Sunday, December 27, 2009
Five Days in Texas
As part of our "Holiday Block" I got 5 days off for Christmas and chose to spend those 5 days at home with family. It was very memorable for sure. First we got SNOW on Christmas Eve that lasted well into Christmas Day (yay for White Christmas!) Then my sister and brother-in-law completely surprised us by flying to Texas to celebrate the holidays with us (the sister actually hid behind my bed and jumped out at me after I got home from visiting a neighbor. Scared the crap out of me but it was a fun surprise regardless). We went to Japan House TWICE for great all-you-can-eat Japanese food, and I also met up with high school friends for our annual Christmas get-together. The familiar faces was not restricted to family members; this morning I met up with Anita at IHOP for breakfast, and this afternoon I ran into Doug at the airport; we were flying back to Philly on the same flight. Not bad for a five-day visit =) And while I'm a bit sad to be back in Philly, it's time to get back to work. I had my five days off; now I got a black weekend ahead of me while the other half of the medicine residents get New Years off.
Sunday, December 20, 2009
Snowed In
Ever since last week, news was abuzz that a huge snowstorm was scheduled to hit the Northeast this past Saturday and Sunday. When I went to the grocery store on Friday, the lines were ridiculously long as people scrambled to stock up with food in preparation for the storm. On Saturday I had the day off so I watched the snow fall from my window, marveling and how beautiful it was to watch the snowflakes dancing in the air as the world turned white.
All that marvel disappeared this morning when I went to my car and found it half-buried in nearly 2 feet of snow. I couldn't believe it; I had to be at work in 1 hr and there was no way my car was going to be properly shoveled free by that time. The only "digging" tool I had was an ice scraper and a dustpan, which helped a little but not much. One man walked by and offered to shovel the snow around my car for $25 but I didn't have that kind of money on me anyway. At 7:30 a.m. (I was due at work at 8) I called the chief resident and overnight PCU resident to let them know I'd be late. One hour later, when my car was still stuck, I called my resident and asked if she could fill in for me until I got to the hospital (she lives across the street). She immediately got angry (apparently she had a bad day at work yesterday and was really looking forward to having her day off) but said she'd go to work after she showered. I could tell she was pissed at me and knew that taking the day off was not an option.
Fortunately one of the landscapers on site walked by with a shovel and offered to dig me out. I got in my car and he was able to help push the car out of the snow blanket into the freshly paved driveway, where I thanked him and drove to work. I arrived at around 9:30 a.m. and my resident couldn't get out of there fast enough, saying that we're never to speak of this again. I had no idea what it meant but took it to mean she forgave me for calling her to work on her day off (since she was only there for about 30-60 min). The nurses, however, had noted her foul mood and said they were glad I showed up. Of the two of us, I'm definitely the nicer one.
The work day was, fortunately, fairly uneventful, though I didn't get out until 5:30 pm (which was expected since I arrived late) Of course, the day was not without its costs. I didn't have any waterproof pants so when I changed out of my wet pants into dry ones, my legs were bright red and I had to soak them in warm water to get feeling back in them. From what I can tell there was no real damage done (just an area or two of blotchiness), but even now there's a prickling sensation on my legs that doesn't feel quite right. My new Uggs are completely soaked (though I'm impressed that my feet stayed dry). And on top of it all, I feel like crap. Hopefully I won't get sick; all I need is to get through the next two days and then...back to TEXAS. Goodness knows I need to get away from Philly for a while.
All that marvel disappeared this morning when I went to my car and found it half-buried in nearly 2 feet of snow. I couldn't believe it; I had to be at work in 1 hr and there was no way my car was going to be properly shoveled free by that time. The only "digging" tool I had was an ice scraper and a dustpan, which helped a little but not much. One man walked by and offered to shovel the snow around my car for $25 but I didn't have that kind of money on me anyway. At 7:30 a.m. (I was due at work at 8) I called the chief resident and overnight PCU resident to let them know I'd be late. One hour later, when my car was still stuck, I called my resident and asked if she could fill in for me until I got to the hospital (she lives across the street). She immediately got angry (apparently she had a bad day at work yesterday and was really looking forward to having her day off) but said she'd go to work after she showered. I could tell she was pissed at me and knew that taking the day off was not an option.
Fortunately one of the landscapers on site walked by with a shovel and offered to dig me out. I got in my car and he was able to help push the car out of the snow blanket into the freshly paved driveway, where I thanked him and drove to work. I arrived at around 9:30 a.m. and my resident couldn't get out of there fast enough, saying that we're never to speak of this again. I had no idea what it meant but took it to mean she forgave me for calling her to work on her day off (since she was only there for about 30-60 min). The nurses, however, had noted her foul mood and said they were glad I showed up. Of the two of us, I'm definitely the nicer one.
The work day was, fortunately, fairly uneventful, though I didn't get out until 5:30 pm (which was expected since I arrived late) Of course, the day was not without its costs. I didn't have any waterproof pants so when I changed out of my wet pants into dry ones, my legs were bright red and I had to soak them in warm water to get feeling back in them. From what I can tell there was no real damage done (just an area or two of blotchiness), but even now there's a prickling sensation on my legs that doesn't feel quite right. My new Uggs are completely soaked (though I'm impressed that my feet stayed dry). And on top of it all, I feel like crap. Hopefully I won't get sick; all I need is to get through the next two days and then...back to TEXAS. Goodness knows I need to get away from Philly for a while.
Tuesday, December 15, 2009
The Story of B.L.
Back in late August when I was working in the MICU, my resident (who was overnight) got called for a code on a 65-year-old woman who'd been found unresponsive in her bed. The attending had last seen her awake and alert at 7:30 pm, and the code was called at 7:45 pm. No one knew how long she had been without a pulse during that time (she had PEA), and like most codes, she was resuscitated, intubated, and rushed to the ICU. Her name was B.L. She was one of the trainwrecks signed out to me on that one day in the MICU when everything went wrong, a vasculopath with ESRD who had come to the hospital days prior for left foot pain and toe gangrene due to arterial insufficiency. Hours before she coded, she had refused to have her foot amputated. Everyone--the MICU team, her vascular surgeon, her nephrologists--expected her to be dead within days.
The first time I saw B.L., she was seizing, a bad sign indicative of anoxic encephalopathy. Her EEG later confirmed that she had low brain activity. Her left big toe looked dried up and withered. I wondered if she could become septic from that toe, but the surgeons who saw her said it was dry gangrene and not a source of sepsis (she was constantly hypotensive). Finding access on her was a problem because most of her veins were too scarred or damaged to use; her only access (later put in by surgery) was a permacath for dialysis. No one could really declare her brain dead because she still had her corneal and gag reflexes, and we couldn't call her a vegetable because it takes 3 months to declare someone to be in a persistent vegetative state. Despite our low expectations for her survival, however, she hung on. Regularly scheduled dialysis and antibiotics kept her going. At one point the surgery chiefs even pulled me aside and asked why she was still alive.
B.L. had a daughter, who also served as her power of attorney. She came to visit every once in a while, and despite doctors' numerous attempts to talk to her about making B.L DNR/DNI, she insisted on keeping her mother full code. My resident tried several times to bring up code status with her, but each time she'd say that she needed to talk with family or some other excuse. Even after 1-2 weeks passed, she still wouldn't discuss the subject. I was able to arrange a family meeting between her, the ICU attending, and the neurologists so that they could explain the poor prognosis of anoxic encephalopathy, and the ICU attending asked whether she wanted to take her mother out of the hospital to a hospice center, or if she wanted a trach and PEG to keep her alive longer. The daughter immediately requested the trach and PEG (much to the dismay of the surgeons, who believed that the woman should be allowed to die peacefully since she would never have good quality of life again), leaving everyone wondering what the purpose was of keeping this poor woman alive. B.L. got her trach and PEG, but not without problems. On my last call in the MICU, she had to be reintubated because her trach was leaking. After I left the MICU, I didn't know what became of her, only that she was sent to the PCU.
Before she coded, B.L. was a fairly frequent flyer to the hospital for her PVD and ESRD. During her hospital stays, she had developed close relationships with the nurses and nephrologists, who later filled us in on her family situation. She lived with her daughter, who often neglected her and didn't give her enough food or blankets to keep warm. B.L. often ended up getting better care at the hospital because the nurses knew of her sad home life and tried to make her as comfortable as possible. Her nephrologists also told us that her daughter was taking advantage of her by living in her home (rent-free) and cashing her Social Security checks for her own use, and they suspected that her daughter wanted to keep her alive for those same purposes.
Three months later, I attended a case conference with "Futility of Treatment" as the main topic. My MICU resident had a case to present: a 65 yo woman with hx of CAD, PVD, ESRD who presented at the hospital for left foot pain. That description could have fit any lady in this hospital, but as soon as he said the pt had a PEA code and was found unresponsive for an unspecified amount of time, I knew he was talking about B.L. I then learned what happened to B.L since I left the unit: she was discharged from the PCU in mid-September and went to a long term care facility for one day before her daughter brought her back for hypotension. The pt's status was still full code, and despite numerous attempts by both the medicine and nephrology attendings to talk to the daughter about making B.L. DNR/DNI, the daughter refused to do so. She would always change the subject whenever it was brought up, and yet had the gall to ask the medicine attending to sign a form that would allow her to pick up and deposit her mother's Social Security checks. The Ethics committee was consulted three times to meet with her, but each time there was no resolution, either because she wouldn't show up to the meeting or else she'd have to "discuss" with some other family member. I couldn't believe that this had dragged on for three months, and yet I was also amazed that B.L's body had lasted this long.
Last week I started my rotation in the PCU, and one of my patients was B.L. Her left foot, which had a slow-growing gangrene when I first saw her, had been amputated (a BKA). Her eyes opened spontaneously and she sometimes moved her head from side to side, but that was the most of it. Now she could be classified as being in a persistent vegetative state. Interestingly enough, on my first day of PCU, the nephrology attending decided that she would no longer dialyze B.L, since every time she's dialyzed her BPs fall to 50s-60s/30s-40s and then we'd have to bolus her to get her BPs up again. "There is no benefit to this," she said, and stated that by stopping dialysis she was willing to be the "bad guy." After all, without dialysis, the patient would surely die within a week or two, and that would be letting death take its natural course.
Needless to say the daughter was pissed when the nephrologist and told her that they would not be dialysing B.L. anymore (the rationale being that HD dropped her pressures dangerously low and that it could no longer be safely done). My attending later called the daughter to once again bring up code status, and while the daughter agreed that chest compressions and defibrillators would be "excessive" for a dying woman, she refused to change the code status to DNR/DNI. No hospice center would take B.L. as long as she's full code, so essentially she'd be staying at the hospital until she died. And despite the daughter's claims that she'd come visit her mother at the hospital, I never once saw her (and I worked every day last week). Nephrology also recommended that we stop drawing labs on her, to minimize anything we do as much as possible. Everyone seemed to be in agreement...for a while.
Then last Sunday, everything went to hell. B.L.'s blood pressures became dangerously low once again, and her nurse asked me why there were no labs on her for the last five days. "You need labs to know what you're treating," she said, so I ordered basic labs on her. As it turned out, a week of no dialysis didn't really budge her electrolytes at all (K+ was less than 5) Then nephrology came by and asked why the heck I ordered labs on her, saying I opened a new can of worms because if she was uremic, then she'd have to be dialysed. My attending said I should start her on pressors, but pressors can only be given in the ICU. The pulm/critical care fellow knew her well (as did everyone in the ICU and PCU) and did NOT want to take her back, asking us instead to give her albumin and see if that would help her pressures. I felt bad for leaving the nurses to deal with her that night, but honestly, I was at the end of my rope, and I went home secretly hoping that I wouldn't have to deal with her the next day.
As it turned out, she did get transferred to the ICU, and my PCU resident expressed her hope that it would be a "terminal transfer" (meaning she'd die in the ICU). When the nurse called the daughter to let her know that B.L. was being transferred to the ICU, she asked (again) why her mother wasn't receiving dialysis. I couldn't believe it. Did this woman really not have a clue what was important, or was she just playing us for fools? And no, she wasn't coming to the hospital.
Early this morning, as told to me later by the social worker and one of the MICU interns, B.L. coded...three times. And because she was full code, everything was done: chest compressions, bagging, epinephrine, everything. I had half-expected the team to run a "slow code" but they went all out. She lasted about 30 minutes before she coded for a second time, and the third time they couldn't bring her back. Each time she coded, someone called the daughter to ask her how much she wanted done for her mother. The first time, she suggested (sarcastically?) that the team do "whatever was ethical." The second time, she got mad and hung up on the doctor who called her. The third time, she didn't even answer the phone; another family member had to answer for her. I'm just afraid that now there'll be hell to pay.
But even still, as news spread through the ICU, PCU, and beyond that B.L. had finally passed away after 3.5 months of living in a vegetative state, I think everyone felt relieved. From the nurses who cared for her round the clock and the doctors who coordinated her care, we were relieved that her suffering was over, and that she was truly in a better place now.
The first time I saw B.L., she was seizing, a bad sign indicative of anoxic encephalopathy. Her EEG later confirmed that she had low brain activity. Her left big toe looked dried up and withered. I wondered if she could become septic from that toe, but the surgeons who saw her said it was dry gangrene and not a source of sepsis (she was constantly hypotensive). Finding access on her was a problem because most of her veins were too scarred or damaged to use; her only access (later put in by surgery) was a permacath for dialysis. No one could really declare her brain dead because she still had her corneal and gag reflexes, and we couldn't call her a vegetable because it takes 3 months to declare someone to be in a persistent vegetative state. Despite our low expectations for her survival, however, she hung on. Regularly scheduled dialysis and antibiotics kept her going. At one point the surgery chiefs even pulled me aside and asked why she was still alive.
B.L. had a daughter, who also served as her power of attorney. She came to visit every once in a while, and despite doctors' numerous attempts to talk to her about making B.L DNR/DNI, she insisted on keeping her mother full code. My resident tried several times to bring up code status with her, but each time she'd say that she needed to talk with family or some other excuse. Even after 1-2 weeks passed, she still wouldn't discuss the subject. I was able to arrange a family meeting between her, the ICU attending, and the neurologists so that they could explain the poor prognosis of anoxic encephalopathy, and the ICU attending asked whether she wanted to take her mother out of the hospital to a hospice center, or if she wanted a trach and PEG to keep her alive longer. The daughter immediately requested the trach and PEG (much to the dismay of the surgeons, who believed that the woman should be allowed to die peacefully since she would never have good quality of life again), leaving everyone wondering what the purpose was of keeping this poor woman alive. B.L. got her trach and PEG, but not without problems. On my last call in the MICU, she had to be reintubated because her trach was leaking. After I left the MICU, I didn't know what became of her, only that she was sent to the PCU.
Before she coded, B.L. was a fairly frequent flyer to the hospital for her PVD and ESRD. During her hospital stays, she had developed close relationships with the nurses and nephrologists, who later filled us in on her family situation. She lived with her daughter, who often neglected her and didn't give her enough food or blankets to keep warm. B.L. often ended up getting better care at the hospital because the nurses knew of her sad home life and tried to make her as comfortable as possible. Her nephrologists also told us that her daughter was taking advantage of her by living in her home (rent-free) and cashing her Social Security checks for her own use, and they suspected that her daughter wanted to keep her alive for those same purposes.
Three months later, I attended a case conference with "Futility of Treatment" as the main topic. My MICU resident had a case to present: a 65 yo woman with hx of CAD, PVD, ESRD who presented at the hospital for left foot pain. That description could have fit any lady in this hospital, but as soon as he said the pt had a PEA code and was found unresponsive for an unspecified amount of time, I knew he was talking about B.L. I then learned what happened to B.L since I left the unit: she was discharged from the PCU in mid-September and went to a long term care facility for one day before her daughter brought her back for hypotension. The pt's status was still full code, and despite numerous attempts by both the medicine and nephrology attendings to talk to the daughter about making B.L. DNR/DNI, the daughter refused to do so. She would always change the subject whenever it was brought up, and yet had the gall to ask the medicine attending to sign a form that would allow her to pick up and deposit her mother's Social Security checks. The Ethics committee was consulted three times to meet with her, but each time there was no resolution, either because she wouldn't show up to the meeting or else she'd have to "discuss" with some other family member. I couldn't believe that this had dragged on for three months, and yet I was also amazed that B.L's body had lasted this long.
Last week I started my rotation in the PCU, and one of my patients was B.L. Her left foot, which had a slow-growing gangrene when I first saw her, had been amputated (a BKA). Her eyes opened spontaneously and she sometimes moved her head from side to side, but that was the most of it. Now she could be classified as being in a persistent vegetative state. Interestingly enough, on my first day of PCU, the nephrology attending decided that she would no longer dialyze B.L, since every time she's dialyzed her BPs fall to 50s-60s/30s-40s and then we'd have to bolus her to get her BPs up again. "There is no benefit to this," she said, and stated that by stopping dialysis she was willing to be the "bad guy." After all, without dialysis, the patient would surely die within a week or two, and that would be letting death take its natural course.
Needless to say the daughter was pissed when the nephrologist and told her that they would not be dialysing B.L. anymore (the rationale being that HD dropped her pressures dangerously low and that it could no longer be safely done). My attending later called the daughter to once again bring up code status, and while the daughter agreed that chest compressions and defibrillators would be "excessive" for a dying woman, she refused to change the code status to DNR/DNI. No hospice center would take B.L. as long as she's full code, so essentially she'd be staying at the hospital until she died. And despite the daughter's claims that she'd come visit her mother at the hospital, I never once saw her (and I worked every day last week). Nephrology also recommended that we stop drawing labs on her, to minimize anything we do as much as possible. Everyone seemed to be in agreement...for a while.
Then last Sunday, everything went to hell. B.L.'s blood pressures became dangerously low once again, and her nurse asked me why there were no labs on her for the last five days. "You need labs to know what you're treating," she said, so I ordered basic labs on her. As it turned out, a week of no dialysis didn't really budge her electrolytes at all (K+ was less than 5) Then nephrology came by and asked why the heck I ordered labs on her, saying I opened a new can of worms because if she was uremic, then she'd have to be dialysed. My attending said I should start her on pressors, but pressors can only be given in the ICU. The pulm/critical care fellow knew her well (as did everyone in the ICU and PCU) and did NOT want to take her back, asking us instead to give her albumin and see if that would help her pressures. I felt bad for leaving the nurses to deal with her that night, but honestly, I was at the end of my rope, and I went home secretly hoping that I wouldn't have to deal with her the next day.
As it turned out, she did get transferred to the ICU, and my PCU resident expressed her hope that it would be a "terminal transfer" (meaning she'd die in the ICU). When the nurse called the daughter to let her know that B.L. was being transferred to the ICU, she asked (again) why her mother wasn't receiving dialysis. I couldn't believe it. Did this woman really not have a clue what was important, or was she just playing us for fools? And no, she wasn't coming to the hospital.
Early this morning, as told to me later by the social worker and one of the MICU interns, B.L. coded...three times. And because she was full code, everything was done: chest compressions, bagging, epinephrine, everything. I had half-expected the team to run a "slow code" but they went all out. She lasted about 30 minutes before she coded for a second time, and the third time they couldn't bring her back. Each time she coded, someone called the daughter to ask her how much she wanted done for her mother. The first time, she suggested (sarcastically?) that the team do "whatever was ethical." The second time, she got mad and hung up on the doctor who called her. The third time, she didn't even answer the phone; another family member had to answer for her. I'm just afraid that now there'll be hell to pay.
But even still, as news spread through the ICU, PCU, and beyond that B.L. had finally passed away after 3.5 months of living in a vegetative state, I think everyone felt relieved. From the nurses who cared for her round the clock and the doctors who coordinated her care, we were relieved that her suffering was over, and that she was truly in a better place now.
Monday, December 14, 2009
PCU: Flying solo
This month I'm working in the Progressive Care Unit, known here as the PCU. It's the step-down unit from the ICU, but is also a place where patients go when they're not quite sick enough for the ICU but need closer monitoring. I thought that a month of MICU would prepare me for PCU, but as it turned out, the two units were quite different from each other. First and foremost was the patient load: I saw 4-5 patients on average in the MICU, while in the PCU I have about 10-13. Next, the entire PCU is run by only one resident and one intern, and for what seems like the last week or so, I feel like I've had to run the floor by myself (which is NOT a good thing).
First and foremost was my resident, who was probably one of the laziest people I've ever met. Intern and resident start dates are staggered by one week so that the exiting resident can teach the intern about how the service is run and what is expected of the intern. My resident flat-out said on the first say there'd be no teaching and the goal of each day was to leave by 5:00 pm (a great rule to have). And while I was struggling to get my notes written (to give him credit, he saw 3-4 patients for me when our patient load was greater than 10), he'd be on the internet checking his email, chatting online, or otherwise being unproductive unless it's to his cause (like doing dictations). My second day of PCU, he left the floor for about 30 minutes for a meeting without telling me and left me freaking out when two separate attendings arrived for rounds. He was also lazy about documenting central line placements and important telephone conversations with patients' families (he rolled his eyes when I documented a central line removal), which caused him to butt heads with 1-2 attendings (one of them later told me my resident was flat-out stupid). To make things worse, he'd worked a black weekend before I signed on, and so I had to work a black weekend my first week as a PCU intern.
On weekends the earliest I can sign out is 2:00 pm, but I didn't leave the hospital until 6 pm on Saturday and 4:30 pm on Sunday (and that was only because I prewrote all 11-12 notes the night before). And because I was the only doctor in the unit, there was rarely any time for rest. I didn't even have time to eat, drink, or pee on Saturday aside from eating a granola bar here and some graham crackers there. Sunday was a little better b/c my patients were more stable, and today I got a new resident (fortunately it was someone I'd worked with in the MICU and I knew she was good). Unfortunately for me, she had worked the night before and left at noon, leaving me to run the PCU for the afternoon. And as expected, I didn't leave the hospital until 6:00 pm.
The PCU nurses have told me that I'm doing a good job and keeping myself together, but most days I just can't wait to go home. One of my patients became very hypotensive yesterday (among other problems), and I went home secretly hoping I wouldn't have to deal with her the next morning. Got my wish; she'd been transferred to the MICU. One of these days I'll have to tell you about this patient; it's a very sad case.
Hopefully today is my last day to work alone until this weekend, when I'm guaranteed at least ONE day off.
First and foremost was my resident, who was probably one of the laziest people I've ever met. Intern and resident start dates are staggered by one week so that the exiting resident can teach the intern about how the service is run and what is expected of the intern. My resident flat-out said on the first say there'd be no teaching and the goal of each day was to leave by 5:00 pm (a great rule to have). And while I was struggling to get my notes written (to give him credit, he saw 3-4 patients for me when our patient load was greater than 10), he'd be on the internet checking his email, chatting online, or otherwise being unproductive unless it's to his cause (like doing dictations). My second day of PCU, he left the floor for about 30 minutes for a meeting without telling me and left me freaking out when two separate attendings arrived for rounds. He was also lazy about documenting central line placements and important telephone conversations with patients' families (he rolled his eyes when I documented a central line removal), which caused him to butt heads with 1-2 attendings (one of them later told me my resident was flat-out stupid). To make things worse, he'd worked a black weekend before I signed on, and so I had to work a black weekend my first week as a PCU intern.
On weekends the earliest I can sign out is 2:00 pm, but I didn't leave the hospital until 6 pm on Saturday and 4:30 pm on Sunday (and that was only because I prewrote all 11-12 notes the night before). And because I was the only doctor in the unit, there was rarely any time for rest. I didn't even have time to eat, drink, or pee on Saturday aside from eating a granola bar here and some graham crackers there. Sunday was a little better b/c my patients were more stable, and today I got a new resident (fortunately it was someone I'd worked with in the MICU and I knew she was good). Unfortunately for me, she had worked the night before and left at noon, leaving me to run the PCU for the afternoon. And as expected, I didn't leave the hospital until 6:00 pm.
The PCU nurses have told me that I'm doing a good job and keeping myself together, but most days I just can't wait to go home. One of my patients became very hypotensive yesterday (among other problems), and I went home secretly hoping I wouldn't have to deal with her the next morning. Got my wish; she'd been transferred to the MICU. One of these days I'll have to tell you about this patient; it's a very sad case.
Hopefully today is my last day to work alone until this weekend, when I'm guaranteed at least ONE day off.
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