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.

---------

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.

----------

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.

----------

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."

----------

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.