Thursday, July 14, 2011

In Which our heroine fails to recognize early shock liver, is once again glad she d/c'd antibiotics, and has a hard time bringing herself to discharge elderly patients. Oh, and anticipates tomorrow's DAY OFF!!!

I know as intern's we're not expected to get it right every time.  Especially not as July interns.  But really, couldn't I have recognized that Ms. _________ wasn't having a panic attack?  I should've listened to my gut that something wasn't right.  I should also have realized her bicarb was 16 (non-medical translation: she had some metabolic process making her blood to acidic) and she was hyperventilating to blow off CO2.  Two days later she was in the intensive care unit, and shortly thereafter she was transferred to another hospital for a liver transplant.  Her metabolic acidosis was due to the lactate her cells were producing due to hypoperfusion.

SO INTERNS READING THIS, IF THERE ARE ANY: remember that agitation doesn't just mean panic attack!  You don't want your patient -- or cross-cover patient, as in this case -- to become the subject of a morbidity and mortality report.

At least I seem to have made the right decision regarding a patient admitted with a supposed urinary tract infection, who didn't have one and who always gets antibiotic-associated C. difficile colitis when treated.  I didn't give any antibiotics, but unfortunately she returned today with C. difficile colitis.  I guess probably from the antibiotics she received before I admitted her?

But maybe she already was infected when I admitted her earlier in the month?  Perhaps I failed to recognize it.  She originally complained of constipation last admit, and Dr. _______ did teach us that C. diff can occasionally present with constipation.   I didn't check then.  If I had, maybe I could have started treatment and she wouldn't have gotten as sick.

Couldn't I have just ordered a PCR before discharging her last time?

So I missed the boat, again.

Is part of this the pressure to discharge patients?  We get so much pressure to push people out.  Of course nobody should stay in the hospital unnecessarily, and other sick people may need that bed, but haste makes waste, too.

I almost cried today over a discharge for an elderly lady who couldn't even walk.  She had strong social support, and good support, but will she go to the bathroom?  Fortunately we delayed that discharge until the appropriate assistive devices can be delivered to her home.  And nobody wants to read my soapbox about discharges.

So how about something happy?  I get a day off tomorrow!!!  I almost bought tickets to the premier of Harry Potter tonight, but then I'd sleep my entire day off away.  No fun.  So I will be very lame and go to bed instead of seeing the last-ever midnight premier.  Oh, well.  I'm hoping to spend time with my grandmother, my aunt and my baby cousins tomorrow, and then of course there's my favorite Shabbat Dinner!  Yes, there will be challah.  Homemade, fresh from the oven.  Mmmmm....And I don't have to write a single progress note or discharge summary tomorrow :o)  I love seeing patients but I loathe documentation.  I know it's SOOO important, but it takes a long time!

Here's something sweet: my patient with the C. diff and her family remembered me!  I hope that means I made a difference.  Because that's what it's about.

And here I am, thinking again about work.  I wonder how other people separate?   But I don't know if I would want to.

At the moment, though , I want to curl up on the sofa next to my husband with the latest issue of my favorite cooking magazine, so enough silly rambling for now.

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