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Bagging 101 (Remedial)

A post at this week’s “Grand Rounds” blog carnival discussed the uselessness of medical school courses with early clinical exposure for the sake of early clinical exposure.  While SUMS has done a good job of creating a first-year curriculum with some degree of clinical exposure and clinical skills development (i.e. history-taking), I can see very easily how simply being thrown into the wild to “talk to patients” can quickly devolve into what apotential describes:

Finally, a moment I witnessed that accurately encapsulated why I’m not sold on this:

Patient:  Do you think the headaches have anything to do with my stomach ache?
MS1: Um, maybe.  The doctor will be here any minute now.  I’m just here to get experience.
Patient:  Well, do you think it’s diverticulitis?  My sister has diverticulitis.
MS1: … diver-what?
Patient: …
MS1:  Um.. was that emotionally difficult, dealing with your sister’s div… illness?

As he puts it, “in the first year […] we know nothing.”

This statement is true not only for clinical knowledge, but even for those basic clinical and mechanical skills that really aren’t that difficult.  Let’s set the scene, going back two weeks:

A grim and cloudy afternoon is becoming a dark and rainy night, as your intrepid blogger is shadowing in the emergency department of one of the large community hospitals affiliated with SUMS.  In theory this hospital has several hundred beds, but they aren’t becoming available quickly enough to make a meaningful dent in the large number of patients being boarded in the department.

Every single bay has a patient (including the resuscitation area), and patient transporters are forced to wheel stretchers around using convoluted pathways and back hallways to avoid being trapped in the increasingly crowded department (as my anatomy professor would say, they were making use of anastomoses to achieve collateral circulation).  “The patient in 9C” could mean the patient in 9C, the patient whose stretcher is parked in front of 9C, or the patient who’s sort of in the area of 9C.

Adding to the volume is the fact that the public hospital nearby has just gone on diversion.  It’s not Sparta; it’s clearly madness.  Organized, well-controlled, professionally managed madness, but definitely madness to my eyes.

One of the patients there has been waiting for a bed for well over 36 hours.  After being stabilized upon arrival, the patient decompensated in the ED while waiting for a bed, but after being stabilized again everything seems to be okay, for now.  Fortunately, a bed has just opened up.

A nurse informs the attending I’m with that patient transport and respiratory therapy (RT) have sent one person each to transport the patient up to the floor, but someone else — possibly a physician? — is needed as well (I’m not sure if this is normal, or because of factors specific to this particular patient… it’s loud and confusing).  The attending glances at his patient list on the computer monitor and subtly gestures towards the mass of stretchers in the hallways as he announces that “‘Dr. NWS’ will be the physician to accompany this patient up.”

(I should add that I’m wearing a short white coat, an ID that proudly proclaims “MEDICAL STUDENT,” and am generally doing a poor job of acting as though this is my day job.  The nurse knows very well what I am, as does every other hospital employee who lays eyes on me.  There was no deceit or intent to deceive on my attending’s part, only irony.)

Fast forward several minutes.  The patient transporter and the patient’s son are decidedly annoyed that the RT has shown up several minutes later than planned.  The RT is decidedly annoyed that he’s been paged several times in the last several minutes, and the patient’s son’s frustration is not improving the mood.  I’m fervently hoping that I need do nothing more than help move the stretcher along, and hoping even more fervently that nothing goes wrong during the transport.

The RT eyes my white coat and “MEDICAL STUDENT” nametag with suspicion.  “You the doctor?”  Upon hearing that I’m not, he stomps off.  A minute later I hear him coming back with a nurse in tow, who’s telling him “yes, I know it’s a medical student, but the doctor said that’s fine.”

Just as it seems we’re about to be on our way, the RT turns to me and snaps “do you know how to bag someone?”  The clouds part!  Angels sing!  My spirits lift!  I do know how to bag someone (not that it’s particularly complicated)!  In fact, I got to practice on an anesthesia simulator during the admitted students’ weekend at a medical school I didn’t end up attending.  (It’s called “training the competition”)

The RT sets it all up:  the bag is hooked up to the oxygen tank at one end, and the patient’s tracheostomy on the other.  I squeeze:

*pop*… hissssssssss

The tube connecting the trach to the bag has popped out.  The RT looks like he wants to do things to me that will make me require his services in the near future.  I fumble with the tubing and pop everything back into place.  Take 2:

*pop*… hissssssssss

This time it’s the proximal end of that piece of tubing that’s popped out.

I put everything back into place again and start bagging.  Everything stays put.  I remember vague admonitions from several months ago to bag at the same rate as I breathe.  However, I’m practically tachypneic (rapidly breathing) myself, what with the stress, embarrassment, and fear.

Fortunately (this word may be the understatement of the week), the nurse — doubtlessly moved by a mixture of pity and annoyance — takes the bag, gives it a couple of “example” squeezes at the right rate, and sends us on our way.  I’m bagging away, the RT no longer looks like he wants to injure me, and we get the patient to the floor. Everything goes fine.

I learned two very important things (in addition to how easy it is to choke on even the simplest of tasks under pressure).

1) You can’t breathe for the patient if you’re not breathing for yourself.  Similar in substance to the third law of the House of God (“At a cardiac arrest, the first procedure is to take your own pulse”).

2) Thank God for nurses.  I knew this abstractly before, but there’s nothing like experience to drive the point home.

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  1. ian ross
    October 12, 2010 at 09:19

    Thanks for a good laugh. I wonder if you can post the best times one should choose to use the services of your hospital. If I only have a broken arm or leg, or have received only minor blunt force trauma to the head, I think I’ll wait till the rush hour is over in the hallways. Say a month or so ?

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