Hi friends,
Well, this first week in the ER sure has been eye opening. I have seen more chest pain and shortness of breath than I could imagine, and more drunks than my whole four years at IU....ok, I'm exaggerating that last part.
Also, pink eye is running rampant through Lexington this week so don't go rubbing your eyes in or on anything suspicious...or if you do, don't say I didn't warn ya.
I have seen so many different things this week and learned so much. First of all, the staff at Good Sam UK are so great. It is such a cozy little ER and everyone is so friendly. They bought me dinner the other night for going to get food for them, that was so nice. Anyways, I didn't exactly know what to write about since you get new patients all the time and the severity of the patients ranges from "my toe hurts" to actually having a heart attack to a drunk man singing amazing grace so I am just going to list my Top 5 cases that were either the most interesting/confusing/entertaining etc.
1. Amazing Grace: This man came rolling in on a stretcher and I honestly thought he was mentally handicapped. Then he starts belting out Amazing Grace at the top of his lungs which he later switched to 50s show tunes. You guys, the man could sure carry a tune for blowing a 0.47!!! Are you kidding me? He was too drunk to properly blow, but that was his initial reading and that's what they went with. He had no idea,who he was, where he was, or that his pinky toe was hanging off. Shout out to my girl Brittany who sewed it back on after I left. Also, he asked me to watch him pee, and asked the PA on duty for some heroin. Bold move, sir. Needless to say I'm sure he provided great entertainment for everyone last night.
2. Superior Mesenteric Artery Syndrome: I have never heard of this, so when I looked it up I was very intrigued. Apparently, the SMA comes off the aorta at around a 30 degree angle, but in those who have this syndrome, the angle of the artery is much smaller and compresses the duodenum causing excruciating pain. This poor 20yo girl came in screaming and writhing in pain all while vomiting uncontrollably. Essentially the artery mechanically obstructs the duodenum which leads to the vomiting. She wakes up like this pretty frequently and has been seen in the ER A LOT. All anyone can really do is control her pain and vomiting, GI has suggested she go to Mayo clinic because this problem is so rare and the surgery to correct it has an extremely high mortality rate. Once she had IV pain medication and zofran she was a new person, I didn't even recognize her. I just hope she gets the help she needs from physicians who are more familiar with this condition.
3.I'm Pregnant, want to tested for cancer, and also need some lunch: Okay, this is one of the HUGE problems of the ER, especially those like Good Sam. I'm not saying that homeless people don't deserve health care, of course they do, but what they don't deserve, or anyone deserves for that matter is an all inclusive stay in ER. This girl, who happens to be homeless, has a chronic cough. But also thinks she could be PG. So we do a urine PG test and the specific gravity of her urine was too low so we needed to do a blood test. She doesn't like needles, so she wants an ULTRASOUND!!!. No way, honey. Talk about healthcare spending. Then, gets off the phone with her dad and says, "my dad wants you to order a test to check me for cancer." I just simply told her there is no test for that. She already had a chest X-ray. We gave her some antibiotics because she did have a nasty cough and it had gotten worse over the last week, but says she can't get a ride to meijer to get it for free and can't afford the $4 at Walmart. It is terribly sad that she is in that situation, but what else could we do ya know? Then said she was starving and wanted to order a lunch tray before she left which of course she got.....just kind of hard to wrap your head around. She was on her CELL PHONE the whole time.
4. The atypical presentation: Teaching moment!! So, we have all been told time after time that not everyone presents in a textbook way. But the first time you really see it, it sticks with you. This lady came in with a chief complaint of "pain all over my body." I walk in and she won't really even talk to me which was very frustrating because I could not figure out what was going on with her or where she was hurting. I put my hand on her leg and she said don't touch me, so obviously the exam was difficult. She kept telling me the inside of her mouth hurt, her neck, her ears, her arms, and everything was burning, steaming, and on fire. She has a very complicated past medical hx, recent pneumonia with steroids so her blood sugars were out of control and to me her pain sounded neuropathic. The only information I could get was from her husband. I had no idea what was going on so I got my preceptor who then gets the attending and eventually narrow down that she is having chest pain and her ECG showed slight ST elevation in lateral leads and she was sent emergently to the UK cath lab. In hind sight, I should have realized her "mouth pain" may have been radiating pain to the jaw, but at the time I had no inclination that she was having a heart attack. It was a humbling experience and a very good teaching moment for me and for everyone really. I keep thinking about her and wonder how shes doing now.
5. The world's biggest pleural effusion: My friend and I watched this man get about 1800cc of fluid drawn out of his pleural space. It looked like apple juice, which apparently is a good thing. I don't know how he could breathe at all with all the fluid in there, what a trooper.
Friday, November 22, 2013
Sunday, November 17, 2013
Work Hard, Play Hard Part 5
I can't believe another rotation has come to an end. I LOVED being at Methodist Hospital and doing inpatient internal medicine. Looking forward to going back for geriatrics. Up next is ER here in Lexington and I am so nervous, but also super excited! I'm sure there will be many "I don't know what to do with my hands" moments as I will be back to messing up sterile technique and shaking through procedures. woo! I apologize for the lack of posts last month, I honestly worked a lot and then spent my free time playing house with Adam. Hopefully I will be able to get back into my blog flow this month. Even though I spent the majority of my free time watching TV and cooking with Adam, below are some fun pics from the last month.
Celebrating my precious grandpa's 91st Birthday! Love him times a million.
Night out on Mass Ave. with my brother.
Quarter Horse Congress with my mom. Tradition we have done forever and so happy I was able to go back again with her.
My sweet husband used his magic legs and completed his first full marathon! Run Adam run!
Steph comes to visit Bloomington! Hanging out at the Sample Gates.
Game night at the Diskey house! Cards Against Humanity is the best/most messed up game ever.
Night out on Mass Ave. with my brother.
Quarter Horse Congress with my mom. Tradition we have done forever and so happy I was able to go back again with her.
Monday, November 4, 2013
Warning: Graphic Description Included
Holy tired. I have worked the past 7 days straight and after not having a weekend, made me realize how important those precious two days are to my mental health. I'm so thankful to have the day off today to catch up on sleep, laundry, and school work.
Let me tell you about one of my most interesting/awful/"you will probably never see this" cases this week. I'm sure everyone in my PA program remembers the very graphic slide during the urology lecture with the heading "Fournier's Gangrene." If you don't, google image it...I'm pretty sure the "you will probably never see this" line came shortly after but I could be wrong, or maybe I was just hoping I would never have to see it. So, when I was handed my patient list and saw "Fournier's Gangrene" as the reason for admission my heart sank.
Basically, Fournier's Gangrene is necrotizing fasciitis of the perineum...usually in men, but from what I've read there is a type that has affected women too. So, this poor man (who I might I add is the most kind-hearted man and has the best attitude I've ever seen) wakes up a couple weeks ago on a Saturday and felt like he had the flu, just didn't feel good but didn't think much of it. He noticed he had a bruise on his butt but couldn't remember hitting anything or any injury. Fast forward to the following Wednesday and he still doesn't feel well and the bruise is getting bigger. He decides to go to a family practice office who thinks it is probably an abscess or cellulitis and gives him oral antibiotics but does some lab work just in case. Lab work comes back really not okay and the doctor worries based on his clinical presentation and lab work that he could have a really bad infection and sends him to a local ER. He is immediately taken to the OR for two debridements at the local hospital. That hospital just did not have a good feeling as the scrotum was now becoming involved and the infection was spreading rapidly. He is transferred to Methodist and again immediately goes to the OR for another debridement. He is in the ICU for a couple days and then gets his 4th debridement. Throughout this time he has been medically stable after his last debridement they transfer him to the PCU where I pick him up.
The first time I saw him, he was covered up and his wounds were dressed so I couldn't see the severity of the infection/depth of the debridements. He was still medically stable so I honestly just sat with him for awhile, but he had some leg pain so we worked that up to make sure the joint was getting infected, thankfully that was all okay. I asked the PT wound team if I could be called when they dressed his wound so I could examine them and watch how they did it. I think my jaw dropped open. I don't know how this man could endure such pain with such grace and kindness. The majority of his right buttock had been removed, at least superficially, which extended down into his perineum where again the majority of his scrotum had been removed. His testicles were free exposed without any covering other than what the wound care team could provide. The wound continued to extend up the lateral aspect of the scrotum into the left side of his mons pubis. To say it was horrific was an understatement. No one on the internal medicine team had seen anything like it.
His cultures grew a very sensitive strand of E.Coli thank God, so the his IV antibiotics were able to knock out the infection to stop the spreading. All his blood cultures were negative. The wound care team took such great care of him and were so gentle and thorough. The major problem/concern which led to quite the debate between the surgeons vs. everyone else was what was going to happen when this man had a bowel movement. The wounds only spared the rectum by two finger breadths. He already had a suprapubic catheter in place, and would for a long time, but the majority of those taking care of him thought he needed a diverting colostomy placed so he could have bowel movements without worrying about contamination. The surgeons did not agree and did not want to go that route and thought he should be able to have BMs and be cleaned up immediately following and to discuss the colostomy if contamination became an issue. So far it hasn't....I just worry about him when he is transferred to a small rehab facility if they will have the staff on hand to provide him with such prompt care every time he uses the bathroom. He has already had a consult with the plastic surgery team so that when the time comes he can have a scrotum reconstructed...that is a ways down the road though as his other wounds try to heal.
He has such a long recovery process ahead of him I almost can't imagine how he can think about the future. Again, you wonder why bad things happen to good people....its really hard to wrap your head around it sometimes. He is an incredibly special person and I know he will get through this, but I'm sure he will have bad days when he is so mad and frustrated and in pain and I just hope he is taken care of once the way he deserves once he leaves Methodist.
So, I'm not happy I saw a "you will never see this" case, but it was a great learning experience. I learned about wound care, and cultures and antibiotics and pain control from the hospital setting...but from the patient I learned so much about gratitude and strength. He would say "thank you" after his wounds were dressed and he was biting his finger so hard through the pain I thought it would bleed. If I'm ever a patient I hope I will treat the staff as kindly as he did, what an incredible person.
Let me tell you about one of my most interesting/awful/"you will probably never see this" cases this week. I'm sure everyone in my PA program remembers the very graphic slide during the urology lecture with the heading "Fournier's Gangrene." If you don't, google image it...I'm pretty sure the "you will probably never see this" line came shortly after but I could be wrong, or maybe I was just hoping I would never have to see it. So, when I was handed my patient list and saw "Fournier's Gangrene" as the reason for admission my heart sank.
Basically, Fournier's Gangrene is necrotizing fasciitis of the perineum...usually in men, but from what I've read there is a type that has affected women too. So, this poor man (who I might I add is the most kind-hearted man and has the best attitude I've ever seen) wakes up a couple weeks ago on a Saturday and felt like he had the flu, just didn't feel good but didn't think much of it. He noticed he had a bruise on his butt but couldn't remember hitting anything or any injury. Fast forward to the following Wednesday and he still doesn't feel well and the bruise is getting bigger. He decides to go to a family practice office who thinks it is probably an abscess or cellulitis and gives him oral antibiotics but does some lab work just in case. Lab work comes back really not okay and the doctor worries based on his clinical presentation and lab work that he could have a really bad infection and sends him to a local ER. He is immediately taken to the OR for two debridements at the local hospital. That hospital just did not have a good feeling as the scrotum was now becoming involved and the infection was spreading rapidly. He is transferred to Methodist and again immediately goes to the OR for another debridement. He is in the ICU for a couple days and then gets his 4th debridement. Throughout this time he has been medically stable after his last debridement they transfer him to the PCU where I pick him up.
The first time I saw him, he was covered up and his wounds were dressed so I couldn't see the severity of the infection/depth of the debridements. He was still medically stable so I honestly just sat with him for awhile, but he had some leg pain so we worked that up to make sure the joint was getting infected, thankfully that was all okay. I asked the PT wound team if I could be called when they dressed his wound so I could examine them and watch how they did it. I think my jaw dropped open. I don't know how this man could endure such pain with such grace and kindness. The majority of his right buttock had been removed, at least superficially, which extended down into his perineum where again the majority of his scrotum had been removed. His testicles were free exposed without any covering other than what the wound care team could provide. The wound continued to extend up the lateral aspect of the scrotum into the left side of his mons pubis. To say it was horrific was an understatement. No one on the internal medicine team had seen anything like it.
His cultures grew a very sensitive strand of E.Coli thank God, so the his IV antibiotics were able to knock out the infection to stop the spreading. All his blood cultures were negative. The wound care team took such great care of him and were so gentle and thorough. The major problem/concern which led to quite the debate between the surgeons vs. everyone else was what was going to happen when this man had a bowel movement. The wounds only spared the rectum by two finger breadths. He already had a suprapubic catheter in place, and would for a long time, but the majority of those taking care of him thought he needed a diverting colostomy placed so he could have bowel movements without worrying about contamination. The surgeons did not agree and did not want to go that route and thought he should be able to have BMs and be cleaned up immediately following and to discuss the colostomy if contamination became an issue. So far it hasn't....I just worry about him when he is transferred to a small rehab facility if they will have the staff on hand to provide him with such prompt care every time he uses the bathroom. He has already had a consult with the plastic surgery team so that when the time comes he can have a scrotum reconstructed...that is a ways down the road though as his other wounds try to heal.
He has such a long recovery process ahead of him I almost can't imagine how he can think about the future. Again, you wonder why bad things happen to good people....its really hard to wrap your head around it sometimes. He is an incredibly special person and I know he will get through this, but I'm sure he will have bad days when he is so mad and frustrated and in pain and I just hope he is taken care of once the way he deserves once he leaves Methodist.
So, I'm not happy I saw a "you will never see this" case, but it was a great learning experience. I learned about wound care, and cultures and antibiotics and pain control from the hospital setting...but from the patient I learned so much about gratitude and strength. He would say "thank you" after his wounds were dressed and he was biting his finger so hard through the pain I thought it would bleed. If I'm ever a patient I hope I will treat the staff as kindly as he did, what an incredible person.
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