A Winter's Poupourri

I don't know what was in the air today, but we were hit and hit hard in the late morning hours.  We had steady business from 7 to about 10 and then the flood gates just opened.  During the barrage, I looked at the clock and ran to the cafeteria around 1230 because I was starving.  I finished my wrap around 3 in the afternoon because I was only able to take about a bite every 1/2 hour because we were so busy.  I think the next time I was able to sit and think it was around 4 p.m.

These are the cases I saw, which are only about a third of the patients seen since my attending and the PA were also frantically running from room to room.  These do not include the massive heart attack who, by the way, was also bleeding into his brain(transfer to ICU at one of the regional heart hospitals that also has neurosurgery);  the patient with the infected leg (ala my trucker from a few days ago) who was septic with a blood pressure into the low 60's (admit to the ICU); the man with the chicken bone caught in his throat from the night before (he came in today because he wasn't able to swallow his breakfast, now he's going to surgery); and several sprains I heard about in passing.

My patients:

Admission for joint infection:  don't get drunk and then into fights with your foster son.  And, Lord 'o mercy, if you're going to, don't hit him in the mouth.  The human mouth has the nastiest of bacteria in it, and especially if you're a diabetic your hand is going to get infected, badly.  He was going to the OR with ortho surgery to get a "wash out."   It means opening up the wound and scrubbing all the badness you can out of it.

Generalized weakness:  LOL NAD from the local nursing home who wouldn't wake up this morning, but who was fine and alert by the time EMS arrived, and even moreso by the time she arrived in the E.D.  Still, we had to do a work-up to make sure she wasn't just extra sleepy this morning.  Back to nursing home for her after all her tests came back negative.

Pharyngitis:  HIV+ patients aren't normal in many senses.  They can't have a "simple cough."  You always have to be thinking about the 100's of rare and opportunistic infections they might have picked up.  Luckily, this patient has a simple sore throat.  Still, antibiotics for a few days.

Knee strain:  Electricians have a hazardous job.  I thought their only worry was getting shocked, but it seems those "cherry pickers" they work in are also a health hazard.  Especially if they don't get lowered to the ground gently.  My patient wasn't and was now having knee pain.  In essence, it's like falling from 6 - 8 feet and landing on your feet.  You get the jar and the shock of the fall, only the machine adds a bit of acceleration.  They'll need an MRI with their ortho follow-up.

Transfer to outside facility for subdural hematoma (brain bleed):  This patient came in complaining of having several days of nausea and vomiting and now feeling week.  They'd taken a couple of falls, but they denied hitting their head.  After several hours, lots of fluid and a full work-up for their vomiting, we tried to stand them up.  They fell over.  So we got a CAT scan even though their neurological exam was completely normal.  Surprise, they had a massive bleed in their head.  "Oh, yeah, Doc.  I guess I did hit my head with that last fall last night."  Obviously, I didn't do a complete memory exam.  They're going to the region's stroke center for a neurosurgery consult.

Admit to ICU for hemoptysis (coughing up blood):  When I was a 4th year medical student, I got to put in my first chest tube.  As an intern in surgery, I put in 13 during my first 5 weeks as a doctor.  I've done many more since then, and other than central lines, I think it's one of the procedures I really enjoy doing.  However, not on little old ladies with lung cancer who came in "for a simple biopsy" and ended up with a collapsed lung and bleeding into their chest.  It's a known complication of a lung biopsy, but if you're that 1 in 100 who has the complication, it's no picnic.

She was intubated (I tried but missed), and then I got the chest tube in.  She had lung cancer on one side, and the biopsy and damage was to the other lung where a new lesion was seen.  So it affected the one good lung she had.  She went to the ICU.  I don't know that she'll make it.  I'll check in on her tomorrow if she survives the night.

Abdominal pain (still waiting for a CAT scan when I left, so I'll get the results tomorrow and see what happened to them.)

Upper respiratory infection:  my token pedi patient.  I might be getting better since I didn't make her scream when I looked in her ears.  Either that or she was too sick to care.  She gets rest and fluids.

Hyperemesis gravidum:  you're pregnant and you get REALLY bad morning sickness that lasts all day and night.  This was her 3rd visit to the E.D. in as many weeks for dehydration.  None of her labs were abnormal, so she got fluid ("tanked up") and anti-nausea drugs.  She'll follow-up with her primary doc next week.

Whew!  That's it.  One more day and then I have the weekend off.  We'll see what rolls in the door tomorrow....

Tags: chest tube, sepsis, hemoptysis, hyperemesis gravidum, cellulitis, subdural hematoma