Nescafe rabbit

Baby central....

I've delivered five babies in the last week, or at least five babies have been delivered to patients under my care. One was a patient I inherited from a previous resident (note: when planning a c-section for after you leave, check with the doctor who will be doing said c-section as a courtesy before scheduling), one spontaneous labor that got my clinic cancelled for the afternoon, before we went to c-section at 5 pm. Baby came out like some kind of infant twister, neck extended, head cocked, holding the cord. "No wonder he wouldn't come down..." my attending mused.
Then there was the 2am section while I was working in the ER, and the VBAC (vaginal birth after c-section) that I ran up two flights of stairs for only to arrive as they were putting the infant on the warmer. 90 minutes from arrival in triage to baby delivery, can't beat that.
Four hours after that I'm fielding the answering service call: "Your patient thinks her water broke." And it had, and at 2 am on Saturday we had our baby.
I've had nobody in the hospital since Sunday afternoon and two first-timerd due next week, while I'm going to be in Philly. I was anticipating peace and quiet.
So wrong, I was.

Second-to-last patient of the day. Primip (first pregnancy) due next week. I'm doing the obligatory cervical check and telling her that at 2cm and 80% effaced she had a way to go. "Get-dressed-checkout-slip-outside-the-door..." I went to see the next patient. Before I get through the staffing room my nurse drags me back. "She thinks her water broke."
It had, she was thrilled, and by the time she got across the street to L&D she was contracting away. I signed into a call room, figuring on a 3 or 4 am delivery, and settled in to wait.
5 hours later I barely had the bed broken down in time to catch the baby.

I only have one more patient due this month. Maybe I should call her in and induce her just to get it over with...
Nescafe rabbit

Part 2

So as it turned out, things got a little hairy before Jill walked out of the hospital against my advice. I'm frustrated to the point of starting proceedings to fire this patient from our clinic, and that doesn't happen often. I'll try and keep this understandable for the non-medical folks.

Hold your breath. As long as you can. If you had an oxygen saturation meter on, chances are it would never dip below the mid-90's - I've seen swimmers who can get it down to 90-92% but that's about it. That driving need to breathe, the dizziness and suffocating feeling - those are caused by elevating levels of carbon dioxide (CO2), not by dropping levels of oxygen.

COPD is a chronic lung disease (usually related to smoking or toxin exposure) which results in impaired transmission both of oxygen into the bloodstream and carbon dioxide out of the bloodstream. These folks tend to chronically have elevated blood CO2 levels, which eventually blunts the response of the CO2 receptors which control respiration.
This results in something known as "the hypoxic drive" taking over. Basically, these people become more attuned to changing levels of oxygenation, and they depend on their oxygen saturations dropping to remind their brains to breathe. If you put someone with severe COPD on 100% oxygen, you can actually kill them, as the patient's breathing will slow down to the point where they don't exchange gases any more. Subsequent to slow shallow breathing, CO2 levels elevate to the point where they cause acidosis of the bloodstream, coma, and death. Ain't pretty.

Jill had a blood gas drawn in the ER at 6 PM, which was normal for her. She went to the floor around 8 or so. She was placed on 100% oxygen (as a nursing decision and not what I had ordered, since nursing wasn't comfortable with her 88-92% oxygen saturation) and given her home dose of narcotic pain meds. Narcotics can also cause respiratory depression. By the time she got confused, fell out of bed, and was seen by my partner at 1:30 AM, she was sleeping and not able to be woken.
We reversed the narcotics (not particularly nice to do to a chronic narcotic user, since it puts them into immediate withdrawal) and put her on Bipap, which forces air into the lungs and augments normal respirations. It's not comfortable, but it's the last ditch effort before we intubate and put a patient on a ventilator. After a lot of tweaking and a lot of lab work, she woke up five hours later. An hour after that she had yanked the mask off, thrown it at the respiratory therapist, cussed out three nurses, told me she loved me and thanked me for saving her life, and was demanding her morphine.

I told her no - not after what had happened. I told her no for the next 24 hours. She told me that if I didn't give her morphine that she would go home against medical advice and buy some Vicodin off the street. I told her I wasn't giving her narcotics - I can only surmise that her lungs must have taken some damage from the fireball, because she's tolerated far larger doses and fairly high oxygen concentrations without a whisper of trouble. I offered to work with her with meds that don't depress respirations, and talked to the pain doctors about what kind of cocktails might work. I answered 27 pages while in clinic regarding her pain control and her threats to leave. I started her on an anti-anxiety agent and she slept all night with no complaints.
In the morning, she had her caretaker (who I suspect is also selling narcotics) call me. I expleined the situation to the caretaker just as I'd explained it to Jill. I used the words "almost died" and "almost intubated" several times. I explained that she had not only violated her pain contract by telling me she was going to buy Vicodin on the street, but that I no longer felt safe giving any narcotics. I explained that she had been weaned off in the hospital and that to restart them would be poor medical care, and possibly life-threatening.
For once, her caretaker didn't argue with me. She agreed and thanked me. Thirty minutes later, the nurse called to tell me Jill was leaving, and that she'd verbally abused several more staff members. I talked to her on the phone. I explained it all. She told me that she thought I was a wonderful doctor and that I was probably right, but she was going to go home now because I wouldn't give her what she wanted.

One of the rights you do not have as a patient is the right to abuse my ancillary staff. My nurses are doing their very best to take care of more than one very sick person. They are doing their best to carry out the orders I'm giving, and they are trying to help you help yourself. I get much angrier when my nurses and PCA's and social workers are being berated than when patients are mean to me. After all, I'm the one in charge. They're just trying to do the right thing.

One of the hardest things about medicine is the right of people to make poor decisions. Could she go home and buy Vicodin and take it and die? Yes. Would I feel guilty? No. I'd be sorry. I'd feel bad. But I can't help this woman any more than I've done, because she won't allow herself to be helped.

And after all that, my tax dollars aren't footing her bill. Instead, she'll be billed directly since Medicaid doesn't pay for AMA visits. She'll never pay it, because there's no penalty for not paying. So ultimately, we'll write it off, which impacts hospital profits, which comes directly back to my paycheck.
Can't win.

In other news, my Miricups had her second febrile seizure today.  She's doing well, trying to sleep in her swing, but my poor baby...
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Nescafe rabbit

A funny thing happened on the way to the forum...

Residency patients, to broadly generalize, tend to be poor folks. Many of them are good honest people who are trying to make a living with what they have, and I love them for it. They're the reason I'm at the clinic with the social worker until 7 PM some nights. They're not the ones this rant is directed at.

I'm talking about the Jill's of the world. You see, O Best Beloved, Jill is a mid-fifties former cocaine addict who moved onto prescription narcotics. I think she's selling them. She gets them because she also has end-stage COPD, and she was in Hospice for a while before she got booted out for abusing the system. At one point this woman was receiving daily Oxycontin with a street value of around $350 and couldn't seem to keep track of them all - and it's been my task to wean her off her meds. I know she's taking some of them...I've seen what happens when I took them all away. I just don't know how many.
Jill is on Medicaid. She pays $3 for her prescriptions, and my tax money covers the rest. And Jill likes it that way. She likes it so much that she hasn't bothered to quit smoking or lift a finger to help herself in the last fifteen years, as far as I can tell.

And now in the middle of my free afternoon, catching up on paperwork, I get a call from the ER. Jill, on home oxygen, was smoking in bed. I assume most of you at some point have had it explained to you that fire + oxygen = BIG FIRE, and that's precisely what happened. Her nasal cannula came out of her nose. Her cigarette butt came in contact with the oxygen. A large fireball ensued. Jill burned her eyebrows and her face and the inside of her nose and wound up being admitted under observation for her flash burns.

The point of all of this is that when I came to the ER to admit her, and talk her into having the lab work done, and talk her out of leaving against medical advice (she could die from this!) because I wouldn't give her a turkey sandwich...I found myself with very little compassion for my patient.

Actually, O Best Beloved, to be honest, I wanted to strangle her. This was a preventable event. More than preventable, this never should have happened at all. This is a woman who is intelligent enough to understand the fire + oxygen equation, and whom I have repeatedly warned that such things do happen. She has refused time and again to even contemplate quitting smoking, despite her condition, and now my life is disrupted (and I know I signed up for this when I became a family physician), and she'll sit in the hospital and drive the nurses crazy with ridiculous and unreasonable demands as she has on every other admission. She'll want to smoke. She'll want to be fed. She'll demand ever-increasing amounts of pain medications. She'll refuse to do anything unless it's precisely the way she wants it done.

And I'm bloody well funding it. I just want to scream.
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Me dreamer

Where did the time go?

Tomorrow night is graduation, O Best Beloved, and even though I won't "officially" be an obstetrics fellow for another 3 weeks, it still seems like the end.

I didn't realize it was coming up so soon! Tonight I have my planning meeting for the fellowship and then there's the senior roast, and then tomorrow night is graduation, and I have to sit up at the head table (what am I going to wear?!?) and then I have to say something.

And I'm lost for words. I don't know how to compress everything that's happened to me in the last three years into thank-you's and goodbyes. I don't know what to say about my class, with whom I've never felt entirely comfortable but whom I've always been able to count on. I don't know if I should talk about the morning that R saw me in the cafeteria in our first year and said something that gave me the will to go through another day instead of going back to my call bed and putting the covers over my head, or if I should just keep it short and sweet and banal.
Last year, someone wrote a poem. I wish I could do that - but what to put into it?

I hate beginnings and I hate endings, O Best Beloved. I never know what to say about them.
Nescafe rabbit

A little update.

Remember the little boy I told you about, O Best Beloved, with the skull fractures and the ventilator? It was a few days later in the middle of the night when the intensivist extubated him. I glanced over and saw two tiny arms waving in the air, swaying back and forth. "Is that my boy?" I walked over to the crib. There was this tiny infant, waving his arms in the air and looking at me. And he was up all night, not crying, just waving his arms and stretching and smiling.

He's home now. His real father sat by his bedside for endless nights, watching over him. After being shut out of his son's life for those pivotal first months, he'll be taking his baby boy home.

Trauma rounds the other day brought him up. The reports from therapy are looking good. "It's amazing how brains heal in little ones."
His name is written in my mind, like so many others. I wonder sometimes what will happen, if I'll ever know what his nebulous future becomes.
I can always hope.
Hush angel

Summer is coming...

Let's talk about my pediatrics rotation, O Best Beloved. Let's talk about the things that one does and that one does not do with children.

If you have three children in your household, and one of them is an infant only a few weeks old, you should cherish them and guard them and protect them from harm. You should absolutely not cultivate a relationship with a man who is not the father of any of the children if he fails one simple test:
Have you been convicted of violent crimes against a child?
You must, O Best Beloved, consider carefully any person who answers "yes" to that question with regard to the safety of your beloved new infant son. You must consider whether you want this person violating his parole to be involved in the lives of your children. You must consider whether you want this person living in your house with your three children, and you must consider with extreme care whether you want this person watching your children while you sleep.
I think there is a right and a wrong answer to this question.

We took the tube out of T's throat tonight, after a week on the ventilator. The intensivist note reads "Hypoxic encephalopathy, traumatic brain injury, status epilepticus, bilateral parietal skull fractures." He's breathing, but I don't know how much else he'll ever do.
He has a matched set, O Best Beloved. Someone as-yet-unspecified did something to this infant that broke the skull on both sides of his head, filled his brain with blood, and then let him suffocate while he seized. And his mother lied about not only the circumstances of the injury but the persons living in her household. It wasn't until the third or fourth draft of her history that she admitted to the presence of the convicted offender in her home...
We all have our suspicions about the guilty party, but I think there is more than one.
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Nescafe rabbit

It's hard to be both...

We took a trip to the ER last night. Miriam ran a fever from a viral kind of infection, and shortly after I gave her some ibuprofen she started seizing.
I don't know how to explain it, O Best Beloved, the feeling that comes over you. I've seen plenty of seizures, kids in status epilepticus, don't bat an eye. But when it's my own daughter...
I got her on her side on the couch and tried - however futilely - to snap her out of it. I debated what to do, screamed her name, blew in her face. She just kept seizing, and about the time she turned blue I called 911.
I'm terribly embarrassed to admit how completely I panicked, but that's exactly what happened. I was amazed at how calm I sounded, how reasonable. "My 16 month old just had a febrile seizure. No, she's not still seizing, I don't think." I pried her eyes open, peered at her pupils. Reactive. "No, she's postictal. Not responding. Yes, she's breathing. Yes, regular." The whole thing was two minutes or so, just long enough to take ten years off my life.

We rode the ambulance to the ER because I didn't know if I could drive. I called ahead, told the ER doc we were coming, picked up my wallet and my laptop and got in the ambulance.

I haven't stopped worrying yet. I know she's fine - blood count was normal, she was back to normal before we left - but I don't think I'll ever forget that scene.
It's one thing to watch Someone Else's Baby gurgling and shaking and choking...it's a whole different thing when it's your own.

One of my darkest fears has always been that if something bad happened to my child that I wouldn't be appropriately concerned about her, that my medical background would preclude me from a mother's instincts. It seems that isn't so.

She's fully recovered and back up to snuff now. And if she lets me I'll tell you later about this summer's public service announcement, punctuated by miracles.

It's hard to be both...

Nescafe rabbit

Just some thoughts.


This morning Angel was in the shower, and I was trying to wait out the headache I had from playing WoW until 2 am, which left the Miricups to roam around the bedroom. We have a stall shower in our master bath, and this will become relevant in a moment. The Miricups is very worried about showers; she will stand outside the door and make worried noises and try to see in. Once, I brought her in with me and that was serious trauma...
I hear the shower shut off and the door open. I hear "Miriam...Daddy has to get out of the shower. Will you let him get out?" I hear her babbling. "Does Daddy have to stay in the shower forever?" There's a pause before I hear my fourteen-month-old daughter say quite clearly: "Yes."

I couldn't stop laughing. She knows a few words; when she signs "food" she's starting to make "ffffff" noises and she definitely knows "up" and "cheese" and sometimes "kitty". But mostly she still communicates by pointing. I'd never heard "yes" before.
She's sitting in the back of the car eating coffee cake right now and making a right mess of it. I've been home with her some over the past few days and it's been nice. I find myself alternately enraptured and ready to strangle her...she's old enough to do things even though she knows we don't want her to. You can see her checking whether we're watching.

I'm tired this morning. Wondering what I'll find when I go back to work on Monday, whether my patient who used all her 2-week supply of narcotics in 8 days actually went to the ER or not. I told her friend who gets her meds for her that I couldn't write any more, not even "just a weekend" worth. The first refill I gave her four days early; the second was absolutely a no-go. If she'ss in that much pain she needs to be seen, not just a phone call that she's out of meds on Thursday afternoon. Especially when I've told them before there will be no more early refills...I meant it. Sorry.

Starting to catch up from med chief, but I feel sort of adrift. I'll be going to Baltimore at the end of this month to do a poster presentation on smoking cessation in pregnant women, and I should start work on that. I have a two-week Research rotation specifically for that purpose, actually.

Working on scheduling for next year. For those who are counting on the Thanksgiving party, I've made it clear that I will not be taking call then, so plan on it at the usual time this year.

I'm getting a little nervous. My mother-in-law and I are talking about contracts and starting to firm up plans for when I practice down there in 18 months or so. I'm looking for a place to do deliveries. I know what her EMR is and I did a month down there seeing patients and rotating around. I like the area. But the idea of not having any faculty...
It's a big deal, really. Frightening. I don't know if I'll every truly be "ready" to be on my own. What if I make a mistake? What if I kill someone? What if I'm really not all that good?
I think I am, though. I think my doubts serve as a spur to make me do my best, and I think maybe I'll be able to do this.

Had a strange encounter the other day. I saw a 4-day-old African-American baby for jaundice. "His eyes turned yellow." I looked him over, confirmed the absence of red flags (eating well, alert, playful) and looked him over. Told mom I thought he was probably OK but that it was hard to tell with dark-skinned babies exactly how jaundiced they were, so let's get some labs to be sure. She agreed. I found the closest lab for her. She left. An hour later she was on the phone swearing at my front desk staff about what a racist I was and how she should have punched me.
I'm sorry, ma'am, but this is an established fact of visible-spectrum physics. Your baby has brown skin. Jaundice is yellow. Brown plus yellow equals...brown. It's not like light-skinned babies who turn orangey-gold.

And that's it for now...the client is cutting me off.
Nescafe rabbit

Paliative Care Service

The man with no spine died the other night. One hour he was sleeping, the next hour he wasn't breathing. The nurse had the presence of mind not to call a code. just like that.
Path isn't back, that I've seen. But at least it was peaceful. Painless, at the end.

Four doors down is a woman whose lungs are polka-dotted with metastases from her uterine cancer. We see the cancer cells in her lab work, in the elevated creatinine and poorly-synthesized clotting factors. Somewhere in her belly is a pinhole leak that brought her to our emergency department in excruciating pain.
She is dying, all 80 pounds of her, with antibiotics running in to stave off the infection, a unit of blood now and then, her family passing in and out of the room. Who knows how long she will linger?

My rounds on her are brief, quiet. Necessary interruptions in her dying process. She smiles when I come in, answers my questions with her Virginia hills twang so thick I can barely understand her. "Doin' awright. Better today." And I do not know what to say. We discuss the price of gas, the snow, the hospital. My job.
I am secretly glad to leave the room, if I am honest. I feel awkward and graceless and dumb with not knowing what to say to her. I cannot fix her, cannot heal her. She is at peace with dying but wants to prolong life while she can, and so here she is - and here I am. There is nothing more to do but wait.
Modern Art

The man with no spine...

Med chief again.
The following is a little disturbing and a little technical. Feel free to ask questions.

B calls me the other night - the resident who always caps the service by midnight. "You gotta come down to the ER. Now. You'll never see this again."

I head down to the ER. We talk for a while about the patient who's probably in fulminant hypovolemic shock, with a side order of rhabdomyolysis and a sprinkling of sepsis for a while - the usual ICU type orders, thyroid, old records, why-did-someone-operate-on-his-brain kind of thing. It's almost routine, although I never quite get over the heart-thumping anxiety of someone saying "ICU". He's beginning to stabilize, after four liters of IV saline, antibiotics, and a hint of Levophed to bring his blood pressure up. He can open his eyes and mumble, at least. Then she pulls on my arm.

You gotta come see this. You gotta.
We don N-95 respirator masks (the orange "duckbill" TB masks you have to be specially fitted to wear) and step into the room.

Patient is a late-fiftiesh male, past psychiatric history of schizophrenia, with a ten-year history of a lesion on his left cheek, approximately 2 centimeters across at the time of this examination. He notes a four-year history of intermittent swelling of the extremities, progressively developing nodules (left ear, right ear, chin, chest) and diffuse rash. He presents to the ED tonight with a two month history of swelling of his head and a two-week history of progressive weakness and inability to walk, culminating in the inability to raise his head without lifting it in his hands due to his weakness. He complains of neck pain. He has previously been evaluated for this but has refused diagnostic biopsy. He declines Western medicine treatments and has been using vinegar on his lesions and herbal remedies prescribed by a preventive health doctor whose name he does not recall.
I don't mind herbal treatments, folks, but somewhere along here I wish he would have noticed that he was getting worse.

I'm looking at a man whose bald scalp is swollen and pitted by edema, fully half an inch deep throughout. His head appeared nearly twice the appropriate size. On one ear he had a 3/4 inch growth that looked like nothing good - cauliflower surface, protrusions, edema around it, good blood supply. The other ear was completely deformed - nearly replaced by more of the same. And there was nothing but swelling around his jaw, his neck, his chest, his arms...
And I'm staring at an inch-wide spot on his left cheek that looked like someone had pasted a picture of malignant melanoma onto his face. And all I could think was "He's going to die."

CT scans of head, neck, and chest had been done by the ER. I started with the cross-table and anteroposterior X-rays, and that was where things got really bad, because all I could see was shoulders and skull. This man has no spine. I said it out loud, I think. B nodded. "Look at the CT scan." Everywhere, from the base of the skull to below the clavicles, the normal configuration of the vertebrae was replaced by swirling masses of soft tissue and thready remnants of bone. The tumor, whatever it was, had not only eroded the bone but almost completely replaced it. He couldn't lift his head - not from weakness, but from lack of muscle attachments to move his head around.
Later, Neurosurgery and I sat at the chart talking. "I don't know how this man isn't dead," he said, shaking his head. "There's nothing there. If he sneezed he'd kink his cord and die."

He's considering having the back of his skull fused by means of steel rods to the intact vertebrae at his waist, so that he doesn't do exactly that. We're waiting on pathology. Nobody knows exactly what this is, but it's not good. We're banking on metastatic melanoma, with a lifespan measured in weeks remaining. He wants us to give him a B12 shot so he can move his neck again, then go to Florida, eat health food and be cured. He refuses to hear the discussion about code status - feigns sleep, orders us out of the room, or changes the subject - and every time someone says 'cancer' he acts like it's the first time. "Oh no, Doctor. It can't be that. Nobody's ever told me that before." We don't know if he's crazy, or toxic, or in denial, or a lot of things, but running a Code Blue on this man would be like trying to intubate macaroni - and inevitably fatal.

Our current plan is to get him a diagnosis, some pain medications, and Hospice. If he wants to go to Florida, we figure it's better than dying here in the snow. What can you do?