Damn If You Do...

You never know what you will get in the emergency department. Two a.m., as I walked into the room, I found a near eighty year-old nearly climbing out the emergency room bed as if she was a 1 year-old trying to get out of the crib. “Ma’am, I need you to say in the bed.” I repeated iterations of this line three more times. She never responded to me, and further she never really acknowledged my presence in the room. She had a blank stare that looked off into infinity. Her language was broken beyond all recognition. Something was seriously wrong; at that point I had not a clue beyond knowing something was seriously and critically wrong here. “Nurse, let’s get some ativan on board, one now please.” This situation was becoming unsafe for the patient. Soon thereafter she calmed down, but unfortunately she still could not tell me what about what happen. I turned to her desperate sister who could only seem to focus on the wrong details of what happen, as if she was trying to explain why the Moon orbits the Earth by comparing it to Chinese economics. Quite frankly, I spent more time redirected the interview than anything else. Fortunately, I was able to obtain some crucial facts and then had a chance to exam her along with looking over the few labs the emergency department had obtained. Unfortunately, it seemed the emergency physician dismissed the case as soon as the call was made to the ICU; such a move is very dangerous for the patient. Furthermore, the physician couldn’t muster any kind of handover or briefing for me. She quite simply left me to my own devices in lieu of working with me. Fortunately, I was able to get down to the E.D. quickly from the ICU. In summary, I found the patient had a critically low sodium level, level low enough to kill and kill quickly. I also discovered a mass in her lower abdomen, which I diagnosed as an incarcerated hernia causing a blockage of the intestines. At least I could now explain the history of vomiting, dehydration, and to a certain extent the low sodium. I ordered another liter of saline, wide open. Now the delicate balance between ultra low sodium levels causing death and repleting the sodium too fast causing irreversible brain injury began. I had to replete her volume and her sodium, but I had to do so without killing her. In all honesty, the quick rehydration is what saved her life, but in the process nearly caused me to lose a few liters of sweat. Given my examination of her, I ordered a surgery consult. They dismissed the hernia as of being any concern by countering my claim of intestines being trapped in the hernia. I left the unit shortly thereafter…my 24-hour shift turned 36-hour shift had to end sometime.

A full day of rest.

6 a.m., good morning to the ICU. I went immediately to my patient that I admitted over twenty-four hours prior. What an amazing sight! She was completely different. I sat and talked with her for a good 15 minutes, and then I read the reports and notes. Turns out, the surgeon, that night, was wrong, and she very much needed surgery and did get an operation soon after I left. What was neat really neat about the whole thing was the attending general surgeon on service came over to our team in the middle of morning rounds. He apologized to us and was thankful we were so persistent. Apparently, after I left on that prior day, our team lead went ahead and had the patient scanned despite surgery words. Later in the day, I had the pleasure of writing the transfer note to step the patient down to the regular hospital wards and also to meet with the patient and her sister again. I cannot explain the feeling of knowing that I played an important role in saving someone’s life. It is pretty damn neat.