He was through the door with the patient within three minutes. The intern appeared and begged me to let her put in the monitoring lines (arterial and central) so we got to work. I put in a subclavian central line as she placed a radial arterial line. The OR called to say that they were ready as the attending cardiothoracic surgeon came through the door. While he was speaking with the family, the chief resident and I wheeled the patient into the OR, the patient was in full arrest and had little blood pressure according to our arterial line. The chief told me to scrub and get ready to open the chest.

This was my first median sternotomy and I shook as I opened this patient's chest quickly. Once the chest was open, we saw that this patient was beyond repair. There was a 50-cent sized hole in his ascending aorta that had dumped blood into the chest. We examined the rest of the aorta, which was quite friable. At this point, we pronounced the patient and I closed the chest with one of the physican assistants. Our attending physician told us that he would dictate this case since it was a fatality. I had literally opened this patient's chest and placed my finger in the large hole in the aorta. The heart was empty of blood and silent. We didn't even have enough time to get the patient on heart-lung bypass which might have bought us some time.

When I had completed the chest closure, I changed into clean scrubs and slipped out of the back door of the operating room and up the elevator into the ICU. I told the nurses about the case and checked all of the patients who had been covered by the resident in the unit upstairs. Since neither of us was particularly busy, he had volunteered to cover my unit while I scrubbed this case.

Christmas can be a time of looking at life and death up close. It can be a time of learning for a fledgeling resident who was beginning to hone her craft. I know that that family will always associate Christmas with the death of their loved one. I had found out later that this patient had known about the aneurysm but had cancelled every appointment for scheduling repair over the past month. The patient wanted to schedule the repair after the holidays but had begun having chest pains on Christmas Eve. This patient didn't want to "trouble the family" with their illness.


Jaysson said...

What can cause a thoracic aortic aneurysm? Is it always a near death sentence when one gets one, kinda like a brain aneurysm?

Keep the posts coming...I really love reading about your everyday life as a surgery resident. could you also possibly post your experiences as an intern?

Drnjbmd said...

The actual cause of the dilation, which characterizes a thoracic aortic aneurysm is unknown. While theories abound, we do know that once the wall of the aorta is dilated, the natural progression of this disorder is to dissection and possible rupture.

Dissection and subsequent rupture can be catastrophic but many times, thoracic aneurysms (TA) are incidental findings on CT scan. Factors associated with the development of TA are hypertension, arteriosclerosis, smoking and advanced age. As with any aneurysm, the greater the size, the more likely rupture will occur. Thoracic aneurysms larger than 5 cm or rapidly enlarging are recommended for surgical (or endovascular) repair. Repair under controlled circumstances (non rupture or dissection) can be quite successful in the hands of an good cardiothoracic surgeon.

The one thing that we know about aneurysms is that often when one is found, a search for others can be fruitful. Patients who develop abdominal aortic aneurysms can have iliac or thoracic aortic aneurysms.

Patients with Marfan's Disease and other diseases where connetive tissue is abnormal can be at higher risk for development of thoracic aortic aneurysms. Here's where the study of biochemistry and the characteristics of connective tissue elements comes in handy.

In the case of brain aneurysms i.e. Berry aneurysms, the defects have likely been present since birth or childhood. Rupture of any artery in any location can be fatal but mass screening for these diseases is not cost effective or practical.