Overload

Well, I’ve arrived every day between 4:30 AM and 5:30 AM, and can barely see all my patients, collect all the data and prepare the computerized notes before rounds at 7:30. This morning was my most organized morning yet, I actually went and SAW my patients first before sitting down at the computer. More time was spent with the patient, examining them, and thinking about them clinically, instead of fussing with the stupid computer.

How are my patients doing?

I have two MVAs, both very similar with multiple fractures. One fractured his humerus, ulna and radius (all the bones of the arm) and the other fractured her femur, tibia and fibula (all the bones of the leg). They both go back and forth to the operating room to have the open fractures “washed out” to help prevent infection. Bucky the 24 year old ejected from the jeep, is still on the oscillator. Every time we try to back off on the settings to get him closer to ‘normal’, he desaturates, that is, his oxygen level plummetts. So then we turn it back up. In addition, his blood pressure keeps dropping, decreasing the amount of blood flow to his lungs, which causes him to desaturate again. So today, we just left the oscillator without trying to wean him down. It will be a miracle if he survives to get off the ventilator.

My most pleasant patient is an older lady with Myesthenia Gravis. MG is an autoimmune disease in which your body attacks itself. The receptor sites on your muscles that allow your muscles to contract at your whim get destroyed by your own body. When the receptor sites are gone, there is no way for the signal to contract to get to your muscles. It is a chronic, progressive disease that results in weakness, first of your eyelids, making them droopy. Then the muscles that allow your eyes to look to the right and the left. It progresses to weakness that leaves you unable to walk, and eventually, unable to breath because the muscles that expand your lungs (diaphragm & rib cage) become too weak. She came to the emergency department about 12 days ago with progressive weakness making her unable to get out of a chair. while in the hospital, she suddenly stopped breathing, was “coded” on the floor, intubated and brought to the ICU with the ventilator helping her breath.

Every morning I go in to see her, and she has a smile on her face. Although she can’t talk to me, she communicates better than most people I encounter in the hospital. By carefully structuring my yes & no questions, I find out how she is feeling, if she is uncomfortable, hungry, cold or worried. She had a tracheostomy performed 2 days ago, is feeling well and is now working on recovering strength in her vocal cords. Her voice is hoarse and deep. Until her vocal cords are working well, we can’t feed her anything by mouth for fear that her vocal cords won’t shut all the way when she swallows, and food or water will end up in her lungs. That would be disasterous for her.

I have three other patients, all of them “rocks.” Rocks are patients who aren’t going to move off of your service anytime soon. My advisor told me that my goal in the ICU, as an intern, is to accumulate as many ‘rocks’ as possible. That way, you never have to catch up on new developments or procedures, your notes and presentations go much more smoothly because you know them so well, and it helps protect you from having to take new admissions. I used to despise rocks until he re-framed things for me. Now I like them.

One of them is a lady who started out with a simple hernia repair. This got infected multiple times, with multiple surgeries to remove the infected tissues and materials. Eventually she developed a “fistula” which is a connection between her intestine and the outside of her body (kind of like an extra anus). This was surgically repaired mutiple times. She became septic and grew out several bad, bad bacteria from her blood and her lungs. We have her on four hefty antibiotics. We tried to extubate her the other day, and she developed swelling in her throat to the point where her high-pitched breathing was audible from across the unit. She was reintubated. In medical-lingo, “she didn’t fly.”

So now she has a tracheostomy as well. The difference between her and mrs. Topshell is that she is very unpleasant to visit in the morning. In fact I avoid her as much as possible. Even her husband avoids her, and goes home after a brief visit. “There’s only so much I can handle before I have to go,” he told me today.

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