Whew! It’s been a kind of busy last few days. Was back on call on Saturday night—after rounding on my patient that morning, and consulting specialists in Anchorage for further diagnostic work-up. I went back home to catch a little sleep before going back on. It was fairly quiet—I only saw about six patients. Until 4am. Then four patients came in. All at once. All extremely intoxicated. One so intoxicated that his Glasgow coma scale (GCS) was 6/15. Usually the rule/rhyme is “GCS 8, intubate!” but even though he looked dead, he was breathing. His O2 saturation was 100% on room air, his respiratory rate was ~15, his heart rate was in the 70s. He was protecting his airway perfectly—surprisingly, because he barely had a corneal reflex. He was also on a backboard with a Cervical spine protection collar (C-collar), because he had been seen falling before he was brought in. And there might be a trauma. But on full physical exam, he had absolutely no signs of trauma—no bruises/scrapes/bleeding/bumps/lumps/crepitus or moving bones that aren’t supposed to move. He was just cold and felt dead. I had to call the doctor who has been here for decades to figure out what to do.
Do I intubate him? I don’t think so, because he is protecting his airway just fine. But on the other hand…his GCS is 6. He barely responds to pain. The other question is—do I need to pan-scan him (with CT scans) in order to clear his C-collar and move the backboard, even if I don’t suspect trauma? Because on one hand, I would hate it if I was wrong, and something happened to paralyze him from a spinal injury. On the other hand, one CT scan is equal to 100+ x-rays, and I would hate to irradiate him that much when I don’t suspect anything. It seemed reasonable to leave him in the cervical collar and take him off the backboard (since it is very uncomfortable and can cause pressure ulcers quickly—plus I wanted to look at his back and make sure i wasn’t missing any wounds or broken bones, and we needed a rectal temperature since he couldn’t take an oral temp and his skin was so cold–I also have to think about hypothermia much more here, since most of the year it is freezing/subfreezing temperatures, and a lot of people come from the villages to drink and are essentially homeless while they are here), and wait till he wakes up more to tell us if anything hurts, before we move him too much.
We had three other intoxicated patients with lots of issues to deal with. A young female with acute alcohol poisoning, nausea/vomiting, and other drugs on board, a mother of a young child we wanted to give another chance to get away from her cycle of alcohol abuse, to talk with behavioral health counselors, to help her find a fresh restart. I admitted her at the time my shift was over, so I spent the time after hours to get her tucked in.
I also inherited a hospice patient who is dying from metastatic lung cancer. With metastases to her brain.
Reflection~I truly believe that none of the experiences we have in life are wasted. Furthermore, I believe they may even serve a purpose; we go through certain things for a reason. In medical school, I ended up with extra Oncology rotations. I first had a surgical oncology rotation. I remember in the OR, late one evening, the older, highly respected surgeon was trying to take out bile duct cancer, as a last-ditch effort to clear a patient of a life-stealing disease. But it was too late. When she saw how far the cancer had spread. She stepped away from the operating table and clenched her hands and nearly yelled “I HATE CANCER!”
I remember feeling so awed and surprised and relieved. To see a cool, calm, collected cancer surgeon, who deals with this several times a day, to be so passionate about her work and upset by cancer. It was before Christmas. Most everyone we rounded on was spending their last Christmas—for some of them they might not even see Christmas. I hated this rotation. I cried secretly almost every day.
I never wanted to see cancer again.
Then I had a classmate ask to switch a rotation with me in my 4th year electives—she wanted Pediatrics (which I had), and she had an Oncology rotation. I didn’t really want to trade, but she was planning on going into Pediatrics, and needed the experience. I held back the tears, or cried again, nearly every day on this Oncology rotation. I figured there must be more that I needed to know about cancer. I ordered books on how to talk with people and families affected by cancer, and I had watched The Last Lecture by Randy Pausch and read “Tuesdays With Morrie”, and they gave me hope. I learned a lot about compassion and the meaning of life. I learned a lot about hospice and pain management in people’s last days.
And I realized, as I was talking to this Alaskan native lady’s family, that I was so glad that I had more training, because I needed it now. The conversation went well. The family was grateful to have a chance to talk through things. They all gave me a hug when I left, for which I was grateful.