Patient several days out from being coded, now extubated and waking up from sedation.
Patient: my chest hurts.
Nurse: yes sir, that’s because they did CPR on you and did chest compressions. You have some cracked ribs.
Patient: I don’t remember any of that.
Resident (under their breath): that’s cuz you were dead, bro.
patient being admitted for severe headache after marathon sexytimes session.
No worries, we won’t put you on tv. But a blog, however…
In a hospital follow up visit with T, one of my favorite patients, whose stroke left her completely without a conversation filter.
T: Dr. Wayfaring! What are all these dark spots on me? I got all bruised up in the hospital and they turned dark and they won’t go away.
Me: Well sometimes people get what’s called post-inflammatory hyperpigmentation, where the skin gets darker after it’s bruised or broken. It can take a long time to fade. It’s more common in people with darker skin tones.
T: Wayfaring, you callin me black!?
Me: Um… well… I’m saying that people of many races with darker skin get this more commonly.
T: So you callin me black then.
Me: No, but…well… you are black.
AHAHAHAHAHAHA! Girl I’m just playing with you!
Geez! I thought we were friends, T! Don’t go messin with me like that!
T: But Dr. Wayfaring, for real tho, what are you?
Me: Whaddya mean what am I?
T: I mean I’m black but what are you?
Me: Uh, white…
T: nah, you ain’t white.
Me: ok, then what am I?
T: You paaaaaale. Girl you need a tan like REAL bad.
Me: True, true. I am very white.
T: Nah, you ain’t white, cuz white people be trippin. But I like you though.
Attending Dr. O, curbside consulting Dr. P, our infectious disease specialist via phone…
Dr. O: hey Dr. P, I’ve got a resident here who has done some traveling recently and has come back with fevers, severe myalgias and arthralgias, and marked distal muscle weakness. Reflexes are still normal. His CBC and CMP are normal, but his CPK is sky high. I’m checking him for Rickettsial diseases, West Nile, and Lyme disease. Do you have any other suggestions?
Dr. P: (Charlie Brown teacher noises)
J, the sick resident: So Dr. O, what did Dr. P suggest?
Dr. O: He’s stumped. He said we should google it.
Wayfaring: Do you take any other medicines besides the two you brought with you tonight?
Translator: **Russian Russ Rushy Russian**
Patient: **All the Russian**
Translator: Yes, he takes one in the morning and one at night.
Wayfaring: Yes, I know he takes this medicine in the morning and at night. I’m asking if he takes any other medicines that he did not bring with him today.
Translator: Oh I see. **Russes**
Patient: **Russes back**
Translator: Yes, he takes it two times a day.
Wayfaring: Ugh, yes, I understand this. How else do I ask this? Am I missing something here? Ok, it says in his history that he has diabetes and high blood pressure. Does he take any medicines for these problems, because he didn’t bring any with him today.
Translator: **Long, flowing Russing**
Patient: **Short, snappy Russing**
Translator: Yes, he has high blood pressure. Today it is 174/90.
Wayfaring: Ugh! Yes, I know this. I told you he had high blood pressure. The question is: Does he take medicine for this?
Translator: Yes, he has high blood pressure.
Wayfaring: You know what, I give up. We’re going to restart the meds on his home list. Please ask him to have a family member bring in any other meds he may or may not take.
Intern during morning rounds
1930: Checkout. I am warned about Mr. CCU. I admitted him last night with a massive, un-stentable MI that took out his entire right ventricle. Tonight he is intubated and is on 2 pressors, and his BP is still 70s/40s. Keep a close eye on him, they say. Wear a gown and mask if you code him. C. Diff. AIDS. Hepatitis.
1945: I am warned about Mr. ICU. He came in after a major overdose and continued to endorse suicidal ideation with a plan. He’s medically stable, but mentally unwell.
2000: Checkout over. Peruse the computer and look over everyone’s vitals and labs. Not a big census, but a sick one.
2020: Head up to check in on Mr. CCU. Oh by the way, his potassium is 6 and his creatinine has tripled. Dialysis just got started. BP 80/60. Ask dialysis tech not to take off any extra fluid.
2040: Check on Mrs. Recently-stepped down from ICU. She’s fluid overloaded. A spot of Lasix for you, my dear.
2100: CCU: “Will you check on Mr. CCU’s pupils? They seem to be fixed and dilated.” Crap. Pupils as big as saucers. Scleral edema. No doll’s eyes. Guess the brainstem is gone. He’s not breathing over the vent anymore either. Great. No reflexes. Not stable enough for brain imaging. Let’s call the family. Oh there is no family. Emergency contact is a friend with a disconnected phone number. Still a full code. Write a note.
2120: Intern and I make a nest in CCU. Preparing for a long night ahead. We got iPads, reading materials, pagers, and beverages. Better order Chinese for me and the intern and the CCU nurse.
2130: Chinese already delivered, piping hot. How do they do that? The restaurant is 5 minutes from here!
2200: CCU smells like egg rolls. Peruse the ER census to find my least favorite patient’s name on the list. She has been there 4 times since she was discharged from the hospital 5 days ago. Awaiting a call from the ER to admit her.
2230: Dialysis over. He got albumin and more fluid during dialysis. BP still 80/60. At least it’s holding steady. Going up and down on the pressors. Write a note.
2330: Things seem to be stabilizing. Change of strategy: retreat to the call room. Wow, no calls for admissions yet? I’m shocked. Let me refresh my knowledge of pressors.
0002: ER: “Mrs. Supratentorial is here again and says she can’t breathe. All her labs are black. Her physical exam, x ray, and EKG are normal. I wanted to send her home but she’s refusing to leave. Will you guys come talk to her?”
0004: Send intern into the fire with Mrs. Supratentorial. If she is not sick, send her home! Do not admit her, I say. Make her leave, I say. She can follow up in clinic in 8 hours.
0101: Haven’t heard from intern. “You still in ER?” “Just sent Mrs. Supratentorial home. Just finishing up the documentation now.” “You’re a freaking rockstar.” I trot back to CCU. One more check and then maybe I’ll try for a nap.
0110: Mr. CCU’s belly is bruised and firm now. He’s bleeding freely from the mouth and rectum. BP 70s/40s. Glad cards didn’t put him on heparin. Let’s get coags, not that it really matters at this point. Write another note.
0130: Paged by intern: Mr. ICU trying to leave AMA. What do I do?
0135: Chatting with Mr. ICU. Nothing is wrong with me, he says. I was just kidding when I said I was going to kill myself, he says. Those 50 pills I took are no indication of my current mental state, he says. And why are you trying to trick me by changing your clothes and putting on a wig? I know you’re all the same person that keeps coming in here. I’m not crazy, he says. I’m leaving.
0150: Intern informs me she has turned down an unassigned admission from the ED. This is not something we ever do. Technically we are open for another one. “Ain’t nobody got time for an admission when everyone’s trying to die and leave AMA on us,” she says. Agreed. We will take the next one.
0220: Involuntary commitment papers done. Geodon flowing. Patient resting quietly on the bed. Back to CCU for us.
0225: Everything kosher in the CCU? Pupils still blown. Belly getting harder. ABG says the bicarb is improving his acidosis just a smidge. Awaiting other labs.
0330: Mr. DKA’s potassium is 5.8. Mrs. Step-down + Lasix’s potassium is 2.7. Is the lab having issues with potassiums? Everyone was normal this afternoon. Someone give Mrs. Step-down some K. Recheck in the AM. Is it naptime yet?.
0500: Mr. CCU is maxed out on 2 pressors. BP 70/30. Now with a heart rate in the 40s. Here, have some atropine. Intern has already pushed more fluids. Let’s get as far as humanly possible away from our comfort zone and put on a third pressor. Sure, why not. Gotta keep him alive until the attending rounds in the AM.
0510: Back to the CCU. 2 nurses, intern, and I are gowned in preparation for the inevitable code that is coming. His ABG is in the toilet. O2 sat in the 60s. Acidotic out the wazoo. Here’s another amp of bicarb. Potassium’s back up to 6, even after normalizing after last night’s dialysis. Still bleeding. Intern writes another note.
0520: Mr. ICU is awake again and just punched a nurse. Intern and security to the rescue with 2 point restraints.
0545: Mr. CCU is tanking quickly. One epi in, and oh look, we have a blood pressure again for about 15 minutes. Now he’s in and out A-fib. Great.
0700: The slow-code continues. We’re on epi number 4 now. Coags are back. As suspected, he’s in DIC. Hemoglobin has dropped 4 points overnight. He’s out of platelets. This is futile. Brain gone, heart gone, lungs gone, liver gone, immune system gone, kidneys gone. Attending makes him DNR since there is no next of kin. Finally got in touch with his home health aide. She will go get the emergency contact friend and bring them here.
0720: Friend arrives and agrees that DNR is what he would have wanted. Excellent. No fighting. Give them some time alone with him.
0800: Inhaled breakfast and headed back to CCU. Day backup is there now, stopping the pressors.”You guys wrote a lot of notes last night, he says.” Yes we did.
0815: Potassiums have been jacked up in the lab all night. Everyone’s K is actually OK. Except Mr. CCU’s, of course.
0830: On-call intern is a no-show to rounds. He is pronouncing Mr. CCU.
Nurse: The patient and his wife are both Cuban, and they’re both deaf. They can read lips a little but they generally communicate with American Sign Language. Which translator would you like?
Resident: Um, the sign language translator.
Resident: **goes into patient room to find the Spanish translator and the sign language translator** Why are you both here? We just need sign language.
Spanish Translator: Yes, but they are Cuban.
Resident: But they can’t hear you speak Spanish.
Spanish Translator: But they are Cuban.
But their primary language is American Sign Language. We don’t need to translate from English words to Spanish words to signs. We just go to signs.
Spanish Translator: But we always offer Spanish translation for Hispanic patients, even the ones who speak some English.
Resident: But they don’t speak Spanish! They don’t speak! They don’t hear!
Suspicious attending is suspicious about everything.
5 year old boy to my nurse: Youw my guwlfwend. I gonna kiiiiss you! Pwease pwease don’t give me a shot!
Nurse: oh my! I better tell my husband I got a new boyfriend! And no shots for you today, buddy.
*2 minutes later, nurse leaves room and Wayfaring enters*
5 year old to Wayfaring: Hey I don’t gotta get a shot and youw my guwlfwend!
Wayfaring: I’m not your girlfriend, I’m your doctor!
5 year old: Yes HUH! Youw my GUWLFWEND and I KISS YOU ON THE LIPS!
*proceeds to attack me*
Wayfaring: Whoa, calm down tiger!
Mom: sorry, he just had ice cream.
Dangit, descant, you ask hard questions. Thinkers, though.
As doctors, we make diagnoses all the time. Correct ones, even. But most of the time we don’t get excited about making a diagnosis unless it’s new or weird or difficult or if it saves someone’s life. I don’t know if I have a favorite situation though. Maybe this one? Incidentally, she’s now in remission after surgery, chemo, and radiation! Every time I get one of these diagnostic thrills it becomes my new favorite. It’s also super cool when a long-shot hunch turns out to be correct.
Last week a friend of mine from church texted me at 4:17 AM. Normally I would have slept through such a text, but on the night in question I had forgotten to turn my phone’s sound off. She told me that she had woken up in a pool of blood and had some abdominal pressure, nausea, and dizziness. Apparently this had happened to her before and she had ignored it, but now it was really scaring her.
Wayfaring: Dr. M, I think this lady is a hoarder. Like probably a pet hoarder.
Dr. M: Why do you think that?
Wayfaring: Because she smells…hoardy? And cuz she’s weird? Like hoarder weird?
Dr. M: good enough for me.