Category Archives: Patients

Due Dilligence

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Being at the children’s hospital for the past few weeks, especially coming off a month of vacation, has been absolute torture. Just…give…me…one…sick…patient! PLEASE! I know that sounds horrible to ask for, but when there are 5 residents covering 13 rooms, and it’s yet another kid with fever, but running around the room like a tornado, it feels like pulling teeth one agonizing patient at a time. The challenge here, and the thing that scares me a little, is that 95% of these kids are totally, absolutely, no doubt about it fine.  But some of these other little buggers, there may be some little thing, some little harbinger of impending doom, that if you don’t pick it up, these kids might not do so well. And that’s really no different than adult medicine when you think about it, but still, they are kids, and no one wants to do harm to a 1 year old. So the challenge has been to stay sharp, to do due diligence on each kiddo, get them all undressed, look em’ over from head to toe. Ask all the questions, to each patient, each time, even though, the majority of these kids can be discharged from the doorway.

So last night, I was seeing a 4 year old, mom brought her in for cough and congestion and some dry skin on the face. Clear as day, the kids got a simple URI, but I got the kid undressed anyways, just to make sure she wasn’t retracting or anything like that. And when I did, I noticed two 4cm marks on her forearm.

“Sweetie, what happened to your arm?”

“My mom hit me with a belt!” (all smilely when she said it too). And of course mom is sitting right there. Mom openly admitted to it, giving the reason that she has six kids, lost her cool one day, it only happened once, she feels horrible, and has enrolled in parenting class.  Fine. Still gotta fill out my paperwork and call child services.

I’m not trying to say, oh look how great my H&P is, rather, just how easy this would be to miss. I’ve been really trying to do my H&P’s the same for most everyone, adults and kids, regardless of what the complaint is, same set of basic questions, same basic physical exam maneuvers, and then focus and expand based on the complaint, just to make it habit, so when it’s 4 am and I’m dragging my feet, habit will kick in and make me check these things that I might not bother to otherwise, as was the case with this kid.


(plus, the set of questions I ask, hits 10 systems on the ROS, two per system, so that way I’m not actually committing medical billing fraud when I document my level 5 chart! Bonus!)

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I think that one of the best things we do in the ICU is when we allow people to die with some degree of peace and respect. We recently had a Cambodian patient, on life support, with no hope of recovery. Discussions were started with family about withdrawal of care. And while they were in support of the idea, their concern was that he somehow had to die at home, and not on a Tuesday.  I understand the dying at home part, but I was never clear on what it would be bad for him to be allowed to pass on a Tuesday. It had something to do with his Buddhist religion, but I was never informed of the specific reason. I would have asked all the monks that where there in their orange robes, but none of them spoke English. So when Wednesday morning rolled around, the monks and family gathered in the room, the ambulance crew showed up. We loaded him onto the stretcher and literally pulled the breathing tube out as he rolled out the ICU doors. Medics were instructed to NOT check a pulse, NOT check for breathing, not to do anything other than get him home as quickly as possible. And, under no circumstances, where they to come back to the hospital. It was the best thing we did in terms of patient care all month.

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I was in seeing an older couple, probably late 60’s, the wife having come in for chest pain. They were recent immigrants from Turkey, if I had to guess, within the past few years. The husband had a basic grasp of English, but hers was still a work in progress.  Culturally, they were still obviously working on acclimating, the husband wearing a bright red, entirely too tight tank top, and leather biker’s cap, on a freezing cold winter day.  They were both very pleasant people, trying their best to understand what was happening, but anxious nonetheless, despite multiple reassurances, both very concerned that I was admitting her to the observation unit for a chest pain rule out. Looking back, their anxiety makes sense, I can imagine that in other countries being admitted into the hospital must be a pretty big deal, and probably only happens if you are pretty sick.  Not necessarily so in this country, but a topic best discussed elsewhere. After multiple trips into the room to answer all the husbands various questions and to reassure the wife that she in fact was not dying, I noticed that they both were wearing matching necklaces. The necklace was a gold chain attached to a black leather triangle, maybe 3cm at it’s widest point, and it actually appeared to be a pouch of some sort. On my final trip into the room, I couldn’t help but ask about the necklace and what it was. The husband turned to me slowly, and put his finger to his lips is a “shhh” gesture. He leaned in close to me, and whispered in heavily accented english “ Wife and I are exiled Turkish royalty, necklace contains key to safe deposit box. BIG stacks of money”, making a wide gesture with his hands.  He must have seen the incredulous look on my face, because he waited a few seconds before him and his wife both broke out laughing. Realizing it was joke, made extra funny given the language barrier, I couldn’t help but cracking up too. He then explained it was a prayer necklace, not in fact a pouch holding a key to untold riches.

The Devil Wears Prada

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It was about 3pm and medics brought in this guy on a stretcher, covered in sweat, all rigid and tremulous, shaking his head back and forth shouting ‘Nope nope nope, not gonna do it”.  I heard the medics telling the nurses “Yeah, his complaint is that someone put the voodoo on him and sold him to the devil”.   Mmmmm hmmm, I see.  The guy wasn’t combative per se, just resistive to treatment, not really wanting to get into the bed from the medic stretcher, in fact just kinda standing next to the bed… sorta bobbing and weaving, moving his feat back and forth, arms pumping up and down, kinda this Gangnam Style meets Techno Viking routine. In fact, as we watching his moves, waiting for security to arrive, one of the nurses started dropping a beat and shit got rather crunk for a hot minute. A B-52 and a 4 point later our hot steppa’ was all snug as a bug in bed. His brother, who had called EMS showed up and told us that when he saw him last night, he was perfectly fine and had just finished a shift at work. The guy had no past medical, never did drugs or drank, and in fact was quite religious. He told his brother he didn’t feel quite right this morning and over the course of an hour gradually went from normal to the rhythm machine that presented to the ED.  Before leaving, the brother placed an open bible underneath the patients head. How sweet.  A few hours later, our patient was awake and calm and pleasant. I sat down and had a little chat with him during a quiet moment, and learned that apparently, after his brother left he “went to the club with a woman I should have known better about”.  Ah, the devil wears stilettos! Who knew!

Looking back, I sincerely feel that if the start I had introduced myself as a doctor AND a priest, whipped off my white coat, fanned at him forcefully shouting “DEMONS BE GONE” we might have saved this guy from most of his troubles. Of course, he then would have fainted and we would have head a trauma on our hands, so maybe it wouldn’t have been such a good idea.

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You know there has been a lot of false alarms when your rhythm strips are feeding directly into the garbage….

Had an impressive patient this week. An 82 year man came in with foot pain. On H&P, turns out he had ever running 3 miles a day, ever day of the week except Sunday, because Sunday’s are for church, since he left the army almost nearly 60 years ago… By my quick count, that’s over 55,000 miles, in other worlds, he’s circled the globe on foot twice. Not bad for 82.

He was a 72 year old gentleman who was in from out of town visiting his family. The family had gone off to church, and him not being the religious type decided to stay home and go for a walk around the block instead. The sidewalks in this part of town receive a minimal amount of maintenance at best, and are full of cracks, bumps, uneven sections and the occasional gaping trench. He was one of the sweet old men, gregarious, pleasant, not upset about being the ED. Flirting with the nurses as only a 72 year old man in hospital gown can. As best as he could recall, he caught his toe on one of these uneven sections and the next thing he recalled was being in the back of the ambulance. He had a nice gash over his eye, and a nasty scrape on his cheek. Clearly his head and the side walk had a bit of a close encounter, but otherwise, he was no worse for wear. So he got the usual work up, repaired and dressed his wounds, checked his neck face and head for fractures. I was getting ready to discharge him when he pulled me aside. “Doc, I’m wondering if I didn’t trip after all. I mean, if I had tripped, I would have gotten my hands up right? I might have a scrape on my hands, or at least not hit my head so hard. But guess what else doc? My wallet and phone are missing. I think I got pushed, and then robbed.” And sure enough, his valuable were gone. He said he only lost $80, and true to his happy nature, he didn’t seem too bothered by it, or the loss of his phone. What he was most concerned about, was that he had no idea where his relatives lived and no idea what their phone number was, as it was all in his stolen wallet and cell. Thankfully, our social work team was able to play detective and get this nice man a taxi ride home. Definitely made me mad though, that somebody did this to this nice guy, someone in town just to visit. Welcome, indeed.

All’s quiet.

It was all quiet in the ED at 2am, literally. The normal noise and commotion, the beeps and dings, all seemed to have stopped for whatever reason. I was catching up on charts, when the sound of cascading water crept into my consciousness.  I looked up from my chart, and spoke the thought out loud “Why do I hear water dripping?” My attending’s head shot up from his own chart, eyes bolted open “Oh no!”  We both scrambled to the far side of the doctor’s area, only a few feet away, to find our worst fears confirmed. On the stretcher was one of our intoxicated patients, completely swaddled in blankets. Completely swaddled that is, except for his penis, which was poking out between the side rails of the gurney, with a steady stream of urine flowing forth. Awesome.

Another First

I walked out on my first patient last night. The guy was being a complete A-hole, refusing to answer questions in a constructive manner, refusing to get in the bed, to change into a gown so he could be examined, being a complete jerk to the nurse etc etc.  I tried playing the empathetic listener for a bit, just let him vent for a minute or two, expressed my sypmpathy for his plight and willingness to help and what not, but that made no difference. So finally I was just like “Sir, I don’t appreciate your attitude. W’e’re doing our best to help you as much as we can, but you are being a hindrance to your own care right now. So I’m going to leave for a little bit. While I’m gone, I want you to think about if you want our help or not. If you do, I expect your cooperation when I come back. If you don’t want to cooperate, you are free to leave” And then I just walked out. I’ve never done something like to somebody in my entire LIFE, haha.  I was all nervous walking away down the hall, waiting for him to start pitching a fit. But he didn’t.  When I came back after seeing another patient, he was much more cooperative, and we got him successfully treated. Yay.

 

On Point

Today, I spent a morning rotating in the sports medicine clinic. My last patient of the day was a young ballerina. She was there to be seen, surprise surprise, for a dancer’s fracture. She was dancing  on point (see above photo) when she suddenly had sharp pain on the outside of her foot. X rays showed the above mentioned fracture. More interestingly, she was telling me about her training regimen and I have to admit I was very impressed by this teenager. She was no ordinary ballerina who takes lessons one or two times per week. She is actually a student at the ballet academy here in the city. Not only does she take ballet classes, but she does it six days a week, twice a day. It’s more than a dance school, it’s a full on school which also has all the classes that a normal kid takes in high school as part of the daily curriculum. Further, she’s actually from the West Coast, so as part of her enrollment, she gets an apartment for her and her family in one of the nicer downtown buildings. All her meals are provided for as well as trainers and other amenities.  I’d never heard of this school, but was aware that the academy existed. I’ve often see them dancing through the windows as I walked to work at 630 AM. She and this program sounded quite impressive, and luckily she’ll be back on her tip toes before long

>Stories

>I don’t know how neuro oncologists do their jobs. I admire them for their ability to handle the sadness they must surely have to endure. I am sure they find it rewarding to bring comfort to their patients and families, but I just don’t think I could do that day in and day out. I mean, most of your patients are going to die in your care, and in all reality, there is very little you can do about it.


Today we admitted to our service a 31 year old woman with an end stage brain tumor. Her cancer was fairly stable on her current drug regimen, however, since the age of 21 she had been trying to get pregnant without success. After starting this drug, she somehow became pregnant, much to her joy. But because of that, she had to stop her cancer medications and her tumor then started to grow rampantly. She had her baby, who is now a few months old, but in turn, I’d be surprised if she lives to the end of the month herself.

Beside the reflexive “damn… that sucks”… there are again so many questions I want to ask her that I never can. Between my weeks in the ICU, and the traumas the past few months, I’ve had quite a few patients die. Maybe I am at one of Ericson’s stages of development, where one starts to question their own mortality, but mostly, I am curious (morbidly perhaps), when you have days hour or minutes left…what does through you mind? To where what or whom do your thoughts wander? Do you have thoughts? Do you know you are dying?




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