4 pm.
i received a discreet warning that the intern
with whom i'd be working needed her work double- and
triple-checked, "especially her orders." then i got the sign-out:
which people had inexplicable symptoms or paradoxical reactions,
which ones were closest to dying, which ones whose "full code"
revival would be impossible to achieve if the worst should happen.
which ones had the fewest resources - lung capacities; arterial
integrities; brain waves; abilities to tolerate pain, hospital food,
and waiting.
6 pm.
we admitted a mentally retarded middle-aged man
with a nonhealing big-toe wound. he'd been in the hospital
a few months back, and the x-rays looked like an infection
of the bone, but the surgeon advised us to send him home
on antibiotics for a month. he finished the antibiotics - a nurse
comes every day and gives him his medicine - but the wound
never healed, and now it was so bad he could almost feel it
(through the neuropathic numbness of late-stage diabetes)
and everyone in the hall could certainly smell it. a band-aid was
falling off; reddish pus wept out, coating the toe and its neighbor.
i squeezed it pretty hard, to see if it could be emptied. it was like
squeezing a rotten onion.
7 pm.
we asked the surgeon to come take a look. actually, we asked his
nurse, who was answering his pager while he was in surgery.
it turns out the patient had never kept his "follow-up" appointment
with this same surgeon, and it was eight o'clock at night when he
visited, after a long day of surgery. we weren't there; the intern
went to update her patient list, and i went to my room to eat some
canned pineapple and watch a doctor show on tv. so per the nurse,
the surgeon kind of stomped in to the unit and rolled his eyes at the
wound, sneered at our notes and declined to look for the x-rays,
cancelled our wound-care orders, changed the antibiotics,
and left a note saying he would not be on call this weekend.
8 pm.
a code blue was called in labor and delivery. as usual when i
heard "attention, attention, attention" over the loudspeaker, i went cold
and tingled for a minute. we ran down the stairs. but when we got there
the charge nurse was on the phone chewing out the dispatcher;
it wasn't a code blue, just an unexpectedly rapid birth.
9 pm.
a woman whose large fulminant perineal abscess had been
cut opened and drained (our attending inserting a gloved finger
deep into the buttock meat to break up the loculations so the
jellied pus could be scooped out, replaced with sterile packing)
- she spiked a 105-degree fever and was, you know, delerious.
the nurses were taken by surprise and wanted to move her
to intensive care, or failing that, at least an icebath. i suggested
we start with a gram of tylenol and they check her temp every 20 min
for 2 hours. apparently that was that. no more calls.
10 pm.
i went to my room and ate some cheese and crackers sitting
on the bed watching animal planet and nervously re-reading
what you're supposed to do in an obstetric code blue.
got a call from a lady who said her stomach hurt real bad,
would only stop hurting if she lifted it up in her hands
and held it to one side while lying on the other side in bed.
fifth pregnancy. morbid obesity. she didn't want to go to the ER.
11 pm.
admitted a guy with his third pneumothorax - the first one
was spontaneous, the second one from being stabbed in the chest
while in prison, and this one possibly related to the giant consolidated
pneumonia in his right upper lobe. it looked like the upper lung was
scarred to the chest wall, so nobody wanted to put in a chest tube
and accidentally pierce the lung itself. when he coughed, i shivered.
we put him on high-risk infection precautions, among other things,
and had his oxygen levels checked continuously. he was awfully thin.
he tested positive for cocaine. he consented for an hiv test.
the chest surgeon said, leave him alone, i'll look at him tomorrow.
he asked, coughing, to go outside for a cigarette, and we said no.
12 am.
meanwhile, the guy my age with terminal heart failure stopped
making urine. nephrology came and saw him and stopped his antibiotic,
saying it was nephrotoxic, and ordered a test for adrenal failure
because of his weird blood electrolytes. later in the night he made a little
orange-colored urine. he's in such bad shape, but he's afraid that if he
makes himself DNR - do not resuscitate - they won't put him on the
transplant list. so he remains full code, with a heart like wet papier-mache,
barely able to hold blood, much less pump it out.
1 am.
i got a choco-taco out of the freezer and got into bed.
got a call about a month-old baby coughing with a fever. sent them
to the children's hospital emergency room, and turned off the light.
2 am.
phone rang; time to admit a little old lady with pancreatitis.
she had never had pancreatitis before. she had no risk factors
for pancreatitis. a lifelong tee-totaler, with a healthy gall bladder;
the preliminary report on the imaging showed thickening
of the head of the pancreas and the surrounding fascia, plus
some spots in the liver and kidneys. while we were admitting her,
we kept getting calls from intensive care...
3 am.
...where our 27-year-old souse, who says he doesn't drink,
here with his fourth severe pancreatitis, was having severe problems.
he couldn't stop vomiting and his blood pressure was going up and up
and his heart rate doubled and he was shaking all over and sweating.
he swore on his mother he wasn't withdrawing from anything.
we had a few theories. we tried a few drugs. some of them helped.
he stopped vomiting for a while. then he lost the ability to pee.
ultrasound showed half a liter of pee in there, but nobody could get
a catheter in. then he started vomiting again.
4 am.
the nursing home called about one of their patients.
she's a 30-something, a private patient of my program director's,
temporarily in a rehab center to build up her leg muscles so she could
go back to independent living after surgery. they couldn't get a
blood pressure on her, they said. and she was cold to the touch.
none of the machines could find her blood pressure. her pupils were
dilated and her pulse, according to the machine, was 40. none of the
night staff knew how to take a manual blood pressure, and they
couldn't feel her pulse themselves.
she'd fallen down the previous day and complained of right hip pain,
but she was still able to walk. now she was awake, despite having
almost no vital signs, and complaining of right belly pain. maybe you'd
better send her to the emergency room, i said sweetly. they said
they guessed they would. i printed up her clinic notes and med list
and went down to the ED and briefed them.
5 am.
the old, old guy with the do-not-resuscitate orders
developed respiratory distress. the nurse said he desaturated
down to 60 (which means the machine indicated that he only had 60%
of the right amount of oxygen in his blood - optimal being 100%)
and his respiratory rate was 48 breaths a minute (normal about 14).
he refused to use the breathing mask. i suggested morphine
and a tranquilizer, and then maybe he'd find the mask more to his liking,
but when the intern went to see him, he was saturating at 86%,
not terrible, and breathing only about as fast as the intern, who'd
taken the stairs. and he was sleeping (mask -free). who knows?
then the lab called with a critical value. his INR had doubled again
(2nd day in a row), so his blood was now 8 times thinner than normal.
i decided to abandon the intern and lie down again. it's winter now,
still dark until seven am. then i got another call. it turned out that -
remember the lady with no blood pressure? they sent her
to the wrong hospital. so the ED doc at the other hospital
called me up and said the patient had a rock-bottom blood count,
appeared to be hemorrhaging from somewhere, needed blood badly,
could we transfer her to our ICU? so i went downstairs to the ICU,
and while i was asking, the nurse manager came running,
waving her arms at me: "No! Stop! We're overflowing down here!"
6 am.
by this time, the nurses were turning the day lights on and
there was a smell of coffee in the air. i took a call about a
teenager 3 months pregnant who was worried her backache meant
she was miscarrying. the intern took a call about a lady who says
the hospital lotion makes her itch, then another one saying
that one of the patients needs to know what time he can leave.
7 am.
i went around and doublechecked the intern's orders. she
did fine. so then i handed off the pager to the next "sucker emcee"
as they used to say, and went home. i write these things down so
someday when i have a better life, i can remember what it was like,
that things like this really happened and were a part of the everyday
surreal, and i went along with it and did my work and got through.
