more from the front lines

Yesterday was that rare good shift: everything seemed to work out. Not too many patients (and it was a Monday!), I was supervising good, hardworking students, and I had good cases. Additionally, I didn't get into one single argument with another resident.

My first patient was a sick guy admitted from the GI clinic. Massive cirrhosis from drinking too much. His liver is scarred down to a nubbin, and his belly is filled with fluid. And it's infected. I get the pleasure of sticking an angiocath into his tummy and I drained THREE LITERS of nasty yellow fluid out of there then start some antiobiotics. I even left a stopcock in his belly so that the admitting team could turn it "on" and drain more as needed. Remember kids, one drink a day keeps the doctor away, but twenty a day will keep the doctor at your bedside sticking needles into your gut while you wait for a liver transplant.

Another lady had DKA (diabetic ketoacidosis). She was short and squat, and her family brought her in b/c she was acting "confused." Not herself, they tell me. What does that mean?

Oh wait, wait -- this is good -- the news is on in the background and Marc Foley -- one of the legions of GOP hippocrites (he was the leader of the Center for Missing and Exploited Children) -- his lawyer just came on and said that the bastard was himself molested by the clergy and thus it's not his fault. Give me a fucking break. It's long been time to clean house -- and senate.

Anyways, this lady had a blood sugar of 750. 750! Normal is 70 to 100. No wonder she was confused -- her blood was like maple syrup. When it's that high, in insulin-dependent diabetics, your body actually goes into "starvation-like" mode. It can't process the sugar as fuel because it has no insulin to bring it into cells, so the body starts breaking down fats for energy and the waste byproduct is ketones. (I guess I did learn a little something in biochem.) Her ketone level in her blood (acetone) and urine were through the roof, and when you walked into her area, her it smelled "fruity." Really. That's b/c the ketones are rather volatile and are excreted into the air when she breathes. It smells like juicy fruit -- not altogether unpleasant, actually.

You know, the literal translation of "diabetes mellitus" means "sugar in the urine." And that's how apothecaries in the renaissance diagnosed it -- by tasting their patients' urine. Yuck. Technically, though, unless you've got a raging UTI, urine is a sterile fluid.

Anyway, DKA is a true medical emergency. This lady was ketotic, acidotic, and had mental status changes. Electrolytes are all fucked up. Potassium too low, bicarbonate WAY too low, pH too low, sodium too low, sugar too high, renal function compromised. The calculations get a bit complicated, but I started an insulin drip on her to closer her anion gap acidosis, and normally you're supposed to flood these patients with fluids to bring the osmolality down, but of course she also had congestive heart failure, which means her heart wouldn't properly pump all of those fluids properly and it would just get backed up in her lungs. And her chest xray showed them to be layered with fluid already. What to do? I doubled the insulin infusion and gave her some potassium.

An hour later her sugar was down to 306 and she was a new woman. Dangerous condition though, that DKA. Needs close monitoring, so off to the ICU she went.

Trauma came in. Some dude completely wasted. At 3pm. Hit and run, awful. The EMTs brought him in to the trauma slot. Face is bashed in a ton of places. Uh-oh, this could be another horrible intubation. He comes in writhing around, spitting up blood, not speaking. Again, all eyes boring into me to secure the airway.

This was disgusting -- I put the intubation blade into his mouth, lift up, and his jaw falls into pieces around the blade. The skin is intact, but I could feel and hear the crunching and grinding of his jawbone pieces. Suction suction suction. All I see is blood. Suction suction suction.

"WELL?" says somebody, impatience mixed with acute anxiety. I have no idea who said that -- there are ten docs in the room, three nurses, ten med students, five volunteers, some police, EMTs and firemen.

His O2 sat IS still 100% you know, I'm thinking, I *do* have more than five seconds to secure this airway. Fuck off whoever said that.

I see it -- vocal cords. Tube goes in. Whew!

Then as everyone else moves in, vomit starts projecting out of the breathing tube. (Seven years into medicine and I STILL can't stomach vomit.)

"YOU TUBED HIS STOMACH," shouted another unknown.

"NO I DIDN'T," I shouted back. "The tube went THROUGH THE CORDS, I SAW IT. I'm sure he aspirated his own vomit in the field. JUST WAIT TILL I SUCTION IT OUT BEFORE YOU GO PULLING OUT HIS AIRWAY."

So I stick a suction catheter into his tube and down into his lungs, suck back chunks of his lunch -- and a lot of vodka -- and sure enough, the O2 sat goes up, I can auscultate breath sounds with my stethoscope, and the end-tidal CO2 detector says I'm in.

Tube in, IV's in, BP stable, heartrate fine, orthopedics is pointing out that his shinbone is sticking out of his shin, off to the OR he goes.

Again: paperwork, talk to the NYPD who always has the same question ("Is he going to die? Cuz then it's a homicide and it's different paperwork for us, you know"), me always with the same answer ("I have no idea, we all have to wait until he actually lives or actually dies, the OR holding area is on 11, go up there and speak with the surgeons when they're done.").

No resting. The ER is still full of people. I eat a Jolly Rancher that's been sitting in my pocket for two days just for the sugar.

I start treating and booting people out rather quickly:

Broken collar bone -- closed fracture, treatment is a sling and send for follow up

Bilateral lower extremity edema with history of liver failure -- subacute, chronic, nothing we can do here, probably needs med adjustments, send to his primary care MD

Cellulitis -- antibiotics, discharge

Hedge fund jockey with three days of bad diarrhea after some bad Mexican food -- gastroenterities, ride it out, it's a virus, can't do anything about it, discharge

Bad cellulitis and homelessness -- no way to ensure compliance and follow up, has to be admitted for IV antibiotics

Another hyperglycemia -- urine ketones negative, no gap acidosis, not DKA, give fluids, insulin, sugar comes down, discharge

Pneumonia -- antibiotics, admit

COPD exacerbation -- combivent inhalation treatments, another, another, another, finally he's feeling fine, he can go home

Ohmigod someone brought cookies, I take two, time to go home.

I don't care how tired I am, I will not touch my bed or 600-thread count Egyptian cotton sheets without showering first. Too tired to eat, I'll do that in the morning.