Trauma ICU: sutures, scalpels, and swears.

At the county hospital, the third-year resident (“R3”) runs the surgery service. Sure, the fifth-year resident (“R5”) looks over your shoulder, but she isn't always around. The R5's job is to do surgery. The R3's job is to learn by staying awake and suffering arguably one of the worst jobs in the system. He also gets to teach me how to keep trauma survivors alive. In the evening, I sit waiting, like a bird dog, ready to chase and gather the bits and pieces of information on the latest emergency department surgical candidate. The R3 slouches in, having just polished off two cigarettes in 10 minutes. I learned my greatest lessons on how to run a trauma from him, sitting outside in the dark and looking over the lights of the city while he sucked on a cigarette butt. The skin around his eyes looks like old bruises. He strings minutes of sleep together here and there, just enough to stay alert. His lifestyle would kill a cockroach. In exchange for scut work, he shows me how things are done the way he learned them, passing on his knowledge in a special form of storytelling. The R3 laces each sentence with swear words. I watch the third-year medical students, here on their first clerkship, looking at him in fear and trembling as the invective rolls off his tongue during morning rounds. I know this fear because it was mine just a short year ago. But now, as a seasoned fourth-year student, I take it all in stride. Nothing phases me: not the belching, the swearing, or the insults. Let the house fall down around my ears, and I will sit with my coffee cup in hand and wait and watch. The R3 asks why I missed the gram-negative rods in the patient's sputum report this morning. After all, we are looking at them right now on the computer. Am I trying to kill the patient? My brain snaps into gear, and I realize that the lab technician must have entered the data the moment after I logged off the system. Problem solved. That was this morning, 18 hours ago. Right now, I need to find the x-ray reports, so I shed my short white coat; now the radiologist actually looks up at me. Even the first-year resident in the emergency department speaks to me as another functioning human. Most residents will trust a piece of paper or a computer screen, but as an essentially parasitic life form, medical students are not as reliable. This view stands regardless of what any of us did before entering medical school, including building spacecraft, teaching kindergarten, splicing DNA, or giving birth. Fair or unfair, the residents would argue that, in the end, the responsibility lies with them. Many hours later, someone in the unit goes into cardiac arrest; this patient had already bounced back from a previous crisis and was considered a “weak transfer”—really a medicine service case, but postoperative, so he is now the surgery unit's responsibility. I have become adept at placing central lines, but the arterial catheter eludes us all. We sterilize the skin over every possibly accessible artery, and with the aid of mini-ultrasound and Doppler machines, the patient is intubated. The nurse looks on the resulting mess with a frown: the bed is stained iodine brown—one giant sterile field. The R3 is unhappy and giddy at the same time—possibly because it's 2 AM. At times like these, it is not just the survival of the patient that is important, but our survival through this night as well. We hope to take this man, and all of our patients, along with us. That afternoon in surgery clinic, the R3 blusters and swears all the way to the door of the examination room. In there sits the umpteenth patient of the day, who is suffering damage very likely as the result of making bad decisions. Having not seen the R3 in clinic before, I am prepared to have my medical student worldview assaulted yet again. Then, to my surprise, he greets the man. Quietly, informally, he asks questions, makes small talk, and examines the required parts of the body. He takes his time doing it. I am stunned. What happened to the bitterness? First he's rough and tough, brash and loud, then he's quiet and polite. The resident who yelled at me this morning and made fun of my hair and shoes turns out to be a nice guy. Later that night, we are back in the emergency department. It is 4 AM. The paramedics call in, bringing four victims of a knife fight from a dance club in Chinatown. The R3's pager is going off again. He tells me that it's the third pager battery of the week.