IM: Crazy Call Night

Yesterday afternoon we had a GI lecture in which our professor gave us a scenario of a Vietnamese man with fatigue and asked us to work him up. Since I recently had a Vietnamese patient with Hep B induced liver failure at Methodist, I knew a good portion of which questions we want to ask (i.e. how long he's been in the US). When our prof asked us what specialty I wanted to go into, I was the only one who said IM (the others either played the I-don't-know card or said something else).

When Angela and I arrived at 1:00, we saw Jordan and his wife (an FP intern) playing with their sixteen-month-old daughter, who had a VCUG earlier that day and needed lots of comfort. Then our first patient came in around 2:00 so Angela went to see him/her, and I hung out in the lounge until about 3:30. My first case was certainly very interesting; a 19-year-old guy that Jordan dubbed "Mr. Roboto" was brought in with catatonia, a rigid body, and a CPK level of about 18,000 (VERY high). He was a schizophrenic prisoner on high amounts of haldol, and so we strongly suspected that despite the absence of fever (this wasn't the first time he had theses symptoms) he had neuroleptic malignant syndrome (NMS) and rhabdymyolysis. When I went to see him, he just kept staring at the ceiling with his arms and legs oddly flexed; I don't think he ever blinked. Dr. L just happened to be on site and he suggested we start Mr. Roboto on Benadryl and if that doesn't work, give dantrolene.

My second patient was a Hispanic lady surrounded by 3-4 adult children and some grandchildren in one tiny exam area, and they didn't speak English. Great. She presented with a headache and left-sided weakness; indeed, her presentation was classic for a right-sided stroke, just like my stroke patient from the last call. When I was testing her position sense, she got several answers right, but we saw her opening her eyes (cheating) or else rubbing her fingers together so she could tell if they were "up" or "down." When Nanette put a quarter in her left hand, she couldn't feel it and tell us what it was. She also lost her balance and fell toward the left after going to the bathroom. Initiate stroke protocol.

After seeing my 2nd patient I got a JPS sandwich for dinner. Big mistake; it make me sick. =( Then I saw my last patient: a middle-aged man with a bad case of altered mental status. According to the nurse's report, he was agitated, kept trying to climb over the bedrails, broke free of his restraints and drank water from the sink when he was thirsty, and "peed on the ER resident" (Jordan's words, not the nurse's). Jordan gave the case to me thinking it'd be something really exciting (mad cow's, maybe? hehe), but in the end, it was EtOH intoxication, pure and simple. The guy had a BAL of 332, which he claims came from drinking 4 shots of vodka but Dr. L and Jordan both think it was more like the entire bottle (the guy's a self-proclaimed alcoholic). When I saw him, he was a lot calmer, but had tremors, nausea, and dry heaves. Then one nurse told Nanette that she saw my patient sticking a finger down his throat to induce vomiting on several occasions, and Nanette said, "Great, a male borderline." I asked if that should go in the DiffDx, and she said no =P We were done before midnight, but I didn't get to sleep until almost 2:00 a.m. This was due to several factors, namely Angela not finishing until that time (I finally went to the ER to see what was up and she said her patient had 2L of "pea soup" fluid sucked from his gut during a paracentesis) and the fire alarm going off at 1 a.m. and scaring the crap out of me. Ben M was the student on surgery call, so we chatted briefly in the lounge. RB saw me at the computer and asked what I was doing up so late, I said I couldn't sleep. Hard to sleep in these call rooms, dang it.

In the morning, we found out we only had 14 new admits; one left AMA and the other was a chemo patient who never showed. Mr. Roboto improved slightly; he was still in and out of it most of the time, but his rigidity was more "waxy." Then we had a young guy who broke his hip in a MVC after getting high on meth; ho was reputed to be a "total ass" by nurses and doctors alike. He was in the same room as another patient, and when we turned away from the other patient to look at him, he was lying on his back, snoring, and totally naked except for his restraints and a Foley catheter. O.O "Whoa..." Angela, Nanette, and I said as we looked away, and Ryan joked, "What, never seen one of those before?" Jordan thought the sight was disturbing and threw a gown over the guy's groin, but it didn't help b/c as soon as the guy shifted his legs, everything became visible again. Fortunately, the patient wasn't too mean when we talked to him; when we asked him if he hurt anywhere, he replied, "I've had plenty to drink." Ummm, okay. Afterwards, Jordan complained, "That guy needs some clothes. I don't get these patients who like to lie around naked; he's the 2nd one I've seen. The first one I saw weighed 400 lbs and was always sweating." Lovely mental image there. When I was in high school, I never understood why patients had to be naked under their gowns, thinking it was an invasion of privacy and basic rights. And even though I know now, it doesn't mean we need to see blatant nudity in hospitals.

With the new shift change coming up, Angela and I are expected to work this weekend and educate our new team on our patients and how they're doing. "It's a big responsibility," said Jordan. I sure hope so, seeing how on post-call days, it's the med student's job to carry the donuts and make sure they don't get left on some random floor. I think I got Dr. L's attention today by knowing the conversion of Celsius to Kelvin (the things I remember from general chem...), but as far as medical treatments and plans go, I'm still in need of improvement.