Friday, January 11, 2008

Not Meant to Be

We had a steady stream of work today.  One of the cases that affected me most was a 22 year old coming in, 17 weeks' pregnant and spotting.  We'd actually had a patient earlier in the morning come in who was in the middle of miscarrying.  She had hoped the baby might be saved, but ultrasound showed she'd already lost it.

My patient basically broke her waters around midnight last night.  When I put the ultrasound probe on her, I could see very little fetal movement even though the heart was still beating.  We did a pelvic (yes, ick, that's right), and we found that her cervix was at 1cm open.  She got admitted and will probably be passing the fetus some time tonight.  She was very sad.

Otherwise, a mishmosh of this and that, mostly things that can be taken care of in a primary physician's office, but when your doctor has a full schedule and can't get you in today, you come to the E.D.  Or, when you don't like the care your doctor gave you, you come to the E.D. for a quick fix, even though it's something your primary care doctor should have taken care of.

My patients today...

Back pain man - I've had chronic back pain for year then fell at work a week ago and my doctor gave me pain meds but they're not helping and I want you to make me better.

Tattoo man - I don't care what kind of bet you make with your buddies when you're 20, when they ask you to tattoo women's clothing on your body and you do it, there's something just wrong there.  (I would have loved to have taken a photo, but a surgery resident just lost their job for photographing a patient's privates that were specially tattooed, on a bet mind you.)

Seizure lady - softball-size brain tumor removed 17 years ago and as a consequence has seizures.  Found in her car in the parking lot of a store after she ran over a curb and came to a stop.

PROM (premature rupture of membranes) girl - the one I mentioned before.  Admitted to OB/gyn.

Rule out MI lady - sent in from her doctor's office after complaining of being dizzy and having been found to have low blood pressure.  Her complaint to us was of chest pain, so we had to admit her to evaluate for an MI (heart attack.)  Very nice lady;  she's had 11 children.  Ouch.

Pneumonia lady - Another patient sent from their doctor's office for a lowO2 saturation (82%).  She had pneumonia and was being admitted.

Sore throat lady - just got that tickle feeling in the back of the throat and wanted to get it checked out.  Cultures sent and she was sent out the door.

No pedi's today (pedi's = children, as in pediatrics).

Back to work over the weekend.  We'll see what's stirring up!  


Thursday, January 10, 2008

Strange Weather We're Having




This is what weather in Buffalo, at least to most people's minds, is supposed to be like during the winter.  However, the storm system I videotaped on my way to work last week which dumped a bunch of snow has now passed, and all the snow is gone.  It sort of feels like spring, but way too early.  I know there's more snow coming... I think.  At least, I hope!  I had planned to go snowboarding on days off because this is my light month.

Regardless of the weather, a strange phenomenon happened in the E.D. today... what if there was an Emergency Department and nobody came?  That's about right.  At most, we had 2 patients on the board at any one time.  I think this morning we might have had 3, but for the most part, just 2, mostly 1.

My patients were unexciting by most means:

"I have a cough and cold and just can't go into work today" - prescription for gaifenesin and a work note

"I have a cough, I don't know why I'm here" - LOLNAD (Little Old Lady in No Apparent Distress, refer to prior posts) sent from nursing home for near syncope (she almost passed out.)  Nothing apparently cardiac, but she got admitted for unsteadiness on her feet and a UTI (urinary tract infection)

"I can't sleep because I feel really short of breath" - congestive heart failure exacerbation (worsening) he gets admitted to be "tuned up."  His concern was the $287 he was going to have to pay for an overnight stay in the hospital that his insurance didn't cover.

"My son has a temp and has been pulling at his ears." - another chance to play pediatrician.  He had some fluid behind one ear drum.  Most likely a chronic collection, but we drew a white count (if it's elevated it could signal an infection.)  It came back normal, and the child was doing better.  Home with instructions for follow-up.  Most cases will get better on their own;  no need for antibiotics.

"I can't pee and I feel like I have to go all the time." - used my ultrasound skills, and the patient did not have a distended bladder.  Urine showed infection, so some antibiotics and off you go...

And, seriously, that was it for my 10 hour shift.  We did also have about 3 other patients that I didn't see.  Again, nothing real exciting, but the weekend's coming up and the weather's supposed to be turning nasty once again.  Pray for big white fluffy snow.

Tuesday, January 8, 2008

Does the sun shine in Buffalo?

Ok, so this morning I got up extra early for a shower before my hour's drive to my new rotation: ED in a small, 9 bed community hospital.  The sky was dark all the way to work.  When I left at around 5:30 p.m., the sky was dark all the way home.  Luckily, I have a lot of days off, so I am sure I will see the sun at some point.

So, new hospital and learning a new system and getting used to new attendings, etc.  I found out today that most of the patients have most of the same complaints.  However, small town life can be a bit more colorful at times, and patients here have a tendency to be frequent fliers.  I also like being back in a position of having everything I need brought to me. 

When I was a house doc working at the community hospital, whatever I needed was immediately retrieved and brought to the bedside.  There was even a situation where I was called to a patient's bedside for SVT (it's a very fast rhythm) in the middle of the night.  My mouth was so dry, and gross (ew, morning breath at 2 a.m. is not fun) that all I wanted was a piece of gum.  I related such to the nursing supervisor that came to every call with the Rapid Response team.  A few minutes later a floor nurse came up and asked if I was the House Doctor.  I said, "yes," and she handed me several sticks of gum that had been tubed to the nurses' station.  Now that's service!

But, I digress.  The nurses indeed were very friendly and happy to set up eye kits, ENT kits, and, ughhh, pelvic setups, when asked.  Orders magically disappeared and were entered expeditiously, and the ED hummed along.

I saw about 8 patients today.  We suddenly got very busy about the time I was leaving so I had to sign out a couple of my more interesting cases.

There was:

Bartender who got hit in the eye with a spitball.  Take these eyedrops and consider safety goggles at work. - corneal abrasion

Mr. Elderly man with knee pain for over 20 years that still hurts.  "What are you going to do to make it better?"  MRI shows a lesion on the end of his thigh bone.  Looks like cancer.  Dude, you get any drug you want from me.  From my attending, not so much.  We advanced his ortho appointment by a few days and gave him a little something for the ride home to help his pain.  For now.

Bipolar, borderline personality with depression lady who came in complaining of chest pain after being on the road for 2 days.  No DVT and no heart attack that I could tell on prelims.  She'll probably be let loose to continue her way home to New England. - most likely some sort of panic attack

I'm-pregnant-with-child-number-nine (yes, nine)-at-age-29 (that's right)-and-I-have-belly-pain.  My ultrasound skills showed a happy bouncing baby swimming in a sea of amniotic fluid.  Poor kid doesn't know what's waiting on the other side.  Mom's smoking, of course.  ("I cut down to just 6 or 7 a day.") Ugghh, pelvic with gross everything.  Doesn't look like a miscarriage, and I will have to check her cultures.  Most likely some pelvic inflammation.

Recovering drug addict sent from clinic for high blood pressure.  He'd had nothing to eat but a piece of toast and some coffee... His usual 5 - 6 cups.  Plus his cigarettes.  Around a pack and a half a day.  After walking a half mile to the appointment and climbing stairs I'd look a little ragged too. Sent him right back out as his blood pressure was normal on two readings, and he had no other symptoms.

Lady with weird groin pain "going down into my leg."  Couldn't see anything on ultrasound, but she had a lump.  She was being wheeled to CT as I was leaving so I will have to find out what happens later.

And, finally, just fresh off the cardiac care unit service, I got a "I had chest pains yesterday, but I didn't want to come in, and today my wife made me and now I have EKG changes."  He's being worked up for an MI, and I signed him out as well, so I'll have to see what happens to him.

That's it.  Tomorrow is Wonderful Wednesday with Grand Rounds and no work for me....

Friday, January 4, 2008

Doing the CCUing Out the Door Dance

1100 (T - 0) My patients are all signed out and my shift is over.  I am heading home for some rest after doing a few errands.  The next time you see me I will be starting my rotation (not until Tuesday!!!) at one of the local community hospitals, and I will be back in the E.D.  So for now, good night, and good luck!
0700 (T - 4h) 24 hours later and I am pre-rounding for my patients again.  Getting their information.  A little behind due to the admission.. oh, I should get back to it!
0600 (T - 5h) My resident paged me.  The perfect night is ruined.  Got an admission in the E.D.  I can't complain.  I wonder what number my colleague is on.
0515 (T-5.45h) I got a page from the same nurse for the "I need a sleeping pill patient" for some lab orders and a Foley (urine catheter.)  I mumbled "yes" in my sleep and rolled over again.
0200 (T - 9h) I just came back from another Code Blue.  This time, a patient that had coded on the floor during the prior code had been transferred down to the MICU.  He had just come down and within about 1/2 hour he was bradying down (heart rate was slowing: bradycardia = heart beat less than 50.)  I went upstairs to find them doing CPR and he had just been intubated.  He was the 6th admission for my fellow EM resident, and, when the patient was pronounced, she came out to tell me she was expecting her 7th admission.  I keep waiting for the pager to go off.  (It did once but only to ask if a patient could have a sleeping pill.  Sure, why not?)  For now, it's back to dreaming about city streets and neighborhood layouts.  Maybe, I've been playing SimCity too much.  Hmm.
23:15 (T - 11.75h) So, for the last 4 hours since my last entry, I have been watching television in our resident room.  I saw all of a CSI episode, followed by most of the movie "Working Girl," and then I channel surfed for a while.  I was just about to get extra comfortable in the recliner when I heard a Code called overhead.  A Code Blue is cardiac or respiratory arrest, meaning the patient's heart isn't beating or they're not breathing, or both.  Although, they called a Code Blue this afternoon only to find the patient was actually just sleeping.  Must have been a young nurse or aide.  Anyway, I went upstairs to find one of my fellow EM residents there and a crowd in the room.  Initially, the story was that the patient was found down on the floor in their bathroom.  Then we noticed the makeshift noose made out of a hospital gown hanging from the shower rod.  Apparently a nurse's aide went in to check on the patient and found him hanging.  He'd been taken off the telemetry monitor just a minute or so earlier, so he hadn't been there long.  We stabilized his neck and moved him to the bed where he was intubated.  He became more responsive and had started to breath on his own prior to having the tube put in, but for his own safety he was intubated.  We have to worry about neck fractures and any damage he might have done to his trachea.  Also, how much brain he might have damaged, although little if the timing is correct.  He'll be going to the MICU (Medical Intensive Care Unit) tonight.  The EM resident working there will probably be able to tell us what happens with him in the morning.  She's on her 5th admission of the night.  I, myself, am planning to settle in my comfy recliner and hope the white cloud keeps blocking out the admissions.
1900 (T - 16h) We had dinner.  It was a nice beef souvlaki salad for me.  Currently on the low-carb/no-carb diet for the next 6 weeks until the wedding.  My patient who's now re-intubated seems to be doing well.  By my read, CT scan looks negative for anything scary.  His heart, lungs, kidneys and liver still have a ways to go.  We got a new patient.  Another 4 - 5 beer a day, plus I smoke and sometimes do drugs, kinda guy.  He's going to be a pain just because, as I've stated before, chronic drug users (ie: heroin, cocaine, etc.) tend to fry out their pain receptors and then usually need more medication to help them with something you or I might take an ibuprofen for.  I am getting ready to relax for a bit and pray my white cloud keeps me covered over night. (Residents, especially surgeons, believe you're either a white cloud - nothing happens when you're on call or it's a light call, or black clouds - chaos rules and you get many admissions.)  I had a friend who I used to call a black cloud with thunderstorm warnings because whenever he took call it seemed the service was suddenly three times as busy.  Here's to praying for blue skies all around me...
1545 (T - 19.25h) Just got back from running downstairs because a patient had self-extubated (pulled out their own breathing tube.)  I admitted this gentleman yesterday.  (Getting on the soapbox)  Everyone should learn CPR.  My patient was at home and told his wife that he felt like he was having heartburn.  Then he suddenly shuddered and collapsed.  She called to him and then called EMS.  Their response time was about 5 - 6 minutes, but meanwhile nothing was done for this patient.  When they arrived, he was in v-fib arrest (let me just say this is bad) and needed to be shocked twice.  They got his heart going again, and when he came to he suddenly became very agitated and combatative.  So much so that they needed to put a breathing tube in when he arrived to the E.D.  We pulled the tube out yesterday because he was responding to voice and following commands.  He was again very combatative and not breathing properly so he needed to be put back on the ventilator.  Today, we had sent him downstairs for a CT scan to check out his brain, and he somehow managed to reach up and pull out his breathing tube despite being in restraints.  When I was a medical student at the VA, this meant the patient was ready to be extubated (have the breathing tube removed) but in this case, not so much.  So, now he's reintubated, and I am going to go see what his CT scan shows.
We got another admission which means the evening resident will be leaving, and I will be responsible for all admissions until morning.  We're in the process of ordering dinner.  Yes, it's early, but you never know when you're going to eat on-call, so it's better to have cold food than no food at 11 p.m. if you're suddenly busy.  The day continues...
1230 (T - 22.5h)  At lunch.  Admitted a patient this morning:  needs by-pass surgery for bad coronary artery disease, but oh, by the way, is a Jehovah's Witness so no blood products, and on peritoneal dialysis for bad kidneys, AND had a severe allergic reaction to anesthesia.  Oh yeah, if you know you have clogged coronaries don't wait several hours for your son to come home before going to the hospital, go when you're having the chest pain.  Every minute is another 1000 heart cells lost.  And, to add to the on-going drama in the CCU (more on that at some other point), the I'm-having-a-heart-attack-again-yet-continue-to-smoke-and-hate-waiting-in-ED's decided he didn't like the No Smoking policy and left.  I think I talked about signing out AMA (against medical advice) once before.  He did.  He was warned he could drop dead.  He didn't care.  He was warned not to drive because he's driven off the road once already.  He didn't care.  Probably was lighting up as he was walking across the lobby and out the door...
0915 (T - 25.75h) - So, rounds just ended, and they weren't too bad.  What's bad is the story of one of the patients admitted overnight.  They started to have chest pain two days ago around 8 p.m., so instead of going to the hospital, they thought it was more important to drive to get kerosene to heat their house.  On the way, they became dizzy and light-headed and drove their car off the road.  Around midnight, they were found by local PD and thought to be inebriated because they were confused.  So, they were arrested and taken to the local jail.  When the breathalizer was negative and a friend who was an officer recognized them, they were released.  By the way, they continued to have chest pain.  So, their fiancee came and picked them up and took them home.  The next morning they went to see their primary doctor who did an EKG and told the patient to go straight to the emergency department.  (Me, I would have called EMS, but that's just me.)  According to the patient, they were ignored for 30 minutes despite complaining of chest pain, shortness of breath and diaphoresis (sweating.)  So, they left.  And came to BGH yesterday evening where they were admitted and are now on our service.  Yep, they've had a heart attack.  Don't feel too bad for them.  They continue to smoke 3, yes 3, packs a day of cigarettes like they have for the last 30 years despite having had 9 heart attacks, a 4 vessel by-pass, and a very strong family history of heart attacks before the age of 40 including deaths on both sides of the family.  Natural selection, folks.  More to come I am sure...
0730 (T-27.5h) - I got to the hospital about 1/2 hour ago.  I brought coffee and donut holes (Dunkin, ooh gourmet compared to the "Timmy's" everyone here seems to like).  I like to show my appreciation to the staff.  I've done it since I splurged as an intern and bought pizzas for 2 shifts at Cook County for the floor 8 nurses.  They REALLY helped me get used to new environs and work around the system.  Anyway, I've collected all the data from last night (vitals, labs, medications) and now I am off to physically examine my patients before rounds...

Thursday, January 3, 2008

Tomorrow's a Big Day

Well, tomorrow is it.  The end of the CCU rotation.  My goal is to do a play by play during call.  We'll see how that works out.  As for today, we did a little cleaning house.  Moved most of our patients out of the unit and onto the floors upstairs.  And, most of my patients went to private services... meaning off my service, and I don't have to do the discharge dictation...!

So, until tomorrow for a Friday night on call...

CCU Countdown:Days until the end of the rotation:  3
Actual number of days I will be working during that time: 2
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off:  2 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0
Number of long call shifts remaining: 1 - TOMORROW!!!
Number of patients: 2 - I picked up a new one from yesterday

Number of evil nurses in the unit: 4 - evil nursing aide actually made #4, she just had too much attitude for one small person
Number of evil Internal Medicine residents: 2



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Wednesday, January 2, 2008

Last CCU Short Call

So this is my first official entry of 2008.  I didn't write on New Year's Day because after an exceptionally long morning of rounds for a non-workday, I decided to take a nap.  After waking up just long enough to have dinner, feed the cats and get things organized for another day of work, I just decided to go to bed.
One interesting thing that happened yesterday is that the patient who was brain dead died.  I spent another hour with the son the day prior and had finally gotten him to the point of thinking in terms of finding a funeral home and thinking about his parent's last wishes.  Then, he suddenly changed his mind again and said that something else could probably be done for his parent, and that as long as they were on the breathing tube, he could still come and see them.
I then told him that if his parent's heart stopped, it was no longer a matter of choice.  They would be removed from the ventilator, and he would have to tell the hospital where to send his parent for burial.  Again, I am usually very kind and understanding when it comes to talking to families about their loved ones, their conditions, and in talking to families about witholding or removing care.  But, this situation called for me to be more brusk and candid than I usually am.  I felt bad about this.  I really like to be as understanding and patient with families as I can be, but that wasn't going to be the case in this situation.
When I came in yesterday morning for rounds, the patient's temperature had dropped to the low 90's, and the nurses were having a hard time getting a blood pressure.  When the patient's heart rate dropped to the 30's, we knew we were close.  When the patient went asystole (flat-lined), we ran the code, gently, and then pronounced the patient.
I called the son to let him know his parent had died, and he would now need to make arrangements.  At that point, he finally seemed to have an acceptance of what had happened and came to the hospital to say good-bye.  The social worker promised to help him out with whatever he needed.  So that was the start of his New Year, and too, I guess, of mine.
CCU Countdown:Days until the end of the rotation:  4
Actual number of days I will be working during that time: 3
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off:  3 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0 - I finish tonight!
Number of long call shifts remaining: 1
Number of patients: 2

Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 2


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