IM: Final Call (Slow Night)

My last call of IM (and 3rd year) began yesterday, and I was warned ahead of time that Sundays were usually very slow, with some teams capping as late as 5 a.m. or not at all. Instead, my team spent the first hour or two sitting in the commons area, watching the Olympic trials for gymnastics and track. Lindsay also told us about her latest encounter with the family of our prostate CA patient (one of our rocks who should have been discharged last week, but his family kept finding excuses to keep him here): apparently, after the patient had an episode of gross hematuria likely secondary to Lovenox, the patient's son got confrontational with her, crossing his arms and saying that he was getting a lawyer to make sure there was "some s*** getting done here." The funny thing was that Terrance had talked to the family shortly before Lindsay did and they had seemed friendly and understanding of the patient's current situation. We'd hoped to discharge him today, but obviously that wasn't going to happen. Dr. L said it was a sticky situation to be in b/c the family is probably going to sue the hospital no matter what action is taken (or not taken). The plan now is to d/c Lovenox (even though it'll increase his chances of a DVT, at least his family can't see the DVT and pitch a fit) and send one of the chaplains to go talk with the family and "defuse" them a bit. Maybe some spiritual guidance will help his family.

My first patient (and Sarah's) did not come rolling in until shortly before 5:00 pm, but I jumped on it the first chance I got. This lady turned out to be one of Dr. RR's patients (I'd never seen her but I recognized Dr. RR's name on her meds as well as the Tessalon pearls he tends to prescribe for pts with cough), presenting with a 2 week hx of SOB, weakness, and hyponatremia. It turned out that she was taking double the dose of Toprol that she was supposed to take (Dr. RR's prescription and a JPS resident's prescription), so that might have something to do with her symptoms. Our second patient was a man on hospice care for end stage liver disease. His chief complaint was SOB, which struck us as a bit odd. What was this man on hospice doing here? He was an interesting case study, though; had scattered spider angiomata along his torso, a huge ventral incisional hernia, and mild ascites. By the time we finished with him, it was almost 9:00 pm, so Sarah and I grabbed some dinner (meatloaf, ugh).

Our final patient was a friendly HIV-positive man who had a 3-day hx of fever, SOB, and cough; his greatest fear was that he had PCP (P. carinii pneumonia). Given his undetectable viral count and adequate CD4 of 850, PCP was not likely, and sputum cultures later revealed the presence of Gram + cocci. It was more likely he had a community-acquired pneumonia. He was also found to have suspicious nodules in his right lung, but so far he's refused to have it biopsied for fear that if he bleeds during the biopsy, the cancer cells will get into his blood and metastasize. At any rate, if he's improving, we'll probably d/c him tomorrow. I finished his H&P at around 1:00 a.m. but went to SSU to check on my earlier patients. There was a Hispanic guy on restraints in one of the beds, continually thrashing around and screaming in Spanish. I later learned he was in alcohol withdrawal, but when I saw him at 1:00 a.m. and later at 6:00 a.m., he was still yelling. I felt really bad for the nurses (and Sarah, who got paged to SSU to write him Ativan on more than one occasion). I ended up falling asleep around 2:00 a.m., only to be awakened by Angela when she came in one hr later. In the morning we learned that the team didn't cap until 4:45 a.m.

During morning report, Dr. L didn't even give me a chance to present my hospice patient b/c in his mind, a patient in hospice should not be at the hospital for something like SOB. I think what happened is that my patient is currently on home hospice but is not doing too well on his own (he's in full code b/c he wants to watch his grandkids grow up, yet he still smokes). And if coming to the hospital was the only way to get into a nursing home, then fine. But I don't think he really needs hospice right now; he looks pretty good and doesn't look like he'll be dying in the next several months. I also messed up by saying that Januvia contained HCTZ when it was really Hyzaar that did (med confusion after 3 hrs of sleep). *sigh* So much for impressing Dr. L. Angela and I are both hoping to get rec letters from him, but that remains to be seen.

On a random note, if there's a fly swatter sitting on the counter of the ER, you have a fairly good idea of what the general population of the patients here are like. =/