Monday, April 16, 2007

2nd Chance

The tulips I planted last fall aren't anywhere near blooming, but these ones are keeping me happy in the mean time.

Last night I got another chance at intubating. A woman came in who was unresponsive, jerking her arms and legs all over the place. She was fighting against everyone and randomly coughing and spitting. Her husband was there, but he said that she was very secretive about her medications and he had no idea what she had taken, just that she was acting bizarre all day and kept falling throughout the day. We tried calming her down with some benzodiazepines, but that did nothing, and didn't help her tremors. She seemed to be having a lot of trouble breathing and controlling her secretions, so intubating was an easy decision.

I once again had a full audience as prior to intubating her, it took five people to hold her down. This time I got it! It took two tries because she had a tight airway and the first tube I tried was too large. Things also got a little hairy as she started dropping her heart rate and oxygen saturation after the medication was given, but that all corrected with intubation.

Since we weren't sure if she had overdosed, was going through some sort of withdrawl, or had a brain injury, she got a pretty extensive workup. When everything came back essentially normal, I called the neurology resident who proceeded to yell at me for intubating her and literally hung up on me. Then he snuck in and saw her without talking to anyone. He basically copied my notes off the chart and wrote that he didn't think it was a seizure and that she needed to be seen by a psychiatrist when she got extubated. I am really getting tired of that service. We wanted her to get an EEG, but those unfortunately have to be ordered by the neurology team. I realize that her being sedated kind of messes up his ability to examine her, but I couldn't very well wait until she aspirated on her saliva and stopped breathing. I also didn't have time to wait for him to come down and see her before securing her airway.


My other "big case" of the night was a 25 year-old with two seizures earlier that day. He had been seen at another hospital, and sent home. I was waiting for the report from that other hospital to decide what all we needed to do for him. My attending said that as he had another seizure since being evaluated there, we needed to do the whole workup. That turned out to be a very wise decision. I was sitting at the computer reviewing all of my patient's results when I pulled up his CT scan. It hadn't been read by the radiologist yet, but clearly there was a huge problem. I saw what looked to me like a tumor, and he had some sort of blockage (obstructive hydrocephalus) that was causing the CSF to accumulate on one side of his head and compress the brain tissue. It wasn't good, and just seeing it made me nauseous.

I pulled my attending away from what he was doing and told him he had to see this scan. I think he thought I was crazy at first. Then I went over the images with the radiologist, talked to neurosurgery, and ophthalmology. Then I had to talk with the patient and his entire family about the findings. I tried to explain it as best I could, but in the end, I ended up showing his mother his head CT. I don't know how to explain the other hospital's decision to send him home, but when I left he was going to get an MRI and he may need surgery right away.

Last night I had a hard time getting to sleep. Two traumas came in at 5 minutes before sign-out and I stayed late doing some dictations, but I was still wide awake at 3 am when I got home. It was snowing hard on my drive home. I just kept thinking about that patient. If it had been up to me, I would have just repeated his labs and not his head scan. This scan was so abnormal that staff from across the room noticed it and kept asking who it was. We never did get the report from that other hospital. Everything else was faxed over, but they said there wouldn't be a typed report until during the week. That's the sort of thing that terrifies me. Forgetting to check one lab or study could be crucial.


~~Silk said...

I've got to wonder about the other hospital re the 25-year-old. Something like that is hard to miss. Scary.

ru said...

I'm just sitting here during the kids' snacktime living a completely different life, vicariously. I could never do what you do, but it is so fascinating. I like the way you write details without being boring; that's a tricky balance.

Chris said...

I am always impressed by your compassion for your patients and your genuine concern.

I completely understand how you just can't "shut it off" when you walk out of the hospital. Thank you for being a physician....I sure the hell couldn't do it!