Whew!

My last call for internal medicine wards was NOT one to forget. It's hard to believe all of the things that went on could really happen within one 30-hour period. Being able to actually use this stuff is much better learning than reading it in books and taking tests. Without further adieu, here is the list of major events (in addition to all of the high blood pressures, low blood sugars, and need for sleeping/pain pills) that took place on my farewell to Medicine Wards...

1. Pathology came back from the mole I took off in clinic last week. Positive for melanoma - skin cancer in a 29 year old. Negative margins, but my excision was 2-mm short of the goal. Arg!

2. Went to evaluate a patient for chest pain. That is nothing special, but while I was standing outside the room writing orders and a short note, her oxygen saturations dropped to 40%'s (normal is >90%). Thankfully, she improved with some suctioning.

3. A few doors down a patient went from being pleasant to acutely agitated and aggressive. She rips out her own IV. Obviously, I can't get any labs or studies. We calm her down with some Vitamin H (aka Haldol) in time for the nurses to note that she now has unilateral weakness. After a stat head CT scan to look for stroke, we finally get the rest of the studies I wanted originally.

4. Speaking of stroke... All morning I worked on getting a different patient calm enough to have an MRI for her stroke symptoms. We finally got a partial study before she freaked out in the scanner and a short time later the Radiologist called me: definite stroke. Next step, call the neurologist.

5. Beep... Beep... Beep... Code pager! They end up coding the same patient four times for V Tach.

6. Nothing exciting, but we did still have to do the standard admissions from the ER. One renal failure. One probable undiagnosed cancer. One delirious pneumonia.

7. Geriatric patient has passed away and needs to be pronounced. Sure enough. Time of death: 14:02.

8. Once again, called for a acute mental status change. On arrival, realize "nonresponsive" would be a better description. Stat labs/glucose/EKG please. Nurses are busy with that so I check blood pressure myself and it goes from 120s to 70s. Seriously!! Fluids wide open. Temperature now 34 - ask for a rectal - 34.6. Not normal! Another stat head CT once his BP is stable, and off to the ICU.

Think that's all. Guess again...

9. Someone else is throwing up blood. NG lavage gets back a lot more blood and of course now he's wretching with the maroon stained fluid oozing out of the sides of his mouth. Vitals and hemoglobin are stable. Another stat imaging study on its way.

10. What now? Another nonresponsive patient. Before I order my third stat head CT of the night we give a little Narcan to reverse the effects of narcotics. His eyes pop open and he glares at me. No more morphine for you, sir.

And to end the night, just as we start our morning rounds...

Beep... Beep... Beep. Code blue! I'm just down the hall so of course I'm the first doc to arrive. No pulse. Chest compressions going. Here we go. Get some meds going. Finally get an airway cleared of bloody vomit. After 20 minutes we have a rhythm, pulse and ICU bed ready across the hospital. Hold up, not so fast. A nurse two doors down starts yelling for help. You guessed it Code blue down the hall. Do you want to know how many crash carts are on the floor... one! That's not a good scenario when two patients are coding. Everyone rushed down there and supplies arrived from the floor below. Remember, the first patient is far from being stable and also now far from the ICU. Sure enough he goes asystole with only me, his nurse, and a respiratory therapist in the room. I start chest compression while ordering a round of epi again. Respiratory is bagging. The nurse is pushing meds. Other people are flipping from one room to the next to help out. We've almost maxed out our drugs and decide this will be our last round when we get a pulse. A good pulse. It was our window so we rushed him the 1/8-mile trek to the ICU. Prognosis is terrible, but at least he'll have a heart beat when family arrives to likely say their final good-bye's.

After all of that adrenaline I didn't even need my post-call Starbuck's. It was a relief to hand off the code pager to the next intern later that morning, but I was also incredibly grateful for the experience. I guess that is the way to end Medicine wards. You can't really top that!

Therapy

What would you do with your first two-day weekend since Labor day? It didn't take long for me to decide what I was going to do. I was in desperate need of some retail therapy! Owen and I were two of the first people in the mall Saturday morning, and it didn't take long to have a bag with two new pairs of shoes. It was glorious!

On the Border

The goal for all of our patients is to get them healthy and out of the hospital as quickly and as safely as possible. Well, we currently have a patient who has been admitted since June. That's correct, they have not been out the walls of the hospital in nearly four months. No fresh air. No warm sunshine on their face other than what filters in through the windows. They came in very sick and unfortunately had one complication after another.

As rocky as the medical course has been, the social issues are even more touchy. Just imagine this: You hop on a plane from Canada for a nice visit to see your family in the States. As you share old memories and laughs you suddenly collapse. Thankfully, you can't remember the whirlwind of being rushed to the emergency department and then flown hours away for more medical care. When your mind finally begins to clear you are surrounded by white coats trying to explain your new circumstances. You can't make out their medical terminology, and in fact, you can't make out anything they are saying because you don't speak their language. For days and weeks you nod your head to be polite and treasure the few minutes a day that they take the time to use the interpreter phone. Some days are physically exhausting; other days are emotionally draining. Not only are you sick, you are lonely. Some days you wonder how this will all end. You are sure you've ruined your family's future as you wrack up hundreds of thousands if not millions of dollars of medical bills. And of course there is no health insurance to cover these expenses. You can no longer eat. You struggle to breath. You can't understand the doctors let alone the television. And your family is hundreds of miles away. Why are these people surprised that you are falling into a depression?

So here we are. What do we do now that they are almost "stable" yet still so medically fragile with a long road ahead? The standard answer would be to transfer to a skilled nursing facility or a rehab center for additional therapy. Unfortunately, the reality is that these places can't really afford to take uninsured, foreign patients. It is a limited resource after all.

Our thoughts wonder how different it would be for this patient if we could just get them home. All that medicine and therapy has too offer will be available from their socialized system. Now, how can we cross that border? Trust me, we've been working with who and what we can, but it's, of course, more complicated than I can begin to imagine. After exhausting our other alternatives, the best plan for now is to get the patient healthy enough to make a 14 hour drive with some family across the country and across border to the nearest Canadian hospital. Even as I type this I hesitate knowing all of the extraordinary things that would have to happen for this to be a safe journey. I know how wiped out I might feel after that road trip let alone all that they will have to deal with along the way. Feeding tubes. Medications. Dressing changes. Stools. The Foley. Suction devices. DVT prophylaxis. And on and on. This is going to require super-human strength.

9.11

This 9-11 isn't a month late reference to the twin towers tragedy. It is actually a weight: 9 pounds 11 ounces. Yep, a 9-pound 11-ounce baby came into the world this week. What a whopper. A cute whopper, too. Thankfully, we planned her C-section for a week before her due date. Can you imagine how much bigger this kiddo could have been?

This surgery was so much fun and again served as a reminder that my job is awesome. This patient was my first continuity Ob. Meaning that I've been following her in clinic for her entire pregnancy, and I've had the privilege of getting to know their family for the last few months. It makes the delivery even more sweeter than all of the others where I show up at the end, barely introduce myself, and then: "It's a boy!" I much prefer this.

The day actually started bright and early - actually, dark and early because I still had to see all of my hospital patients for the service I'm on currently. I tried not to be too hasty in my excitement, but I was so anxious for the big moment.

Finally, we were standing in the OR and thick black hair was visible through the incision. After a few tries to pull the dark, round head out into the world, we resorted to the vacuum to give a little extra leverage. (You know it's a big kid when you have to use a vacuum during a C-section!) Within moments he was out. I cut the cord and handed my newest patient to the nurse waiting behind me. Perfectly healthy. Perfectly happy. As the baby was screaming and getting accustomed to the world around. I got to sew the muscles, fascia, and tissues back together. The adrenaline pumped as I remembered how much fun surgery is.

Then, shortly before Dad was showing off the tiny face to Mom, the nurse yelled out "Nine Eleven." All I could think was: thank goodness we didn't do a TOLAC*!



(*TOLAC = Trial Of Labor After C-section; i.e. attempting to have a vaginal delivery after having a prior C-section.)

Resources

What a waste! I was so frustrated as I left the hospital today. So often hospital resources are wasted. Just wasted. And it is incredibly frustrating.

One of my patients is a "frequent flier." And that alone generally doesn't bother me. But today all of it was frustrating. Today, my patient was ready to get out the door. "Okay for discharge" was written in the chart and then, with my purse on my shoulder, the dreaded buzz of the pager. (My pager has become such a part of me -loved and hated- that I seriously have phantom pages when I'm not wearing it. It's like people who loose limbs and have terrible phantom pains.) The voice on the other end crushed my soul as she informed me that my patient was now a wobbly mess seeing clocks and dogs that weren't there. "No longer safe to go," was the dagger at the end of the conversation. Crap. No, they weren't having a stroke, an aneurysm hadn't ruptured, and they weren't over medicated. All of which could be possibilities except that we all knew exactly what was happening. Alcohol withdrawal. I had failed to get them out of the hospital before their blood alcohol level bottomed out. Darn it. I tried so hard because I knew this was bound to happen.

Knowing that the patient wasn't interested in quitting, we now had three options: 1) let them go in the middle of withdrawal and hope that they get a drink before they seize; 2) write a "prescription" for beer in the hospital before they leave, and then send them on their way with a little buzz; or 3) keep them for a few more days, go through detox, then discharge them to drink 30 minutes or less after they walk out the door. The first option was bad from a legal standpoint. The second option was tough from a professional and moral standpoint. And the last option was difficult from a practical standpoint. See what I mean? Frustrating. We opted for the third, but it was with hesitation.

The patient's (I mean the government's, actually I mean our) bill will be in the thousands of dollars just so that we won't be legally responsible for the half an hour between them walking out the hospital doors and their next drink. Think of all of the man power that will be wasted between the nurses, techs, doctors, therapists, and support staff in the next few days. Not to mention the tangible stuff like IVs and medications.

Oh well. Big sigh.