Thursday, November 01, 2007

Medical Student Lore

My ICU rotation ended with a bang on Wednesday. Patient rolled in from the floor, respiratory distress, status post intubation for same. She had a history of breast cancer and sigmoid colon cancer, and for months had been complaining of constipation. Now in the ICU on the vent, she still looked pretty ill.

Her chest x-ray was a thing of beauty. This thing will be published somewhere, I can almost guarantee it (in fact, I wish I could write it up). The diaphragms were grossly elevated, probably 4 inches higher than they should be. Below you see tons of air with some haustra. Basically, the diaphragms are elevated because of massive colon gas. On a plain abdominal film, all you see is colon gas and stool, distending the abdomen in every direction. On exam, she looked pregnant, and her abdomen was tense and hard.

Upon viewing her films, my attending turned to our group and said "This looks like a job for a medical student."

Yes, friends, she meant manual disimpaction.

I looked at my two fellow med students, then quickly looked away. I knew if I went in there, I would vomit--I am sensitive to smells like that. There was no way in hell I was volunteering for this job. Finally, the other two students, Derm Guy and Medicine Guy, volunteered to go in. I gave a huge sigh of relief and ran to help grab equipment.

They donned scrub gowns, double gloves, masks with face shields, and scrub hats. They went in, with the attending and the resident, and I sat outside, occasionally giggling and thanking my very lucky stars. Eventually they emerged from the room shaking their heads. Their efforts were only modestly successful, and the patient remained "FOS". Medicine Guy admitted to getting queasy at one point, even though Derm Guy had done the actual deed.

At lunch that day, we presented her chest x-ray to the rest of the teams. One attending joked about the "life-saving procedure" that the medical student had performed--"you saved her by relieving that impaction!"

After lunch, our team was called to the patient's bedside. Crash carts were brought, as her pressures had dropped and they feared a code was near. Another patient came to our team from the OR, so I left the scene to go handle the new patient. I figured there were enough people to handle the code (at least 20 people usually show up), and I wasn't really looking forward to performing chest compressions on my last day.

Half an hour later, I came back to check on the situation. My teammates were standing outside the room, and there didn't seem to be a code running. As I approached and started to ask, "What happened?", I inhaled too deeply and shut up fast. Easily 15 feet from the patient's door, I knew exactly what had happened. My teammate, Medicine Guy, elaborated.

"We were in there, and she was crashing, and the attending looked over and said, 'Guys, you've got to try again.' Her belly was hard as a rock--she said it was like compartment syndrome of the abdomen. So we went and gowned up, and I went a little bit slower, so Derm Guy went in there, and there it was, just hanging out, so he reached in and grabbed this huge thing, and yanked, and all hell broke loose--her belly just deflated with the world's longest fart. I kept thinking she was going to groan and say 'Thank God, that feels so much better.' And yes, I almost vomited AGAIN! It was amazing, though--she didn't code! Her blood pressure came back up and she started breathing better! Derm Guy saved her life with his finger!"

So many people complained about the smell on that unit that the nurses had to order orange oil from central supply and spray down the whole unit. The attending let Derm Guy go home early after his "life-saving procedure", number two. So to speak. For the rest of the day, every time Medicine Guy and I looked at each other we'd burst into giggles.

And thus ends my ICU rotation. On to internal medicine clinic!


Caroline said...

Geeze, I wish they let nurses go home for disimpacting someone!!! :)

Tiny Shrink said...

Yeah, the nurses were definitely giving all of us a hard time for making such a big deal out of it. "Man, I've disimpacted hundreds of people!" I never said it took fortitude or courage or a strong stomach to get into med school.

Caroline said...

Well if you don't laugh you'll cry...apparently it's one of those moments. :)