Behind the White Coat

The Needle Stick

Pain.  That is what I feel today.  And by "today" I really mean since yesterday morning, which is when my "day" really began.  It was my last day of the MICU, and I was lucky enough to be on call overnight.  It was probably the busiest call I have had all month!  Lots of sick people, lots of high maintenance.  Though Im proud that this whole month, during my watch at least, there were no deaths, and no code blues.  Not too bad.  Unfortunately the last day was the day I was not careful enough while putting in my first central line of the day.  Now I've put in plenty, and am always careful, but this time, after putting in the line (sucessfully) in a new patient, from whom we had yet to obtain any medical history, one of the needles slipped while I was cleaning up, and jabbed right into my thumb.  Fuck.  It was a smaller needle, the one I used to aneshthesize the skin (so in theory it never made contact with the patient's blood), but I certainly bleed into my glove, and it was worrisome enough for me!  Needless to say the rest of the day I was in quite a horrible mood.

So now what?  I looked through the labs, and there was no HIV or Hepatitis C test on this patient.  Great.  Now the patient seemed like she was low risk-- 41 year old female, diabetic, with no known history of intravenous drug use.  But shit, how can you be sure?  So I had to get my ass over to emplooyee health, where I filled out some forms, they drew my bloods (apparently partly to test my status now, in case I was positive and am trying to scam for worker's compensation by claiming I converted durin a job accident! Guess it makes sense for them to do so).   I also obtained consent from the patient's family to get an HIV test from the patient.  In the state of New York, you must have the patient or family member's consent to get an HIV test.  Isn't that insane?  In extreme cases you can get administrative consent (if the patient cannot respond or communicate), but imagine the patient refused?  There should be no such law.  If a health care worker gets stuck, it should be obligatory for the patient to submit to HIV testing.  This is the only communicable disease requiring consent.  Everything else you can check for.  Lucky for me I got consent.

Now the rate of HIV transmission on a needle stick (assuming the patient is positive) is pretty low.  Something like 0.5%, which also depends on the size of needle, amount of blood exposure, and the patient's HIV viral load.  The more concerning stat is for hepatitis C, which is up to a 20% transmission rate.  The latter is also not preventable, so I'd be more scared about that.  For HIV, prophylactic medications can pretty much elminiate the transmission as well.  So when I went to the health center, they recommended anti retroviral therapy until the test came back.  I figured there is no use takin a chance, so I am now on Kaletra and Combivir, two anti-retroviral drugs.  I am hoping the test returns soon, because I have had serious GI upset and myalgias, and am not happy!  Like I said, its the Hep C that scares me more, but I am confident the patient was low risk....

So that is how my day started.  After rounds this morning (no sleep overnight), which ended around 10:30am, I had to head over to the medical wards, where I was inheriting a brand new team, with 2 interns, one sub-intern (4th yr medical student), and one 3rd yr medical student.  Our service has about 15 patients on it.  Basically I am diving into one of the busier months of the year, but also one of the more fun and interesting ones.  Regardless, I was running on zero sleep, and could barely absorb anything!  I got out by 2pm, figuring I'll go in tomorrow to see everyone when I'm conscious....

Alright thats it for now.. Lets hope for negative tests!

Deadly Reaction...

We had the saddest case come into the ICU the other day.  It was a 54 year old lady healthy woman who only had hypertension, who had ben referred for an outpatient CT scan (cat-scan) with intravenous contrast to evaluate some swelling.  For certain CT scans you give an intravenous dye, or contrast, to better light up organs and structures.  It does have some risks, which usually occur in sicker people.  However there is a small number of people who will have an allergic reaction, anything from a rash to severe anaphylaxis.  The latter is uncommon.  I've never seen it, and I have sent tons of patients for CT scans.  This one time, it happened to this poor lady.

She was getting her scan in the outpatient scanner, which is in a building over from the main hospital.  From what we heard, she got onto the table, and as she was going into the scanner after the dye was injected she complained of an itch.  The scan went to completion (about 2 to 3 minutes), and she was found unresponsive on the table, with no pulse.  A street call code was called into the ER, and they sent their team over to the other building (a good 4 minutes away).  When they arrived, they performed CPR and ACLS for 15 minutes, including multiple shocks, and rounds of epinephrine and atropine to revive her.  She eventually regained a stable heart rhythm, and came to the unit, intubated, and unresponsive.  Since then, because of the cardiac arrest, she has gone into ATN shutting down her kidneys requiring dialysis, had an ischemic liver injury, has swelling in the brain from her anoxic brain injury.  She does have brainstem reflexes, meaning she is not brain dead; nonetheless, she is on the ventilator, and unresponsive. It is likely she may never wake up, or she may die...

Truly horrible.  A healthy person undergoing a simple outpatient procedure.  They say there is something like 1 in 100,000 people who will have an allergic reaction to intravenous contrast, but you never expect to see it!  The family is shocked, is always angry and rude, and they are going to sue.   But would you not do the same???  Sometimes even the simplest tests and procedures can prove to be life threatening...

LA Again

Man am I tired.  Last thursday I was post-call in the MICU, and due to an interview cancellation (those bastards), I had Friday off, which wasn't bad.. Especially since I had been on call Monday and Weneseday, so I had a day to recover.   Saturday was my interview at Robert Wood Johnson in NJ, which wasnt too bad of a program I thought, and the interviews went well.  That same afternoon I caught a flight to LA, arriving Saturday night at 8:30pm.  I basically went from 25 degree weather to 95 degree weather, quite a shocker.  But it was nice, a solid dry heat, and I certainly coudln't complain.  Sunday I had the day to enjoy. I been to LA several times, and it is a nice place in some ways, but in other ways it is definitely an annoying city.  It is hardly a real "city" as us east coasters view it, it is more of a collection of different suburbs, connected with one another by freeways, which may be 6 lanes wide, but alwyas have traffic!  So even though I have about 4 or 5 friends who live in "LA", they live ages apart from each other.  The first night I stayed in Los Feliz(?), which is near the hollywood area.  On Sunday we drove over to Santa Monica to meet my other friend for lunch, a nice trendy area though touristy, which was like 45 minutes away.  That same evening I went over to stay with my friend TVT in Brentwood, near the UCLA campus and medical center.  That same evening we went to some place to meet another friend, his ex-roomate, which was somewhere randomly in the middle of the suburbs, which was another 40 minutes away.  So it is insane trying to coordinate anything in LA, especially if you want to go out and make it by the 1:30 or 2am closing of all establishments!   Anyhows, despite these factors, the weather is great, the ladies are hot, and the mentality is nice and laid back... Did I mention it never gets colder than 45 or 50 deg in the dead of winter?  Wow...

Now the UCLA interview was a full day marathon.  I gotta say I was a little out of my league.  Everyone there was interviewin from top 5 institutions, from Harvard to Hopkins.. And then there was me...  I am sure it was some sort of clerical error.  Nonetheless, the interviews went well, and it is definitely a strong program.  However a tad too academic for me, and not enough clinical emphasis.  Which I suppose is the nature of these big programs, they have such a strong emphasis on research, and some of their tracks are like 4 or 5 years..  Hell no senor.  If anything, I'd apply for the clinical track, which only has 6 months of research (still a shit load).  But I guess it was just not what I am looking for, since my goal is to be a clinical cardiologist, and not a research lab rat.  Having said that, it was a good overall day.   My day ended by meeting up with a bunch of my other friends, having some happy hour beer and sushi, and heading to the airport, not before stopping by my favorite fast food ever:  In-N-Out, for a seriously kickass burger (double double animal style).  So I'd say I made the most of my 2 day stay, and amazingly made the effort to see 4 of my good friends from medical school.  Takin the redeye home and going straight to work wasn't the most excitin thing the next day, but such is life!

Oh, and when I left it was cold in NYC, while I was in LA, it became much milder, up to the 60's in NYC, and yesterday when I was on call it hit 75.  Now, as I awake in the evening post-call, it is raining at 42 deg, with 6 inches of snow expected tomorrow afternoon.... Are you kidding me?

Familial Relations

The MICU is really sucking the life out of me.  As it is, being on overnight call every 3 days leaves with you no time, little sleep, and intense work.  If you think about it, it is kind of frightening that the lives of 10 critically ill people is essentially in the hands of me and an intern overnight.  Of course there is a critical care fellow available for help, but really you are the first line of care.  This past few days I have been q2 call!  So I was post call Tuesday, and on call again on Wednesday.  I had to switch around to make my interviews this week, but it is still brutal. 

You really see some interesting things and insanely sick people in the MICU:  some of who somehow are miraculously saved, and others who just slip away despite the most aggressive therapy you can provide.  You also deal a lot of with families.  Now I consider myself pretty good when dealing with families of patients, whether they are saved, or they die, I feel like I relate to them well.  This week, someone did their best to prove me wrong!

We have this ridiculosly sick patient, with a metatsatic cancer syndrome, who has been in the hospital forever with all types of complications.  Anyway, she is severely sick, and is probably going to die within the next 1-3 months.  the family is nuts.  I mean I feel bad for them having to deal with their sick loved one, and you do allow some degree of blame and anger towards you by the families in their times of emotional distress, but there is a limit.  This family somehow accused me of cursing at them on the phone, and being uncurteous, and other things.  Hah!  This was from a conversation of me telling them (the sibling and spouse) the status of her loved one and that she was doing poorly.  It was a stream of stupid questions and comments clearly the result of intense google searches, regardless, I explained everything to them on the phone, in my normal professional manner (amidst 9 patients, 3 unstable, at 11pm at night).  Anyway, they apparently thought I was uncourteous and complained about me like no tomorrow.  The family apparently hates everyone, and have been rude and complained about all the doctors, but because maybe they didnt like my voice, they want my blood.  Come and get it you fools!  I hope they taped the conversation as they said to clear myself.  Anyway, they insist on going to the top of my supervisors.  Insane.  Let them, it just pisses you off when people hunt for someone to blame like that, when they should be looking out for the best interests of their loved one (instead they are making her suffer with their decisions).  Well it shouldn't bother me that much, this is stuff we deal with as doctors!  But man does it piss me off.

Ok that was my delirious rant after bieng awake since 7am Wed, it is now 1pm Thurs.  Time to sleep.  2 interviews coming up, and at least I'll be in LA for a few days!  I feel like I haven't been home in days.  Though at least my DVR has a nice line up of new episodes: Lost, House, Heroes, 24.

Enjoy a dark, banging, tabla infused joint by Talvin Singh:  Download Dubla.mp3 (7178.3K)

 

March

I have been in the hospital since Friday morning, and as I walked out at around 11am today, the weather was amazing!  I walk in to the ICU on a cold freezing morning, and emerge to meet 60 degree blue skies and shining sun!  I managed to get 3 hours of sleep, so I can't miss the first beatiful day in NYC of 2007.

This was the hot tune in my car as I drove home in the March breeze:  Download Thievery Corp. - Warning Shots.mp3 (5905.4K)