Hard Day's Night

I just finished a string of overnight shifts. Fortunately, last night was slow and I was able to catch up on all of my dictations. For two blissful hours in the middle of the shift, I actually didn't have a single patient. I saw a nursemaid's elbow early in the shift. Nursemaid's elbow is subluxation of the radial head. It occurs in small tots when they get picked up by the arms or sometimes from sudden pulling forces. It is one of my most favorite things to fix because it is so dramatic. Usually, the toddler comes in with one arm hanging limply by their side, and they refuse to lift it. All it takes is some slight pressure in the right spot and a quick twist, and you get a satisfying click. When you check up on the kid a few minutes later, they suddenly have full function of that arm again. I guess I just like quick and easy solutions.

I was glad to have a catch-up shift after the frenzied pace of the previous nights. In our hospital, there's typically an attending on the pediatric side until about 2 am, and after that it goes down to one attending covering both the adult and the pediatric sides until 8 am. As as 2nd year resident, I now work overnights by myself on the peds side, or with one intern and usually no senior resident on the adult side. The decreased coverage at night is usually adequate, but we can get overwhelmed in a hurry. Discharges can get slowed down as each patient has to be seen by the attending before they can go, and they are often busy with more critical patients on the adult side.

For some reason there is this phenomenon on overnights where parents will awaken their children from a dead sleep and drag them in for the silliest of things (runny nose, rash, etc.) thinking that there will be no wait to get Tiny Tim evaluated at 3 am. This stuff is all pretty benign, but it clogs up the works, and when we actually are busy in the middle of night, people get pissy pretty fast at having to wait.

Things that stalled me up on seeing the rashes in a timely fashion on some of the overnights included: a teenager shot in the neck (the bullet went right through the spinal cord and he's now paraplegic), four teens involved in a rollover (none of them wore their seatbelts), and 5 stab wounds that presented on the adult side all at once. The stabbings didn't involve me directly, but they resulted in a riot in the lobby. It was bad. At one point, parents were asking me if they were safe, and I had to tell them to just stay in their rooms with the doors closed. Apparently, there was a metal detector malfunction.

Last year, we had a metal detector that didn't actually work. Then they put up a "No Guns" sign. Finally, we got a working metal detector. When the thing goes off, the entrance door to the waiting room automatically locks. Apparently, the lock malfunctioned, so there was suddenly a horde of people in the waiting room, and people fighting in the street. We have our own security guards, and PD was there quickly, but we basically had to go on internal disaster and completely shut down until the lobby could be cleared out. All of my sore throat and fever kiddos had to be police escorted with their parents to the parking lot.

It didn't help matters either that I'm still getting over my stupid respiratory virus. I was feeling much better, but then started to lose my voice. It was so bad that by the end of one of my shifts, the parents were having trouble understanding me. My voice kept cracking like a 13 year-old boy's. I can only imagine all of the blanks that will be showing up on my dictations.

Wild Hogs

Christmas was nice and quiet.I spent most of the time just sitting around visiting with my parents, brothers and sister-in-law. The rest of the time was spent napping as my parting gift from the children in the ED was a nasty respiratory virus. I don't know why anytime I have any time off or my schedule slows down my body insists on getting sick.

One thing that I guess is a little bit different about the part of the country where my parents live is that javelina rove the streets at night, looking for food anywhere they can find it. My mother was bitterly complaining as on Christmas Day they decided to completely obliterate the pointsettia that she had out by the front door. They really are a small-sized pig, and more of a menace than anything else, knocking over trash cans. Kind of like what raccoons are in northern areas, minus the rabies.

Tamales are also a Southwestern part of our Christmas traditions. Ever since we moved to that small town, one of the ladies that my mother used to work with brings us tamales every year. Tamales are such a pain to make that many women in that area will get together and make a day of it, and then freeze them to serve throughout the year. Her tamales are different than what you can get in a restaurant as they are made with more of a white cornmeal, and she always sticks an olive in each one for extra flavor.

So that was about it: continuous feeding and talking for a few days. My flight back the other night got in just in time for me to run home, turn the heat in the house back up, and head off to work. I was a little more tired than usual after sitting around the Philadelphia airport for about 6 hours due to my jet being stuck somewhere in Canada, but it wasn't bad.

Home for the Holiday

Tomorrow I fly back home for a few days. The visit will be very short, but it will be good to be home for Christmas. I haven't seen my younger brother since he left for Kenya over 2.5 years ago. It will be nice to have a few days of warmer weather, too. I am a little nervous about the flight back here, as I work the overnight shift. I gave myself a four-hour gap between my arrival time and the start of my shift, but with the way the weather is around here, you can never be sure that a flight won't get altogether cancelled. At least I know the flight out of Arizona won't be a problem, it's always the small connector flights that are the problem.


I also just saw Army Guy for what will be the last time for several months. He went home to see his family. However, immediately after the break, he heads down to Georgia for Army Ranger training. Army Ranger school, if one passes each phase on the first try, takes about three months. Three months of being out in the field, being pushed to the limit physically, without access to a phone or the internet. Bleh. He does get a few hours here and there in between phases, but it isn't like we know when those will be, or what my work schedule will be like. I am happy for him as he has been wanting to do this since he joined the Army last year. And, I really can't complain at all about it, as originally he was scheduled to deploy to Afghanistan for 15 months next fall, and that has been cancelled indefinitely. It's just a long time to go without communicating with someone. I suppose it will be a good period of time to throw myself back into my workouts, reading up on educational stuff, and maybe even getting some projects done around the house. I do wish that I was better at saying goodbye. I kind of just tend to avoid it until the very last minute. And then it is probably not very romantic to send someone off with warnings to keep their feet dry and change their socks often so that they don't lose any toes. Sigh. Wordsmith, I am not.


Merry Christmas!

Fever & Diarrhea Land

Want to know how to not be taken seriously by the doctor in the emergency department?

Bring your kid in for fever, vomiting, and diarrhea and then give him an 12" chocolate Santa to tide him over while I'm examining him.

I couldn't thank these people enough. Normally we give our viral illness kiddos anti-emetics and then hesitatingly give them some juice or a popsicle an hour later and see what happens. As long as they are not clinically dehydrated and can tolerate oral intake, they can go home and safely outlast their stomach/respiratory bug. But if Junior is in there chomping away with chocolate running down his face at a faster rate than the mucus running out his nose, I have just deemed him immediately dischargeable. This kid seriously got a quick glance-over from me and a head-nod from the attending. It took longer to get him registered than it did to interview and examine him.

Jesus Loves Bad Spellers

All I am saying is that if you are going to tattoo something on your person in big 1" letters as a statement to others for the REST OF YOUR LIFE, you might want to consult a dictionary or encyclopedia first to make sure that you have spelled everything right.

"Jeasus Saves" just doesn't have the full effect.

Free at Last

I survived my ICU month. Yesterday I stumbled out of the hospital after my last call night EVER. I know that it was a good rotation education-wise, the hours were just so tiring. Last week I spent 85 hours in the hospital, with much of them being without an attending being in house.

My last call night was rough. Most of the day we spent trying to fix this guy that needed surgery. His pH was 6.9 and his potassium was over 7. All day long we poured blood and various medications into this guy, and even dialyzed him, hoping to get him stable enough for surgery. In the end, the surgeon signed off, saying it was just too risky.

Meanwhile, one of my usually more stable patients responded to being ignored all day by going into SVT. I pushed adenosine (medication that temporarily stops the heart) and when that didn't work but slowed him down long enough for us to see that he was in a-flutter, we started him on several other medications. While all of this stuff was going on, we put central lines into two other patients, performed a lumbar puncture, and admitted another patient who was having a heart attack.

So it was a busy four weeks. While there wasn't much time for reading, I did learn a lot on the job. I also suppose my confidence level went up a bit. I am halfway through my residency program now, with the remaining time being pretty much all in the emergency department. There are just a few more rotations left, but none will have the intensity of high-acuity patients or the time demands of the intensive care unit.

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In the last 24 hours it has snowed over 12 inches here, and rather than the usual melt away mess, it really has built up. This morning I wasted by lounging away, but it took me 1.5 hours to clear the driveway and we're supposed to get more tonight.

Jingle Bells

This is all gossip and hearsay, so of course I am determined to repeat it:

Apparently, after a patient passed away in the unit the other day there was quite an uproar. As they were being taken to the morgue by the transporter, a maintenance worker stated that he saw one of the arms of the patient move.

He said something about it to the transporter, who just kind of shrugged him off and continued with their delivery. The worker was really bothered by seeing this though, so he then reported it to the charge nurse. In the meantime, the body was delivered to the morgue and placed in storage (I don't know if there's a technical term for a morgue refrigerator).

The charge nurse immediately got on the phone with the morgue, who confirmed that they had the patient and was told that they hadn't observed any movement, but couldn't say for sure that the patient had expired.

And this is how one of our poor junior nurses got ordered to go into the morgue and confirm on the cardiac monitor that the patient was in fact, dead.

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First of all, I don't know who pronounced this particular patient, but it was someone who had been on a ventilator for days and was in multi-organ system failure. The odds of them having the strength to move anything other than it just being an act of gravity are extremely small. Usually, although the monitor screen is turned off in the patient's actual room so as not to distress family members, staff members are watching and recording heart rate, respirations, blood pressures, and oxygenation on a main screen behind the desk. While I can't speak for my colleagues, when a patient expires in the unit, they are examined for any signs of life. Despite all the technology, there's no substitue for listening for a heartbeat, feeling for a pulse, and feeling for any air movement from even the slightest of breaths.

Then, there is also often a lag time from pronouncing the patient to transporting them to the morgue to give the family plenty of time to come in to the hospital or time alone with the patient.

Finally, this particular hospital has a bizarre thing that they put over the stretcher (almost like a covered cake plate) so that people passing by in the hallway/elevator don't know that they are next to a dead body. I don't know how anyone could have seen any arm movement, unless it was before the patient was even moved over to the stretcher.

However, this story brings me to two conclusions: 1) The transporter should have stopped and checked the patient. If, by any slight chance the patient wasn't dead, it certainly didn't help to put them in a refrigerator. 2) The maintenance worker should be commended for not only having the courage to say something to the transporter, but also for bringing it to the charge nurse's attention.

So, I don't think we put anyone on ice prematurely. However, in the small off chance that this could happen, maybe morgue drawers should have bells in them, not unlike quaint Victorian coffins.

For an interesting read on urban legends and being buried alive, check out this snopes.com article.

Lost in Translation

I finally got all of my holiday shopping and even mailed all of the packages. It actually wasn 't too difficult this year as my immediate family makes use of Amazon's wish list feature.

I was in Macy's today, trying to use up a $15 off on $50 worth of purchases coupon, and had picked up just enough stuff to meet the spending requirement (60% off flannel sheets and a sturdier spatula to replace the one I melted last week). The clerk at the counter was very confused by the card.

Clerk: This says it's good on your NEXT Macy's purchase.

Me: Right, I got it in the mail last week. This IS my NEXT Macy's purchase.

Clerk: Oh. Hmm... will you be charging this to your Macy's card?

Me: No, Mastercard.

Clerk: You have to use your Macy's card.

Me: I don't HAVE a Macy's card. Why would you send me a coupon to be used with a card I don't have?

Clerk: Oh. Wouldn't you rather spend $100 and get $25 off? (referring to an attached coupon)

Me: Why would I want to spend more to save less?

Clerk: You would save more... $25 instead of $15.

Me: Right, but that's a smaller PERCENTAGE.

Clerk: What?

Me: Nevermind. How about I pay cash?

She finally credited the coupon, but it was a bit more painful process than I had expected. I guess I was just surprised it was difficult to use an actual coupon when just earlier at a sporting goods store, I said something about there being a sign that the item I was buying was marked $10 off and they just subtracted the amount without even verifying it.

Very Superstitious

This morning there were painters doing touch-up work in the room where we had a particularly messy code last night. Coincidence? I think not.

People in our Emergency Department are constantly discussing the White/Black Cloud Theory. The idea is that things either stay relatively calm (white cloud) or rapidly go to Hell (black cloud) depending on whether or not a particular person is on. I am typically a white cloud, with shifts being hectic, but not typically all-out disasters when I'm at work. I seem to have lost my white cloud this month. Three patients died last night. Two were rather expected, as they were on comfort care status (no interventions), but the third was a freaking mess, despite having a cardiologist, nephrologist, intensivist, and general surgeon available in the unit.

I keep checking my pockets to make sure I don't have some sort of scythe hiding in my coat, but am coming up empty-handed. At first I thought it was just me, but this morning at shift change, the charge nurse was telling me that I am getting a reputation for being on during general badness. On the plus side, one of the floor nurses sought me out last night to tell me that a patient I had been called about several hours before had expired, and complimented me on being calm and collected (which was totally not the case internally) on the code I ran the other night.

Two more call nights and I am done.

Post-Mortem

He flipped the thick slab over on the white cutting board. In a different place, at a different time, you might think that we were in the kitchen, not in the sub-basement of a hospital. As he maneuvered the slice of liver, it kind of jiggled-- purple and shiny. With a probe, he poked at one of the bile ducts, digging around until he felt the scrape of the metal against something solid. With a quick twist of his wrist he dragged out the stone, black and yellow-speckled. Behind that stone, several more pebbles were lodged.

It seemed so small, but there it was, cause of death: biliary sepsis, secondary to obstruction.

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This is what I was dreading in my last post. The other day, we went to the autopsy of one of my patients, the one that suddenly crashed overnight. Despite having spent hundreds of hours in cadaver lab, I dreaded this. I didn't want to be there when they opened the chest of a patient that I had talked to and examined, a patient whose family I had several conversations with. Luckily, we weren't there for the whole thing, just for the gross inspection after they had already removed the organs.

Maybe I was being over-dramatic, and when I talked to a friend, he didn't really think this was any more gory than the things I witness in the trauma bay. I suppose that from that aspect he is right. Technically this isn't any worse, but it was something that bothered me emotionally. I can deal with blood and guts. I still remember the rush during the first month of med school of reaching into an abdominal cavity, sliding my hand down the posterior ribs, and blindly finding the spleen when everyone else at the table was still too squeamish to really look for it. However, mentally I have difficulty seeing someone opened up and explored, someone that I had planned on being able to fix.

The autopsy itself was performed to find an answer. We had suspected biliary sepsis all along, but couldn't find an obstruction. The patient had a cholecystectomy several years ago that was complicated by a biliary leak. We were suspicious of there being a stone stuck somewhere in the remaining bile ducts, despite not being able to see anything on ultrasound. The patient was septic, and we couldn't find the source of his infection. His hepatic panel was elevated, like there was something stuck somewhere. When a more invasive study (ERCP) was performed to look again for the stones, the patient expired on the table.

Technically, we did everything right for this guy. He was placed on an appropriate antibiotic in the ED, confirmed later by sensitivities on his blood cultures that came back after he had died. He was fluid resuscitated, intubated, and ventilated aggressively. It was simply a case of not being able to catch up with a late presentation. The stones sat there hidden, slowly leaking bugs into his bloodstream, while the symptoms of his illness were masked from his wife by his dementia. By the time anyone realized he was sick and he came to the hospital, it was too late.

It is what can be so frustrating about medicine: when everyone works so hard to fix someone, and in the end, it's the battle of pulling a brake on speeding train already mid-air, going over a cliff.

It's Over

It is official: the vacation glow has worn off.

I have had a horrible stress headache today... the kind where you feel like your brain is going to herniate into your spinal cord and run down your neck in a sloppy, not quite finished over-easy egg-like concoction. There is something coming up tomorrow that I really don't want to do, and am hoping it doesn't come to fruition.

Urban Hiking

Last night I felt like I was living in the stairwell. All the silly climbing back and forth reminded me of M.C. Escher's drawing, "Relativity". By the time I get to the ICU in the morning, I have climbed 7 flights of stairs. I decided to keep track of just how many flights I would do in the course of a shift on-call. My final number was 54, but that includes both going up as well as going down stairs. I did take the elevators once during the shift, but that was only because my intern was with me at the time. A few weeks ago, she had a bad experience of getting locked in some obscure stairwell, without her cell phone, and had to pound repeatedly on a door until someone happened to walk by. I personally found this hilarious, but took pity on her and got in the elevator. (It is hard to empathize with someone who averages 8-10 hours of sleep on call nights compared to my 1-2 because she only gets paged by me for admissions, and doesn't get woken up every 30 minutes by "updates" or lab results from well-meaning nurses.)

Last night was my 5th call night of the rotation out of a total of 9 scheduled, so as far as I am concerned, it's all downhill now. Things got a little hairy this morning when a patient that we had expected to do well overnight decompensated and now doesn't look like he's going to make it. When I left, the ICU attending thanked me for my hard work, but part of me thinks he was just being nice. As far as keeping up on people's studies and labs, I tend to stay pretty well on top of things, but these people are so sick that I don't think I always understand the whole picture of what is going on.

When I got home this morning, there was over 6 inches of snow on the ground. I couldn't get my car into the driveway, so after a quick nap, I cranked up the snowblower and got to work. The thing works so much better on a level driveway, unlike last year when it was pulling up chunks of asphalt with the snow. Hopefully it doesn't snow so much tonight that I can't get the car back out onto the street, but there's no way I'm getting up early to make sure I have a clear path.

Things I Didn't Think I Would Need to Say

Sometimes discussions with a patient's family members don't go as planned. When there's a large group involved, no matter what gets said, someone will be unhappy. Here's a few lines I said the other night that I wish I hadn't had to:

"The face mask is helping him breathe, but I don't know if it is actually prolonging anything."

"No, I can't take the face mask off. He is awake, and is choosing to keep it on."

"I understand that you are his healthcare proxy, but as long as he is capable of making his own decisions, we go by what HE wants."

"No, I can't intentionally drug him into unconsciousness and then take the face mask off."

"I understand that you were told he had less than 24 hours left, and that it has now been several days. I really can't accurately tell you how much time he has left."

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As life would have it, a few days after this, my parents tell me that they have just listed me as their healthcare proxy in the new revision of their will. I told them they have never been specific with me as to what their wishes are. To this my Dad said, "Just do whatever you think is reasonable." Argh.

Ditto

I couldn't agree more.

Last night, I benefited from the Emergency Department being closed. The ICU was short on nurses, so while we actually had empty beds, there was no one available to take care of any more patients. Meanwhile, all of the regular floor beds were full, so the Emergency Department was closed all night to ambulances. (Despite being overcrowded with horrible wait times, ED's are required to stay open to walk-in patients, but transfers and ambulance patients get rerouted to any open departments in the area. The exception to this is that if a patient demands to go a specific facility the ambulance crew has to follow their wishes, and if all of the local departments are closed, then we take alternate taking ambulance traffic.)

For me, this meant only 2 admissions overnight (we had to steal a float nurse from another floor), as compared to the sleepless night of 7 admissions last week.

So Sleepy

Ru moved out yesterday morning... onwards towards colder lands and her pursuit of writing. The house seemed strangely quiet when I got home from work this afternoon. It was good having her here, and when I think of her stay, I'll remember being reintroduced to Nutella and graham crackers, Mexican hot chocolate (it has cinnamon in it!), and her showing me how fold origami cranes while I complained about my daily frustrations.

Today it has been a great struggle to stay awake. I went to a hospital recruiting dinner last night with some of the other residents, and getting home after midnight made today's early rounds particularly painful. Tomorrow is another day of being on-call, so I'm definitely laying low tonight.

... Pants On Fire

One of my favorite things about working the Emergency Department is that you never know what you are going to encounter.

The other day, I pulled back the curtain in Room 5 to find a couple of paramedics sliding over an elderly gentleman onto the stretcher. A quick survey of the room revealed that there were several police officers there as well. The guy kind of smelled funny, so I thought maybe he had been picked up off the street.

As it turned out, the guy had gotten into an argument with his girlfriend. Apparently, he tried to shoot her with a shotgun (and missed). When the police officers got on scene after being called for shots being fired, they noticed that the house smelled like there had been a fire. Upon further questioning, it turned out that the guy had caught the cuff of his pants on fire while he was burning some leaves in the yard a couple of weeks back. He had trouble putting out the flames, and suffered some pretty severe burns to the back of his legs. Not liking to waste time with the doctors, the guy decided to treat his burns himself... by applying a home remedy of boiling water and Vaseline! The entire back side of one of his legs was one big, black scab, and his foot was now swollen.

To the officer's dismay, there was no way this guy was getting medically cleared to go to jail, especially as he turned out to be septic, and it looked like he had an arrhythmia as well. Apparently, he hadn't seen a doctor in over 20 years. When I asked him what his daily medications were, he answered "90 proof alcohol"! I had expected this guy to be from some rural area, given the shotgun use, and lack of healthcare. However, oddly enough, his address was right in the city!

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As for my ICU rotation, I now have survived two nights on call. During each one, I only slept about an hour of the twenty-seven hour shift. The first call night was an admission-palooza with just constant work to be done. Last night, there were a few breaks here and there, but I didn't manage to catch much sleep as I always seem to have trouble sleeping in foreign surroundings. I suppose this will get easier throughout the month as fatigue kicks in.

Less Whining

So far, not much to talk about in the ICU. I will actually have THREE days off during this rotation. Unfortunately, I have to work almost two weeks straight to get to the first one. Today was a short day as there was some confusion about the schedule and I was allowed to leave after rounds.

Since I had the rest of the day off, Ru and I went to a late lunch at the very popular local "honky-tonk" BBQ restaurant. The place is always packed-- its clientele an odd mix of bikers and businessmen. We dined on fried green tomatoes, and I ordered the "Big Ass Pork Plate." Ru, being much more ladylike, instead of saying the title said, "I'll have what she's having." So there we were with our plates of "road food" surrounded by beer swillers, and she sips her hot tea like nothing has changed (including the tattoo-to-tooth ratio).

Happy early birthday Ru, and don't ever change!

Slow, Deep Breaths

Tomorrow I start my four-week rotation through the ICU. I am somewhat anxious about it, as I am going to be the senior resident on the service (ha!) with some poor medicine intern to help/hinder me. Every 3rd day will be a 27-hour work day, after which I will go home, try to enjoy part of the day, work a normal 8-hour day the day after that, and then show up for another 27 hours. Repeat this about nine times. No actual calendar days where I am not physically in the hospital at least for some part of the day.

The ICU is not my favorite place. It is where we keep all of the actively dying people. Many times, their loved ones are completely unaware of just how sick they are. Sure, there are people that recover, sometimes miraculously, but often it seems to be a slow, steady decline. A decline over days and weeks, in which one gets to know a patient's family. I remember the rotation from medical school as being a month of terminal weans from ventilators.

It is also a good rotation for learning. There are a lot of bedside procedures to be done, and I am definitely going to be challenged to make quick decisions and know my own limits. There will be an attending physician on call at night, but they aren't even in the hospital.

I was talking with one of our chief residents about his experiences the other day and he said, "Well, you are either really going to learn a lot, or there's going to be a lot of people dying and you won't have a clue why." Great, I can't wait to get started.

Snow!

It is after 2 am and I just got home. My shift ended at midnight, but I ended up staying late to do some last minute stuff, and to sew up somebody's face. I am tired, and I left over an hour's worth of dictations behind. Stuff that can wait for tomorrow.

Today was the first real snow of the year. Very fine flakes this afternoon, and just before I went in to work, the thick, "lake effect" flakes that I love. When I got home, there was about 3 inches coating the fence and my roof. At this point, it's so clean and somehow magically insulates all of the background noise (although admittedly there's not much at 2 am). The slippery crunch under my sneakers is somewhat therapeutic. I am sure I will be sick of snow soon enough, but right now it's a welcome change.

Mothering

The other day I got a stern lecture from the charge nurse. The family members of my gunshot wound patient had arrived, so I went back to the family room to talk to them. I introduced myself, got everyone's relation to the patient, and sat down with them. About halfway through, the charge nurse showed up at the door and she did not look happy. I told the family members several times that the patient was doing just fine, that he had been shot through the ankle. It looked like the blood supply was ok, but he was going to need surgery and rehab to get back on his feet. I thought I did a good job, and other than not being able to answer any questions about who shot the guy, the family seemed pretty satisfied.

Later, the charge nurse told me not to EVER go into the family room by myself because I had basically surrounded myself with upset family members in a room with only one exit. Oops. I guess that I didn't really even think about it because the guy's wounds were so minor. We have had family members flip out and attack our staff, but usually it tends to be in situations where the patient is a lot more critically injured. Anyway, I guess it was nice that somebody was looking out for me.

Know a Good Priest?

The other night, I had a patient that needed an exorcism. She was rolling around on the bed, throwing up/spitting and inappropriately touching herself. You can imagine that this made her somewhat difficult to talk to. I thought briefly about calling a priest, but at our hospital, we have different clergy people that rotate through... so I just pictured some poor Presbyterian minister showing up and wringing her hands. However, I did think that needing an exorcist would be perhaps the only way I could ever justify transfering a patient to the nice, community Catholic hospital in town, a place I like to refer to as St. Elsewhere. With a crucifix in every room and nuns running up and down the stairwells in their habits and sneakers, there would be no escape there for her!

A quick scan through the computer showed she had just been discharged two weeks ago for an admission for intractable abdominal pain. The lady had a 3-year history of abdominal pain, and had been through the gauntlet as far as colonoscopies, catscans, etc. Clearly, this was a problem I was not going to fix that night.

She was thrashing around so much, that the IV team couldn't get a line in her. After she had been there three hours, the lab called and told us that there was only enough blood for them to run the lactic acid level... that I could forget about all the other tests I had ordered. So finally, I went in there and consented her for a central line insertion because if nothing else, I can't even admit someone for intractable pain if they don't have IV access.

She was sleeping soundly when I went in the room. After explaining the procedure to her, she started slamming her arms and legs into the bed, like your average two-year old throwing a tantrum in the candy aisle at the grocery store. I just stood there until she wore herself out. I had a long discussion with her about how I would not continue to give her muscular injections of morphine because if something bad happened I needed an IV line. She agreed to the line, and also agreed to let the nurses try one more time. This time, she miraculously held still so that we finally got her labs. Everything was negative.

A contrast-enhanced catscan was ordered. Then she started playing new games, "accidently" spilling her oral contrast solution all over the floor and whining about having to drink it. I went in there again and had another discussion with her about why she would come to the hospital for help and then refuse any kind of assessment from blood draws, to x-rays, to CT scans. She was still there drinking contrast at the end of my 8-hour shift. The new attending coming on decided to take over this patient personally. She has a reputation for not putting up with any behavioral crap, and was talking to me about putting restraining orders on patients that spit at her. I'm interested to find out how the situation turned out.

Randomness

One of my Flickr photos of the Tomb of the Unknown Soldier was picked to be part of an online map of Philadelphia:

www.schmap.com/philadelphia/home/#p=44873&i=44873_6.jpg

Lighter Stuff

Sometimes you have to find the humor in small things. A chapter in our textbook that was part of this week's required reading titled "Male Genital Problems" was written by someone named Robert Schneider.

The Switcheroo

Many Emergency Medicine doctors would probably agree that one of the main times where mistakes happen with patient care is at sign-out. At the end of a shift, care of any remaining patients left in the department is transferred over to the incoming physician. The goal is to get as many of one's patients dispositioned (discharged home or admitted with orders by the admitting service) prior to sign-out. As one may imagine, with "emergencies" continuously filtering in throughout the shift, it is sometimes difficult to know exactly what is going on with Mrs. Smith or her catscan. Patients are re-assessed by the incoming physician, but is generally a much more brief process than the initial history and physical exam, and often patients that are signed out as "stable" may not be checked up on until other, larger fires are put out first.

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The other morning, I took over a patient with a rectal bleed. However, this was not your typical rectal bleed. This patient had intentionally shoved a paring knife up her rectum. This story of course set off all sorts of bells and whistles in my head regarding psychiatric issues. The overnight team left, saying that she had some blood products ordered and the surgery team was taking over. Fortunately, it was slow enough, and her story was bizarre enough that I went in to see her right way. The woman was pretty quiet, and seemed rather hesitant to talk about it. At first she just said that she cut herself so that she could get admitted to the hospital. However, after a few minutes of talking, it turns out that she thought that she had "telepathic" powers with her dead boyfriend, and that by killing herself she thought that she would be able to see him. At that point, I had the patient put on a psych watch as she had been left unattended before that. She ended up staying all morning in our department though as her blood was too-thinned with coumadin and had to be reversed with transfusion before surgery would take her for exploration under anesthesia and repair the damage. She ended up doing fine, but she definitely required more time and attention than what was discussed at sign-out.

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On the overnight last night it was pretty much a one-woman show. There was a medicine intern there, but she can only handle about two patients at once. This meant that I took all of the patients at sign-out, plus saw my own new patients, and supervised patients picked up by the med student. The shift started off with a very minor gunshot wound in the trauma bay, and several transfer patients from other hospitals that had multiple injuries. Much of my night was unfortunately spent on the phone with consultants. It took hours just to wade through the sign-out patients that I had assumed care of at midnight. Our nursing staff is pretty awesome, and I get along with them. I think that what saved me was having the patient's nurses let me know when studies had been completed or the patient was essentially wanting to go home, because there were just too many people to check up on.

I think that we did a pretty good job, and by sign-out at 8 am, there was no evidence that we'd had a messy night. However, the shift was such a blur that I can't help but worry about things that may have been missed here and there. There were definitely people who could have been sent home sooner if it weren't for the volume of patients.

I watch the attendings in our department, and their styles range from very conservative with workups to relying almost entirely on clinical assessment. At the end of the day, this is a specialty where one definitely has to be able to rely on their colleagues. Sometimes there simply isn't enough time or resources to check and re-check someone else's work. It is becoming obvious to me that you have to like the people in your workplace, but I don't know how to assess whether a place will be a good fit when it comes time for interviews.

Daylight Savings Time

While I appreciate that the extra hour gained over the weekend meant that I only slept in until 9 am on Sunday, I hate the fact that it is now pitch black by 5:30 pm. I definitely DID NOT SIGN UP FOR THIS. It's hard to combat seasonal affective disorder when it's dark out before you go into work and after you get out. Bleh. I suppose that the crazy swings of ED shifts (8 am to 4 pm today, MN to 8 am Tues night) help combat this, but the whole Daylight Savings thing drives me crazy.

It's Not Them, It's Me

On Thursday I noticed that pretty much all of my patients were lovely, nice people. And then I started to think about it. Were they really all pleasant, or was it more that I was well-rested and not stressed out? I think that I am definitely guilty of letting stress influence my interactions with other people. Yes, there were constant interruptions all day long. I even had a secretary personally snip at me for not hearing her page me overhead. The difference was that I didn't let it get to me. Normally, I think I just let people dump their frustrations on me, and I end up internalizing it, and probably passing it on to others. I don't know how long it will be before cynicism returns, but hopefully I can keep it away for a while.

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Yesterday, I spent almost 11 hours with Army Guy. Last night we went to a comedy show, after just spending a day hanging out. We have been dating for a couple of months now, and it's going pretty well. Sure there are times when our schedules don't align (or he gets shipped to Georgia for two weeks for weird training stuff), but I still like him. He's smart, funny, polite and can even tolerate my teasing. I think that it helps that he has a career completely different than mine, so that I don't have to talk about work stuff, but he's always interested to hear about my work escapades. I have some rough scheduling ahead, and he has to run off to Ranger School in a few months, but for now, I am just enjoying having someone to go out and do things with.

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Today I worked at the basketball game downtown. We cover the first-aid station at the local University's football and basketball games. I was allowed to watch the game and have free range of the stadium, as long as I wore a headset and carried a walkie-talkie. It was an exhibition game, so the full crowd wasn't out today, and I didn't get ONE SINGLE CALL. The home team won (although they made us nervous for a bit), and the whole thing was over in two hours.

A funny thing happened during one of the breaks. The male cheerleaders each grabbed a large flag and together spelled out the home team's name. However, for some reason, the last guy wasn't a cheerleader, just some random band guy. Well, the cheerleaders took off at a sprint around the perimeter of the court, forming a parade of the team's name. Poor random band guy couldn't keep up with their pace. It was obvious he wasn't used to running with a large flag. The last letter was sadly a good court length behind the rest of the flags. Worse yet, as he turned the corner, random band guy slipped and fell. The mascot, who was keeping up with him, despite being in a full-costume grabbed his flag and finished off with the others. Guess you shouldn't expect to keep up with trained flag carriers.

It was a good day, and I think my game coverage (three hours total) replaced a full eight-hour shift! We don't get paid extra for covering, but you just can't beat a work day of eating nachos and watching basketball!

Ending October

Tomorrow I go back to the department. Between my toxicology rotation and my vacation, I have been away for just over five weeks. We had Wednesday lectures as usual today, and several people told me that I looked really good, or different somehow. I think it's the vacation and my general disposition. In general, I think I am smiling and laughing more... which is good.

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Today my driveway got resurfaced. I finally found a responsible contractor who actually shows up when he says he will. As an added bonus, this is the same guy who insisted that he could fix the existing unevenness, when everyone else wanted to break up the old driveway, and start all over from scratch for two-three times the cost! The driveway looks great, and the edges are nice and tidy. It definitely will be smoother on my snow blower this winter and should help with some of my water drainage problems, too.

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I also talked with my computer repair guy (the same shop my car rolled out of), and my laptop is unfortunately a total loss. The problem is either with the motherboard itself, or the battery, which is so expensive to replace that I might as well get a new laptop. I think I'm going to just have this PC for a while. My main concern was that before the laptop imploded I was able to backup all of my digital photos, but my iTunes music (20 GB) was still on there, and with about 15 minutes of work-time when the laptop would actually boot up, there was no way to get the transfer process going. It would have been easy enough, had I not downsized to a 4 GB iPod Nano earlier this year. However, what the computer guru suggested was that we salvage the hard drive from my laptop and transform it into a portable external hard drive, that way I could keep all of my files. I thought this was pure genius on his part. I donated my laptop shell to the store, so that they waived all of the labor and diagnostic fees and only charged me $30 for the work and the hard drive case!

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And as for my research project, that has not taken off yet. First, there was problems with getting the chemicals, and then the pharamaceutical company "forgot" to send us the drug. Over the past two days I have done more computer modules on the proper handling and treatment of research rats. I just want things to get going before I start my ICU rotation at the end of November because that month I take 24-hour call every 3rd day, so to be running over to the animal lab is just going to kill me schedule-wise.

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The other morning I woke up to find frost on my car, which prompted a much-overdue oil change and putting the snow tires back on. I am really not ready for dark winter skies just yet. However, in the time that I was gone, many leaves have fallen, and the neighborhood trees have fully reddened.

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The Trick-or-Treaters have been really few tonight. I guess I could have gotten into the candy corn a whole lot sooner!

Turks and Caicos Islands

For our vacation, "The Phoenix" and I stayed at Beaches, Turks and Caicos Resort. It was great. The company is the same as Sandals, but it caters to families with small children. Being two single girls, we figured it would be better to be around families than honeymooning couples. The resort was all-inclusive, including two scuba dives per day.

I was really impressed with how responsible the resort was with the diving. Before they would let us go, we had to demonstrate basic skillis in the pool first. Every morning, resort guests could choose to go on either a one-dive or a two-dive trip. Being basic Open Water level divers, we are not supposed to go below a depth of 60 feet, and the resort was really good about adhering to this. They also made sure that there was an hour surface interval between dives.

I had been a little concerned about diving at a resort. I don't know that I mentioned it here, but over the summer a resident in a different program at my hospital died while scuba diving in Belize. Apparently, he took a short resort course, and then went on too many dives. The first couple of days that we were there, I mapped things out on the dive table and found that they were being pretty cautious, despite the fact that our guides were all equipped with dive computers (which keep more precise depth measurements and allow divers to extend the time of their dives).

As for diving in October, the temperature was perfect. It was 85, and probably about 75-80 in the water. We didn't use wetsuits, and with it being off-season, the beaches and the swimming pools were never crowded, and our room prices were 40% off!

The diving was also much easier than my certification dives. The resort supplied all of the equipment, but we brought our own masks, snorkels and fins. The tanks were lined up along the side of the boat, so that all you had to do was set up your stuff, and walk just a few steps off the end of the boat. I think the buoyancy of the salt water made it a lot easier as well.

The water was really clear, and the numbers of tropical fish that we saw were amazing. On one day we descended to the bottom with two black-tipped sharks circling around us. We also saw barracudas, lobster, and my favorite-- a sea turtle. At the end of one of our dives, a dolphin followed the boat back, jumping out of the water and showing off.

Another great thing was that there was a protected coral reef about a ten-minute walk down the beach from the resort. In the afternoons, we snorkeled there several times and got a great look at many more fish.

On Thursday, we went on a night dive. It was fun. At one point, we all turned off our flashlights, and by waving your arms around you could see little sparks of light, or bioluminescence underwater. We had hoped to see an octopus on the night dive, but it didn't work out. I'm glad that I did it, because everything did look a little different, but I much more prefer daytime dives as you can see so much more. Plus there's something kind of creepy about only being able to see the 5-foot diameter beacon of light from your flashlight while other, bigger things are able to spot you from a distance away.

Unfortunately, as our flight left early Saturday morning, we weren't allowed to dive on Friday. Instead, we went on what was supposed to be a 3-hour kayak tour. The tour was fun and included more snorkeling, a stop at an iguana preserve, and "The Phoenix" found a huge beautifully colored conch shell right there on the beach. Unfortunately, it was quite windy that day and our 3-hour tour ended up being 5 hours of difficult paddling.

The food at the resort was delicious. I think I ate some sort of fish every day for lunch and dinner. There wasn't much of a night life there as it was more set up for families, but with waking up at 6 am to get ready, it didn't really matter. I would highly recommend this place for new divers. They did allow more experienced divers to buddy-dive away from the group.

Vacation!

Off to a warmer climate for a week! Hopefully there will be plenty of sun, lounging, and diving.

Everyday Miracle

If you have been reading this blog for any length of time, then you already know that I get into more than my fair share of mishaps. I seem to attract odd characters, or sometimes things just happen to me (like an attack squirrel coming down a lit fireplace) that just don't seem to plight your average person.

This afternoon, I took my laptop back to the shop. During the summer, they re-soldered the jack which fixed my charging problem. However, now the internal battery is entirely shot. I can't even turn the darn thing on after leaving it plugged in for a week!

Anyhow...

I had been in the repair shop for only about 10 minutes at the very most. When I walked out of the store, I was a little confused because my car was not next to the maroon van that I remembered parking by. I walked around the van, thinking that maybe I was mistaken about which side of the van I had parked on. However, my little blue car was not there. Had someone stolen it? Who, in their right mind, would go through the trouble of disengaging a security system on a 6 year-old Saturn? My heart started to beat a little faster...

... and that's when I saw it:

My poor baby had not only rolled backwards out of the parking lot, but she had crossed FOUR lanes of traffic and come to rest in a small, grass-covered ditch! I couldn't believe it. There had been no sounds of horns or screeching of brakes while I was in the tiny window-paneled shop.

I guess it is a good thing that there was no median on that road, otherwise my car would have seriously blocked traffic. I also can't believe that my car rolled across all of those lanes on a fairly busy road at 5:30 pm without anyone getting hurt. It could have been really bad.

So, I did what any other grown woman would do: I walked straight over to my car, like I had intentionally parked backwards into a ditch and drove it out of there! Then I pulled into the nearest gas station to inspect it, and there wasn't a single scratch on it.

Can you believe it? What a goofball I am! I figure that I must have forgot to put on the parking brake as my car has manual transmission.

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I also went for my first run in about a month. I only did 2.5 miles (with walk breaks). I went to my usual spot along the lake parkway. I was almost a mile in when I saw the police tape. I had forgotten all about it, but this morning there was a story on the radio about how a jogger discovered a body along the parkway. I don't know why they still had the area roped off after almost 12 hours, but the four officers just by their cars looked pretty bored.

And that was about all of the adventure that I could handle for a Tuesday!

On Writing

Ru has joined the NaNoWriMo project, the goal of which is to write like mad and crank out an entire novel during the month of November. Part of me is jealous because I simply don't have that kind of ambition.

The other part of me sees her sitting at her laptop typing "All work and no play makes Jack a dull boy." over and over. Inconveniently, I don't have a big maze-shaped garden in my backyard to hide from her when she comes after me with an axe. Let's hope it doesn't come down to that.

Organ Donation

Many people are uncomfortable with organ donation. They don't want to think about their own death, or don't like the idea of being all "hacked up". Many more aren't ready to think about this topic immediately at the time of their loved one's death, or are concerned about violating a loved one's wishes.

Here's something you may not know: if you do want to be an organ donor, you had better alert your family of this because once you are gone, the decision is basically theirs. It doesn't matter if it is on your driver's license. It doesn't matter if you are listed with an organ donation registry. At the time of your death, if your next of kin isn't agreeable to the donation, it doesn't happen.

The other day, a thirty-something male intentionally overdosed on cocaine. His dingbat girlfriend drove around with him for several hours before bringing him in to the ER. By that time he had suffered a major stroke. After several days in the ICU, there was nothing left that we could do. He had no will, and unfortunately, his next of kin was his 18 year-old daughter. She wasn't very close to him, and definitely wasn't prepared to make any decisions. Eventually, life support was withdrawn and he died. Despite being listed on his license as an organ donor, his daughter had never discussed his wishes with him, and she wasn't comfortable making that decision. I don't blame her. She's very young, and it is a difficult predicament to be in. However, at the same time, the guy was fairly young and healthy, and at least his death could have helped several people.

Talk to you family or spouse, whatever you decide.

October Skies

I think it's official... summer stuck around here kind of late, but all of a sudden, it's gone. Unfortunately, the sunny skies disappeared at the same time as my stupid cold symptoms. It has rained every day this week, which doesn't bode well for my contractor showing up and getting my driveway redone before the winter arrives. All of the bulbs and dead-plant replacements that I ordered weeks ago finally showed up and are actively drying up in the garage since even I am not crazy enough to plant bulbs during lightning storms. I was scrambling to get the lawn mowed this afternoon as the first few raindrops started to fall.

It is also no coincidence that with the cooler weather, I am finding myself hungry all the time. I guess it is time to put away the sunscreen and re-vamp my gym regimen.

Sigh.

Certifiable

I spent this past weekend in "Nearly Canada" finishing up my Open Water Diver Certification course. The last part of the course involves completing four dives over a two-day period. The water was cold enough that we had to wear wetsuits, hoods, and gloves. While wearing all of that equipment made performing our basic technical tasks awkward, I am also confident that I will have a much easier time in warmer water.

To my surprise, we did shore entries on all four dives. I think that shore entries are much more physicially exhausting because you have to strap on all of your weights, tank, BCD (buoyancy control device) and clambor down a plank while holding onto your fins and mask and hoping that you don't fall on your rubber-encased butt. In a boat, you can just gear up and jump off.

The bay where we were diving was pretty cool because there was an old ship that had sunk right there off the shore many years ago. Although visibility wasn't more than about 20 feet, I did get to see a few fish and some interesting wreckage. However, most of my time was spent trying to focus on my breathing, not dropping to the bottom or bursting to the surface.

Saturday night I spent in a roadside motel. While the staff was extremely friendly, I was more than thankful that I hadn't seen that recent slasher film about motels in the middle of nowhere. I guess it was actually kind of quaint... if you like wood paneling, shag carpet, and red lighting in the bathroom! There wasn't even a deadbolt on the door. Yikes.

Today, I am surprisingly sore. My calves ache, despite all of my running this past summer. My shoulders hurt... which I kind of expected given that I have the upper body strength of your average 7 year-old girl. However, when I take a deep breath, my entire rib cage hurts. I think I pulled every single one of my intercostals!

The reason that I pushed to get the course finished is that I have another adventurous vacation with "The Phoenix" coming up in a couple of weeks. With being at opposite ends of the country for residency, we decided that the best way to stay close friends would be to vacation together. So after suriving our crazy Grand Canyon hike, we decided that SCUBA would be the next adventure.

Omission

Entirely forgot to mention our first procedure: a cricothyrotomy.

Have a great weekend!

All in a Day's Work

This evening I was watering some of the plants out in the front yard when I overheard some of my neighbors talking about their daily activities. I ended up with somewhat of a smirk on my face because I wonder what they would think if they only knew what I was up to.

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Yesterday, we had a morning of lectures, reviewed journal articles, the usual stuff. Then, in the afternoon, I went to cadaver lab with all of the other second-year residents. There were enough to go around that we worked in teams of two. Our mission was to basically perform as many procedures as we could with the equipment that we had available over the course of two hours.

My partner and I went right to work. We did venous cutdowns on both ankles, both thighs, closed and open DPL's (Unfortunately, my buddy perforated the bowel on that one, which made us in a bigger hurry to get out of there!), a couple of Burr holes, bilateral chest tubes, followed by a thoracotomy. The idea is that some of these procedures we may not actually get to perform during our residency time, or even during our careers (DPL's are kind of obsolete) and we should at least be somewhat familiar with the basic technique.

It was helpful to be in a low-stakes environment to practice, rather than our typical on-the-spot trauma bay learning, with tons of people watching and judging. And there's always something somewhat amazing about holding a lung or heart in your hands, even if it is not actively beating.

After that, I picked up my friend at the airport. He offered to thank me by buying dinner, and although I may not be the brightest crayon in the box, I am certainly not dumb enough to turn down a free meal! We ended up going to the casino that he's been trying to drag me to since we started residency. After dinner, I watched him play craps (I wasn't confident enough about strategy to fork over any of MY money, but I was more than happy to roll the dice with his!). I finally pulled him away from the table an hour and a half later and $95 richer, so technically, I think he owes me another dinner since it didn't actually cost him anything!

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Today's activities were much more common. I went to work, sat through some lectures, and followed it up with an evening of watching television and baking chocolate chip cookies. Not exactly the satisfaction of hand-drilling into someone's skull, but still a good day.

Ode to the Taxi Cab Driver

The hours are horrific,
His sense of direction uncanny.
His malodorous backseat
Has carried many a large fanny.

That guy on the corner--
"Where to?", no other question.
A good driver knows
There's more pay for discretion.

A gunshot or stab wound
Gets driven with haste.
When they prepay,
There's no time to waste!

Drop him at the ER,
Somewhere near the door.
At $2.80 per mile,
That is all he paid for.

The man in the lot,
His story, no one knows.
"Hey wait, Mr. Cab Driver!"
But silently he goes.

With a screech, he drives off
To the next airport or bar.
Wherever it is,
May the next fare go far!

Unexpected Simile

"Come look at this, it's so pretty!" she exclaimed from the kitchen.

I left my dark office to go have a look. Ru was slowly stirring a concoction of sugar and eggs on the stovetop. It had this opulent, creamy sheen to it.

"Hmph."

"Isn't it pretty?" she asked.

"Well, it kind of has that shine-- like pus draining from a shooter's abscess that I've cut into." With that remark, I went back to my study, after receiving a cutting glare.

Vocabulary Lesson

This past week I started a toxicology rotation at the poison control center. Unfortunately, (or fortunately, depending on whom you ask) there haven't been many overdoses lately, so business has been pretty slow. I was sitting around the table with a couple of the pharmacy students when one of them turned to me. (Keep in mind these women are six months away from becoming doctorate-level pharmacists.)

1st student: "Excuse me, can I ask you a question?"

Me: "Sure."

1st student: "Which word means country: rural or urban?"

Me: "Rural."

1st student: "Are you sure about that?"

Me: "Pretty sure."

2nd student: "The way I remember it is that the store, Urban Outfitters, is like, in the city."

1st student: "Oh, yeah." (Long pause here, then much scrunching of the face.) "But what about Keith Urban?"

Me: "What about him?"

1st student: "Isn't he a country singer?"

(I shake my head and walk out of the room to keep from laughing.)

2nd student: "I'm pretty sure she's right that rural means country."

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Am I wrong here, or aren't those 4th grade vocabulary words? Maybe these two have dedicated all of their brain power to chemical reactions, but I found this conversation kind of scary.

Crazy People Get Sick, Too

During medical school, several of us wrote down funny quotes from different speakers throughout the year, and then some of the best ones were printed on our class t-shirt. One of the better ones was, "Managing physicians is like trying to herd cats." Another favorite, "Crazy people get sick, too. Don't get distracted by all of the craziness."

The other day I almost missed a bread and butter diagnosis. This guy came in complaining of a headache for three months, chest pain for two days, and abdominal pain for twelve hours. He was really distractable, and the more I tried to get him to focus on one thing or another, the more symptoms he kept developing... like insomnia, and left ankle pain. Perhaps I was already annoyed by my ongoing cold and the opportunity to hone my mouth-breathing skills, but I just was losing all of my patience with this guy. It didn't help either when later he started having pseudoseizures... he would start twitching at random, but still was able to answer questions and follw commands, like from the nurse to "Stop twitching and hold still so I can start this IV."

Annoying, just annoying.

Somewhere along the history of present illness for his headache, he told me that the only thing that made his headache of three months better was, "Stabbing myself in the temple daily with a butter knife."

Review of his daily meds revealed two narcotics, and an asthma inhaler.

Review of his computer chart revealed a previous mention of schizoaffective disorder... for which he was not currently being treated. It was becoming clear to me that this guy hadn't just "slipped through the cracks" with regard to follow-up care, it was more like he had fallen down a gorge and the vultures were circling.

So I called the psychiatry resident on call, and told them that I was working on clearing him medically for his chest pain, headache, and abdominal pain. However, what he really needed was assessment and follow-up with a therapist and a psychiatrist.

Easy enough, right?

Things got a little busy in the trauma room, and the next thing I know my personal intercom is going off while I'm putting in a central line. It is his nurse. She tells me that his blood sugar is 690. (Normal is 70-110 fasting, or less than 200 after eating.)

Oops.

Not only is this guy an undiagnosed diabetic, but he is in DKA and as all of his bloodwork starts coming back, it is becoming apparent that he is actually quite sick. Fortunately, he had already been started with IV fluid replacement, but I could have been a lot faster with the insulin therapy had I not so been distracted by all of his psych stuff.

He actually ended up getting admitted to the ICU for monitoring, but should be discharged by now after having received diabetic teaching and started on new meds, and will be seen by the psychiatry service before discharge. Before he went upstairs, he thanked me for taking his complaints seriously. I felt like such a jerk. I guess that's why we do lab workups on our psych patients.