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Appearances can be deceiving (I) - Sing a Song of Sixpence
Pocket full of rye
figent_figary
figent_figary
Appearances can be deceiving (I)

Remember: all patients and staff are compilations. Behind a cut as usual for length and grossness. Broken into two parts because LJ doesn't like the length of my posts

    Tonight's going to be good. I can just feel it. I am caught up on sleep, I am properly caffeinated, I've even managed to get some laundry done and see the sun today. I've gotten a prime space in the parking lot, Cooper is my charge nurse and he is awesome, and the first person I see when I get to the doctor's station is Shawn - a senior resident who is excellent. I'm actually trying to recruit him to work at Hospital X when he graduates. It's going to be a good night.
    "Hey!" Shawn says, we work well together and he is as happy to see me as I am to see him, "The outgoing attending is caught up in a trauma that won't live and won't die. He's been in their for an hour, can I staff a bunch of nothingburgers with you and get the department moving?"
    You can see why I like him.
    I crack open an fresh diet coke and listen to his stories. A couple of cocaine chest pains - they'll be straightforward four hour rule-outs and home; a woman who came in with belly pain but probably just wanted a pregnancy test and an ultrasound since the pain magically went away following these interventions, that's fine, I'm glad she'll be getting prenatal care from here on out; a big time smoker here with another COPD exacerbation; a chronic alcoholic here to go to the sobering house - the same way he did 2 days ago and 2 days before that and 2 days before that, it's a 36 hour stay and considerably nicer than the shelter. Shawn says the sobering house laughed when he called. They suggested just having a cab on call to the ED every two days until the weather cools off and the guy can go back to sleeping on the street. Shawn and I agree that it would save a lot of time and phone calls.  I go off to see the patients, they're as billed. All straightforward, none particularly exciting. One of the cocaine chest pains has enough risk factors and enough of a cardiac history that I suggest we might keep her overnight to see a cardiologist in the morning. She's not excited by that plan, I ask her to think about it. I'm not going to push her on this one, the thing that would help her heart the most is if she stopped smoking crack and she isn't ready to do that yet.  Until she makes that change there isn't a whole lot that a cardiologist can help her with.
    "Why does this keep happening to me, doc?" Mr. Edin, the COPD patient asks plaintively around his albuterol nebulizer, "I've cut way down on my smoking." I check his chart. He has cut down an impressive amount, he's decreased his daily cigarette intake by 1/3. Which is great, except in his case it means that he's gone from 3 packs a day to 2 packs a day, which would still be two packs a day more than his lungs can take.
    "Well, Mr. Edin, you've been smoking for about 50 years. Most of that time you smoked three to four packs a day. Let's call it three packs. That gives you an 150 pack-year history of smoking. You're doing the right thing by cutting down, but your lungs have already sustained a lot of damage. That doesn't disappear overnight."
    My general feeling is that the guy is 72 years old, he's already on home oxygen, and besides the risk of blowing himself up from smoking on oxygen there isn't a lot of point in him quitting.  Even if he stopped smoking tomorrow, he'll die of his pre-existing lung disease or his vascular disease (also secondary to his smoking history) long before his lungs remodel and he actually gets any of the benefits of quitting. Other than that whole not blowing himself up.  Someday I'll have enough courage to a patient that; as it is, I applaud his efforts to quit and tell him to keep it up, that I know it's hard.
    I know Mr. Agresti, the alcoholic, well. He knows me. We chat about his bum back and his ungrateful children, he tells me that this time he is serious, he really wants to quit.  He told me that last week, too. I hope of that one of these times he means it and I hope  that when he actually does means it someone takes him seriously.
   
    When I get back to the desk the trauma has gone up to the surgical ICU and the other attending is ready to sign out.  Shawn has been busy dispositioning people and there isn't much left from the previous shift. I tell him to go home. I tell Shawn that all the people he told about look fine, he tells me about an upper respiratory infection and a nasty STD.
    "Is it just you and me tonight? Let's crank through patients and if it gets a little slower in the middle of the night I can go through some oral boards questions with you." The oral boards don't test medical knowledge so much as how well you can take the oral boards. It is a totally artificial scenario, practice is key. Shawn looks uncomfortable.
    "It's sort of just you and me."
    "Sort of? How does that work?"
    "Well, it's you, me, and Malina."
    "What?!" I thought Malina was gone. As far as I knew, she had failed every rotation last year. Maybe my night wasn't going to be so great.
    "Yeah, it's going to be a long night." The other residents were sick of picking up her slack.
    "I'm confused, why is she still here? The rumor had it that she was out of the program."
    "Yeah, well," Shawn picked up the next two charts in the rack, "She was supposed to be out but then she started claiming discrimination. Based on what I don't know, ankle size, hair length, something, and the administration said she could have one more chance. She's repeating the year, she didn't advance and she's officially on probation. But now that she's on probation, nobody wants to fail her because then it will be their fault that she's out.  It sucks. Some of the attendings just need to grow some balls." He suddenly remembers that he is talking to an attending and that I am remarkably unlikely to grow balls. "Um, ah, what I meant was..."
    "Or ovaries. Or something. I get it.  Don't let her slow you down tonight, you keep cranking on patients. If the nurses come to you with problems about her patients, send them to me, it isn't your problem. It's my job to make sure she doesn't kill anybody."
    Shawn noted agreement and took off with the two charts, still obviously mortified about his previous comment. I wasn't hurt or offended by it and I didn't disagree.
 
  I go to see the next patient, a 23 year old woman with the chief complaint "DFO." In medical school they teach you that the chief complaint is literally what the patient is complaining of in his or her own words. "I feel like an elephant is sitting on my chest," "I feel woozy," "I passed out." In the real world the chief complaint is how the triage nurse interprets the patient's complaint. "Chest pain," "Dizziness," or in this case "Done Fell Out." I'm not sure whether it is a idiom that is specific to city X, but the first time I heard a patient use it I asked "Fell out of what?" and the whole room erupted into laughter. "I done fell out" means that the patient fainted or passed out or had a seizure and is such a common expression that it is charted as "DFO." The other chief complaint that I hadn't encountered before I started working at Hospital X was "WADAO." That's "weak and dizzy all over" and is a catch all for "I just don't feel good but can't explain how."
    The 23 year old DFO was a thin, tired appearing woman still looking a little woozy. No previous history was listed on the chart.  I introduce myself and shake her hand, noting the dark circles under her eyes; she looks like she is at the end of her rope. She is mildly tachycardic, and mildly orthostatic but otherwise has a normal exam. Her finger-stick glucose in triage was 47 which is low enough to make her pass out. Given all of that I write for her to receive two liters of fluid with some sugar in it and sit down to chat. I probe for anything unusual. She's not diabetic, she's not pregnant, she has no history of seizures, there is no history of sudden death at a young age in her family, she denies using drugs or alcohol. She does have two children of her own and is raising a four year old niece  since her sister is in jail and the kid's father isn't in the picture. Three kids under six would make anyone exhausted but most moms don't pass out. I ask her if she has any idea why she fell out. She thinks for a while, avoiding my eyes. I can't figure out whether she is deciding if she can confide in me or if she is coming up with some lie she thinks will be plausible. I wait.
    "Can you pass out from not eating?" she finally asks.
    "You can. Why aren't you eating?" There is another long pause.
    "I'm not asking for charity!" Ah. Not anorexia.
    "I didn't think you were." Another pause.
    "Well, it's the 28th."
    "It just turned into the 29th. Go on."
    "Well, I work at..." she names a clothing store in the mall in the failing suburbs of City X, "they pay good, you know. I don't need welfare. And they say another 18 months and I'll make assistant manager and then I'll make even more.  But I got three kids, y'know. And I've got my truck which still has payments and that's due on the 15th. I get paid on the 31st. Rent is due on the 1st. The store is 20 miles away, sometimes late in the month it gets hard. If I don't go to work I don't get paid, so if it comes down to gas or food..." there is another pause.
    "That's just food for me, you know. The kids always eat. I'll hook before they go hungry. I got powdered milk and enough cereal for 9 more bowls; the little one doesn't eat a lot for breakfast so some of the bowls can be sort of small. I've got peanut butter and two loaves of bread at home. That's 36 pieces of bread. Two loaves, 36 pieces. Each sandwich has two pieces. I've got enough until the 31st. I haven't run out yet. I'm careful. They're not going to go hungry."
    "What about you?" I ask, gently.
    "It's the 29th. I get paid on the 31st. I'll be okay."
    "You weren't okay today. If you passed out when you were driving, your kids could lose their mom."
    "This doesn't happen when I'm driving. This only ever happens when I stand for a long time or when I go from sitting to standing. I told Maria not to bring me but she wouldn't listen. I bet she thought I was going to sue the store or something."
    "So this has happened before?"
    "Sometimes at the end of the month, things get hard. I told you. It all depends on gas prices, you know? Last year wasn't much of a problem. Eighteen months I'll probably get a raise. This is just a temporary thing. Gas can't keep going up forever, right?"
    This isn't the first time I've heard this story and it won't be the last. I'm hearing it more often these days. Unlike my patient, I think gas prices will continue to rise. This winter is going to be ugly. People are going to have to choose between food, rent, heat, and gas. There is no public transportation in City X and last year, when oil prices were lower, the state fund to pay for heating for low income people ran out before Christmas. I am dreading the first cold snap.
    I suggest food stamps. She is irate.
    "I don't need charity! I work hard, I've always had a job. I'm not a 'welfare mom,'" she spits the words out, "I'm not a bum. People always say "go to a food pantry, go get food stamps." That's bullshit, you know? I work at a fucking full time job. I have my neighbor watch my kids so I can work and be a role model and shit. I don't want my kids to think it's okay to sit at home and watch TV and have the government give you something for nothing. I don't want a hand out. We're going to be fine. I'm going to be fine. It's just gas prices right now, you know?"
    I know.
    I tell her we're going to hydrate her, re-check her sugar, make sure she isn't orthostatic, give her a sandwich and get her on her way. She tells me she doesn't want charity. I tell her the sandwich is standard for anyone who comes in with low blood sugar. That's true. I write for the nurse to put two sandwiches on her tray, that's not standard but if one happens to go home in her pocket it wouldn't be a bad thing. Is it charity if I'm trying to prevent a return visit to the ED for the same problem? I tell her to talk with billing and they'll arrange a payment plan to cover the cost of the visit. Our billing department is so happy to get anything at all that they're very flexible. If you can do 5 or 10 dollars a week they're usually okay with it. Unfortunately for my patient, an extra $5 a week isn't affordable and we both know that. I close the door before she starts to cry.
    My diet coke is quickly going warm and flat but I take a long swallow and think about how lucky I am.

    Shawn comes up, I still haven't seen Malina.
    "You're going to hate this. I've got room 14 and 15. Room 14 is an 85 year old African American woman brought in by family for "not acting right." Family has left. We've got no history, no meds, no nothing. The phone number they left doesn't work. She can't tell me anything, she's totally wacked."
    "Okay, so?"
    "Room 15 is an 85 year old African American woman brought in by EMS for "not acting right." EMS has gone. We've got no history, no meds, no contact number. And, you've guessed it, she's totally wacked."
    "You're right. I hate it."
    "No, wait. It gets better. Room 14 is Ida Brown. Room 15 is Ida Brown."
    "You're shitting me. Cooper!" I holler for the charge nurse, this is ridiculous.
    "Nope, room 14 is Ida S. Brown; room 15 is Ida E. Brown."
    "That's a nightmare. I'm never going to keep them straight. Nobody is going to keep them straight. Cooper!" Cooper materializes, looking frazzled.
    "Room 14, Ida Brown; Room 15, Ida Brown? Are you trying to kill me?"
    "We needed monitored rooms, they were the last two left. You're pretty safe on the nursing side, they're in two different cores." I've never quite gotten the nursing cores, they are groups of rooms that are tended by the same team of nurses. The back, non monitored rooms tend to get less acute patients, the front rooms get more acute patients, the trauma bays get dying patients. The nurses get cores that contain some of each (except for the less experienced nurses who mainly manage the back hallway until they've been there for a while). I can never keep track of which rooms are in which cores. Having room 14 and 15 be in different cores will definitely cut down on the name confusing but it will still be a problem for the clerks, the lab, xray, and -worst of all- me and Shawn.
    "Could you please put big "NAME ALERT" stickers all over their charts? 14 is E, 15 is S."
    "No!" Shawn jumps in, "14 is S, 15 is E."
    Crap, I'm totally hosed.
    "I'll just look it up myself. We'll take care of this, you take care of everything else, don't stress. You guys are doing fine. We're only 6 down in the waiting room and 2 of them are prompt care patients. We're tight on monitored beds upstairs but plenty of ICUs and generals."
"Great. I'll make sure that I only admit sick and not sick people, no one in the middle." I give him a grin.
"Your intern, though, she's a little scary." Cooper has seen a lot of residents come and go. For him to think someone is scary, they have to be really, really scary.
"Yeah. She's not an intern and we're very aware. Don't let her kill anyone."
"Don't worry," Cooper says, "The nurses have your back. We won't let her hurt anybody." Cooper disappears. He's a great charge nurse. He never loses his cool and the department runs smoothly when he is here.
    "Help me out, Shawn, how am I going to tell these two babes apart?"
    "It's pretty easy once you meet them. Ida S is smilely. She's wacked but nice. She kept patting my hand and telling me she felt terrible for not being able to remember her medicines or her history.  Ida E is evil. She wouldn't answer any questions, it was just one constant stream of abuse. She knows some cuss words that I didn't know. S is for sssssssmilely. E is for eeeeeevil.  14 S, 15E. They're easy to keep straight once you've met them."

    E for evil, s for smiley. I think I can handle that. I see Malina out of the corner of my eye,
    "Malina! did you have anyone you need to present?" Given that I've been here for close to two hours and I haven't seen her see a single patient this seems a reasonable question. Shawn suddenly makes himself scarce. Malina gives me the evil eye and flounces into a chair.
    "Yeah, I've got Edward Durcan in room 2, some minor history nothing really pertinent to this illness. Yesterday he started vomiting, today he's still vomiting, having a hard time keeping down liquids, and feels a too weak and dizzy to walk so he came here. He's got straightforward gastro. My plan is hydrate and home."
    That seems like a reasonable plan. Except that I trust Cooper much more than I trust Malina and he wouldn't have put a straightforward gastro into room 2. I lean over and take the chart from her.
    I'm not quite sure what past medical history Malina would consider pertinent to this illness, but Edward Durcan turns out to be a 78 year old ex-alcoholic on a list of medicines as long as my arm with a previous medical history that includes pancreatitis, multiple prior abdominal surgeries, several MIs, poorly controlled high blood pressure, diabetes requiring oral and IV medications, and mildly impared renal function, He's also tachycardic and mildly hypotensive, could be dehydration could be something more serious.
    "That's a start. Can you expand your differential diagnosis for me?"
    "Well, he could have viral gastro or, I guess, some bacterial endotoxin. If he had been on antibiotics recently he might have c. diff, but that is usually more diarrhea and less vomiting."
    "I have a hard time calling anything gastro that doesn't include some diarrhea. Gastro is usually shorthand for gastroenteritis and I'm failing to see a enteritic component here. So lets take that diagnosis entirely off the table. What else could this be?"
    There is a pause. I'm not sure if Malina is thinking or just wishing she were somewhere else.
    "Food poisoning?"
    There are now three more charts in the rack; it is too late at night and too crowded in here for me to want to spend hours on the Socratic method with a resident with a bad attitude and a worse track record.
    "You can do better than that. You have to do better than that. It is our job to think of things that could be life threatening. A lot of things can be life threatening to a 78 year old with this kind of history. This could be aspirin toxicity, a heart attack, a diabetic crisis, a cerebellar stroke, a small bowel obstruction, urosepsis, gut ischemia, gastroparesis, pancreatitis or a new presentation of cancer. Old people sometimes present weirdly, this could be a perforated viscous or an aneurysm. Your differential has to include the most deadly things and the most likely things. Old people keep us humble, they can be really sick and not look it, they can look really sick but their body hasn't read the same textbooks we learn from and they don't present straightforwardly. It's our job to assume they are sick and their job to prove they're well.  We shouldn't assume that someone is well until he or she proves to be sick."
    "Okay." says Malina, unenthusiastically.
    She sits there. I sit there. I want to shake her. I think that is probably against some rule somewhere. We sit. Another chart goes into the rack.
    "So, what do you want to do now?"
    "I'd check back to see if my hydration made him feel better. If it did, I think he can probably go home and follow up with his primary care doctor."
ARGH! Did she not listen to anything I said? I try not to raise my or act as impatient as I feel.
    "Malina, I just told you that it is our job to think of the worst possible things this could be and make sure that none of those things exist before we decide the patient is well. Do you think your plan does that?"
    "I guess not."
    "So what do you want to do?"
    Malina finally decides to start some labs, check an EKG, and an abdominal film for free air or obstruction. I remind her to check an aspirin level, she adds it on sullenly. I remind her to get a urinanalysis and urine culture. She grinds her teeth and checks the box. I'm a little unclear why she is fighting so hard to stay in a program where she so obviously hates what she does. Maybe it is just Hospital X or just overnight shifts. Maybe she is Ms. Mary Sunshine in the other hospitals she rotates through and is a truly lovely person at 4 in the afternoon. Maybe.  If all the other attendings see what I see and aren't failing her, they really do need to grow some balls. Or ovaries. Or whatever. By not failing her they are putting patients in jeopardy and compromising department flow. I failed her the last time we worked together, I would have no qualms whatsoever about failing her this time as well.
Continued in the next post...

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4 ellucidations or expositions or put your $0.02 here!
Comments
theweaselking From: theweaselking Date: August 21st, 2008 05:45 pm (UTC) (Link)
I love your ER stories, and I'm glad to see you posting them again.
dd_b From: dd_b Date: August 21st, 2008 07:36 pm (UTC) (Link)
Glad to see your stories coming by again!
uplinktruck From: uplinktruck Date: August 23rd, 2008 01:59 pm (UTC) (Link)

Scary

So let me get this straight. We have Malina who obviously should not be in charge of anything above the level of applying a Bandaid. And we have a system that is so terrified of her complaint, they are willing to expose more patients to her rather then to do the right thing and wash her out?

This is too much. Something has got to give.
From: (Anonymous) Date: January 27th, 2011 12:29 pm (UTC) (Link)

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4 ellucidations or expositions or put your $0.02 here!