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Thursday, September 22, 2011

She cried, good Luck with needle stick!

She cried not that she was stuck, she cried because I was stuck with her needle.

Sometime back I saw her initially in the ER, around 4:30 in the morning; she was a young girl, a high risk IV drug user who was septic. She was in shock, confused and burning. Her anxious father was pacing nearby; I was afraid that he was going to pass out any time.
I provided not much comfort to him when I told him that she was in septic shock and that she has a guarded prognosis.

She initially refused a central line placement but after much debate she consented but only if my other colleague in the ER would do it. Maybe she found my ER attending to be more comforting. I spoke with the ER physician and she obliged and placed the line.

The next 24 hours were tough for her, but utilizing the 6 hour and 12 hour sepsis bundles we were able to stabilize her. I was questioning a vegetation on her heart valve. During a transesophageal echocardiogram, cardiologist saw an artifact in the atrium. Assuming that this could be the central line, we pulled back the line and the artifact on the echo disappeared. Viola… no vegetations.

As I was almost done with securing the line I stuck myself. For a second my mind went blank, thinking about the significance of this needle stick from a very high risk patient. Naturally I started to think about my wife, my daughters and our baby who is on the way. All the statistics about needle stick started to resonate ….. risk of transmission after HIV infected blood 0.3%, risk of Hep B 30% and Hep C 10%....

Initially I was very angry at myself, I didn’t know what her status was, I should have been more careful, I should have double gloved or ….. done something else. For a moment I felt anger towards her too, though I knew it was not her doing.

As I was desperately washing my hands, squeezing as much blood as I could, she found out and started to cry. She tried to reassure me by saying “I do share needles but I always clean them”…. not much of a comforting thought.

In the middle of this suddenly a sense of calm came over me, I found peace with myself and with her, and I thought for a second and said “it is not your fault that I stuck my self, though it shows that how our actions can affect other people lives.”

I started the HIV prophylaxis, I need testing in 6 weeks, 12 weeks and 6 months. These medications were not easy to take and there were lots of them.

She walked out of the hospital, determined not to use again and plans to go to rehab, she was doing wonderful. On her way out she winked at me and said “good luck”.

So what is the lesson from this?........Sepsis Bundles work!….

Blog you later.

PS: About the picture, I saw this in field's museum in Chicago. Myth is that some diamonds bring bad luck. So it is a good thing that I do not own this rock.

Monday, September 19, 2011

Conundrum of Consultation.

Few years ago a fellow physician asked me to see a patient. When I asked him why he said “STP”,  he chuckled and said “for STP, share the pain”.

As a hospitalist, medical consultation is one of the essential components of our work. Various specialists require assistance in areas which are beyond the scope of their expertise. So, an orthopedist may want a hospitalist to manage infections or diabetes or a cardiologist wants us to evaluate a patient for abdominal pain. The reasons could vary. Some are from orthopedist, some from cardiologist etc….. 
They vary from atypical chest pain to coagulopathy. Most of them are very appropriate and we love to tackle medical problems of all sorts. But then there are some consults which are called for all the wrong reasons.

Interestingly when you look at the reason for consult, mostly it is a very vague reason like “medical co- management”. However, at times when you ask the nurse the reason is entirely different.

Don’t take me wrong, most of the times physicians need assistance like if someone is septic, they want a hospitalist or intensivist to take over the case. If someone has brittle diabetes, they want an opinion for better glycemic control. But some times the consult could be just STP (share the pain) or just indifference. At times  referring physician just want someone else to do their scud work. 
However, regardless of nature of the consult you would almost always find this statement at the end of dictation “Thank you for allowing me to assist you in this very "interesting patient”"

I will give you some very “interesting” consults I have received in the past few years.

-      A nurse called me for a consult for “medical co management”. I asked her what the story is? Apparently patient was very belligerent towards the attending physician. After the attending physician left patient wanted to leave against medical advice.  Nurse called the attending physician; he did not want to be bothered. When she asked for further direction, he said lets call for a hospitalist consult. That left me very perplexed. What am I suppose to do, get a couch, asks the patient to lie down and provide behavioral counseling?

-        I was called for diabetes management on a chest pain patient. When I came down to evaluate the patient I found out she was a 91 year old lady with hospice for terminal lung cancer. Apparently EMS brought her to the hospital while they were on their way to hospice house from nursing home. In the ambulance she started to moan. EMS thought it was a good idea to stop at the hospital. ER physician decided to admit this hospice patient.  On the whole scheme of things diabetes was the least of her problem. I spoke with the family and transferred her back to hospice.

-        Sometimes the consult is called because the surgeon or a refereeing physician does not want to perform medication reconciliation or discharge paperwork; we are consulted for “hypertension”, when patient is on a hint of diuretics for hypertension. They just don’t feel like doing it I guess.

Now on the other hand I would rather be a consultant on some cases than being the primary attending. Few years ago I was called to admit a 42 year old man with chest pain due to a thoracic aortic dissection. After ER physician finished presenting the case I asked him “do you think I have some divine connections, if you want I can come down and pray for this patient at bedside, as I am surely not a cardiothoracic surgeon and you want someone who can crack open his chest”.

Sometimes when I am being consulted I feel transiently important, it is good for my ego that they want my opinion. On the other hand I think we need to have very clear and defined reason for consult, not just “co- management”. This would not only improve care but also clearly focus on the specific issues which need to be addressed. Like the other day I saw a patient for “co-management”. Later found out that the physician was concerned about the side effects of a certain medication. I missed it completely as this was not mentioned nor conveyed to me at any time.

I can see how we need to improve communication from our side. This is an ongoing project at this time.

PS: About the picture: This is not a magic ball. Inside Vatican Museum.

Tuesday, September 13, 2011

Dante’s Inferno.

Nine Eleven.... always brings a feeling of dread, though it has been a decade now. 

In Dante’s Inferno, when Dante along with Virgil started to descend deeper into hell (Inferno), they observed Contrapasso, best explained as symbolic punishments, best suited for one's sin. A kind of a poetic justice. 
For example a con man in hell would be reassured that he will be served a full meal, when he would become hungry, he would be served with putrid and rotten food. A murderer will be kept alive for eternity, where he would only wish every second for death to relieve him from his agony.

If there is hell, what would be the punishment for our deeds? Let’s assume if we are not …..Umm….. not adequate. Not just adequate but negligent, if I may say so ... pernicious to others! So those guys who crashed the planes, what should they get in Dante's Inferno?

I have been in a hiatus, working on my book, busy with work etc and ... OK, have you ever come across a situation when someone calls you after a long time and you try to provide some lame excuse of being really busy? And when they ask you what you have been up to? You reply sheepishly “nothing much”.  
Well, I will not give any excuses, I will stop while I am ahead.

Just some random thoughts...

PS: I wrote few words last year on Nine eleven here. Took this picture around the same time.