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.
Resident: Are you sexually active?
Resident: with one partner or multiple?
Patient: oh no, me and my wife are mahogany.
Pregnant patient on drugs who does not have custody of any of her children and will likely not have this one either: Dr. Wayfaring, do you have kids?
Patient: You want this one?
Wayfaring: When did this diarrhea start?
Wayfaring: What did you eat this weekend? Anything new?
Patient: Well I had raw oysters at lunch and then I ate a bunch of fried stuff and wine at the fair that night, and then the diarrhea started the next day.
Wayfaring: Ding ding! I think we’ve found our answer.
Wayfaring: have you had any surgeries?
Patient: I ruptured myself the last time I was in the hospital and they had to go in to do surgery to put it back in.
Wayfaring: you ruptured…yourself. Where on your body was this?
Patient: you know *eyes crotch*
Wayfaring: ok, did they call it a hernia?
Patient: maybe. I think I ruptured myself again though. There’s a big swellin’ down there. It’s kinda sore too.
Resident: any allergies?
Patient: I’m allergic to wheat?
Resident: oh that’s terrible. Do you have Celiac disease? What does wheat do to you?
Patient: well one time I mixed some flour and water together in a jar and drank it and it gave me terrible diarrhea. And then I did it again a second time and I got diarrhea again. So I’m allergic to wheat.