This weeks contestants for most disturbing patient story:

1)The 45 year old lady with a gc/chlamydia infection in her stoma. For you laypeople, have you ever heard of a colostomy? If not, that is when the surgeons repurpose your intestinal tract so you can poop out your stomach. The stoma is the opening created for this function. Unless of course, you and your husband happen to be kinky-then it's a brand new opening for intercourse! Also, std's

Winning Quote: "It's like anal, but through your bellybutton"

2) The 32 year old female with a vaginal infection who was offered antibiotics. Until her boyfriend stepped in and asked (no I am not making this up, please stop reading here, I mean it, you have only yourself to blame)

Winning Quote: "Actually, can you not give drugs? I kind of like the taste"

3) The 50 year old naked homeless man who comes in complaining of chest pain to get a warm bed and hot meal, and also has scabies. Well, one of the things he has is scabies based on the trademark sign of burrows on his hands. There is also a couple fungal infections, and oh yeah the bugs which are now crawling over the blankets which I cant even identify.

Winning Quote: "I still have those?"

I will be so happy when night float is over

I just pronounced my first patient.

Specifically, I pronounced him dead. shuffled off this mortal coil. An ex-human, as it were.

The nurse rang me up, and informed me that the patient in room **** had died and I was needed to come pronounce him. I was unsure of what exactly this entailed. Was I supposed to just waltz into the room with a quick, yup, he's dead? Was I supposed to perform some kind of extensive workup? Was the family in the room?

As it turns out, pronouncing a patient is a lot easier than I thought it would be. In some ways it almost seemed easier than it should be. No causal observer to the room would have known he was dead. Eyes clothes, head lolled a little to the side on the pillow, trach tube in his throat, he could have just been sleeping.

I approached cautiously (because I have seen too many zombie movies not too), and called his name, tapped his chest. Felt for a pulse, listned for breath sounds. Where once his heart had beat a self affirming rhythm of "I'm here, I'm me, I am" there was now only a quiet emptiness. The eyelids when I lifted them up were fixed, dilated, staring off into some distant horizon that only the dead or possibly highly intoxicatd can see.

And that was it.

No code had been called, as this patient had advance directives, (aka living wills, aka obama's "death panels") which specified he was do not resucitate (DNR) and do not intubate (DNI). Reading over his medical notes, the only biography most of us will ever get, he had been sick. He had seen this coming. And he had made his peace with it.

Being the cross-cover night doc, I had never spoken to him. I knew next to nothing about him. And yet on me fell the onus of contacting the next of kin. Another first in my medical career. Thankful for the small favor of it still being early (who wants to be woken up to receive bad news?), I rang up his wife. I could hear in her voice that she already knew why I was calling.

Not knowing any better way to break the news, I simply went with blunt...I am sorry to inform you that your husband passed away at such and such a time.

She seemed flustered (and who wouldnt be?), kept repeating okay as if it was a mantra that really could make everything alright, and told me she would be there first thing in the morning. Long after I am gone, the one who ruined her day.

Could I have done a better job? Probably, but I dont know how.

After all, I still had another 10 pages to return, and the night was just beginning.

marriedtothesea.com

My first month of Night Float is almost done (I think, timekeeping is a little tricky with my sleep schedule) and It has been an eye-opening experience to say the least. Residency is three years for a reason and I hardly expect to become proficient in medicine only 2 months in.

That aside, I have occasional sensations of stepping outside myself and seeing how far I have come in only 2 months. Certain facts have come back to me instantly from med school, and I can create a differential and plan for conditions like dark stool or chest pain almost immediately, while things as obvious as back pain or shortness of breath leave me drawing a blank.

Its as though after years of seeing all the information in medical school, I was blinded and am learning to walk again in fits and starts, sure of my stride here, hesitantly stepping there and hoping that I dont walk into a bus while I wait to regain my vision.

Even as recently as my first night ago, I remember handing out pain med orders like pez because I honestly couldnt assess if the patient actually needed them or not. Tonigh has been just the opposite-my jerk side is in full swing and despite prodding from the nurses and whining from some of the patients I will not prescribe opioids simply because you ask for them. Doubly so if no history and physical is available on the patient its being requested for. My job is to handle crises as they arise and while it is unfortunate and uncomfortable that people are suffering, people are unlikely to die from not receiving morphone for their pain.

Certain decisions have become easier, and I am beginning to develop an idea of how to screen which patients require visitation, which calls are wasting my time, and which people are trying to pass the buck to me because I sit on the bottom of the totem pole.

My metamorphosis has begun, and it simply remains to be seen what will emerge at the end.

"Confusion never stops
Closing walls and ticking clocks
Gonna come back and take you home
I could not stop what you now know
Singing: Come out upon my seas
Curse missed opportunities
Am I a part of the cure
Or am I part of the disease?"

As I filled up my tank at the gas station in downtown Hollywood on the way to work today, a balding white dude pulled in, put his blinkers on, and made a cell phone call. Then a youth with a small bicycle and a large white t-shirt rode up, dumped the bike, got into the car, and quickly exited and cycled away as the man drove off. It all took about fifteen seconds, so maybe he was just saying hello? And he had to do it all up close and personal. And he probably had to give the guy a little baggie, because he knows how much his friend likes to organize all his small items, and then he asked for some ice-cream money and the balding guy was happy to oblige on this beautiful summer day. Yes, that’s probably it.

***

Somewhere around 1 or 2 AM (it can be hard to tell) I got a call to go check on a patient who the previous night had a "pseudo code". A pseudo code is when a patient for one reason or another becomes unstable enough that a code is called, but by the time everyone gets there it is canceled. This is usually due to respiratory more than cardiac issues.

But I digress. According to the nurse, the previous night the patient had some mild vomiting and when he was turned on his side, he went into a brief respiratory (not cardiac) arrest. This current night he had also had some mild vomiting, so the nurse wanted to give me a heads up. Because nurses are awesome like that.

Sure enough, probably not even an hour later, a code was called and we all rushed in, me thinking a proper doctorly "OH CRAP OH CRAP OH CRAP SOMEONE GET THERE BEFORE ME" only to find that the gentleman had once again had an apneic (he stopped breathing) episode. Of course, this one was made all the more disturbing because since this had happened the previous night, he was already on a facemask with 100% oxygen when he had this episode. An ABG (arterial blood gas) demonstrated a pH of 7.074 O2 of 61.2 and CO2 of 107. Yes, fellow meddites, you read that correctly. and Laypeople, that is ludicrously high. Practically non compatible with life high.

In case you are wondering, you bet your sweet fanny I went straight up the ladder to the Hospitalist to confirm any ideas I even thought of having. And he concurred that the patient should be intubated and transferred to the ICU, at least for the night. Remember my job on night float is to keep everyone alive til MORNING. What they do after I go home is someone else's problem

Then the fun began as I had to explain to the family what was going on and why, as family remained convinced that they should have just taken the patient home with them and he was doing fine until the doctors got at him, and isnt putting a tube down his throat dangerous on all the tv shows, and he was the picture of health not even a day ago and the like

Sometime around 4:50 AM I finished all of this and realized my dinner was still down somewhere in the residents lounge unfinished, lonely, cold, neglected, and unlikely to fulfill its destiny.

Guess it's my breakfast now.

marriedtothesea.com

On night float, I mostly admit or cross cover patients. I am not responsible for following them, just getting them in and up to the floor. If you think of a hospital as a hotel (and some of our patients clearly do) then I would be the equivalent of the check-in desk, or maybe the bellhop

Some Memorable Patients recently...

Snoop Dogg Granny  with a social history of her smoking says she had a pack a day for 7 years, then quit for 15 then started again because she "likes [her] nictonine better than her lungs" Next I asked her about alcohol consumption and this 88 year old frail looking responds that she drinks gin and oj every day! "rolling down the street in my wheelchair, sippin on gin and juice, laid back, with my mind on my heart meds and my heart meds on my mind..."
 
A 400lb pregnant woman with a 180 pound husband...Bit the bullet and asked the patient how she got pregnant. Not like how could anyone ever be attracted to her, but simply, mechanically, how does a 400 lb person have sex? And she replied that her mother and her husbands sister used a broom to lift her pannus so she and the husband could have sex. Good luck trying to get that image out of your head...

No word on the casting call yet. I know you are all in suspense.

That aside, my previous entry was a bit disturbing, to both you out there in internetland, and to me as well. I wanted to come back and reassure all of you that while night float absolutely IS tough, and stressful, and confusing, I am doing OKAY with it.

The previous entry was during my first week, learning the computer system, the attendings, remembering basic medicine, things which piled up to seem almost overwhelming.

I am now in week 4, and while I still dont know much, it turns out I know more than I think I do. That patient who had high blood sugar over the sliding scale? Without a clue of what to do, I gave more insulin. Turns out that is exactly what I was supposed to do. Sure I could have given more than I did on that occasion safely, but I didnt know it at the time.

The patient who was vomiting blood and I started suction, while frantically calling the attending? Turns out he didnt have any recommendations beyond what I had already done.

So somewhere deep in my psyche, I actually DO know what I am doing...I have just chosen not to communicate it to myself at this point.

Of course in my downtime at the hospital, I still peruse up to date, ask advice from interns and attendings I bump into, and read classic journal articles so I can start bringing that knowledge I supposedly have to the forefront faster. And I still have a long way to go before anyone not related to me by blood or incriminating photos would call me competent and on top of my game.

The point is, while the whole situation is stressful, it is surmountable. It is character building stress. And with each shift, I get a little bit better at handling whatever is thrown at me. And before I know it, the next two months will be over. And then the year. And then residency. As long as I remember to slow down, take it one problem at a time and just BREATHE.

So long story short...things are tough, but there is still nowhere else I would rather be...except maybe not getting paged so often

Night Float Twitter roundup:

Opened up the nightstand drawer in the call room to discover lots of vaseline. Also some hemeoccult cards. How often do people give rectals?