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Name: Derrick
Metro: Washington D.C.
Gender: Male
Interests: Teen flicks. British humor. Seeing the world. Falling for San Diego girls. Legally sticking sharp objects into people. Daydreaming.
Expertise: Sleeping - supine, fetal-position, reclining, sitting, standing, in private, in public, in class, in the operating room, in moving vehicles, +/- drool.
Message: message meEmail: email me
Website: visit my website
Member Since:
9/12/2002
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| Sometimes I wonder if the redundancy of having patients seen by 3-4 residents/attendings/students isn't just ridiculously inefficient, but man, when it gets crazy it's really helpful. Recently on a really busy shift, one of my senior residents saved a young "worst headache of my life" guy from getting a lumbar puncture (ie spinal tap) by ordering a flu swab (which was positive). Anytime someone says they have the "worst headache of my life" we think of a head bleed, and the only way to completely rule it out is to do a lumbar puncture... very safe procedure, but usually you prefer to avoid sticking people with needles in their spine if they don't need it. The same night, I caught a guy with a heart attack (troponin 2.5) because I spent the extra 5 minutes double-checking his past visits and questioning his story and realized that his vague weakness/dizziness complaint was exactly the same as his prior heart attack. Mind you, this fellow was far from the sharpest tool in the shed (ie didn't realize he had a heart attack before even those that's why he was hospitalized). Oh yeah, unrelated, but the same night, also got a compliment when I tubed a morbidly obese woman on my first shot--attending said, "Good job on the intubation. I thought it was going to be a clusterf***." It's always nice to have a good shift like that every once in a while for the confidence.
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| 1) diabetic Maasi woman who stopped taking her medications in favor of 'herbals' admitted for diabetic coma (Hyperosmolar nonketotic coma), 2) woman with advanced esophageal cancer now at the point where she can not swallow her own saliva, 3) CHF exacerbation, 4) pneumonia +/- tuberculosis, 5) 40 year old man with new diagnosis diabetes and acute renal failure (creatinine 5.7), 6) 40 year old woman with tuberculosis versus pneumonia, 7) 60 year old woman with respiratory distress with massive pleural effusion versus mass (failed drainage and ultrasound show that it's probably a mass), 8) 77 year old man with ischemic stroke (driven to Nairobi for CT scan), 9) 19 year old with massive upper GI bleed (Hb 3.9) from esophageal varices from portal hypertension from ?Tropical splenomegaly syndrome. | | |
| Audrey's summary of our weekend activities: http://audrey47.blogspot.com/ I've been realizing that I really suck at primary care. When Casualty isn't busy, my second responsibility is floating over to the outpatient side and see patients that the clinical officers feel are complex. Not only is it painful to manage diabetes and hypertension, but I can only really take care of about half of those patients. Yesterday I sent Audrey a kid who has a questionable seizure disorder and a big mass in his right lung... uh, what the? I have no idea how to work up a big mass in a lung (that's been there for years) besides order a CT scan. Today I saw a guy with just a ton of different complaints. I was thinking worst case scenarios and some weird off-the-wall diagnoses, but then one of the family practice docs saw him after the lab work (normal) was back and said, "I talked to him, and I've never seen it here, but it's classic celiac disease (a gut malabsorption problem)." Uh... okay, I guess I was a little off entertaining the possibility of a adrenaline-secreting tumor of the adrenal gland. Anyways. I suck at primary care... but I don't feel all that guilty about it. I had way more fun on the Casualty side sticking my finger into a huge gash in a foot with arterial blood rhythmically pumping out of it, and resuscitating a wasted patient with PCP pneumonia (at least). | | |
| I think I have the flu. I woke up this morning heavily, then had a persistent light-headedness and nausea throughout the morning. I gave up and went home, took a nap, and now I have a fever. blah. It's been kind of fun running Casualty. Yesterday was fascinating: I admitted cerebral malaria, meningitis in a HIV patient (I thought for sure Herpes because he was acting so weird, but he responded to antibiotics alone), a 15 year-old exhibiting Cushing's reflex (hypertension and bradycardia due to intracerebral pressure), a CHF exacerbation, a guy with a deep palmar abscess, a broken femur, a smoker with a big white mass in his R lung, and a 3-week old hemorrhagic CVA. In outpatient, I also diagnosed hypothyroidism on a history alone! It was so classic, but the clinical officer missed it (thought it was all heart failure)... basically a 30-40 year old woman with whole body swelling (myxedema), decreased appetite, increased fatigue, the sensation of having a swollen tongue and throat, bradycardia. I told the clinical officer (who had already ordered a number of tests) just to order a TSH and it came back 60 (upper limit of normal 5). I did several fist-pumps in Casualty when the TSH level came back. So I started her on Synthroid and had her follow-up in a month to see if everything improved at all. It's challenging because now there's very little backup (because everyone is so busy here), and so my decisions are final. Fortunately, all the docs here have been super-available for consulting them by phone, but ultimatley, I have to live with the decision to send home a kid with fevers only to come back 3 days later with significant dehydration. I have the nagging thought that maybe if I had given insulin and glucose like I was supposed to for my volvulus patient yesterday, it might have preventing his cardiac arrest (see below). I make all the ultmiate decisions in Casualty. Like one recent GW grad told us, the first month he was an attending, "the sphincter tone is pretty high." The very poor thing about yesterday was my intern is lazy. He left on-the-dot 5:00pm, leaving me with his patients unfinished, and was unreachable by pager. This is the second time this week he took off when the clock struck 5:00pm even though things were crazy (last time, two pediatric codes had just rolled in the door at the same time). I ended up alone with a single nurse, trying give medications and admit 5 patients--took me two additional hours. Even though I expressly told him our plan, he left without giving antibiotics to the menigitis patient and giving dexamethasone to our kid with something herniating in his brain. We discussed a few misunderstandings (eg he thought my offer to help with paperwork meant that I was going to do ALL the paperwork, he thought my instruction to broaden antibiotic coverage on the guy with meningitis meant to wait hours until we decided what to give before giving anything at all), but I ripped into him this morning anyways. I was furious. I was not happy with repeated laziness and selfishness. Well he's on his own this afternoon, good luck to the outpatient department and casualty. I told the head RN Lucy to page me if anything crazy happens, but so far nothing. My guy with the volvulus coded yesterday evening for a couple minutes (was back by the time the covering ICU doc got there, and got re-intubated). He probably had some sort of hyperkalemic arrythmia (his potassium was 6.9, upper limits of normal 5.0). He came in at 6.9, but we dumped so much fluid into him 6 liters by the time he was to the operating room, that in came down pretty rapidly to 6.0 by post-op. However, it went back up to 6.9 in the ICU and the ICU doc thought the sample was hemolyzed because it had sat in the room for over an hour before it went to the lab. I made an error not giving him insulin and dextrose (standard emergent treatment of hyperkalemia) in Casualty, but his potassium was rising so rapidly, it probably would have only postponed the inevitable cardiac arrest a couple-several hours at best. Still waiting for my fever to break. blah. | | |
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