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Appearances can be deceiving (II) - Sing a Song of Sixpence
Pocket full of rye
Appearances can be deceiving (II)
Continuation of the previous post.....
I go to meet the two Misses Browns and Mr. Durcan. Cooper stops me with some lab results, the chest pains ruled out and can go home, the COPDer is feeling better and moving more air and can go home. Shawn stops me with some new charts. A chest pain, might actually be something; a swollen hot knee; a kidney stone; a pregnant bleeder. Fine, fine, fine. He knows what to do. He goes and does it. I quickly see the new patients, most of these I'm content to stick my head in the door, introduce myself, and move on. The only ones I'm worried about are the Browns and Durcan.
    I finally reach Brown #1. The room stinks of urine. Ms. Brown has manage to completely tangle herself in her bed clothes is flailing helplessly. I straighten her out.
    "Oh, thank you. Thank you so much, dear. Aren't you a pretty thing. And so young to be a nurse!"
    "You flatter me, Ms. Brown. I'm not patient enough to be a nurse. I'm your doctor. How are you feeling?"
    "A doctor?! Oh my! That's wonderful! It is just wonderful what you young ladies can do these days. Little girls now can grow up to be anything, it's fabulous. Don't you think so?"
    "It's fabulous, I love my job. Now, how are you feeling?" I smile at her. This must be Ida S. Ms. Brown grabs my hand and squeezes it.
    "Are you angry with me for calling you a nurse? I am sorry. I forget sometimes that woman can be anything these days. They can be race car drivers or doctors or, or, anything at all. In my day you could be a mommy or a nurse or a teacher and we didn't know anything else. Now you can be anything. Men, too! There's a young man on my street, he wears a skirt. Have you ever seen that? A man in a skirt! Well! But he seems perfectly nice and he shovels my walk in the winter and I got used to him wearing a skirt. It would look odd to me now if I saw him in pants."
    "Ms Brown, do you hurt anywhere?"
    "Oh, all over sweetie. I always do. It's my rheumatiz. But I can't complain, can't complain." She pats my hand and grins. I grin back, it is hard not to.
    "Do you know why your family brought you in today?"
    "Oh, they worry. Or maybe they were mad at me.  Where are they? Where did Vergie go?" She sounds a little panicked, I squeeze her hand.
    "I'm not quite sure, but we have a telephone number and we're trying to get a hold of them to get them back. Ms Brown, can you tell me, why are you here today?"
    "Why am I where, honey?"
    "Why are you here? Here in the hospital?"
    "Oh, well, I certainly don't know.  You're the nurse. I'm sure you can figure it out."
    My physical exam on Ida S. tells me nothing. She's old, she has a scar that indicates she had a c-section and one that might have been for a gall bladder. Her lungs are mildly junky, but it sounds more like a long term smoker than a big pneumonia. Nothing else particularly exciting.  I'll wait for the lab work. I go to see the next Ms. Brown. This room also stinks of urine. She is also as billed. I see someone has put 4 point restraints on her, which means she attacked staff or tried to hurt herself.
    "Go away!" she yells as I enter the room, "I don't want any!"
    "Hi Ms Brown," I say, "I'm your doctor. Don't want any what?"
    "Don't want any of your lip, that's for sure. "I'm your doctor" Well, whoop dee doo. Good for you. What do you want, a cookie?"
    "Do you hurt anywhere?"
    "Take these offa me!"
    "Do you know why the paramedics thought you ought to come in today?" The run sheet says that they were called because she was stark naked in a parking lot screaming at a parking meter for looking at her with lust in its eyes.
    "Because they're a bunch of miserable pigfuckers who hate Negroes. You're a pigfucker, too." She attempts to evade my exam but I persevere. She has some mild tenderness over her lower abdomen. Maybe. Otherwise it is a completely benign exam. She has a long jagged scar on her abdomen and another on her arm. Both very old.
    "How did you get these scars, Ms. Brown."
    "I killed someone who looked like you." She grins. I do not grin back.
    Shawn is right, I will have no problem telling Ms. Ida S and Ms. Ida E apart.

    Mr. Durcan looks like crap. When I was in medical school some attending told me that the only thing you needed to know to be an okay ED doctor was who had outeritis and who had interitis - who could go home and who should stay. Mr. Durcan might not have had enteritis but he certainly had interitis. Hydrate and home was not an option for this guy. I didn't know what was wrong with him yet, but he looked sick. Really, really sick. He certainly looked dehydrated but I didn't like his breathing, either. He was taking deep rapid breaths that made me think his body was trying hard to blow off CO2. His entire belly was tender, but nothing that made me think he needed to be rushed to surgery. His lungs were clear, his heart rate was faster now than it had been in triage. His tongue looked like it had spent three weeks in the desert. I sniffed.
    "You don't want to do that, doc. I keep puking. I can't smell too good."
    It wasn't vomit I was smelling, it was something fruity and chemical. Some people compare the smell to an apple. Some people say it smells more like acetone.  If this were a healthy 20 year old with food poisoning, it would just mean they hadn't manage to take in any carbohydrates in many hours. With Mr. Durcan's diabetes, I think it means he is in diabetic ketoacidosis, a potentially life threatening condition.
    "Did you check your sugar before you came in today?" I ask him.
    "I tried to, but my machine is broke."
    "Oh no! When did your machine break?"
    Mr. Durcan grimaces, "Just in the last day or two. It always worked great before this but now whenever I check my sugar it just says "Hi!" It's nice that it is being friendly and all, but I don't want a greeting, I want a number. Sometimes I think these smart machines aren't so smart."
    I tell him we'll look into it and go off to ask Mr. Durcan's nurse for a finger stick glucose reading. One should have been done either in triage or when he hit the room but I can't find it on the chart. Ellen, the nurse taking care of him is very sweet but is a recent nursing graduate and I've noticed a couple of things that have gotten dropped.  I have to be just a tad more vigilant about her patients. I don't think his machine was giving him an amicable salutation. I'm pretty sure it was saying "HI!" the only way a machine can say "this is too high to read" on a three digit display. It probably says LO! below a certain number as well. That doesn't mean the machine is suddenly saying "Look! See what we have here!" It's saying the blood glucose is too low to read.   Most machines top out at 500, if Mr. Durcan's sugar is that high or higher, he'll need an insulin drip and an ICU bed.

    I tell Shawn that I've seen his patients and agree with his plans for dispo.  Malina presents another patient, equally sloppily. She thinks this guy has a viral upper respiratory infection.  I go to see him. He has a viral upper respiratory infection. I probe and I press to find something that Malina has missed but she's right, this is a mostly healthy 29 year old guy who takes meds for anxiety and depression who is here with a straightforward cold. That's good. I feel comfortable with her seeing healthy patients with cough, cold, and congestion. As long as she doesn't actually see anyone sick, she can't mess up. I tell her I agree with her assessment and I appreciated her coming up with a broad differential. Usually my differential for mild congestion, sore throat, and a fever of 101.5 doesn't include plague, legionnaire's disease, Tularemia, or Q-Fever but I'd rather have her coming up with some differential than none. I have the distinct feeling that Malina spent more time thinking up things to impress me on the differential than she spend seeing the patient but I have no factual basis for that and try to squash the thought.

    Some of the labs are coming back on the two Ms. Browns.  Ida E. has a white blood count of 26 with a marked left shift, she has bands and segmented forms in her blood - signs of her body trying desperately to crank out more white blood cells to fight an infection. She's mildly acidotic, which makes me worry that she's in full sepsis. Before I have time to verbalize the thought Shawn says that he's worried about her anion gap and has sent off a lactate level to make sure she isn't in  full sepsis. He is a very good doctor. I would be comfortable with him taking care of anyone I know. We don't have a source for the infection yet, I'm guessing it's in her urine because old people tend to get very sick very quickly with urosepsis but we can't rule out something bad in her guts or spinal fluid yet. Her chest Xray shows no free air in her abdomen, which is reassuring but not 100% definitive. I discuss this with Shawn, he says that he's waiting for her urine to come back. If her urine is clean, he'll do a spinal tap, if her  tap is clean we'll CT her abdomen.  Shawn tells me that Ida E's blood pressure is starting to drop and her heart rate is remaining high. He's told the nurses to start another IV and to start flooding her with fluids in addition to starting two very broad spectrum antibiotics. I like this plan.

    Ida S is more of a mystery. Her blood count is unremarkable, a little anemic but no more than a lot of older women. No signs of infection. Her electrolytes are mostly normal. Her liver enzymes are elevated, why I don't know, but they're only about twice normal - not particularly impressive. Her urine is clean. I check with her nurse. She's still, as Shawn puts it, wacked. Her nurse says she's drowsy but easily arousible, sweet but completely confused, very talkative.
    "What do you think?" I ask Shawn. I yawn, it's time for more caffeine.
    "Well, this could be her baseline, but family brought her in for not acting right. So, we'll assume this is all new." I wish Malina was here to hear him say that, "After I saw her labs I went back, got her up and walked her. Ida S can barely walk, she's got this really wide based gait and she's totally ataxic. That room stank of pee. So she is wet, wobbly, and wacky - I think we have to consider normal pressure hydrocephalus. And  I think we still have to consider viral meningitis or encephalitis because sometimes you  can have a normal white count and have a positive tap." We both make a face. I hate torturing a sweet old lady, but we don't have a source and we do have an altered patient.
    "I think we have to." I say, reluctantly.  Both of those diagnoses make sense. Both require a tap and if it crosses your mind to get an LP, you probably should get one.
    "I think so too. She's on the skinny side, it won't be hard."
    Shawn orders a CT on Ida S and asks the nurse to set up for an LP. We quickly talk through the rest of his open patients. The chest pain will stay be admitted as an unstable angina, a tap of the swollen knee has determined that it is gout and not an infection so the guy is going to go home on standard gout medicines, the kidney stone went home with a strainer and pain medicines, the pregnant woman has what we call an "inevitable abortion." There is still a 6 week embryo in her uterus but there is nothing modern medicine can do to stop her from miscarrying. He grabs another stack of patients to see while I check on Mr. Durcan's labs. I'd really be drowning if Shawn weren't here.

    Mr. Durcan is sick. Sick sick. I stand up and catch the charge nurse's eye.
    "Cooper, can you start trying to find an ICU bed for Durcan? He's your top priority right now."
    "Did you see his finger stick? Ellen did it a little bit ago. It just read high. Is his real glucose done yet?"
    I check the labs, everything is back but that. "No, it looks like they're still diluting it."
    These labs are ugly. It looks like Mr. Durcan has an infection...somewhere. I don't remember his lungs being particularly impressive, it could be in his urine. It could even be a viral gastro-y thing that would make Malina happy. But in addition to and probably because of the infection, Edward Durcan has gone into full DKA.  His body has run out of insulin and because of this, even though his blood is full of glucose the cells of his body are not receiving enough fuel to produce energy. All of his body has gone into starvation mode which starts the breakdown of triglycerides into free fatty acids (FFAs) so his body can start gluconeogenisis, another pathway to make energy for the cells. His body has started to metabolize protein and fat to produce a source of energy and the FFAs are metabolized into strong organic acids known as ketones.  In normal life, small amounts of ketones are used as energy in the peripheral tissue.  Mr. Durcan's body thinks it is starving, though, and doesn't use the circulating ketones. The increase production and decreased use of the ketones leads to his blood and body become steadily more acidotic. due to the starvation state of the cells, the ketones are not used. An increase in ketone production and a decrease in peripheral cell use lead to metabolic acidosis. A normal blood pH is 7.4,  his is 7.01. A normal bicarbonate level is in the upper 20s, his is 14. The beta hydroxy butyrate, the test we use to screen for ketones, should be zero; Mr. Durcan's is 87.
    As I stare at the screen in horror, the glucose comes back: 653.
    "Cooper! 653!"
    "Eh, that's not that high."
    "That's just because you've been seeing a lot of HONK. I'd rather he have a sugar of 1200 than the rest of the shit I'm seeing on his labs. Could you please page Malina to the doctors' desk?"  I haven't the foggiest idea where she is and this is her patient. She should be at least as scared as I am.  HONK is hyperosmolar non-ketotic illness, you see it a lot in non-insulin dependent diabetics. As our patient population gets fatter we see more of it. It is also life threatening, just less quickly so than DKA. And, Cooper's right, I've seen a lot of sugars over 900. But 653 is scary when you're looking at blood this acidotic.  I use the back of a prescription pad to figure out his corrected sodium. Because of the way we measure the electrolytes, the huge glucose load gives us incorrect values. In DKA, the potassium will look much higher than it is and the sodium will look much lower.  Malina slouches around the corner.
    "Hey, what did you think of Mr. Durcan's labs?"
    "Oh, are they back?"
    I take a deep breath. If I just wanted to manage all the patients myself I wouldn't have gone into academia, but Malina's lack of involvement is getting on my last nerve. "They are; why don't you take a look and see what you think?"
    Malina glances at the computer, sees all the red panic values and takes a better look.
    "I think he's in DKA."
    "He is. This is not someone you can hydrate and send home. But we do have to hydrate him, what do you want to give?" I hand her the chart. She needs to write her own orders or she'll never remember what we ordered and why.
    "Two liters of normal saline." That's a pretty safe answer for most adults who aren't on dialysis and who don't have congestive heart failure.
    "That's a reasonable place to start and then reassess. His fluid deficit is likely much higher so don't be surprised if we end up giving four or more liters down here in the ED. What about his potassium, do you want to do anything about that?" Malina writes on the chart and then looks back at the computer.
    "6.7?! That's really high! We should get an EKG and then start....wait. Potassium is abnormally elevated in DKA, it's going to fall as we give him insulin and shove the extracellular potassium back into the cells." She glares at me through narrowed eyes, "You're trying to trick me!"
    "Not at all, I'm asking you to interpret your patient's lab values. I would still get an EKG so that if there are potassium related changes you can keep an eye on them, but I agree, do not try to lower that. You're going to end up chasing your own tail. We'll probably end up repleting him in a couple of hours anyhow. What about the sodium?"
    Unsurprisingly Malina does not know how to do the sodium correction that tells us that the low sodium we see now will actually normalize as his glucose comes down. I show her how to do it and then point her to a web page that will do it for her if she enters in the right values.
    "So we're going to hydrate and track his ins and outs, and watch his potassium closely. But what drug do we want to give to fix this?"
    "Insulin." Malina does everything but roll her eyes at the inanity of the question.
    "Right. And how much do we want to start with?"
    "One unit per kilo per hour." She says it confidently.
    "Right, and...wait. Say that again."
    "One unit per kilo per hour insulin drip." I can't believe this.
    "One unit per kilo per hour?"
    "Yup! you'd switch the fluid over to something with dextrose when his sugar gets around 300 or less and then...." I interrupt.
    "Malina! It is 0.1 units/kilo/hr. Not one. 0.1.  You're off by a factor of ten. 1 unit per kilo per hour would kill somebody. Think of how much insulin that is! We write sliding scale insulin dosing starting at 2 and maxing out at 12. For a normal sized guy, you're talking about 70 units!"
    "I meant point one. I'm just tired." She did not. She meant one. She hadn't a clue that she was giving me a potentially lethal dosing.
    "Even in the middle of the night, you have to have dosing right. Even when you've been up for two days, you have to have dosing right. I'm sorry you're tired but that kind of mistake could kill someone."  I notice that she has another chart in her lap, "Is that a new patient?"
    "Yeah, I'm not ready to present them yet, I'm still getting the history and physical."
    "May I see it?" She hands it over as she continues to write the orders we've discussed on Durcan's chart. Alicia Rose Bradley is a 6 week baby girl brought in for congestion. Her vital signs are normal. This is a good patient for Malina. I hand it back, "Tell me about her when you're ready. I want Durcan to go up to an ICU ASAP so start making some phone calls once those orders are in. You're going to need to talk to his doc, the covering ICU attending, and the ICU resident on call. We also need to check a repeat set of electrolytes every 2 hours and a repeat glucose every hour while he's down here."
    "I know!" Dealing with Malina is like dealing with a hostile adolescent. I've met hostile adolescents I've liked more. At this point I think there are probably many hostile adolescents who could do a better job of pretending to be a doctor. The fact that she has an MD after name scares the crap out of me.

    Shawn is charting, pretending not to hear our conversation, waiting to talk to me.  He gives me the update. Eeeeevil Ida has a huge urinary tract infection and an elevated lactate. She is truly septic and will be going to an ICU step down bed. Shawn tells me that he's also talked to the ICU resident because while she doesn't currently meet full ICU criteria he thinks she might crash and burn later on tonight or some time later this morning and wants everyone to be aware she exists.
    "I love that plan. Any idea how long until we get a bed for her? She gives me the creeps."
    "All the telemetry beds are full, if she gets more stable I'll switch her to a general, if she gets sicker I'll switch her to a unit. Until that happens, we've got her for a while."
    "What about Ida S?"
    "Smiling Ida continues to be a mystery. Her CT shows normal age related change, nothing scary. She was sweet about the tap, but it was harder than I thought it might be because she even has some trunkal ataxia. She just sways, I was feeling seasick trying to keep up with her! I thought my NPH idea was brilliant but her tap had a normal opening pressure, no signs of NPH. The lab results weren't back the last time I checked, but if they're negative, I'm running out of ideas."
    I check the labs. The CSF is back. It's negative. It's actually what is known as a "champagne tap" - no red cells, no white cells, nothing but spinal fluid.
    "Nice job. Now what?"
    "I don't know."
    Shawn and I sit in companionable baffled silence trying to figure out what makes smiling Ida so goofy.
    "Let's go look at her again," I suggest. Ida E is sedate now, out of her restraints. Her blood pressures is still low on the monitor and I suggest upping her fluids and perhaps starting a central line. Shawn agrees.  Ida E now looks just like a very sick old woman. You'd never know how monstrous she was. We peer into room 14. Ida S. is singing to herself and occasionally laughing. She is smiling and charming even though there is no longer anyone there to appreciated it.  She's taken her teeth out and her singing is both atonal and nearly completely without consonants. She does indeed sway side to side as she sits in bed. I don't get it. I'm missing something huge. I think of the things we've ruled out so far and other things that might cause this bizarre constellation of behaviors.
    The other shoe finally drops. I turn to Shawn,
    "I'm going to send one more blood test. I think I know what's wrong."
    "Well that makes one of us." He grimaces. "I feel so dumb! Gah! I can't believe I have one year left and then I have to be an attending. What would I do if my grandma started acting like this? 'Well, Ma, I know you sent me to four years of college and four years of medical school and four years of residency, but I haven't a clue what's wrong with her. Sorry!' That's going to go over well!"
    I grin and write the lab order I want on her chart, "Shawn, I could be wrong. I don't know your grandmother. But I don't think this is going to happen to her. We'll get that lab test back and you tell me if I'm right." I suddenly realize that Malina is standing at my elbow, waiting for me to notice her. I don't know how long she's been there. "Yes, Malina?" For the first time this evening she doesn't look sullen, she looks...worried. And that worries me.
    "Uh, the baby? The one you sent me to see? The one in room 19?"
    "Uh. She's not breathing."


    I run, Shawn runs, Malina trails behind us, if she's talking I'm not paying attention. I yell for nurses and a crash cart. The distance between room 14 and room 19 seems impossibly long. In room 19 there are two young parents, looking down at an unmoving lump on the bed.  I knock dad out of the way as I get to the bed. Alicia Rose is still and blue and ... dead. She has no heart beat and no respirations. There is nothing set up in the room. No monitor, no infant face mask, nothing. I think the parents are talking to me but I don't hear them.  I grab Alicia Rose and do something I've never done before in 10 years of medicine: true mouth to mouth.  I've run hundreds of codes, I've intubated, used bag valve masks, done chest compressions, but I've never physically breathed into a patient's mouth. It is terrifyingly intimate to have our lives connected this way. She is still warm and smells like a baby although she is floppy and unresponsive in my arms. Breathe in through my nose, breathe out into her. My hands work instinctively, I've done plenty of chest compressions on plenty of infants, that's not the hard part here. Breathe in through my nose, breathe out into her. It only takes the volume of air in my mouth to fill her entire lungs. I've never before understood before how tiny infants are, how fragile. Breathe in through my nose, breathe out into her. Alicia suddenly twists in my arms and makes a squawking noise and then a good solid bellow, with her next inhale she goes from blue to pink and bellows again.
    My world, which had narrowed down to just Alicia Rose suddenly refills with noise, the room is packed. The parents are crying in one corner, Malina is standing in the opposite corner looking blank, the rest of the room is filled with nurses, techs, a crash cart, the respiratory therapist, everyone I could possibly want. Cooper is on his pocket phone demanding a bed in the pediatric ICU. Two nurses take the baby from me and hook her up to the monitor, another swiftly and competently inserts an IV and starts to draw blood. I try to talk and make a sound that isn't a word but might be a sob. I take a breath and try again,
    "Shawn, I'm going to want a cbc, chem 7, ekg, chest xray, cath urine for culture, and we're going to need a spinal tap on this one, too. Start some broad spectrum antibiotics and I'll take care of the PICU." Our social worker has shown up, Cooper must have called her, and is talking to the parents. I'll let her do her thing, I'm too shaken up to talk to anyone right now. I keep thinking about the feel of the lifeless baby in my arms and her mouth under my mouth. We'll see how she turns out, I don't know how long she was down without oxygen or a heart beat, but the fact that Alicia Rose is now screaming at the top of her lungs and trying to wiggle out of the monitor leads is a good sign. Babies are resilient. I don't know why this one was dead for a while. Could be a breathing problem, could be a heart problem, could be that we just saw SIDS in action. That's not something I'm going to be able to figure out in the ED but I can make sure it isn't an infectious process or a huge heart problem and get her upstairs to the people who can figure it out. I call the PICU, the primary care doctor, the covering resident for the PICU.
    "Hey!" It's Malina, sullen again, in my face, "Why did you just give the procedure on my patient to Shawn? That was my LP to do!" I do not brain her with the phone in my hand. She should count herself lucky.
    "Malina, what does ABC stand for?" She looks confused and mistrustful. This is probably another trick I'm pulling on her,
    "Airway, breathing, circulation."
    "Yes. Exactly. It is not attending, breathing, circulation. You're a doctor. If there is someone not breathing you make them breathe, you keep them alive. And if you are the only one there, you shout for help and get other people to help you. That's not emergency medicine, that's what you should have learned in a CPR class somewhere. You never, never leave someone who isn't breathing to get help."
    "The parents were right there, I didn't want to scare them!"
    "I think, given the fact that the baby was blue and not breathing, they were already pretty scared. And, if they weren't, it was a great time for someone to be scared and the first someone should have been you!" I realize my voice had been steadily rising during this tirade. I think it is poor form to yell at the residents in public. It doesn't help them learn and it scares the patients who can hear the yelling.  I lower my voice, "Go check on Mr. Durcan, see how he's doing, make sure all those phone calls are made. I'll see you back at the doctors' station."

    I walk out the doors of the ED and sit on the curb, taking deep breaths of the early morning air. In an hour or so the sun would rise. In an hour or so my shift would be over and I would get to go home and not sleep; how much brain damage did Alicia Rose sustain? I think about the tiny volume of air it took to fill her lungs and the way she smelled and I shudder.
    "Hey, are you a nurse? I'm worried about my auntie" A young man was trying to get my attention.
    "No, actually, I'm one of the doctors. The nurses are inside."
    "Hey, that's cool. My auntie is real sick, I came as quickly as I could."
    "I'm sure she'll appreciate it, that was nice of you." Talking to someone else makes me feel more normal. I'm slipping back into my doctor-persona and it is an enormous relief.
    "Nothing I could do would be too nice. She's old but she's awesome. She's in charge of breakfast every day the food kitchen down on Van Buren. She's in her 80s and she still cooks breakfast for 20, 30, sometimes 40 people every morning. She's just the nicest lady you can imagine. She half raised my mom. I can't think of any time in my life she hasn't been there. I can't believe she's sick. I've never even seen her in a bad mood."
    "Who is your auntie?"
    "Ms. Ida Brown. Is she going to be okay?" I debate telling him what I think is wrong with his aunt, I decide that until the lab test confirms my suspicion there is no reason to burden him with it.
    "Yeah, we're waiting for one more test to come back, but I'm pretty sure she'll be better soon."
    "Oh, that is so good to hear. When I told my mom she started a telephone prayer line going for her at the church. My mom said "The good Lord won't take Ida, she's too nice. She's helped too many people. He needs her to continue His work on earth."
    "She's obviously really important to you. That's great. We were frustrated last night when we couldn't reach anybody." He looks confused,
    "Well, how would you know who to call?"
    "We didn't! The telephone number in the chart seemed to be disconnected and we had no other leads."
    "The paramedics gave you a telephone number? Was it to their boss or something?" I stare at him in growing dismay, "I just found out came home from work, I work swing shift, see? I came home and Ms. Lucy up the block said that auntie was acting crazy and had been taken to the hospital by paramedics."
    Crap. Best just to be honest.
    "We actually have two patients with similar names. What's your auntie's middle name?" He looks at me like I'm crazy.
    "Middle name? I have no clue. I didn't even know she had a middle name. So you were telling me about the wrong patient? What about my auntie?"
    "Does your auntie have any identifying marks on her?"
    "Oh you mean her big scars? She's got a huge one on her arm and then another one on her belly. Is that what you are talking about?"
    "Yeah...." I am about to tell him about Ida E's urosepsis but he keeps talking right over me.
    "She's real proud of those scars. She got between a little kid and a police dog in 1964 in Birmingham. She says they're her badge of courage. 'I wasn't brave enough to sit at the counter, I wasn't even brave enough to go on the marches, but when push came to shove and someone was going to be hurt I discovered that I was brave enough to do what I had to do.' That's what she told me when I was a little kid. My auntie is something special. Is she going to be okay?"
    Eeeeeeeevil Ida.
    "You're aunt is really sick. She had an infection in her urine and it spread to her blood. We've got her on a bunch of medicines and we're going to admit her to a monitored bed so we can keep a close eye on her overnight. She'll probably be fine, but she's older and she's really sick so we're worried about her." The young man gives me a hand up off the curb.
    "Don't worry, doctor. She'll be just fine. Ms. Ida is way too nice for the Good Lord to let her die."
    I'm a miserable pigfucker and can't deny it.

    Cooper meets me at the door with an expression like thunder on his face.
    "We've got trouble,"
    "What kind of trouble?"
    "The "please hope to god that no one calls the papers and that you and I survive to work in another ED somewhere far, far away" kind of trouble. I'm so sorry," I've never seen Cooper loose his cool before, I'm not liking it now,  "I told you this wouldn't happen and it did."
    "Cooper, don't worry about it. There is no way you could have predicted that baby's apnea. She had totally normal vital signs when she hit the door. Ideally the code would have been started sooner, but at this point we just have to hope for a good outcome." Cooper looks like he might be sick,
    "No. Not the baby. Mr. Durcan."
    I stop walking and look at him. There is a beat of silence. Unbelievably, my night just got worse.
    "What about Mr. Durcan?"
    "Ellen's a recent graduate and didn't know that she should go to you with questions about orders. I should have had her under supervision for another week or so, I guess."
    "Cooper, just tell me what the fuck happened to Mr. Durcan." The story came out.
    Mr. Durcan weighs about 200 pounds, Malina estimated that to be about 90 kilos, a reasonable estimation. She had then written for 1unit/kg/hr of insulin. Not 0.1.  One. Whole. Unit. Ellen had questioned the order. "I've never given 90 units of insulin an hour before. Are you sure that's right?" Malina not only pulled some "I'm the doctor, you're the nurse, you do what I say" shit but also told Ellen that the two of us had discussed the orders and that this was specifically what I wanted. So Ellen ordered a 90unit/hr insulin drip from pharmacy who, in yet another systems error, had sent it up with out any question. Ellen hooked up the drip and Mr. Durcan had gotten some 140 units of insulin before his sugar was checked.

    Shawn is still seeing patients like a madman, the only saving grace of this night. Given how little I've actually managed to accomplish, the department would be a complete logjam except for his actions. Alicia Rose has gone upstairs to the PICU.  Ms Ida E. Brown has continued to get worse and is now on a medicine to keep her blood pressure up. Shawn has changed her bed to a full ICU bed. If she continues to deteriorate we'll have to intubate her. He still calls her Evil Ida, I don't have the energy to correct him. Ms Ida S. Brown is getting more sleepy, that doesn't surprise me. He wants to know if we should consider intubation, I tell him to keep an eye on her but I thought she'd be fine. I explain what has happened to Mr. Durcan and tell Shawn to keep seeing patients while I do damage control. I start fluids that have sugar in them on him. I put in a 2nd IV line so we can draw frequent blood checks. I have a long talk with Mr. Durcan. When things go wrong I think it is crucial for patients to know it. Secrecy doesn't help anyone. I tell him that we gave him much too much of the right medication and now the sugar level in his blood is falling too quickly. It's hard to explain why I wanted his sugar lowered slowly and not quickly; osmotic forces are a hard thing to explain at any time of the day, let alone at 5 in the morning to someone who doesn't have a high school education. I talk about the salts and sugars in his blood falling too quickly, about cells swelling, about the risk of parts of his brain being affected. He pats my hand and tells me I worry too much, that he feels fine, that he knows I'm taking good care of him. Why do people have so much faith in us? I file an incident report. I call Risk Management and have a long and painful conversation with them. I call the patient advocate and fill her in on the situation. I dictate a long addendum to his written ED chart. I call the ICU attending and update him on the situation and sit patiently and quietly while he chews me out and tells me how terrible the ED is and suggests that we should shoot our patients at the front door since it would be quicker and more humane than the care we provide. I check back on Mr. Durcan, he is unchanged.

    Then I go and do what I have been putting off: find Malina. I make sure we're in as private a place as possible when we walk, I don't think I can keep from raising my voice. I manage to corner her in the X-ray reading room.
    "Sorry," she says, looking sullen.
    "Malina, I told you what dose to write and you still wrote the wrong dose. You ordered a potentially lethal dose of medicine on a patient. You overrode the safety check in place when you didn't take the nurses query seriously. 'Sorry' isn't sufficient here. Seppuku might not be sufficient. You don't seem to be aware of the severity of this error."
    "Well, yeah. It was bad. And I'm sorry. And it won't happen again, but I just checked in on him like fifteen minutes ago and he was fine."
    "Brain damage and organ failure from osmotic shifts can take up to 72 hours to manifest. I don't really care what he looks like right now.  I'm worried about what he's going to look like when he leaves the hospital."
    "Oh. Well, I'll  call the ICU at the start of my shift tomorrow and find out how he is." Like this is some kind of favor to me, like this is going above and beyond anything that could reasonably be expected of her. I've had enough.
    "No. You won't. Because you're not coming in tomorrow. And you're going home right now. I won't have you in my ED. You endanger patient safety and I want you out of here." Malina is so shocked that she forgets to look sullen and resentful. She now looks surprised and resentful.
    "But I've got 45 minutes left in the shift!"
    "I don't care how long you have, you're going home. Now. And you're not coming back tomorrow. Two patients almost died tonight because of your actions, either or both of them might still have horrible long term sequelae.  I can not accept that kind of risk while I'm in charge of this ED. I'll call your program director this morning and tell her  exactly why I don't feel safe having you in my ED."
    "I know why you're doing this!" Malina is crying and shrill,
    "I hope so. I'm doing this because you put patients' lives at risk and are unsafe to be practicing medicine."
    "Whatever! That's bullshit and you know it." She is screeching at the top of her lungs, I'm pretty sure the entire ED can hear her through the door, "You hate the thought that there could be another female doctor practicing on your turf.  You think I'm a potential threat to you and you're determined to keep me in my place." I have a hard time not laughing
    "Malina, we've already determined you're a threat. But not to me. Now leave." I walk back into the bright light of the ED and don't look behind me.

    A quick splash of water on my face and another cold diet coke and I feel almost human again. Not having Malina in the department is like having an enormous weight lifted off my back. Shawn is waiting for me at the doctors' desk. I sign a bunch of his charts and check on the few patients he has left. I tell him that he is the only reason there isn't rioting in the waiting room right now.
    "The nurses say you just fired Malina."
    "I don't have the power to fire her. I did throw her out of the ED and tell her not to come back."
    "Holy crap! That's amazing."
    "No, it's depressing. If you want to see something amazing, check out smiling Ida's lab value." Shawn checks and his jaw literally drops. It is very satisfying.
    "Many, many hours after she hit the door!"
    "Yup! So, was I wrong? Is your grandma going to come down with the same thing?"
    "Gram? Hell no! Not in a million years. But how did you know?"
    "I took a step back and went through the causes of altered mental status in my head. We had ruled out sepsis, which was my first thought, and NPH and encephalitis, which were also excellent thoughts. I wanted the two Ida's to be similar, since they certainly had similar presentations and we got snowed because of that. When I took the patient out of the picture and just looked at the symptoms it became more clear. We have a confused, hyperverbose, inappropriate patient who is incontinent of urine with a wide based gait and trunkal ataxia. We have a woman whose liver enzymes are elevated for unclear reasons. We have someone whose family dropped her off with a positive taillight sign - they're obviously not real worried."
    "Oh god. I'm so stupid."
    "No! No, you're not, at all. I was totally going down the wrong path myself. If she had presented at a different time than the other Ida maybe we would have seen it earlier but I think it's just hard when you're dealing with a sweet little old lady."
    "But when you put it all together it is so obvious."
    "Only in hindsight. Really, you're fine Shawn. I love working with you. Stop beating yourself up."
    "But we see it all the freaking time! How could I have missed the fact that she was drunk?!"

    The day attending picks that moment to walk in.
    "If the most interesting patient you have to talk about is some drunk, you must have had a pretty quiet night." He pauses. Looks around.  "Weren't you supposed to have another resident on with you?"

    I call Malina's residency director when I get home. I tell her that I don't care whether the program fails her out or not but she is never allowed back in my ED when I am working.  The residency director tells me to calm down. The conversation goes downhill from there. I then call the PICU.  Alicia Rose looks great, has breastfed several times since I last saw her, nobody yet has an idea why she lost her breathing and heart rate. So far she seems neurologically intact, she'll have several more days in the hospital, dozens of more tests scheduled, and we may not know the end result for years. But for right now she seems to be okay. And for right now, that has to be good enough for me.

It takes me a long, long time to fall asleep.

Thanks to Dr. Memory who told me how to improve my formatting and to all the lovely people who wrote comforting/encouraging things after my last cranky post. I'm still sleep deprived, so if you see any huge typos/editing errors let me know and I'll fix them.


26 ellucidations or expositions or put your $0.02 here!
sageautumn From: sageautumn Date: August 21st, 2008 05:18 pm (UTC) (Link)
*encouraging thoughts*

I truly do enjoy reading your posts.
penk From: penk Date: August 21st, 2008 05:46 pm (UTC) (Link)
Your postings are always fascinating, and I enjoy taking the time to read them beginning to end.

What was the final disposition of Malina? It doesn't sounds like the RD was very supportive of your evaluation of her. I dont know how the politics work in hospitals - this has the potential to be a lulu.

If push comes to shove, I assume Shawn and the rest of the staff can support your position on how, through ineptness, she endangered the lives of two patients?

Again, thank you for sharing.
dawnwolf From: dawnwolf Date: August 21st, 2008 06:00 pm (UTC) (Link)

Thank God for you

Seriously. Thank you for throwing that dangerous twit out of your ED. Thank you for being there to save those people from her intentional, malicious incompetence. I pray that The Powers That Be tell Malina that discrimination against the maliciously stupid is not only ok, but part of natural law; that bitch would have been thrown off a boat 100 years or so ago, and good riddance.

In other words, total support.
dr_memory From: dr_memory Date: August 21st, 2008 06:01 pm (UTC) (Link)
Happy to be of help. :)
netmouse From: netmouse Date: August 21st, 2008 07:01 pm (UTC) (Link)

To walk away from a moment of such impact as giving breath to that baby and then to just pick up and start going again and handle the next crisis... You blow me away. Bravo.

And that girl should not just be fired, she should have her MD stripped from her. Walking away from an unbreathing patient (not even running! walking!) is worse than negligence.
keyne From: keyne Date: August 21st, 2008 10:47 pm (UTC) (Link)
Strongly seconded. On both counts.
uplinktruck From: uplinktruck Date: August 23rd, 2008 03:48 pm (UTC) (Link)
Oh yeah. The reason I'm not in charge of discipline is simple. I have a very simplistic set of problem solving skills. But if it were up to me the people that put her back in Emergency would be hanging upside down on crosses in front of the hospital main entrance.

But that's why I'm not the President, police officer, prison guard...
blue_duck From: blue_duck Date: August 21st, 2008 07:20 pm (UTC) (Link)
I sincerely hope that you are gathering your stuff in preparation to write a book at some point.
shekkara From: shekkara Date: August 21st, 2008 07:25 pm (UTC) (Link)
Your story of reviving the baby had me in tears.

Thank you for taking a stand against life-endangering incompetence. I wonder what Malina's true reasons are for pursuing and MD.
tanac From: tanac Date: August 21st, 2008 07:29 pm (UTC) (Link)
I'm working at Red Cross now in Health and Safety, and yesterday the girl teaching the babysitting class (11-15 year old kids) walks into our office and says, "um, one of the girls in my class just passed out?"

The instructor. Who's teaching kids WHAT TO DO IN EMERGENCIES.

cochese From: cochese Date: August 21st, 2008 09:09 pm (UTC) (Link)
I continue to love your posts. The ED stories continue to be just heartwrenching and amazing and I appreciate you taking the time to write these.
From: morgan_x Date: August 21st, 2008 09:31 pm (UTC) (Link)
I am so sorry you've had such a rough time, but I love your posts.
inhumandecency From: inhumandecency Date: August 22nd, 2008 02:08 am (UTC) (Link)
I always enjoy reading your stories. I'm impressed by your knowledge and quick thinking, and also your ability to remember all this stuff long enough to write it down! I guess med school training helps with that too.

These stories are very well laid out dramatically. There's a narrator who sees a lot of what's going on, but not everything, and there are heel characters and face characters and quick scenes and extended mysteries and comic relief. Even if that's just what your job is like, you do a good job of bringing it out.

Thank you also for doing your job so well.
inhumandecency From: inhumandecency Date: August 22nd, 2008 02:11 am (UTC) (Link)
Her liver enzymes are elevated, why I don't know, but they're only about twice normal - not particularly impressive.

This is a useful tidbit. Every time I've had a blood test for the past ten years, my liver enzymes have been flagged as high. They're just a point or two above the reference range, and they don't change over time, but even when I tell my doctors this they keep trying to diagnose me with terrible diseases. It's good to have confirmation that there probably isn't anything wrong with me.
From: tlatoani Date: August 22nd, 2008 01:47 pm (UTC) (Link)
Really wonderful, as usual. I was late reading this due to work-related travel.

I second the idea that you should publish. You're the "James Herriot" of the inner-city ED.

(BTW, if Malina isn't a composite, sic Risk Management on her as well. They won't want her in their ED either.)
From: (Anonymous) Date: August 22nd, 2008 03:18 pm (UTC) (Link)

Another fantastic entry!

I dropped by the other day after finding your blog while doing some research for a medical trade piece I'm writing. I just wanted to say how much I'm enjoying your posts and that I too, think you should start seeking a publisher. What wonderful work you do! Hospital X is lucky to have you, as are those of us who get to read your insights.
uplinktruck From: uplinktruck Date: August 23rd, 2008 03:41 pm (UTC) (Link)

Re: Another fantastic entry!

What anonymous said. I would be happy to start the process to get you an agent.
figent_figary From: figent_figary Date: August 25th, 2008 07:53 pm (UTC) (Link)

Re: Another fantastic entry!


I wrote the first post because I got tired of answering the question "So is it just like ER?" I wrote the second post because I discovered the first one was cathartic for me. Honestly, I was shocked when people I didn't know started reading my stuff and giving me feedback. Publishing was never in my mind.

But now 4 people commented on LJ and 3 people contacted off of LJ and I am intrigued. Sure...I'll talk to an agent.

I'm not going to get my hopes up, though. I think my readers here are a highly self selected audience.

Thanks for the offer, I look forward to seeing what happens. Just tell me what I need to do next.
uplinktruck From: uplinktruck Date: August 25th, 2008 09:17 pm (UTC) (Link)

Re: Another fantastic entry!

Drop me a line at lks1 at 14ghz.com. After the DNC is over I'll make some calls.

Edited at 2008-08-25 09:18 pm (UTC)
From: (Anonymous) Date: August 27th, 2008 10:22 pm (UTC) (Link)

Re: Another fantastic entry!

It's funny, I found your blog because I was looking for exactly what you mentioned in your reply: I needed to know what happens in an ED for that article I mentioned. It helped but then as I started reading your older entries, I was hooked and I've been popping back in every few days since then.

I do mostly B2B stuff (boring case studies) and ghostwriting for magazine articles, so I don't actually know what goes into you finding a lit agent, but I hope you pursue it. Or at the very least, you should shop yourself out as an anonymous columnist to some of the major metro dailies (newspapers). I bet they'd love to run a series about "Hospital X". I know I'd definitely read it. :)
From: (Anonymous) Date: August 26th, 2008 05:18 pm (UTC) (Link)
I know that this question may not make sense, if Mr. Durcan is a composite, or may not be answerable for legal reasons, but I'd love to hear that he came out all right. I'm diabetic, and have depended on IV drips set by others a few times, and that story is freaking terrifying.
figent_figary From: figent_figary Date: August 26th, 2008 06:14 pm (UTC) (Link)
Mr. Durcan is a composite - as are all of the patients and the staff in my posts.

I have seen many cases similar to this. Some were on insulin drips, one was a very potent blood pressure medicine where the right dose was requested but the pharmacy sent up an incorrectly mixed bag, one was with heparin where the doctor wrote the right dose and the nurse set the mechanical pump wrong. In the vast majority of cases, the problem is picked up before or immediately after the medicine reaches the patient. The senario I describe here is vanishingly rare and requires a set of systems to fail in order to happen. In this case I didn't check Malina's written order, the nurse questioned it but didn't come to me, the pharmacy sent up a toxic drip, the drip was hung and not checked for over an hour. Multiple system failures like that happen very, very, very rarely.

So, in this case....

Mr. Durcan had a rough couple of days in the ICU with eletrolyte shifts but went home a week later at his baseline health status. He was very happy with the care he received.

The quality assurance committee is looking into the multiple systems errors that occurred to ensure this type of event does not happen again. An inservice was held with the pharmacy techs to implement a triple-check system for drip dosing and new nursing guidelines were passed requiring a verbal check by the nurse with the attending for all bolus drip orders written. Needless to say, the nurses, attendings, and residents all hate the new guidelines. The residents feel that they are being infantalized, the senior nurses feel that their ability to provide timely patient care is being compromised, and the attendings are annoyed at one more "patient safety" measure that they feel fails to increase patient safety and decreases the effectiveness of flow through the ED. The issue is being discussed again at the all staff meeting next month.

When Mr. Durcan receives his Press-Gainey card he returns it rating his hospital stay a 4/5. He would have rated it a 5, he states in the comments, except that he hated the food.

From: (Anonymous) Date: August 26th, 2008 06:36 pm (UTC) (Link)
Thanks! And thank you for the stories!

same anonymous
treebones From: treebones Date: August 27th, 2008 06:03 am (UTC) (Link)
shadowriderhope From: shadowriderhope Date: August 28th, 2008 02:29 am (UTC) (Link)
Wow. (that's "wow" on several levels, for several reasons.)

The thing that terrifies me about going into medicine is that I might be a Malina. :-( I've been having a lot of doubts lately about whether I can really do this, whether I can trust myself enough, if I'm smart enough.

And I totally agree you should publish/be published. Your work is completely engrossing, and I wish selfishly that there were more of it. ;)

I hope that all of the patients turn out OK - thanks for giving the update on Mr. Durcan.

Did I ever tell you I was in DKA once (or they thought so?) - sugar got to something around 700, and that was when they started me on insulin. I thought it was odd that they wanted the sugar to come down slowly, over a week or two (iirc). It was a really baffling occurrence, and had come on (seemingly, at least in terms of symptoms) suddenly over the course of a convention weekend when I had a cold....
From: (Anonymous) Date: September 28th, 2008 08:44 pm (UTC) (Link)


I'm at a loss for words. You are an amazing doctor. The resuscitation of the baby had tears flowing down my cheeks.
26 ellucidations or expositions or put your $0.02 here!