Mmmmm.......

If you eat a whole chocolate cake, but you donate money to charity..... does that make it ok? I need to know before I go to Costco.

Bad Call Day

I just got up a little while ago after sleeping for fifteen and a half hours. Sometimes that happens after my 30 hour call shifts when I don’t get to sleep. And even after the fifteen or so hours of sleep I still feel tired. Thursday to Friday afternoon was my call shift. It was crazy. At about 2pm on Thursday the computer system went down for the VA hospitals. The regional system went down at the main frame….. what ever that means other than BAD, VERY BAD. Since EVERYTHING is on computers for the VA it makes it very hard to take care of people when the system is down. It was especially hard to admit people and get them the right medications and the right tests. The system came back up at about 10pm and then went down again at about 3am. It was a very frustrating call shift.

And one of my cute little patients died. He was a 59 year old guy who had terrible heart failure from ischemic cardiomyopathy (very enlarged heart because of lack of oxygen to the heart muscle—usually from a heart attack or something). His ejection fraction was about 18% (how much blood is pumped out of the left side of the heart with every heart beat, normal is about 65%). Because of his very poor heart function, several months ago they had put in a pace maker/defibrillator. He was actually doing pretty good at home. Very functional, up and about. He lived with his daughter and granddaughter. Went shopping, went for walks. Doing well.

He came in to the ER on Thursday morning because he was sitting on his recliner at home about to get dressed when he passed out. Then later during the morning it happened two more times. Other than that, he was feeling great. Good energy, happy.

In the ER they evaluated his pace maker. His heart had been going into a rhythm called V-tach (very bad rhythm where your heart doesn’t pump like it’s supposed to). His pacemaker was kicking in and trying to pace him out of it, but instead he was going into V-fib (even worse rhythm where you don’t really pump blood around at all and will die if you don’t come out of it with in a couple minutes) at which point he was passing out. Then the pacemaker would shock him and put him back in a normal rhythm. Normally we want the pacer to shock before someone goes into vfib and passes out. But it is a little nicer if someone isn’t awake when they get shocked. It hurts. But it’s safer than letting them pass out all the time.

So in the ER they adjusted his pacer settings and then decided that even though he was doing really well that they wanted to admit him to the hospital to put him on a new medication that would help prevent these funny rhythms. He was on a med for this called Mexelitine but it obviously wasn’t working.

When I saw him in the ER he was awake, alert and happy sitting on the end of his gurney, swinging his feet back and forth. He was in a talkative mood and I couldn’t stop him from telling me stories. He told me all about what had happened this morning and also all about his neighbors and his ‘adopted’ son who he could always count on. And about the guys down the street who were growing meth in the house and how he told his detective friend that there was something weird going on there—and they were arrested a couple days later. When I asked if he had noticed any fevers lately he told me about how his 5 year old granddaughter would bring him drinks and leave them on his night stand, but wouldn’t get too close because she had a cough right now. And he told me all about how he usually watched ‘Touched by an Angel’ and sometimes the show was good, but sometimes it wasn’t so good. But he liked it anyway.

So the arrhythmia guys decided to try Sotalol to help his heart. We gave him a dose of it in the ER before he came up to the floor. But then they called back and said they wanted to use Amiodarone instead of the Sotalol. We told them that he had already gotten the Sotalol and they said it was fine, just give him the Amio a little later.

A couple of hours later, the system still down, as I was trying to admit another patient and wishing I could rip out someone elses’ chest hair (not mine because I don’t have chest hair and if I did have chest hair I think it would hurt if it got ripped out) one of the nurses called me to tell me that my little guy had a low blood pressure and was feeling really dizzy and sick to his stomach. I gave him some IV fluids to help with his blood pressure. Just a little though, because of his heart. His blood pressure came up a little so we decided to start the Amio. Amio is usually given through the IV at first. First with a loading bolus and then then at a certain rate for 24 hours. Then we give it in the oral pill form. So we started the bolus. But his blood pressure dropped again. And he started feeling very sick to his stomach and like he couldn’t breath. Then he started feeling a lot of chest pressure. We stopped the bolus and the IV fluids and then called the ICU to have them come take a look at him.

Ten minutes later we moved him into the ICU because he looked so bad. And about twenty minutes after that he stopped breathing and lost his pulse. While one doctor did chest compressions and another put in central IV lines, I intubated him. We coded him for about two hours off and on. We’d get a heart beat back, but then lose it again. His family came in, and after a few discussions decided that this was not what he would want and so we let him go.

The hard part for me about him dying, was how good he was doing earlier. He wasn’t feeling sick at all. He was happy and didn’t really think he needed to come into the hospital. I couldn’t stop him from telling me all his stories. And then ten hours later he was dead.

We’re not sure why he crashed. But we have a couple of theories. His heart was obviously getting worse because he was having those bad rhythms. He may have had another massive heart attack while he was in the hospital. We also gave him new medication meant to prevent arrhythmias. But maybe his heart function was so bad that any more blocking medication was too much for his heart to work against.

We will never know exactly what caused his death. But I hope it was the first theory. I hope he had the heart attack and that he didn’t die because we gave him a new medication.

They tell me that someday I will directly cause the death of one of my patients. I already hate that day.

Wet Underwear Day

When I was in college we had to write a process paper. It was all about how something happened. Like how did you make a peanut butter sandwich, or how did you get straight A's in all your classes, or how did you get the toilet clean (not one single guy in our class picked that one). It had to show a step wise process. Cause and effect. And there had to be multiple steps involved.

Like today. But the process of today started last week. Saturday was my birthday (anyone who hasn't sent a gift is highly encouraged to do so) and I never do laundry on my birthday. It's not like a moral rule or anything. It just has never come up in all my......uh.....26 years or so. I only had to be at the hospital until around 2pm that day, and then I went and bought myself a really yummy chocolate cake at Costco. It's a really big cake though and while I was chatting with the woman standing behind me in the check out line she mentioned that it was also her birthday. And since it was a really big cake we decided to split it. The bakery was kind enough to cut it in half and give us another container. She told me all about her family and how her 17 year old daughter had recently decided she was a lesbian and thought cocaine was 'way cool' and needed a little whiskey shot to get going in the morning. She said girls were much harder to raise than boys.

And then I picked up a couple of friends from the airport and made it to dinner with the fam---just about an hour late.

Sunday I was on call at the hospital. Technically it's only supposed to be a 30 hour shift, but sometimes it oozes over a little. I left at about 1:30 on Monday afternoon. And I was lucky. It was a good call shift. I only admitted 4 patients to the hospital and I got to sleep for almost three hours. Not all at once, but cumulatively. Not too shabby.

Driving home from the hospital, I felt wide awake. Almost even energetic. Usually post call I take a shower and go right to sleep. But Monday I hung out with my new roomie Loni--who moved in almost 2 weeks ago, is really nice and has already done the dishes more times than Rochelle did during the whole six months she lived here. Because I was so 'energetic' I decided to go for a run and then remind my friends that really it was my 'birthday month' so I was going to need presents every day during April. But I got kind of cold, so I took a hot shower instead. And then I got tired. And instead of doing all the things I planned on, I hung out with my friends and then fell asleep at about 8:30.

Tuesday was a short call day. Which if I'm lucky means I get out of the hospital by about 4 or so. But I wasn't so lucky. I admitted a guy who has heart failure. His symptoms have been getting worse lately and he was actually seen in the ER three weeks ago. They fixed his meds and sent him home when he was feeling better. But he's got a little drinking problem and sometimes he doesn't have the best reasoning skills. It made him really nervous that he was having more symptoms so when he left the ER he thought the best thing to do would be to stop taking all of his medications and start drinking more alcohol. In Psychiatry this is called 'poor insight'.

I signed out to one of the other doctors around 5pm. At 5:02 I got paged by one of the nurses. 'Mr. ----- in room 2c02 had a critical lab result'. Critically low red blood count. Dangit. I left a couple of hours later than I planned.

At this point it was critical to get the laundry done. I started the most important load and then fell asleep reading a new book. My roommates woke me up an hour later and I was just coherent enough to turn over and tell them to put my clothes in the dryer.

Usually I get up around 5 in the morning so I can make it to the hospital on time by six o clock. I'm always on time. Or just a little late. Or a little more late. But I always blame that on the traffic. And since I fell asleep before I planned on it, I didn't turn on my alarm clock. So I was pretty bummed at 5:50am when I opened my eyes and looked at the clock. DANGIT. I ran down stairs to get my clothes, only to find them wet on top of the dryer. Not dry IN the dryer like I was hoping for. ON TOP of the dryer. I'm pretty sure I didn't say 'please put my wet clean clothes on top of the dryer for the night'. But I was sleeping, so maybe... If I'd been up on time I could have dried them. But I wasn't. And I didn't have a choice. It was a wet underwear day. Luckily for me it decided to be freezing cold outside again today so I got the full effect of wet underwear.

I got to leave the hospital by 2pm today, and they were completely dry by then.

I just put the rest of my clothes in the dryer. I'm on call again tomorrow and I don't think wet underwear will add happiness and sunshine to my call day.