He finally ended up in the ICU today. According to the nurse, the CCM doc took one look at him and started the transfer process. Last I heard they were talking about intubating him. This one's gonna sting for a while. We had fixed him. He was better. He was going home. And then this, on our watch, while we were taking care of him. Yeah, I'm taking it personally. Yeah, I feel like I failed. It's going to be a while before I stop berating myself about the things I should have done differently. Damn it, he was BETTER! This didn't have to happen! There has to have been some way we could have stopped it...there has to be...
*Sigh* sorry, it's been a rough couple of days. Prayers for this patient and his family would really be appreciated. At this point it would be a miracle for him to leave the hospital in the same condition as when he arrived...anyhow, till next time, peace and God bless...
Thursday, February 17, 2011
Wednesday, February 16, 2011
Condition C
Long day = short update. Seems I was unfortunately right about the patient I mentioned last night. At first, it seemed like things were going much better today...he was more with it, alert, oriented, communicative. But as the day wore on it became clear that some things just weren't quite right. He was still running fevers despite being on antibiotics. He was still breathing too quickly. His heart was beating even faster than it was yesterday and it just looked ugly on the monitor...lots of PVCs, atrial fib, even non-sustained v tach. (Non-medical people: if you're really interested, you'll have to ask for a specific translation, because this one requires a lot of explaining.) And then his IV blew. And the IV team couldn't get access. And he started having longer runs of v tach. And his temperature went up. Without an IV we couldn't give him fluids, antibiotics, beta-blockers to control his heart rate, anything. So after ascertaining his code status with his power of attorney (my first time getting a code status on my own...more about that next post) I grabbed my intern and attending who decided to call a Condition C. Long story short, by the end of the day he looked pretty bad and was getting a central line from the CCM fellow. It's probably about 50-50 whether he ends up in the ICU overnight, and if that happens...well, we'll cross that bridge when we come to it, but I'm afraid it'll work out poorly.
So yeah, that's the update for the evening...wish it were a happier one. Now I'm off to grab a few hours of sleep before long call tomorrow. *Sigh* Till next time, peace and God bless!
So yeah, that's the update for the evening...wish it were a happier one. Now I'm off to grab a few hours of sleep before long call tomorrow. *Sigh* Till next time, peace and God bless!
Tuesday, February 15, 2011
Every now and again...
...you just have one of those days. Days that you wish you could just erase and forget even though you know there's a lesson in there somewhere. Days that leave you questioning yourself, your abilities, your competence and wondering if you've made a wrong turn somewhere in life. Days that rank among the most unpleasant of defining moments.
So I have this one patient. I've been taking care of him for a week now. He came in with viral gastroenteritis, a really common bug that's unpleasant for a couple of days (nausea, vomiting, diarrhea) and then goes away. We gave him some fluids, watched him for a day, and prepared to send him home. What's that you say? The bed at the nursing home has already been filled? You didn't even hold it for 24 hours? Oh, that's ok, because it's GREAT for people to stay in the hospital for a week when they're well. It's not like you can catch all manner of horrible nasty illnesses or anything. (...yeah, you see where this is going...) And sure enough, yesterday he spiked a fever to over 102 F. And started puking. And becoming tachypneic (translation: breathing faster than usual). He turned out to have pneumonia, probably from aspirating something or another. That would be bad enough. Except it's not the end of the story. You see, today his blood cultures grew out Gram (+) cocci in clusters. That means staph. Probably S. aureus. Possibly MRSA. For the non-medical folks: that's BADBADBAD. S. aureus bacteremia has about a 30% mortality rate. The last patient I knew who had it died. And oh-by-the-way, did I mention that because of his demographics and current condition he has about a 30% chance of not surviving the pneumonia? Or that he's immunocompromised because he's a transplant patient? We've been working on summary statements; here's one: this guy is NOT going to do well. Maybe he'll pull through. But even if he does, it's not going to be a short, easy process. It's going to take some time, and he's likely not to regain his former level of function. And as I worked on writing his note and putting his orders in today, I wondered what I had missed. Had I failed to see something that would have given some warning? Or worse, had I inadvertently done something that contributed to him getting sick? Had I missed some finding, some cue, some opportunity to prevent his nightmare in the first place? What could I have, should I have done differently? Where did I screw up? What did I do wrong? I'll probably never have answers to those questions -- I'm not even sure there ARE answers to all of them -- but I couldn't stop running through them in my head today. And as Dad pointed out, maybe that's not all bad. Maybe it's a thought process I need to allow myself to run through, as he called it, a "mini-M&M" [that's "Morbidity and Mortality" btw] that forces me to analyze my thought processes and holes in my reasoning, that helps me recognize patterns, gaps, and things I need to change next time. Because there WILL be a next time. Instead of an old guy with pneumonia, it might be a young kid with appendicitis, but many of the principles will still apply. Don't let your preconceptions get the best of you. Sometimes short-term discomfort prevents long-term death. Err on the side of getting help. Just because you're "only a med student" doesn't mean you're not right, and it ALSO doesn't mean your team won't listen to you. If something looks wrong, treat it like it is until you find out a reason. Too much information is often worse than too little. And no matter how sure you are that you've got a handle on everything, remember that the plot *ALWAYS* thickens.
Anyway, those are my musings for the evening. Prayers for my patient would be appreciated...we'll see how he does tomorrow. Hope everyone is doing well! Till next time, peace and God bless!
So I have this one patient. I've been taking care of him for a week now. He came in with viral gastroenteritis, a really common bug that's unpleasant for a couple of days (nausea, vomiting, diarrhea) and then goes away. We gave him some fluids, watched him for a day, and prepared to send him home. What's that you say? The bed at the nursing home has already been filled? You didn't even hold it for 24 hours? Oh, that's ok, because it's GREAT for people to stay in the hospital for a week when they're well. It's not like you can catch all manner of horrible nasty illnesses or anything. (...yeah, you see where this is going...) And sure enough, yesterday he spiked a fever to over 102 F. And started puking. And becoming tachypneic (translation: breathing faster than usual). He turned out to have pneumonia, probably from aspirating something or another. That would be bad enough. Except it's not the end of the story. You see, today his blood cultures grew out Gram (+) cocci in clusters. That means staph. Probably S. aureus. Possibly MRSA. For the non-medical folks: that's BADBADBAD. S. aureus bacteremia has about a 30% mortality rate. The last patient I knew who had it died. And oh-by-the-way, did I mention that because of his demographics and current condition he has about a 30% chance of not surviving the pneumonia? Or that he's immunocompromised because he's a transplant patient? We've been working on summary statements; here's one: this guy is NOT going to do well. Maybe he'll pull through. But even if he does, it's not going to be a short, easy process. It's going to take some time, and he's likely not to regain his former level of function. And as I worked on writing his note and putting his orders in today, I wondered what I had missed. Had I failed to see something that would have given some warning? Or worse, had I inadvertently done something that contributed to him getting sick? Had I missed some finding, some cue, some opportunity to prevent his nightmare in the first place? What could I have, should I have done differently? Where did I screw up? What did I do wrong? I'll probably never have answers to those questions -- I'm not even sure there ARE answers to all of them -- but I couldn't stop running through them in my head today. And as Dad pointed out, maybe that's not all bad. Maybe it's a thought process I need to allow myself to run through, as he called it, a "mini-M&M" [that's "Morbidity and Mortality" btw] that forces me to analyze my thought processes and holes in my reasoning, that helps me recognize patterns, gaps, and things I need to change next time. Because there WILL be a next time. Instead of an old guy with pneumonia, it might be a young kid with appendicitis, but many of the principles will still apply. Don't let your preconceptions get the best of you. Sometimes short-term discomfort prevents long-term death. Err on the side of getting help. Just because you're "only a med student" doesn't mean you're not right, and it ALSO doesn't mean your team won't listen to you. If something looks wrong, treat it like it is until you find out a reason. Too much information is often worse than too little. And no matter how sure you are that you've got a handle on everything, remember that the plot *ALWAYS* thickens.
Anyway, those are my musings for the evening. Prayers for my patient would be appreciated...we'll see how he does tomorrow. Hope everyone is doing well! Till next time, peace and God bless!
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