I said I'd tell you a story, O Best Beloved, about doing something Good.
And I did do something Good on Friday. I picked up a chart and I read through the notes and Megan and I went to talk to a very nice paranoid schizophrenic who had such a charming story. It seems that he hears voices from the TV and the radio, but they only talk to him when they're lonely or when he wants them to.
Why would you want them to talk to you? He smiles, displaying teeth that are rotting at the corners of his mouth and missing in the front. "Boring TV shows."
The trouble all started when his Zyprexa was discontinued a few months ago, and the voices suddenly turned mean.
"They told me to do bad things. Hurt people. Kill myself." He didn't sound distressed as he spoke; the schizophrenic has an odd affect about him. Flat, we call it. He heard the voices whenever he was near a TV or radio, every day, for a couple of months.
There is a question we must ask those who have made a suicidal gesture, particularly those who have a history of ideation. It's a question that has always seemed strange to me, and must be carefully worded. I asked it, feeling as strange as always.
Why did you do it today? Why not yesterday or tomorrow or next week? It always feels to me like I am asking "Why did you try to kill yourself on my shift?"
"I don't know," he says to me with another smile, frighteningly casual about this matter. "I just got tired of them bothering me."
He got tired of them turning mean, so he took a whole lot of his lithium tablets. About sixty, from my best guess, and my best guess was what ruled the day. Sixty 300mg lithium tablets. That's a lot of lithium, which is a drug with a narrow therapeutic range and a 10% mortality in overdosing. And then he called the paramedics. I thought of you, pharmboy and mama0807 and fyrfitrmedic, and what you would have said.
He came in, they drew a blood lithium level and called for a CIU consult. That's us. An hour or two after that Megan and I showed up. We checked the labs, we walked back to the CIU, we talked to the resident. "What's his lithium level?" 1.0. Within therapeutic levels. No need to worry. In fact, suddenly we began to doubt whether he'd taken the lithium tablets at all. But he was sure he had.
Resident was not so concerned. I believed the patient. I went back and checked the time on the lab draw. Less than an hour after ingestion. We'd done a quick read-up on lithium toxicity and knew that blood levels peaked between 2 and 4 hours after ingestion. The time was now 3 hours post-ingestion. "Dr. E," I said, tapping him on the arm. "We need another lithium level."
We found the Medicine intern for the team he'd been admitted to. She hadn't seen the patient yet. We filled her in. "We need a lithium level now." She turned a little pale. Busy woman. "I'll get that order in."
Then we went back to the CIU and waited. 45 minutes later we had our lithium level. 3.6. 3.6 is not good.
He was still awake and alert and talking to us, but he was getting nauseated and threw up quite a bit. We found the medicine intern again. "Did you see the lithium level?"
No, she says, but Toxicology was just here 10 minutes ago and left a note. Dr. E looks at me.
"Your lithium level's 3.6. They didn't have it when they left their note. Better call Renal, Tox says approaching 4 is cause to consider dialysis."
If it hadn't been for two medical students with nothing better to do on a Friday afternoon, O Best Beloved, the intern wouldn't have gotten to him for another hour or so. Nobody was worried, because the lithium level was so low. They were going to check it after admission, sometime later that evening. If it hadn't been for us being so thorough (Megan laughs, and points to me. "She wins the prize for that.") he wouldn't've been on monitoring later on, when he went to the shock room after we'd left for the weekend.
We checked this morning. He's still alive, lithium levels peaked at 3.7 that evening and came down by Saturday evening. And I will always remember Dr. E, the PGY-3 resident, looking at us at 5:30 on a Friday and saying:
"Go home, guys. Enjoy your weekend. You really made a difference today."
I am a medical student, O Best Beloved. I cannot write prescriptions and I am clumsy at intubation and when I try to start an IV or draw blood my hands still tremble with nervousness. I have to go home and read about my patients' common diseases to understand what medications have been started and why. The school pays for my malpractice insurance and I am glad, because I am afraid still that my inexperience will inadvertently injure someone. But once in a while, being a medical student means that I have a little more time than the doctor, that I am not afraid to spend extra minutes flipping through charts and writing down labs and double-checking results so that I can look polished in front of a resident. Once in a while, being a medical student gives me twenty minutes with a patient instead of ten.
Once in a while, O Best Beloved, it doesn't matter what class or rank or grade I claim, because what I am makes the difference.