Behind the White Coat

Bring on the Klau

So my medicine floor month at Weiler has come to an end.  Tomorrow I begin my ward month at the infamous Klau Pavillion at the main Montefiore hospital.  No more good ole days of carrying 4 to 5 patients average, no more soft ROMI's (rule out myocardial infarction), and no more signing out to the day float at 4pm.  Ah yes, Weiler hospital was definitely not as bad as Montefiore is going to be, but at least I eased my way into it.  Since it has been a while since my last post, lets see if i can recollect some highlights...

So my last overnight call day this past Sunday, I got there around 5pm with a bunch of free time before I started admitting.  So I decided to help out the day float resident put in a central line on some patient so I can get some procedure credit in.   So it was some 90 year old hispanic lady with dementia, and admitted for a giant pulmonary embolism. She had no access so we decided to put in a femoral line (a central line is like a big IV that goes into one of the large veins, in this case the femoral vein).  I've done them before so was quite comfortable.  Got draped, sterilized the area, and proceeded.  Took me a few stabs as her pulse was weak, but finally got my needle with venous blood flowing back.  Now as I was doing it she was very agitated, moving around and saying demented "Ay-yay-yays".  As I was almost done, she calmed down, and stopped talking.  She was almost.... TOO quiet.  We looked at her closely, and looked at each other.  Was she breathing.  Oh dear.  The nurse came in and we tried to get her head up.  Then a voice from the telemetry room spoke from the intercom "ASYSTOLE!"  Her heart had stopped.  Well that would explain the lack of talking.. and well.. breathing.  I finished what I was doing and we quickly tried to figure out what to do.  We learned she was DNR (do not resuscitate, in case her heart stops).  So in essence there was not much to do.  We were hanging some fluids to try and get her pressure up.  But alas, there was no pulse.  She threw out a few Cheynes-Stokes respirations, and that was it.  She lay there, mouth open, eyes open. Dead.  Damn.  Wrong place at the wrong time.

Now obviously it wasn't the procedure that caused her hear to stop.  She was a sick old lady with a giant clot in her lung vessels, but nonetheless, it was kind of freaky.  It's the first time I was in the presence of someone who was totally fine one minute, to totally dead the next.  Usually you catch them before, after, or during their process of death, whatever that may be, (cessation of her heart to function in this case) so being there start to end was a first.

Anyway. Certainly some more exciting stories from the floor month, I'll postem as i remember em.. Though I'm sure my montefiore month will be filled with utter, bitter, madness.

You want a piece of me Klau?  Come and get some.

Bright Ideas

This probably was the easiest month of the wards I will ever see during my monte reign.  Our team's census is down to 3 patients... That's right.  We have more doctors on our team than we have patients.  Quite impressive I gotta say.  I have had one patient for the past two days, this hysterical and hyper little 75 year old Ecuadarian guy.  Quite entertainning, and unnecessarily in the hospital.  The coumadin nurse was too busy to set up his home visits, so I basically have him sittin here just to get his coumadin to therapeutic levels (coumadin being an anticoagulant which has to be monitored by blood tests until you get the dosing to the right levels).  Anyway, since I have nothing to do, I signed out at 11:30am yesterday.  Crazy!  It's impossible to get out that early ever again on a ward month.  And today, since we were at Rock Candy (a new club)  last night till about 1:30am.  I took a nice 2 hour nap in the call room after attending rounds.  Enjoy it while it lasts Haider.

One of our team's 3 patients is an interesting case and is worth mentioning.  So this guy is about 34 years old, no real medical problems, contracted lyme disease about 2 or 3 years ago.  He has had a pretty rough course, with several episodes of flaring up of symptoms, and numerous courses of antibiotics, including long-term IV therapy.  He recently was completing a 6 week course of IV Rocephin, which is often used for more refractory and recurrent symptoms.  He can get the medications at home through a PICC line(peripherally inserted central catheters), which is like a long term IV inserted under flouro by interventional radiologists. 

Now this guy is a little type-A personality type, a cocaine user, is on some anti-depressants, and is just kind of weird when you talk to him, so we kinda felt he aint all there.  Which would make sense given what he did.  He felt that the numerous medications he was taking aren't good enough, and he looked for some Alternative Medicine therapies.  Now apparently there are some quacks out there who wrote on the internet that intravenous hydrogen peroxide can be used against many diseases, including cancer, chronic illnesses, infections, etc.  Insane, I can't believe there is literature advocating this on ther internet!  So this genius goes ahead and starts injecting hydrogen peroxide into his picc line.  By himself.  Now hydrogen peroxide oxidizes things.  It breaks shti down. I mean you seen that shit sizzle when it hits something, that shit is no joke. It kills all kinds of bugs and cleans wounds.  Imagine that in your blood!  Well when this guy started pissing out dark ass urine, turning all yellow, he came in to find out the peroxie has been hemolyzing his blood cells.  It basically reacts with the heme groupss in the red blood cells, and breaks them apart.  What you get is a hemolytic anemia.  So we hydrating him, givin him blood, which he keeps hemolyzing for now.  So we gotta keep doing it until its all cleared out. 

Pretty wacky eh?  It's an interesting case and I think our subintern is gonna write it up to publish.  I doubt many of us will ever see a case of self-injected hydrogen peroxide!

First Call

So tonight was my second call as an intern--hard to believe it took so long, but my first 2 months were non-call months, so my luck had me delay it as much as humanly possible.  My first was 4 days ago on the night of Thursday Sept 2nd, overnight call.  We have about 2 overnight calls per month, the rest of the call days are from about 6am to roughly anywhere from 8pm-12am (it widely varies depending on who gets admitted!) 

Overnight call is a little different.  Our overnight calls begin at 9pm.  So you come in the morning to round with your team, leave to go home at 11am, and then come back at 9pm.  Their logic being you stay overnight, and then stay the full day the next day so you can do the workup for your patients yourself.  Personally I think it is retarded.  How the hell are you supposed to sleep during the freakin day after you already woke up?  It aint easy. Especially on a warm sunny day.  So I went to my uncle's house in Westchester about 15 min away, and dosed some nyquil to try and catch some Z's.  I managed to get about 4 hours.  But clearly barely enough to sustain my 24 hours in the freakin hospital after that.  I was all alone after 12pm the day after call (zero sleep mind you), and I am the orphan intern, so I was running solo with no resident or co interns.  Needless to say it was pretty rough.  Yet somehow I survived.  Of course my Friday night was shot as I ended up sleeping a wopping 15 hours after that.  Thank the lord my intern covered my notes on Saturday to give me a true "golden weekend"  (the glorious term when we get both days off on a weekend).

Tonight's call wasn't too bad. Granted I worked on labor day, but got only 3 admissions, bringing my grand total to about 7.  Of course half these gomers sit around for social work issues, waititng to get their sorry asses some home health care, or visiting nurse services, or nursing home placcement.  Of course social work is so goddamn slow, by the time they get somwhere to go, theyll be spiking fevers and become septic.  Ahh such is the life of medicine.