Behind the White Coat

Green Team, First Call

So I am home now status-post being awake for the past 36 hours.  I got zero sleep during the day Thursday when I tried to rest up for my overnight call.  Who the hell can sleep randomly in the middle of the day anyway?? All I did was waste a beautiful 73 degree day, the first nice day of the entire year!  Alas, the night was long and tiring.  I had all five of my admissions waiting for me when I got into work at 8:30 PM.  Three out of the five were HIV with some infection:  Pneumonia, infected ulcers, urine infections...  One of the guys has a CD4 count of 10, has had TB, PCP pneumonia, endocarditis, pulmonary embolisms, chronic leg ulcers, thrush, and crack-lung (literally your lung gets "cracked" from... well, smoking/inhaling crack-cocaine).  He is actually the most with-it guy who can actually give a good history!  Still, I am amazed he has survived since the late 1980s until now without therapy for years..

My other patients are one guy with active Tuberculosis, with a giant cavity on his chest x-ray, who roams the halls with his "mask on."  Yeah like I am sure he fits it properly on his mouth.  I gotta keep this guy in his room in isolation before the whole floor gets TB.  Granted the poor bastard is stuck in an isolation room for probably weeks until his sputum smears are negative.  Bummer.  My other patient is this 22 year old girl with spina bifida, and  ventriculo-peritoneal shunt for her hydrocephalus (a conduit from the brain to the abdomen to relieve pressure of backed up spinal fluid), who is parapalegic with a neurogenic bladder, so she has to straight-catherize her self twice a day (put a catheter up into her bladder from her urethra, because her bladder doesn't function), who also has sickle cell disease.  She is here with a urine and kidney infection, and chronic abdominal pain... Poor lady.  I don't blame her for not wanting to talk to any of us.  Finally I have this 64 year old Bengali lady who had such a bad stroke she cannot get out of bed, control her bowel or bladder, or talk. Yes, she is aphasic.  She also has diabetes, blood pressure, and is on dialysis.

Depressing aint it?  Anyway, I need to sleep. This is my so called "golden weekend", but I have to go in the morning to write notes on my patients.  Now I have to sleep, and if Im lucky I'll wake up in time to go out for maybe an hour or two to see my friends who are visiting from Cali, have one drink, before I have to go home and sleep... Lovely... Well better than being tired when I go to draw blood on any of these patients when they spike a fever.... There aint no room for a slip!!!

Return to Klau

So CCU is now over.  No more overnight call every fourth day, but alas, I must face my arch nemesis... The Klau Pavilion.  If you ever read my blog earlier in the year, you'll know that Klau is the main medicine wards at Montefiore.  I have two back-to-back months in store for the start of the summer.  This month I inherit the "Green Team", which is also known as the HIV service.  So a large chunk of my patients will be AIDS related cases, which also means a lot of IV drug abusers and difficult to deal with patients, and all the fun that comes with them.  Should be interesting though, since those are the sickest people around.  Though it will be painful and draining as well.  Lucky I have only 3 patients right now, but I am about to head out to my overnight call, where five admissions await me...  So it begins....

Saving Lives

I have been MIA for a bit.  I have pretty much been engulfed by the CCU for the past few weeks.  That, and the telemetry floor, which is kind of the "stepdown" unit from the CCU where we send patients who are stable enough to leave the unit but still need to be in a monitored setting.  However most of the time the people are pretty much medically stable and we are just dealing with social issues, rehab, and other discharge planning related stuff.  If we are lucky some of the people will still have some medical problems to treat, like fluid overload, rapid heart rates, or awaiting re-implantation of their pacemakers or automatic defibrillators.  But its a lot of scut!

So a lot has happened this past week.  The guy I wrote about on my last post, the aortic dissection, is still around, and back in the unit. He went to the OR, they cracked his chest open and replaced part of the aortic arch that was dissected with a graft.  They also "repaired" his aortic valve (which was leaky as a result of the dissection), and glued the remaining flaps of the dissection to the walls of the aorta.  The procedure seemed to have gone well, but is anything that easy?  So post-op, his blood count began to drop, so we gave him something like 6 units of blood in 24 hours (trust me thats a lot), and his hematocrit (or "crit" for short, a measure of his blood count) did not budge.  He had no obvious source of bleeding, CT scan was negative for a bleed in the chest where the surgery was, or any bleed internally.  There was no obvious GI bleed, but we sent him for EGD anyway.  And lo and behold they found a Dilefuoy's lesion.  That is a rare cause of upper GI bleeding where there is an abberrant dialated vessel (usually an artery) that spurts out blood. It's the second one I've seen, but usually you see massive amounts of melena, which he didnt' have... Until the day after when it just poured out.  Guess it was just hangin out in his gut.  Anyway, they cauterized it and we waited a few days and restarted anticoagulation.  Of course then his toes started to turn blue, and one foot was cold.  Shit.  A CT scan repeated showed the guy had dissection of the aorta all the way down to the iliac vessels (in the pelvis)!  He may have dissected and fired down some thrombi from there.  A repeat TEE showed severe aortic regurgitation, and a flap near the aortic valve which was either a thrombus or unreparied dissection.  This could also be the source of micro-thrombi, but regardless, this had to be repaired.  That means we have to crack open his chest yet again!  Talk about a bad day at the office...  Though if Pablo the fellow didn't pick up the little abnormal flap on the bedside Echo at 2am, the man would be long dead.... Lets hope we can save him yet.

Anyway, today is the surgery, we'll see how he does...

We've had some other pretty amazing stories.  Our Bengali guy who came in with a huge inferior wall myocardial infarction (heart attack) who dropped his pressure, needed ionotropic and pressor support (meds to keep his heart pumping and his BP maintained), and an intraaortic balloon pump (which pumps with the heart in the aorta to keep his heart and body perfused, pretty amazing), he was intubated and near death.   He walked out of the hospital yesterday after 2 weeks.  Amazing.

Goes to show that we really can save some people, despite how deathly ill they are.  Though usually its the younger people (under 65) who do better with such severe and sudden diseases.

Plenty off more stories to tell, but gotta go get some work done....

I am also supposed to write a piece for this online magazine http://www.egothemag.com.  It is a pretty cool diverse magazine with interesting articles.  Check it out.  Hopefully I'll get something together soon... 

Sick Patients in the CCU

CCU calls can be quite viscious.  My first night wasn't horrible considering I got 3 hours of sleep, but nonetheless there were people crashing, getting intubated, and all that good stuff.  Last night however, was crazy.  There wasn't even time to consider sleep!  Sick patients getting intubated, dropping pressures, turning blue, and having heart attacks.  We had it all. 

One of the admissions was a 54 year old man with hypertension come up from the ER with a diagnosis of rapid atrial fibrillation.  It is an abnormal heart rhythm that patients get for a variety of reasons, usually older people with a history of heart disease.  It can cause problems with clots that lead to strokes, and symptoms such as dizziness, palpitations, syncope, etc.  This guy came in after 2 weeks of shortness of breath.  He comes up and looks a hell of a lot more unstable than what you would expect, and he seems extremely short of breath--more than we would expect at a heart rate of 120.  The goal is to control his rate, which was not working too well.  He got all kinds of meds in the ER to slow his rate, but to no avail.  His pressure was also on the low low end of normal, which was also somewhat concerning.  But the real thing that brought him in was his difficulty breathing.  He was breathing at about 40 breaths a minute, and he was tiring fast.  His ECG showed no evidence of infarction or ischemia, and his chest xray showed some fluid overload in the lungs.  Ok so maybe he needed some diuresis? So we gave him lasix and meds to get fluid out of his lungs, but it still did not do much for his symptoms.  To top it off his kidney function was bad, and he was approaching acute renal failure. He was deteriorating fast, and getting very tired.  We knew that he could not keep breathing as fast as he is much longer, and we would soon have to intubate him. 

We continue to give him oxygen and control his rate, but nothing changes.  The fellow finally comes to do a bedside echo.  The study was very poor because he was a large man who kept moving, and we could not see very clearly.  The heart wasn't contracting too well, but we could not see much else.  We try to get consent for intubation.  "Sir we need to put this tube down your throat to help you breathe." He refuses.  "Sir you will die if we don't."  He consistently refuses... Finally I ask him if he wants us to keep him alive, and he says yes.  Eventually he gets the picture, and we intubate him.   The sedation we give him further drops his pressure and we have to put him on dopamine and vasopressin to support his heart.  I manage to get in a central line into his groin for better venous access, and we put in an arterial line to get continous BP monitoring.  But we have yet to have an answer.  What was going on???

The cardiology fellow tries again for an echo to get some better pictures.  As he is finishing, he sees something on the screen. "Oh shit!"  Next thing we know he dissapears, and 10 min later, he returns with our attending!  It was 2am and our attending was still in the hospital having finished an emergency angioplasty for an acute myocardial infarction.  They look at the screen and he points to what appears to be an aortic intimal flap.  In plain English, it looks like the aorta was dissected by the aortic valve! Something you almost never see on a transthoracic echo.  So next thing you know, we page the Echo attending on call at 2:30am, and she comes into the hospital to do an emergency trans-esophageal echo to better visualize the aorta.  What did we see? A huge aortic dissection, all the way back to the aortic valve, probably into the RCA ostium.  From that he had horrible aortic and mitral regurgitation, which is when blood flows the wrong direction in the heart, which is what was causing his shortness of breath and symptoms of heart failure. This was a surgical emergency!

A few hours later in the morning, he was taken to surgery and they repaired his dissection.  He is currently in the Surgical ICU doing remarkably well.  He is awake, intubated, and off pressors.  He may actually make it! 

This was probably the most atypical presentation of aortic dissection ever.  It is usually chest pain and tearing back pain, and almost never presents with shortness of breath and atrial fib.  My guess is he had  it for a while, and it progressed to cause these valve problems and dialated his atrium to cause fibrillation.  But that is all a guess.  Very weird.  Perhaps we will write it up!  Regardless, lets hope he lives to tell the tale...

Lost and Found

I have been pretty prone to losing things in my life, from money to wallets, phones, keys, coats, etc.  Though I have done pretty well in the past few years.... Well past year... Well for wallets at least.  So what do I do? I go and lose my wallet last weekend.  I didn't even lose it while I was out, I had it in my hand in the cab, and I probably just left it in the cab.  Son of a bitch.  Lucky for me when I go out I take out most things except credit cards and ID.  Which are still bad enough, but at least replacable.  So I am pissed as I call to cancel all my credit cards and ATM cards, and wonder when in God's name am I going to find time to go to the NJ DMV.  Torture.  So anyway, a few days later I get a message from my local blockbuster.  Apparently the cabbie, Mr. Salam, called them (because I had my card with the phone number in my wallet) and they tracked me down and left me a message.  So I called the cabbie, who lives in Queens.  He came by the next day to drop it off!!  Amazing.  "We are from same country brother, It will be safe in my hands, don't worry"  And he was true to his word.  What are the chances??  Guess there still are some goods samaritans out there.  Of course I cancelled all the cards so have no money or credit for a week, but at least I got my license back, and my metrocard that still had 26$ waitin to be used....