Thanks to freezing rain and the prospect of an ice storm, flight 42 to Anchorage has been canceled, so I am stranded in Bethel until tomorrow. To add insult to injury, I've developed a minor case of impetigo, a Staph infection most commonly seen in small children and wrestlers; luckily, I am paranoid enough to have brought Bactroban with me so I can slather my right philtrum with its strong antibacterial formula TID.
Thankfully, I also have the tendency to bring too much food with me on these excursions to rural southwest Alaska. This time, I cooked and froze lentil soup, chicken casserole, and runza (a Nebraskan treat made of ground beef, cabbage and onions with allspice & coriander, enveloped in a delicious homemade dough). The food gets transported efficiently in my checked baggage, and is usually still frozen by the time I land in Bethel, because the cargo hold on the plane is very chilly. I must confess I did eat runza for breakfast this morning (Beef! The breakfast of champions!). For the rest of the day, I will most likely imbibe hot tea, munch on popcorn, and watch 1000 consecutive episodes of "The West Wing" on DVD. Any television show or movie about medicine, hospitals or Alaska (or about practicing medicine in hospitals in Alaska) is strictly off-limits.
Tuesday, November 13, 2012
Monday, November 12, 2012
Where Are My Jelly Candies???!
Yes, this is what I've been reduced to: after 9 exhausting days on the inpatient wards and the possibility that my flight out of Bethel tomorrow may be cancelled due to freezing rain, all I can do is turn my room inside out in a herculean effort to locate the tiny prized bag of berry-shaped jelly candies with vitamin C that I got from the hospital vending machine in a feat of fortuitous timing. The vending machine can remain in a sad state of neglect and near-emptiness for quite a while before it gets re-stocked with snacks, and I was lucky enough to venture by just after a new supply was deployed. Combine that with my fear of scurvy, and you can see why I am so preoccupied...
My patient with endometritis & postpartum hemorrhage was discharged home today, freshly showered, hair in pigtails, looking much happier. Her first night here was a frightening one that involved being transferred from the floor to the ED (which functions as a pseudo ICU for patients who are too sick for the wards and are awaiting transport to a higher level of care in Anchorage), massive blood transfusion (5 units of pRBCs) and fluid resuscitation (5 liters of NS!). After a few days on a triple cocktail of clindamycin, gentamicin and ampicillin, she looks fantastic and no longer needs antibiotics.
Mr Lice Infestation left AMA this morning, but was willing to carry home several large bottles of permethrin for his wife and adult son to slather themselves in.
My 63-yr-old patient who was admitted for seizures after a 3-day drinking binge in which she completely abandoned her daily dose of keppra has finally started eating and looking a little more lucid. She was getting wheeled down the hallway as I left, and she gave me a perfect Queen Elizabeth coronation wave of her right hand, nodded her head, and gravely shook my hand, telling me "Quyana" which is Yup'ik for thank you.
My patient with endometritis & postpartum hemorrhage was discharged home today, freshly showered, hair in pigtails, looking much happier. Her first night here was a frightening one that involved being transferred from the floor to the ED (which functions as a pseudo ICU for patients who are too sick for the wards and are awaiting transport to a higher level of care in Anchorage), massive blood transfusion (5 units of pRBCs) and fluid resuscitation (5 liters of NS!). After a few days on a triple cocktail of clindamycin, gentamicin and ampicillin, she looks fantastic and no longer needs antibiotics.
Mr Lice Infestation left AMA this morning, but was willing to carry home several large bottles of permethrin for his wife and adult son to slather themselves in.
My 63-yr-old patient who was admitted for seizures after a 3-day drinking binge in which she completely abandoned her daily dose of keppra has finally started eating and looking a little more lucid. She was getting wheeled down the hallway as I left, and she gave me a perfect Queen Elizabeth coronation wave of her right hand, nodded her head, and gravely shook my hand, telling me "Quyana" which is Yup'ik for thank you.
Friday, November 09, 2012
Mucomyst for Dummies
Now we've got a strange combination of rain from the sky with stubbornly persistent slush and ice on the ground, and all flights have been cancelled. Medevac has been on hold for most of the day, so the RMT calls have been out of control. There are patients in the villages with broken ankles and dislocated shoulders who can't book a flight out because of the weather, and we can't activate a medevac for a non life-threatening condition. Some of the smaller clinics are running low on morphine and tylenol #3 for the patients with painful injuries who can't get to Bethel.
To top it off, I get 12 calls from a health aide about a 17-yr-old girl who was drinking last night and suspects she may have been sexually assaulted but can't recall the exact details. She started feeling depressed, so she decided to overdose on tylenol. She tells the health aide that she took 10 of the 325 mg tablets; when I briefly consult with the ER doc, he says there is no way to confirm whether the girl took 10 tablets or 100 tablets since depressed adolescents are notoriously unreliable historians, so she needs to take the oral mucomyst that is standard issue at all the village clinics, given the astoundingly high rate of suicide attempts here by tylenol overdose. The health aide tells me she can't find the mucomyst. I ask her if maybe someone else knows where it is. She calls me back to say no one can find any mucomyst anywhere. I ask her to check with Emmonak which is the nearest village. She calls me back to say that Emmonak has no mucomyst. After conferring with the ER doc again, we decide the girl needs to come in because excess tylenol could seriously fry her liver, so I activate the medevac. The health aide calls 10 minutes later to say actually Emmonak does have mucomyst and they will send it over. I call medevac and apologize profusely for wasting their time.
Meanwhile, between checking on my 82-yr-old patient admitted for an egregiously out-of-control lice infestation (I feel mildly pruritic just thinking about it) and chatting with a floridly psychotic 31-yr-old male on a psychiatric hold who wants to know if my pager is a recording device and whether I believe in human clones, I have sketched out a frighteningly detailed flow chart for the health aide who is waiting for the mucomyst to arrive because she seems a little...confused. Mucomyst for Dummies, based on the 17-yr-old girl's weight in kilograms, tracing out various dosing schemes depending on whether Emmonak sends the 10% or the 20% solution. Apparently mucomyst has an extraordinarily unpalatable flavor, so it needs to be mixed 1:3 with a deliciously cold beverage like orange juice or soda. Otherwise, no one would want to drink it. Frankly, I think their marketing department should consider changing the name of the product to something that sounds more...appetizing.
To top it off, I get 12 calls from a health aide about a 17-yr-old girl who was drinking last night and suspects she may have been sexually assaulted but can't recall the exact details. She started feeling depressed, so she decided to overdose on tylenol. She tells the health aide that she took 10 of the 325 mg tablets; when I briefly consult with the ER doc, he says there is no way to confirm whether the girl took 10 tablets or 100 tablets since depressed adolescents are notoriously unreliable historians, so she needs to take the oral mucomyst that is standard issue at all the village clinics, given the astoundingly high rate of suicide attempts here by tylenol overdose. The health aide tells me she can't find the mucomyst. I ask her if maybe someone else knows where it is. She calls me back to say no one can find any mucomyst anywhere. I ask her to check with Emmonak which is the nearest village. She calls me back to say that Emmonak has no mucomyst. After conferring with the ER doc again, we decide the girl needs to come in because excess tylenol could seriously fry her liver, so I activate the medevac. The health aide calls 10 minutes later to say actually Emmonak does have mucomyst and they will send it over. I call medevac and apologize profusely for wasting their time.
Meanwhile, between checking on my 82-yr-old patient admitted for an egregiously out-of-control lice infestation (I feel mildly pruritic just thinking about it) and chatting with a floridly psychotic 31-yr-old male on a psychiatric hold who wants to know if my pager is a recording device and whether I believe in human clones, I have sketched out a frighteningly detailed flow chart for the health aide who is waiting for the mucomyst to arrive because she seems a little...confused. Mucomyst for Dummies, based on the 17-yr-old girl's weight in kilograms, tracing out various dosing schemes depending on whether Emmonak sends the 10% or the 20% solution. Apparently mucomyst has an extraordinarily unpalatable flavor, so it needs to be mixed 1:3 with a deliciously cold beverage like orange juice or soda. Otherwise, no one would want to drink it. Frankly, I think their marketing department should consider changing the name of the product to something that sounds more...appetizing.
Thursday, November 08, 2012
Flakes of Snow
The inpatient wing recently got a makeover with mesmerizingly gorgeous simulated wood laminate flooring that makes it look like a spa. Very soothing to look at in the midst of complete chaos. Upon arrival to the hospital this morning, I was given a heads up from the night float about a patient arriving via medevac who had given birth to a stillborn infant at 29 + 5/7 wks EGA, had retained placenta for more than 3 hours, and was being transfused in transit with 2 units of blood for postpartum hemorrhage. By the time the patient arrived, I had already discharged 4 patients and admitted 2 new ones. She was strapped to a gurney, very quiet, with part of a placenta (clamped umbilical cord still attached) protruding slightly from her vagina, actively bleeding. The paramedics had given her almost 5L of IVF and her SBP was only in the high 80s to low 90s.
After drawing blood for CBC, type & cross, and bile acids (cholestasis of pregnancy is a common cause of fetal demise here), the OB nurses started infusing 20 units of pitocin. The placenta was manually extracted, and I did a quick repair of the patient's 1st degree vaginal laceration. Only after all the procedures were completed did the patient burst into tears. Admit her to OB or to the inpatient unit? The OB nurses were skilled with postpartum care, but it seemed insensitive to keep the patient where there were so many mothers with healthy newborns. The nurses pulled me into the supply area to assess the stillborn infant. He weighed just over 4 lbs and appeared to be at least 34 weeks old. They debated whether it would be all right to clean him up so the mother could have photographs taken; a quick call to the Medical Examiner (autopsy is mandatory in fetal demise beyond 20 weeks) confirmed that the stillborn infant had to be left in his current condition without any alteration.
The patient was transferred to the adult inpatient unit, doing well until she suddenly developed chills and tachycardia 20 minutes before the end of my shift. Minimal vaginal bleeding since the manual extraction of the placenta, no significant uterine tenderness, no dysuria or foul vaginal discharge. Pt's temperature skyrocketed from 97.6 to 101.8 within a matter of minutes. I got blood cultures, started clindamycin and gentamicin for presumed endometritis, and kept my fingers crossed.
Walking home, I noticed gentle flakes of snow falling from the sky and landing softly on the ground.
After drawing blood for CBC, type & cross, and bile acids (cholestasis of pregnancy is a common cause of fetal demise here), the OB nurses started infusing 20 units of pitocin. The placenta was manually extracted, and I did a quick repair of the patient's 1st degree vaginal laceration. Only after all the procedures were completed did the patient burst into tears. Admit her to OB or to the inpatient unit? The OB nurses were skilled with postpartum care, but it seemed insensitive to keep the patient where there were so many mothers with healthy newborns. The nurses pulled me into the supply area to assess the stillborn infant. He weighed just over 4 lbs and appeared to be at least 34 weeks old. They debated whether it would be all right to clean him up so the mother could have photographs taken; a quick call to the Medical Examiner (autopsy is mandatory in fetal demise beyond 20 weeks) confirmed that the stillborn infant had to be left in his current condition without any alteration.
The patient was transferred to the adult inpatient unit, doing well until she suddenly developed chills and tachycardia 20 minutes before the end of my shift. Minimal vaginal bleeding since the manual extraction of the placenta, no significant uterine tenderness, no dysuria or foul vaginal discharge. Pt's temperature skyrocketed from 97.6 to 101.8 within a matter of minutes. I got blood cultures, started clindamycin and gentamicin for presumed endometritis, and kept my fingers crossed.
Walking home, I noticed gentle flakes of snow falling from the sky and landing softly on the ground.
Wednesday, November 07, 2012
Dust Bowl of the North
Against my better judgement (what sane person would want to willingly trek northward to subzero temperatures?), I'm back in Bethel for another round of pummeling on the inpatient wards. There's something very endearing about the staff and the native Alaskan patients...or maybe I'm overconfident and delusional because I have a pair of ice cleats and a goosedown Goretex parka rated to -40 degrees, neither of which are needed at this moment because of the odd weather situation: daytime temperatures in the teens (but mildly subzero with the wind chill factor) and not a speck of snow on the ground.
The roads are hazardous to pedestrians when the climate is dry and windy; sidewalks are rare, and with every car that passes by, a giant cloud of dust swirls up to assault your eyes, nose and mouth. Luckily, I just had my annual respiratory fit test and my teal blue N95 respiratory mask matches my REI windbreaker. Making my twice daily trek between the residence and the hospital armed with the N95 mask and my headlamp, I look like a crazed (but stylish?) coal miner who is afraid of SARS.
Speaking of N95, I seem to be accumulating quite a few patients who require isolation rooms for a TB rule out. They're all awaiting results of sputum cultures for acid-fast bacilli. One patient was admitted for hip pain after being hit by a van and had a RLL cavitary lesion found incidentally on CT. Another was admitted for pneumonia with slightly blood-tinged sputum and mentioned being in contact with someone with active TB a few months ago. The third patient told the nurse she coughed up blood, then later back-pedaled and said the blood came from her nose. Too late, you win an instant PPD placement and a couple of days in isolation, booyah!
The roads are hazardous to pedestrians when the climate is dry and windy; sidewalks are rare, and with every car that passes by, a giant cloud of dust swirls up to assault your eyes, nose and mouth. Luckily, I just had my annual respiratory fit test and my teal blue N95 respiratory mask matches my REI windbreaker. Making my twice daily trek between the residence and the hospital armed with the N95 mask and my headlamp, I look like a crazed (but stylish?) coal miner who is afraid of SARS.
Speaking of N95, I seem to be accumulating quite a few patients who require isolation rooms for a TB rule out. They're all awaiting results of sputum cultures for acid-fast bacilli. One patient was admitted for hip pain after being hit by a van and had a RLL cavitary lesion found incidentally on CT. Another was admitted for pneumonia with slightly blood-tinged sputum and mentioned being in contact with someone with active TB a few months ago. The third patient told the nurse she coughed up blood, then later back-pedaled and said the blood came from her nose. Too late, you win an instant PPD placement and a couple of days in isolation, booyah!
Monday, September 17, 2012
Abdominal X-Ray, Anyone?
For most patients who come in for evaluation of abdominal pain, an x-ray rarely elucidates the etiology of the pain, with a couple of rare exceptions:
1. An 18-yr-old male accompanied by his mother is here for a one week history of vague symptoms: intermittent nausea and vomiting, generalized achy abdominal pain, no fever. It was difficult to get much detail from the patient, who was quite taciturn. [A preceptor that I worked with in medical school would often compare trying to elicit information from sullen adolescents to "veterinary medicine"]. The physical exam was not particularly remarkable; there was no abdomen rigidity or rebound tenderness. Imagine my surprise when the abdominal x-ray revealed a developing small bowel obstruction with air-fluid levels. Why would a previously healthy teenager with no surgical history develop SBO? Turns out he had a perforated appendicitis that was confirmed only by exploratory laparotomy.
2. A 38-yr-old man comes in for evaluation of sudden left-sided sharp abdominal pain that started at 4:00 am. I've learned to take it very seriously when people recall the exact time that a specific pain started. This man looked uncomfortable but was oddly dismissive of his pain, initially declining an abdominal x-ray. I am very glad that I finally talked him into it, because what showed up on the imaging was free air under the diaphragm which I had only read about but had never seen in real life. By this time, he had become tachycardic with a systolic blood pressure in the 80s, and he was promptly shipped off to the ED. The surgeon who took him to the OR found the source of the free air to be a perforated diverticulitis, remarking in the operative report: "This was the most pristine bowel I had ever seen". Five points to Gryffindor for having such a clean colon!
1. An 18-yr-old male accompanied by his mother is here for a one week history of vague symptoms: intermittent nausea and vomiting, generalized achy abdominal pain, no fever. It was difficult to get much detail from the patient, who was quite taciturn. [A preceptor that I worked with in medical school would often compare trying to elicit information from sullen adolescents to "veterinary medicine"]. The physical exam was not particularly remarkable; there was no abdomen rigidity or rebound tenderness. Imagine my surprise when the abdominal x-ray revealed a developing small bowel obstruction with air-fluid levels. Why would a previously healthy teenager with no surgical history develop SBO? Turns out he had a perforated appendicitis that was confirmed only by exploratory laparotomy.
2. A 38-yr-old man comes in for evaluation of sudden left-sided sharp abdominal pain that started at 4:00 am. I've learned to take it very seriously when people recall the exact time that a specific pain started. This man looked uncomfortable but was oddly dismissive of his pain, initially declining an abdominal x-ray. I am very glad that I finally talked him into it, because what showed up on the imaging was free air under the diaphragm which I had only read about but had never seen in real life. By this time, he had become tachycardic with a systolic blood pressure in the 80s, and he was promptly shipped off to the ED. The surgeon who took him to the OR found the source of the free air to be a perforated diverticulitis, remarking in the operative report: "This was the most pristine bowel I had ever seen". Five points to Gryffindor for having such a clean colon!
Thursday, August 09, 2012
The Natural History of Gel Shellac
I had my very first manicure done in preparation for a friend's wedding, and I foolishly allowed the manicurist to talk me into getting gel shellac applied to my fingernails. I am not particularly girly, and I rarely wear nail polish, so I am at a complete loss to explain what on earth possessed me to agree to a nail embellishment that would last for 3 weeks. The manicurist failed to mention that gel shellac can only be removed by either:
A. industrial strength solvent (100% acetone, which--if I recall correctly from a couple of organic chemistry labs that I survived eons ago--has potential toxic effects on the skin, reproductive system, and central nervous system), or
B. sanding with a power tool (I'm guessing some type of ladylike Martha Stewart style Dremel rotary tool)
Week 1
See how shiny and delightfully perky it looks initially? Gel shellac is baked on in several layers with the use of a special UV lamp, and it is designed to give you a manicure that won't chip or scratch during its entire 3 week tenure on your fingernails. But what if your nails grow at a freakishly rapid rate and you really don't feel like going to a nail salon to have the gel shellac removed by either method A or B?
Week 2
By the second week, I've already experienced a brisk fingernail growth spurt that exposes the nail base. But I will admit that the gel shellac still looks quite well preserved.
Week 4
Now you can really see the difference between the shiny gel shellac surface and the matte fingernail surface underneath...I start to develop a subconscious nervous habit of picking at the edges of the remaining gel shellac. I've noticed that the shellac softens a little after a hot shower, making it easier to peel away in small bits.
Week 5
Hooray, my thumbnails are free at last! I've still got gel shellac remnants on the other fingernails, and although I'm quite certain I look like a psychiatric inmate with too much time on my hands, I am fairly confident that I can peel away the rest of the gel shellac by the end of the week.
A. industrial strength solvent (100% acetone, which--if I recall correctly from a couple of organic chemistry labs that I survived eons ago--has potential toxic effects on the skin, reproductive system, and central nervous system), or
B. sanding with a power tool (I'm guessing some type of ladylike Martha Stewart style Dremel rotary tool)
Week 1
Week 2
By the second week, I've already experienced a brisk fingernail growth spurt that exposes the nail base. But I will admit that the gel shellac still looks quite well preserved.
Week 4
Now you can really see the difference between the shiny gel shellac surface and the matte fingernail surface underneath...I start to develop a subconscious nervous habit of picking at the edges of the remaining gel shellac. I've noticed that the shellac softens a little after a hot shower, making it easier to peel away in small bits.
Week 5
Hooray, my thumbnails are free at last! I've still got gel shellac remnants on the other fingernails, and although I'm quite certain I look like a psychiatric inmate with too much time on my hands, I am fairly confident that I can peel away the rest of the gel shellac by the end of the week.
Thursday, July 19, 2012
Not Your Garden Variety Urgent Care Patients
Patient #1
He's an 88-yr-old man brought in by his adult son. For the past 2 days, the patient has been feeling dizzy and, curiously, leaning to the left (physically, not politically). "I feel like I'm on a ship," he tells me, holding onto the wall as he ambulates. His neurological exam is completely normal, except that he really does lean extraordinarily to his left side, even while perched on the exam table. There is no facial asymmetry, no hemiparesis, no aphasia, no slurred speech, no visual impairment. I send him to the ER because I'm worried he has had a stroke. His head CT was normal, but sure enough his MRI revealed evidence of a stroke in the posterior cerebellum.
Patient #2
A 76-yr-old man comes in and tells me his heart rate has been in the 30s for the past 4 days. He generally feels fine, although occasionally he experiences mild transient shortness of breath. An ECG reveals bradycardia at 35 bpm with complete atrioventricular block. I explain to him that his heart is beating very slowly because the upper portion of his heart is not communicating well with the lower portion of his heart. Although he looks remarkably well, he will probably need a pacemaker. He waves goodbye to me as the paramedics wheel him out on a gurney, smiling and winking as he clutches the Mario Puzo novel he's been reading. He gets a pacemaker inserted within hours of arriving in the ED.
Patient #3
A 53-yr-old man accompanied by his wife is here for what he calls a rash. "I thought it was an allergic reaction to something, " he says, and his wife adds, "We've been putting warm compresses on it and hoping it would go away." The left side of his face from his forehead to his cheek is remarkably red and swollen, and multiple pustules with yellowish discharge are visible. His left upper eyelid is so swollen he can barely open his eye which is exuding an endless stream of pus. His left sclera is erythematous, he has pain with eye movements, and there is slight proptosis. I sent him to the ER out of concern for herpes zoster ophthalmicus vs orbital cellulitis. On CT, an "incidental" brain tumor was found--and by incidental, they meant a 7.8 cm meningioma which had been miraculously asymptomatic. The patient got IV acyclovir, IV ceftriaxone, and a 12-hour craniotomy.
He's an 88-yr-old man brought in by his adult son. For the past 2 days, the patient has been feeling dizzy and, curiously, leaning to the left (physically, not politically). "I feel like I'm on a ship," he tells me, holding onto the wall as he ambulates. His neurological exam is completely normal, except that he really does lean extraordinarily to his left side, even while perched on the exam table. There is no facial asymmetry, no hemiparesis, no aphasia, no slurred speech, no visual impairment. I send him to the ER because I'm worried he has had a stroke. His head CT was normal, but sure enough his MRI revealed evidence of a stroke in the posterior cerebellum.
Patient #2
A 76-yr-old man comes in and tells me his heart rate has been in the 30s for the past 4 days. He generally feels fine, although occasionally he experiences mild transient shortness of breath. An ECG reveals bradycardia at 35 bpm with complete atrioventricular block. I explain to him that his heart is beating very slowly because the upper portion of his heart is not communicating well with the lower portion of his heart. Although he looks remarkably well, he will probably need a pacemaker. He waves goodbye to me as the paramedics wheel him out on a gurney, smiling and winking as he clutches the Mario Puzo novel he's been reading. He gets a pacemaker inserted within hours of arriving in the ED.
Patient #3
A 53-yr-old man accompanied by his wife is here for what he calls a rash. "I thought it was an allergic reaction to something, " he says, and his wife adds, "We've been putting warm compresses on it and hoping it would go away." The left side of his face from his forehead to his cheek is remarkably red and swollen, and multiple pustules with yellowish discharge are visible. His left upper eyelid is so swollen he can barely open his eye which is exuding an endless stream of pus. His left sclera is erythematous, he has pain with eye movements, and there is slight proptosis. I sent him to the ER out of concern for herpes zoster ophthalmicus vs orbital cellulitis. On CT, an "incidental" brain tumor was found--and by incidental, they meant a 7.8 cm meningioma which had been miraculously asymptomatic. The patient got IV acyclovir, IV ceftriaxone, and a 12-hour craniotomy.
Thursday, June 21, 2012
Vaginal Discharge with Sore Throat and No Insurance
It's always a dilemma when we see patients with no health insurance who are paying out of pocket for everything: you want to provide high quality medical care, but you don't want the patient to end up shelling out $800 just for one visit with a few lab tests that may or may not yield a diagnosis. So for the 23-yr-old female with thick yellow vaginal discharge and a sore throat, I had to ask...
Me: Are you sexually active?
Patient: No
Me: Have you ever had intercourse?
Patient: Yes
Me: When was the last time?
Patient: Wednesday
Me: Have you & your partner been having oral sex?
Patient: No
Me: At any time, was there a penis in your mouth?
Patient: Yes
Me: When?
Patient: Wednesday
For the vaginal discharge, I ended up doing a wet mount and a cervical swab for GC/CT. I had to make a decision about the sore throat: if it was due to a sexually-transmitted infection, I would have to perform separate throat swabs for chlamydia and gonorrhea, and the patient was concerned about paying for multiple tests with her limited funds. If it was due to respiratory infection, I could just order a rapid strep test. Luckily, the patient did have a low grade temperature of 100.2 with swollen tonsils, so we got a strep test and...it was POSITIVE.
Me: Are you sexually active?
Patient: No
Me: Have you ever had intercourse?
Patient: Yes
Me: When was the last time?
Patient: Wednesday
Me: Have you & your partner been having oral sex?
Patient: No
Me: At any time, was there a penis in your mouth?
Patient: Yes
Me: When?
Patient: Wednesday
For the vaginal discharge, I ended up doing a wet mount and a cervical swab for GC/CT. I had to make a decision about the sore throat: if it was due to a sexually-transmitted infection, I would have to perform separate throat swabs for chlamydia and gonorrhea, and the patient was concerned about paying for multiple tests with her limited funds. If it was due to respiratory infection, I could just order a rapid strep test. Luckily, the patient did have a low grade temperature of 100.2 with swollen tonsils, so we got a strep test and...it was POSITIVE.
Monday, May 21, 2012
Injuries in the Era of Digital Technology
When I saw "wrist laceration" on the list of chief complaints for patients waiting to be seen, I couldn't help wondering if it was due to a suicide attempt, and I half-expected to find a somewhat depressed individual in the procedure room. Instead, I discovered a rather cheerful, bon vivant 19-yr-old male flanked by his equally cheerful parents. He had been in the woods with his friends, participating in a Bored Teenager pastime: hurling hatchets at trees with the intention of embedding the blade in the trunks. The patient's grip on his hatchet slipped, and the blade made a 3 cm laceration that was just millimeters away from his radial artery. "Are you sure I didn't nick the artery?" he asked. I assured him that if he had severed his radial artery, he would have been gushing blood like a Monty Python skit. I was able to irrigate the wound and suture everything back into place with 3-0 ethilon. His parents, ever the enthusiasts, took video footage of the entire procedure with their iPhones so he could post it on his Facebook page.
Sunday, April 15, 2012
Possibly the Most Useful Thing I've Done in the Past 3 Months...
She was unfailingly polite, despite her embarrassment, as she introduced herself, shook my hand, and explained her problem. She and her husband had gotten rather tipsy the night before, and despite an exhaustive search of their bedroom, neither of them could find the condom they had used. "I think it's stuck somewhere inside me," she said tearfully.
After gently reassuring the patient, I was able to visualize the condom immediately upon inserting the speculum, and I neatly retrieved it with a handy pair of ring forceps. I told my greatly relieved patient not to feel bad and recited a litany of other items I had successfully removed from other people's vaginas, including an old tampon (the patient had cut the string off a few days before and forgotten about it) and a make-up sponge (I was afraid to ask).
After gently reassuring the patient, I was able to visualize the condom immediately upon inserting the speculum, and I neatly retrieved it with a handy pair of ring forceps. I told my greatly relieved patient not to feel bad and recited a litany of other items I had successfully removed from other people's vaginas, including an old tampon (the patient had cut the string off a few days before and forgotten about it) and a make-up sponge (I was afraid to ask).
Saturday, January 14, 2012
TB Or Not TB
A 15-yr-old girl came to the ED after 9 days of fever, night sweats, and productive cough that did not improve with antibiotics. She had been very healthy with no significant illnesses, so we were all shocked to see her CXR which revealed an astounding plethora of tiny pulmonary nodules. A chest CT also showed multiple tiny pulmonary nodules, along with a 1 cm cavitary lesion, which the pulmonologist in Anchorage agreed was highly suspicious for miliary tuberculosis which is disseminated hematogenously. Other conditions on the differential diagnosis included collagen vascular disease and neoplasm. Per protocol, I alerted the authorities (in this case, Alaska State Public Health and the office of Infection Control at the hospital) and started our patient on the potent 4-drug tuberculosis regimen. Two days later, her PPD was looking extremely positive, with a raised erythematous induration of 25 mm.
Friday, January 13, 2012
Medevac Wars
The other doc on wards with me got a call about a 50-yr-old male with bright red hematemesis and a rapidly falling hematocrit in one of the northwestern villages, so he activated the medevac to pick up the patient and bring him to the hospital. Fifteen minutes later, he got a call from one of the northeastern villages about a 61-yr-old male on antiepileptic medication who had been in status epilepticus for 20 minutes. The health aide did not have any ativan or diazepam in the clinic. My colleague had to activate the medevac again--but there was only one plane, and the two villages were quite far from each other. He & the ED doc conferred about which patient should be picked up first. They decided the man with the GI bleed was more critical, and as they directed the medevac to head northwest first, I called some of the northeastern villages to ask if they had any ativan or diazepam that someone could transport by snow machine to the patient having nonstop seizures. An hour later, the patient did get some diazepam delivered from a nearby village, and he was going to be next in line for the medevac, but then another call came in about a 5-yr-old girl with no known seizure disorder also in status epilepticus. The decision was made to medevac the girl first--it turns out she had a serum sodium of 110 (!) and marked neurologic abnormalities, and she ended up being transferred to Anchorage.
Thursday, January 12, 2012
If Work Doesn't Kill Me, This Virus Might
It's -24 degrees (closer to -40 degrees with the wind chill factor) and my lungs are very unhappy. The walk between the hospital and my current habitat is getting more painful as frost develops on my eyelashes, and my face literally hurts from being pummeled by the gelid winter wind. Bottom line: I have a huge stockpile of cab vouchers and I'm not afraid to use them!
I definitely have some kind of viral respiratory infection which makes my crazy work day feel a bit surreal. You! I mutter to my airways. Don't you dare succumb to a bacterial infiltration! One of the nurses very kindly offers me a highly prized (and much appreciated) chocolate truffle from Dilettante which I eat immediately, along with zinc gluconate lozenges and a ridiculously high dose of vitamin C. I make several calls to the hospital in Anchorage and to the medevac team about an 85-yr-old man with severe dementia and a slow GI bleed who needs to be transferred to a higher level of care. I am glad that I document everything so well in my notes, because I can't remember a single thing I said to either Anchorage or Lifemed. One of the ED docs hijacks my patient's medevac flight for a police officer who accidently shot himself in the leg with his service revolver and shattered his own femur.
Now I'm discharging 5 patients in rapid succession (including the 400-lb woman with a COPD exacerbation who keeps making up reasons to ask for ativan and morphine but still manages to be quite endearing). But wait! Is the 4-yr-old with RLL pneumonia really ready to fly home? Why has his WBC increased to 22? Can I blame it on the prednisolone? Five minutes later, his CRP comes back as 10.39, which is much improved from the initial value of 23--hooray! I have managed to complete all the discharge summary dictations, pushing through my viral haze with herculean effort. But I immediately get hit with 2 direct admissions: a elderly man with pneumonia from Kusko Clinic, and a 42-yr-old male with a bad case of LLE cellulitis extending to his groin from Delta Clinic. Then there are multiple garbled RMT calls from the health aide in Kipnuk: something about a possible suicide in the village...there's a pool of blood on the floor of someone's home...but the health aide isn't allowed inside the house because the state troopers are investigating the scene. It took an accumulated 30 minutes of phone calls to garner those juicy bits of information.
Now I'm swabbing the posterior fornix of a 20-yr-old primip at 31 weeks with preterm contractions in order to get a fetal fibronectin test. Don't touch your vagina, I told her 24 hours ago. Don't put anything inside your vagina, including your boyfriend's penis. Her ultrasound yesterday revealed a closed cervix measuring 2.7 cm which was mildly reassuring, but we couldn't get the FFN at the time because she was a couple of hours post-coitus.
Three hours later, an alternate medevac arrives to transfer my GI bleed patient to Anchorage and I am greatly relieved, because his hematocrit has dropped 10 points in 2 days and he can't get an EGD or colonoscopy at our tiny hospital due to his multiple comorbities. Where is the fried dough that the inpatient clerk gave me, I wonder. Did I eat it in my feverish delirium without realizing it? Probably.
I definitely have some kind of viral respiratory infection which makes my crazy work day feel a bit surreal. You! I mutter to my airways. Don't you dare succumb to a bacterial infiltration! One of the nurses very kindly offers me a highly prized (and much appreciated) chocolate truffle from Dilettante which I eat immediately, along with zinc gluconate lozenges and a ridiculously high dose of vitamin C. I make several calls to the hospital in Anchorage and to the medevac team about an 85-yr-old man with severe dementia and a slow GI bleed who needs to be transferred to a higher level of care. I am glad that I document everything so well in my notes, because I can't remember a single thing I said to either Anchorage or Lifemed. One of the ED docs hijacks my patient's medevac flight for a police officer who accidently shot himself in the leg with his service revolver and shattered his own femur.
Now I'm discharging 5 patients in rapid succession (including the 400-lb woman with a COPD exacerbation who keeps making up reasons to ask for ativan and morphine but still manages to be quite endearing). But wait! Is the 4-yr-old with RLL pneumonia really ready to fly home? Why has his WBC increased to 22? Can I blame it on the prednisolone? Five minutes later, his CRP comes back as 10.39, which is much improved from the initial value of 23--hooray! I have managed to complete all the discharge summary dictations, pushing through my viral haze with herculean effort. But I immediately get hit with 2 direct admissions: a elderly man with pneumonia from Kusko Clinic, and a 42-yr-old male with a bad case of LLE cellulitis extending to his groin from Delta Clinic. Then there are multiple garbled RMT calls from the health aide in Kipnuk: something about a possible suicide in the village...there's a pool of blood on the floor of someone's home...but the health aide isn't allowed inside the house because the state troopers are investigating the scene. It took an accumulated 30 minutes of phone calls to garner those juicy bits of information.
Now I'm swabbing the posterior fornix of a 20-yr-old primip at 31 weeks with preterm contractions in order to get a fetal fibronectin test. Don't touch your vagina, I told her 24 hours ago. Don't put anything inside your vagina, including your boyfriend's penis. Her ultrasound yesterday revealed a closed cervix measuring 2.7 cm which was mildly reassuring, but we couldn't get the FFN at the time because she was a couple of hours post-coitus.
Three hours later, an alternate medevac arrives to transfer my GI bleed patient to Anchorage and I am greatly relieved, because his hematocrit has dropped 10 points in 2 days and he can't get an EGD or colonoscopy at our tiny hospital due to his multiple comorbities. Where is the fried dough that the inpatient clerk gave me, I wonder. Did I eat it in my feverish delirium without realizing it? Probably.
Wednesday, January 11, 2012
My Nemesis Dr Tran
There is locums hospitalist named Dr Tran whose visits to Bethel often precede mine by one week or less. This causes a great deal of confusion, as many village health aides and hospital staff that I speak with on the phone will address me as "Dr Tran" even after repeated corrections. Although I have only met Dr Tran once (for about 5 minutes in March 2011), one of the OB nurses often asks me, "How is your little friend?" [referring slyly to Dr Tran]. It's mildly amusing, but I would be lying if I deny that some tiny evil part of me is occasionally tempted to wreak havoc and embark on a minor crime spree under the guise of being Dr Tran. But only while I'm in Bethel, of course.
Tuesday, January 10, 2012
You Know You've Been Thoroughly Bethel-ized When...
...you're excited to purchase your very first pair of ice cleats! Which, it turns out, I didn't really need because we're in the middle of a blizzard and snow drifts are blowing everywhere. I was completely blinded by the flurries furiously pounding my face and couldn't find the trail leading from the boardwalk to the hospital this morning; consequently, I found myself frequently stepping into knee-deep snow (2 thumbs up for my excellent ski pants, by the way, which marvelously kept snow out of my insulated boots!). All flights were canceled today--yes, even the 737 planes that fly between Bethel and Anchorage! Fortunately, the medevac is still running, and when I left the hospital tonight, they were duking it out over which kid in respiratory distress to pick up first (Emmonak vs Mekoryuk: discuss).
I was hoping to sample some elk stew or a reindeer burger during this week on the wards, but, alas the cafeteria has been serving mainly fried chicken, pork tenderloin, and tacos. My favorite patients are two frail elderly ladies (one who wears her hair in pigtails), both with hyponatremia and sharing the same hospital room. I finally got their serum sodium levels back to normal (one with a slow infusion of normal saline, the other with free water restriction) but now the one in pigtails is persistently dizzy, so I started her on a baby dose of meclizine. In other news, the hospital is still using paper charts, but there are intriguing rumors of an EMR launch scheduled for January 2013...
I was hoping to sample some elk stew or a reindeer burger during this week on the wards, but, alas the cafeteria has been serving mainly fried chicken, pork tenderloin, and tacos. My favorite patients are two frail elderly ladies (one who wears her hair in pigtails), both with hyponatremia and sharing the same hospital room. I finally got their serum sodium levels back to normal (one with a slow infusion of normal saline, the other with free water restriction) but now the one in pigtails is persistently dizzy, so I started her on a baby dose of meclizine. In other news, the hospital is still using paper charts, but there are intriguing rumors of an EMR launch scheduled for January 2013...
Monday, January 02, 2012
Mormon Fisticuffs and Other Sources of Excitement
New Year's eve was a wildly eventful day in clinic. From a 36-yr-old woman with probable pneumonia who was tachypneic and only satting 65% on room air but didn't want us to call an ambulance to transport her to the ED... to a tall 24-yr-old man with excellent cheekbones and a tiny laceration on his face requesting "just one stitch" and lamenting that the scar would ruin his not-yet-launched "modeling career"... to the most fresh-faced wholesome-looking 19-yr-old blond teenager in a dress shirt and pressed trousers sporting a swollen black eye and a scalp abrasion after getting in a fist fight with another church member at a Mormon holiday event...
We thought all the excitement was over after we finally finished treating the last patient about an hour after clinic was officially closed...but when I arrived back at work on New Year's day, there was a huge gaping hole in the northwestern corner of the clinic building, cordoned off with caution tape. Turns out a very inebriated driver from the nearby air force base collided into the clinic late at night, completely totaling his car...then he got up and walked over to Taco Bell (where he was arrested) because he suddenly felt extremely hungry.
We thought all the excitement was over after we finally finished treating the last patient about an hour after clinic was officially closed...but when I arrived back at work on New Year's day, there was a huge gaping hole in the northwestern corner of the clinic building, cordoned off with caution tape. Turns out a very inebriated driver from the nearby air force base collided into the clinic late at night, completely totaling his car...then he got up and walked over to Taco Bell (where he was arrested) because he suddenly felt extremely hungry.
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