Wednesday, April 8, 2015

G is for Grrr

On a trip and I can't connect to wifi and my personal hotspot on my phone won't work either.  Going to be in a hotel tomorrow so I should have a real post then...

Until then, enjoy this oldie from today's date in 2008 while I was still in residency:
And technically I talk about Guillain-Barre so there's a G involved...

My Guillain Barre patient took a breath today. Just a small one. Well, maybe half of one, but it's a big thing! Even she was surprised. So excited she tried another breath and was able to do it. It all started this morning when I noted that she was able to flex her fingers, ever so slightly.

We decided to do a "nif" (negative inspiratory flow) test. It tests how much pressure a patient can create when inhaling. You and I, normal lungs, we can generate a high pressure, greater than 40 or 50. My patient inhaled to an 8 or 9. But this is HUGE considering that she has been on a ventilator for over a week, not able to move anything below her neck during this time.

She finished her last session of plasmapheresis and was being transferred back to Children's Hospital as I was leaving this afternoon. Of note, her primary caretakers since her admission have been my fellow Emergency Medicine residents. One of my colleagues evaluated her in the Emergency Department. He then sent her to the Pediatric Intensive Care Unit (PICU) where a 2nd year EM resident intubated her and took care of her. When she was transferred to BGH, another of my colleagues admitted her to the ICU and then transferred her care to me when I started. We're hoping the 2nd year EM resident on service in the PICU tomorrow will be able to take care of her... kinda like keeping it in the family.

Other than that, the most I can comment on is other patients in the unit. My fluffy white cloud is following me around, and as I left this afternoon my second patient was being transferred out. I picked up no patients during the day, and tomorrow I will round on one of the other intern's patients as she will be taking the day off. We'll see if I get any patients after rounds tomorrow from the overnight service.

So, these are some of the other patients in the unit:

- a schizophrenic patient intubated with pneumonia. They are literally "crazy" and won't be easy to extubate. We'll have to see how they do.

- a patient with severe aortic stenosis (heart valve that is blocked) who is not eligible for surgery and who needs to remain on the ventilator to keep their lungs from filling with fluid. The attending is trying to talk to the family about placing a tracheostomy versus extubating the patient and "letting nature take its course."

- a patient that pulled their own endotrachial tube out and actually seems to be doing ok despite the fact that they were near death about 3 days ago. Still touch and go, but holding their own right now.

- a patient with lung cancer who has multiple complications and abscesses. They are end-stage, so for the most part we're doing palliative care. They were too sick to be in the cancer institute so we are trying to get them stable enough to be transferred back.

- a patient who developed severe sepsis, almost died and needed to be intubated within a few minutes of arriving in the ICU, who is unable to clot their blood and who had the misfortune of having a venous line placed into a non-compressible artery. They were headed for a procedure to try to safely remove the line when I was leaving.

- a patient who ate something bad (not sure if at a restaurant or some old hamburger meat) and was infected with e.coli 0157:h7 which causes a severe bloody diarrhea. Unfortunately, this patient developed sepsis and is now in multi-organ system failure. I will have to see if they are still alive when I go back in the morning.

finally, the GI bleeder with a "spurting" artery at the base of a massive stomach ulcer. I placed an NG (nasogastric - nose to stomach) into him when he came back from the endoscopy suite, and he was being wheeled to interventional radiology/surgery when I was leaving.

Funny, I keep saying, "as I was leaving" but that's how my day went. Everything happened in the afternoon, as I was leaving. That's what's been interesting about this rotation, not knowing what I am going to find when I step in the door in the morning...


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