04 December 2010

My Patients, My life

I've been taking care of a lot of patients lately. Working 60-90 hour weeks in the hospital and trying to study.

But I've decided I need to get myself a pair of white gloves. More like mittens actually. Check them out at the site below.


The vast majority of my patients at one time were wearing them.

One of my most memorable patients was Mr. C. He was admitted to my service about a week into my rotation. I really had no idea how to handle patients at this point, let alone a patient with an altered mental status and aggression.

When he came in, his chief complaint was altered mental status and aggression.  Great, I'm not sure I've read any book or had any lectures about how to deal with aggression as an inpatient on a medical ward.  That's all the information we had on him.  When we went to do a History & Physical, we quickly realized that that was all of the information we were going to get.  We were unable to get a response out of the patient at all.  His eyes were open, but he wasn't moving much.  We were able to do a decent physical exam: (a bunch of "doctor talk , you can ignore this if you're reading my blog…) heart rrr, no mrg, lungs ctab, skin covered in lesions that looked self inflicted with his cm long fingernails.  extremities severely wasted.  lines included a picc line, femoral line (apparantly placed by the ER before they saw the picc because they couldn't get peripheral access, ridiculous), a g tube, and something else.

The only response we were able to get out of him was a sharp "STOP" when trying to elicit a babinski reflex.  Which scared me half to death.

We called the nursing home he came from to try and get more information.  They had him for a grand total of 21 hours and really were of no help as to his Past Medical History.  Both numbers listed for family (a mother) were incorrect. Great.  So we called JPS hospital in Fort Worth, who had taken care of him previous to his short stay at the Skilled Nursing Facility/ Nursing Home. 
And they were able to fax me a huge packet of information to sift through.  Oh, fun.  Upon examination of the packet, he had suffered from an anoxic prain injury some unknown time in the past, and was only A&O x 1.5 on a good day. (meaning he only knew who he was, not where he was or what the date was)  He also had T1DM (type 1 diabetes mellitus) and a seizure disorder.  As well as ESRD (end stage renal disease: broken kidneys which means he was on dialysis) and GERD (Gastro Esophageal Reflux Disease, or heartburn), at the tender age of 32.

His name, we learned, was Mr. C.  After correcting his electrolytes (blood salts) and hypoglycemia (low blood sugar), he was able to sit in bed with a 1:1 (a person paid to sit with him and watch him all day).  He was also, shockingly, able to walk with PT (physical therapy) and eat with assistance.  I would have never guessed!  He still remained, largely, a mystery to the team.

And so, another call cycle came and went and he sat there.  We were working with the endocrine consult service to control his blood sugars.  They ranged from less than 40 to over 600 (normal is 80-120).  His other medical problems had long since resolved.  He fluxuated up and down despite changing control of his lantis and aspart (insulin given to drop his blood sugars)...and on and off glargine (another insulin)...and on and off D5/ Glucose to correct for hypoglycemic (low blood sugar) episodes.

One of our fist tasks was to clip his nails.  They were dangerous to him and other people.  But apparently the nurses at Parkland are "too good for that job." Honestly?! Whatever. So, instead of passing the task off, our Attending got washable nail clippers from her Nurse Practitioner and cut them herself.  That made me respect her SO much!

We tried to take him out of restraints, but the nurses and1:1 sitters were impatient with him, which frustrated me.  All he wanted to do was walk up and down the hallway...but they were afraid of him.  He even had those great mittens to keep him from scratching himself or another person.  I mean, why have a 1:1 sitter if they won't help the patient?! Restraints just make someone more agitated!  (something my attending taught us, which was another great learning lesson)

I was tired of him being here because a lot of people, most of the nurses and staff, thought he was difficult and insisted on keeping him in restraints because he occasionally called out "help me."  when he wanted to walk around.  I think I would too if I were strapped to a bed all day! But he was so easily directable with guidance. If you took the time to guide him.  Which I did (and I'm not that skilled!) but most other people never took the initiative to do!

He was THAT patient I had that was just there, each day we would hope to better control his blood sugars, and each day they either ranged dangerously high or low.
He went to dialysis Monday, Wednesday, and Friday.  I usually missed seeing him those mornings.

Then, after having him in my care for almost 3 weeks, the endocrine consult service  put him back on an insulin schedule they had already tried and failed. What?! So I talked to my resident, but instead of jumping in to save the day, she had me call the endocrine fellow.  So I did. At this point, people on my team had given up on ever getting him under control.

So, after talking with the endocrine fellow, she agreed to talk to her attending about better managing him.  And then I talked to the Pharm Ds (people who got their PhD in Pharmacology, the study of drugs).  Brilliant people.  They came up with a new plan: keep him on short acting to see what he needs, and then make a long acting schedule, that works with his dialysis schedule.

After another long week his blood sugars were under better control.  Not perfect, but workable.  Nothing that would get him sent right back to the hospital!  We made his chart nice and organized so information would be easy to find on him if he was ever admitted again.

One day right before he left, I was able to have a good conversation with him.  He told me he liked be called A, instead of "Mr. C"  He told me where he was (almost) and I helped to explain to him why he was there.  He always smiled when I walked into the room.

I left the service and started a new rotation before he left.  And wouldn't you know, I was on a completely different team based on a completely different floor, but one of the new patients I was assigned was an elderly man with Altered Mental Status (delerium!) who was A's roommate.  So I still got to check up on A.  And I was happy to see him doing much better, and finally make his way back to a Skilled Nursing Facility.

I helped someone.  I fought when no one else wanted to!

But then last time I was on call, my intern got a page on a cross-cover patient. (the team on call takes care of all the other teams' patients plus admitting their own patients on call night…it's a bit crazy!) I recognized the name, and so I went with him to see if we could talk to him instead of just slamming him with more drugs. Which we did. It was heartbreaking to see him in the hospital again, and to learn that he had already been admitted and let go of earlier that week. So much for fighting. I don't know what's going to happen to him now.

Since them my patients have come and gone in themes:

Congestive Heart Failure

Cirrhosis (dead livers, which there is no treatment for) with big bellies full of fluid, which they let me drain off with a big needle…SO cool!!

AMS/ Agression/ Delerium



Thankfully, I'm almost done with my 2 months of crazy Parkland wards and being at the hospital 30 hours every 5 days plus 10 hours on normal days. I'm ready to sleep again, but not ready for our test at the end of the rotation…

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