Fog, Glorious Fog!

Having recently returned from a CME on hospitalist procedures in San Francisco, I must admit I kind of miss the fog that often rolls in as evening falls.  A lot has changed in my favorite town since I moved away, but many things remain the same.  Between practice sessions spent mastering the insertion of central venous lines in the right IJ and right subclavian veins of anatomical models (you know you hit the right spot when your finder needle aspirates windex-blue fluid), I was able to hop on the 38 Geary bus which whisked me away from Union Square and rolled all the way down to Land's End, where I took a lovely stroll by the Pacific Ocean during low tide.

Snip Snip

Have you ever completed a vaginal laceration repair shortly after a successful delivery, wondered, "Why is there a bandaid on this patient's R buttock?", and removed the bandaid (which was starting to peel off anyway), only to find a growth that resembles a small penile glans?  The texture was a cross between a stale marshmellow and a lipoma.  The patient's PMD had been reluctant to remove the growth, fearing it might be highly vascularized.  I anesthetized the skin around the lesion with a field block of 1% lidocaine with epinephrine, stuck a needle in it, and when no giant geyser of blood erupted, performed an excisional biopsy and sent the odd growth to pathology for further evaluation.

When All Else Fails, Hold A Sleeping Baby

One of the Yup'ik elders on my service has the dwindles.  He's 87, he has Lewy body dementia, and he has slowly been losing his strength and mobility over the past several months.  He was originally admitted for acute R gluteal pain that radiated down his leg, likely secondary to a herniated disc at L4-L5; but he soon stopped eating and drinking altogether.  He has an amazingly large and caring family, all of whom are deeply invested in his well-being.  I have had numerous conversations with his siblings, adult children and adult grandchildren about his prognosis all week.  We had a family conference by speaker phone yesterday so that family here at the hospital could communicate en masse with family back home in the village.  The ones who had been in Bethel all week by his bedside felt strongly that he should go home to familiar surroundings.  The ones in the home village were less certain and wanted to try more aggressive interventions (i.e. artificial nutrition by NG tube) in the hospital.  The patient's sons were on their way home from fish camp (everyone sets up fish camp by the river in the summertime, in order to catch and then slowly dry an adequate supply of salmon and herring to last throughout the winter).

This morning, it was decided that the patient would go home to be cared for by family.  I put in a special request for a "reverse medevac" because he was too weak to sit up for a commercial flight home. An Expected Home Death form was filed in his chart.  When the paramedics finally arrived (the flight time had been delayed several times due to regular medevac requests that pre-empted the reverse medevac), we all got a little teary-eyed.  The family graciously thanked me, and there were hugs all around.

After the plane took off, I tiptoed to L&D and sat quietly in a rocking chair for a few minutes, holding the baby I had delivered the day before, which somehow made me feel just a little bit better.