History, more important than physical exam

So I ran this lady with AMS. And by altered mental status I mean, she was totally unresponsive. But her vitals were all perfect, she was defending her airway beautifully, her lungs were clear, her EKG was better than mine and her blood glucose was normal. Baffling.

So then I decide to read her paperwork, since of course, the report I got from the SNF consisted of helpful comments like "I don't work with her usually" and "I'm calling her daughter, so I can't talk to you right now."

In there I discover that she's had multiple admissions for sepsis where she presented with AMS. Aha! Lightbulb! I check her lactate. It's 6.5. I start her IV and hang some fluid. And then I go back to reading.

And then, there is was. In the nurses notes: "Recently, patient has been playing in her feces more. She has been seen rubbing them in her vagina and licking her fingers. Also, this morning Ms. CNA found a ball of stool in her coffee, which she was drinking."

...

Guys, I think I found the problem.

Nope, didn't want those labs

Me: "Hey, I wanted to check on some pending labs for Mr. Imactivelydying."

Lab tech: "Sure, what are you looking for?"

Me: "That repeat CBC from around 2330."

Lab tech: "Oh, that was cancelled and thrown out."

Me: "WTF?! Why was it cancelled?"

Lab tech: "Well that patient had a CBC two hours prior and another two hours prior to that, so we didn't think you needed it."

Me: "Seriously?! For one, if I sent you the lab, we probably want it run. For two, how is that your decision to make?! And for three,  did you notice that those other CBCs were distinctly abnormal?? Which maybe would have prompted you to think that maybe we were actively doing things to fix his H/H of 2/12 and wanted to see a repeat?! No? None of those? Ok, please run the next one I send down. Thanks." click

Ugghhhhhhhhhh. Angry face.

We have different definitions of "code"

So I was working the other night when I heard the code bongs going off. The code was in the surgical observation unit, which I literally don't think I've ever heard before. (Basically overnight observation for routine procedures where you're expected to be discharged in the am. Things like biopsies, some laproscopic ortho and abdominal procedures, lots of plastics and ENT stuff, etc, etc...)

Much to my fortunate luck, I got a call a few hours later that I need to take that patient in my lonely one remaining ICU bed. Reasonable, I think... resuscitated codes should probably take the last ICU bed in the house.

And then I got report.

Obs RN: "So Mr. S is 83 years old, day of surgery from a lap hernia repair. No complications. He's voided after his foley out and all that good stuff. So I put him on his home CPAP and put him to bed at like 2100."

Me: "Mhmmm... yea... mhmmmm." Thinking: "I bet he got overnarc-ed and forgot to breathe for awhile. 

Obs RN: "Well then when I went to take his vitals at like 2330 his SBP was in the 70s!" pause for dramatic effect

Me: "Mhmmm... yea... mhmmmmm..."

Obs RN: "So then I called the code, of course."

Me: "Mhmm... wait, what?"

Obs RN: "He got hypotensive so I called the code."

Me: "Oh so that's when he arrested? It was like a hypotensive/PEA kind of arrest thing?"

Obs RN: "Oh no, just that one pressure of 70 systolic. The next one was 130/80 once I woke him up."

Me: "I'm sorry I'm confused. So he didn't stop breathing or anything?"

Obs RN: "Oh of course not. So anyway, neurologically he's a 15, moves everything, ambulatory, pupils equal and.........."

Apparently "code" doesn't mean pulseless/apneic to everyone...?

New rule

New rule.

If you squirrel my call, a stabbing that of course was the only interesting call of the night, you then have to also squirrel the next call I get toned for (which, by the way, should have been your call).

This second call, of course, will be a nice rectal bleed at the nursing home.

Not that this happened tonight or anything...

PSA for bikers in all black

Dear lady on the bike,

Kudos on your healthy lifestyle. Not many people have the dedication to be riding their bike to whatever destination they may need to get to when its raining and 230am. But you, clearly are superior to them.

However, I just want to inform you of one little thing. You are incredibly lucky I didn't kill you tonight. And if I had done so, no one would hold me liable. Because you see, you're an idiot.

Only an idiot would 1) wear entirely black clothing, 2) including a solid black helmet, 3) while riding a black bike, 4) that doesn't have any lights or reflective striping, 5) in the middle of the night, 6) when it is raining and foggy and 7) run a red light without even slowing down, 8) cutting in front of an ambulance with it's emergency lights on.

Not only is that an incredibly idiotic combination of life choices, a good portion of them are illegal. (I mean, what did you do, pry off the little reflector thingy that's on the back of every bike I've ever seen??) However, I'm very glad I didn't hit you and kill you. I feel very lucky. Because ambulances are known for their precision stopping, especially in the rain. (Siiiike.) And I really don't want to kill anyone.

Good luck next time.

xoxo,

A

No I wasn't driving that car...

So the other night at about 0300, I responded for a motor vehicle accident at a busy intersection. Well, it's a busy intersection at not 0300. But still, apparently busy enough for some guy to T-bone another guy.

So we get on scene about the same time as the engine to find two sedans, one with pretty decent intrusion on the driver's side (the T-bonee) and one with a crumpled front end (the T-boner). I went to see the T-boner, while my partner went to see the T-bonee with the engine company in tow to maybe cut him out of his smushed car.

As I approach the T-boner car, I see a young male in the front seat with a fair amount of bleeding from a nice lac on his head. He seems a little dazed when I start talking to him. He's a little squirrelly, but talking to me.

Then the cops show up. Which they usually do for MVAs... My friend Mr. T-boner took one look, jumped out of the car and bolted for the woods.

Me: "Uh guys... guys...?"

Police Department: "Who's that guy? Why's he running?"

Me: "He probably caused the wreck... and doesn't seem happy to see y'all. And I'm definitely not chasing him."

Cue multiple officers running for the woods as well.

They come back a few minutes later with my lovely patient in tow. Turns out drunk and bleeding from the head makes running stealthily kind of difficult.

He denies that he was the driver. He seems confused over the fact that he can still be arrested while denying that he was driving. Even though 1) I IDed him. 2) His driver's license that he conveniently left on the front seat IDed him. 3) He has an otherwise unexplained bleeding gash on his forehead. And 4) the police caught him running from the scene. But I mean, we should probably take his word for it.

He blew a 0.22. I'd be confused too.

Old people rule!

So we went to pick up a lovely 91 year old lady in the middle of the night, who had no chief complaint and didn't want to go to the hospital, but whose family wanted to go to sleep. Or at least that's the best I can figure.

She was super demented, but friendly and chatty. On our way out, she quipped, "Does it really take 4 men to carry me out?"

I came back with some sarcastic comment about them being weak.

To which she promptly proceded to put up her dukes, started air boxing and yelled, "Let me at 'em. I can take 'em."

Love her. Want to keep her.