The Lady With The Lamp...Not!

Sunday, November 06, 2005

I'm at ASN this week. 10,000+ nephrologists in one place. That's kind of mind blowing. So I wrote this before to post while I was gone:

Generally I take care of very sick patients. That's kind of a no brainer, because even at their healthiest dialysis patient have many, many things wrong with them. Lets' put it this way-it's hard to impress NYC EMS workers, but dialysis patient's will do it almost every time.

But as I've been seeing patients I've been compiling a list of things that I've actually seen that I feel are VERY bad prognostic indicators. Most (if not all) have to do with lab results. So here are some of them, in no particular order:

"It's a bad sign when..."

  • the PEEP on the ventilator is higher than the pt's a)platelets, b)hematocrit
  • the white count and the hemoglobin are the same
  • the white count and the hematocrit are the same
  • the white count and the serum bicarb are the same
  • the serum bicarb is higher than the platelet count
  • the creatinine is higher than the serum bicarb
  • the PT is higher than the PTT
  • the INR is higher than the hematocrit
  • the chart is heavier than the patient

Still working on more.

Clearly I haven't written anything in a LONG time. And every time I see the bookmark for this blog I feel guilty. Not sure why. But I've been busy. Some of the things that have happened since I last posted:

-The painting/plastering that was being done to my apartment is finished. Now if I could just get all of the crap that's still sitting around put away I'd be really happy.

-My daughter's 2nd grade teacher is a disaster. I can pretty much sum it up by saying that a teacher should never tell a student to shut up. I would think that this would go without saying, but obviously not. Even the kids think that there's something weird about her. The principal keeps telling the parents how hard it is to find teachers for this program (dual language (English-Spanish), gifted and talented) but come on!

-I went on vacation. England, Wales and Iceland. Saw family, stayed in great places, went to a geothermal spa in Iceland (
http://www.bluelagoon.com/top_en/About_Blue_Lagoon/ ), had myself a really spectacular panic attack on the Pier in Brighton ( http://www.brightonpier.co.uk/indexflash.htm , when you're out near the end and you look down it's a LONG way. Not a good thing to mix w/ a fear of heights!).

-I took care of a patient with Wilson's disease. No, I'm not going to tell you what it is. Go look it up.

-I had a nurse practitioner student who's interested in dialysis follow me around for a day. She got more pheresis than she bargained for. By the end of the day she was pretty blown away by all of the patients that we'd seen who had (fairly) rare diseases: Waldenstrom's macroglobulinemia, cold agglutinins, homozygous familial hypercholesterolemia, Wilson's disease, among others. Next week she's going to follow one of our nurse practitioner's in an outpatient dialysis unit.

-One day I was sitting in the dialysis unit and I took a call from a nurse on one of the floors. She was getting frantic b/c her pt was looking very unstable and she couldn't find anyone to come and see him. Many reasons: he was a medical boarder on a surgical floor so they didn't know the team following him, it wasn't clear in the chart who was following him, when they called the floor that he should have been on they were given 4 different beeper #s, and, last but not least, when they pages the renal fellow the answer that they got was that fellows don't do vomiting (coffee grounds) and that they should call the resident I may be paraphrasing here, but that's the gist of it). I told the nurse that I would come and see the patient and help them figure out who was covering. However, when I walked into the room he was dead. Still breathing, but trust me, that was a mere technicality. I started telling people what to do but he stopped breathing about a minute later. The code was a disaster from start to finish. Bad, bad, bad.

I'm trying to think of other things that have happened. I know that there have been some. But I'm drawing a large blank right now. Tomorrow I'm leaving for the ASN meeting in Philadelphia (
http://asn-online.org/education_and_meetings/renal_week.aspx ). One of the fellows and I are going to take a really cool looking course: "ICU Nephrology and Acute Renal Failure: What the Nephrologist Must Know". I feel like it's costing about a gazillion dollars to send me to this conference, but I think that's partially b/c I'm used to nursing conferences which are generally much cheaper.

I think that I really am going to try and maintain this site (after the obvious false start). I even have a couple of ideas for posts circulating in my head.

Wednesday, August 17, 2005

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Tuesday, August 16, 2005

Blech!!!

OK, today and yesterday have kind of sucked rotten eggs. Multiple reasons:
1) First and foremost, MY. HOUSE. IS. A. TOTAL. DISASTER. AREA!!! We've been having painting and plastering done. Originally I was told that it would take 3-4 weeks. We're going on 10. Half the time no one shows up. The painter who runs the outfit isn't returning any of my calls. (But I usually call at night, so I'm going to try a sneak attack tomorrow morning.) The real problem with all of this is that all summer I've been buying stuff to redo the apartment. In a big heap in the living room or jammed in the lined closet I have: curtains for 4/5 windows, including blackout curtains for 2 of them (it's an apartment. And the windows are 6'x5'.), curtain rods for 4/5 windows, 2 new towel bars, 2 glass shelves for the bathroom, a new sofa cover, cat repellant for the sofa cover so that it doesn't end up looking like the sofa that it's covering, a bed skirt, bedspread, assorted organizational thingies, a new bathroom sink faucet, a new rug for the bedroom, a new shower curtain, rug and hand towels for the bathroom, new door knobs for every door in the house except the front door...you get the idea. I HATE living like this!! Every time I put something down I loose it. 2) My father was supposed to have a hip replacement on Monday. But the OR suite sprung a leak, and he's been moved to Friday. This is bad for 2 reasons: 1) We leave on vacation next Wed, and I feel bad leaving my mom all alone to cope with the aftermath of his surgery (although it can't be as bad as the double knee replacement that he had in January. 2)This is really selfish, but this means that my weekend is pretty much shot. And I have about a gazillion things to do before we leave for vacation.3) My patient who at one point had a heart rate of 170 and later had to be intubated has decided to stop dialysis and has been moved to a hospice, which is what HE wanted. And if he got what he wanted then I'm glad. But I didn't get to say good bye, b/c it all happened in a hurry. I have their contact info so I'll be able to send a card to his wife after he dies. And I'm pretty sure that I'll know when it happened if I just pay attention to the obits in the NYT.

4) One of the docs who leaves everything to me (orders-I swear that he hasn't written any in the past 3 years since I've been there, and notes) is gone for the week. No problem. Except that he didn't see fit to tell me. Grrr. Caused a little confusion today.

5) (Boy, this list is getting long) There are 2 MDs and me in pheresis. It basically all goes though us. One of the docs isn't really involved because he's now doing other thing, so it's really just 2 of us. Makes it hard when I want to go on vacation b/c that's the only free time between camp and school for my kid, and the doc that I work with won’t to take the week off to drive his kid to college. When he's on vacation he tells his secretary to foreword all pheresis consults to me. So apparently I'm running the world-or my little corner of it anyway. Actually I have to say that I do think that it's kind of neat that an MD is signing out to an NP. Of course his wife is an NP, which explains a lot. She says she always hears about it when I go on vacation! Of course today this doc (I'm going to have to think of a name for him) brought me peanut M&Ms today, so I really shouldn't be complaining!

6) I'm missing some of my patients. We run a very specialized program for a genetic disease. We have 21 patients, and we're the largest center in the US! Some of our patients are kids. One of them is out of the country for several months, and isn't coming back until Sept. She's the same age, grade, height, etc as my daughter-in fact they've met each other. The problems here are twofold-she shouldn't be missing treatment for this long, and I miss her!

OK, I guess I'm done complaining. Maybe.

Sunday, August 07, 2005

Still Tired

I was trying to figure out why the last post was dated Friday, but it only contained stuff about Thursday. Duh. It was because I wrote it after midnight. Because it didn't contain any stuff about how I was in the hospital until 7pm on Friday too. We had tried to dialyze a patient, but his blood was so thick that it wouldn't go through the membrane. So we had to do pheresis instead, and hope that it would make it less viscous so that we could do the dialysis on Sat (it worked). We also have a patient whose kidneys have failed (
http://ladywiththelampnot.blogspot.com/2005/08/oh-what-morning.html ) who is now in the ICU. On Friday morning he needed to be intubated. I was there b/c we were changing things with his dialysis. I was also talking to his wife, and explaining, and trying to comfort her a little. The staff finally had her go into the waiting room, and when I left a little later to go downstairs I her alone, bent double in a chair, crying. Ever cry so hard that you feel like you're going to just explode? That's how she was crying. There was just nothing that I could do at that point except sit next to her and put my arms around her. I think that it helped just a little bit.

Honestly, my job isn't usually like this. It has its ups and downs, but this has been one of the worst weeks that I remember. And the problem is that that makes other things worse.

Succinctly put, I have depression. Technically it's post partum depression, but the "baby" is 7! But I was never able to come off of medications. The post partum stuff was beyond awful, and I ended up with an 8 day stay in a psych unit of the hospital where I now work. At that point being locked up was a really good idea. (At some point I'm probably going to write about that, but this is a quick outline of some of the symptoms that I had:

Friday, August 05, 2005

My day went to hell in a hand basket at about 3 pm today. In a total of 6 hours we got 3 calls for emergent pheresis (never mind that one of them didn't have access!). My attending and I got the 1st 2 taken care of, and then I went to round in the ICUs and write my CVVHDF notes (waaaay to many of them right now!). My attending and I were trying to get out so that we could go and pay a shiva call, but it was not to be. 4pm-a phonecall from an intern in the MICU. They have a 37 yo pt who they think has TTP. We all went over a lot of possibilities (DIC? Something to do with her scleroderma?) but the final decision was to do the pheresis. One of our 2nd year fellows came up to put the line in. He's really good, and he had a hell of a time-the 1st 2 clotted before he could even get the guide wire in. Finally it was in. The FFP was being defrosted, all 12 units of it (and let me just tell you, if you've never had to do it-blood banks are NOT happy when you ask them for that much FFP. However asking for 12 units is better than asking for 20!), the nurse was getting ready to go, and the patient was relatively stable. I started leaving, but I was caught by one of the nurses and asked to come look at a dialysis pt on CVVHDF who had just returned from having a pericardial window and was having SOB. Turned out in the OR he had had 1 unit of packed cells and 1 L of fluid. BP was 190/100. After turning up the UF, getting a nebulizer and some Morphine he was better. I spent some time with his wife-they;re both really nice people, and it really sucks b/c he has a crappy prognosis.

OK, so anyway, I left. At 7 pm. Drained. Went home, vegged, combed my daughter's hair, put her to bed. And vegged some more.

At 10 pm my beeper goes off.

The TTP pt had arrested 2/3 into the tx. Asystole. They got her back, but only for 20 minutes. And that was it.

And all I could think about was her father. When we were getting the consent he asked when the blood bank was open so that he could go donate. My attending said that it probably wouldn't be used for his daughter. His response? "Some one else gave the blood that they're going to give to my daughter. I can help some one else the same way." I felt very...humbled, I guess.

And now he's going to be planning a funeral. It. Just. Breaks. My. Heart.


Someday I'll write about other stuff-my family, the wreck that is my apartment as it's being painted and replastered, the fact that the green that I had chosen for the bedroom looks more blue, our trips, my experiences with postpartum depression. But right now all I can think about is that woman's father, asking where he could go to donate blood.

Wednesday, August 03, 2005

Nothing major today, just a chunk of time trying to get a cardiac MRI pre-approved by a patient's insurance. The primary is GHI and the pt doesn't have a primary care GHI provider. Not a huge deal, this particular GHI plan doesn't seen to require it. But the secondary insurance is HIP. >:-( And apparently HIP requires you to have a HIP primary care provider, even if that's your secondary insurance. Got that? Right, me neither. But apperently we need to help the patient find one. Of course it's going to take all of an initial visit to just go though the 1st half of the patient's history (let's just say the the 1st MI was at the age of 12. Twelve.). I know that there are reasons for some of the things that the insurance companies do, but at this point the patient's care is being obstructed. Grrrr.

OK, time to go and watch "So You Think You Can Dance" with my daughter. Let's hear it for quality TV!

Tuesday, August 02, 2005

Oh, what a morning. I was sitting in the dialysis unit quietly writing a note (which I ended up finuishing about 1.5 hours later) when 1 of the nurses came to tell me that a patient we were dialyzing had a heart rate of 170. !!!! Luckily the patient was still awake-truly amazing what the human body can take, especially when it was not in good shape to begin with. So I rounded up the usual suspects-gave O2, stopped the dialysis, did an EKG and wrote an order for the medication I wanted. I also called up the nephrology fellow.

I'm now going to make a statement that won't make a lot of sense if you've never worked in a teaching hospital. And that is...it's August. Not quite as much of a statement as "It's July" but still. (If you've never worked in a teaching hospital the significance is that medical house staff all move up a notch. Medical school grads become interns, interns become residents, residents become fellows, etc. Imagine a lot of people wandering around with dazed expressions and you've pretty much got it.) I felt really bad for our fellow. He's from another institution, so all of our computer systems (which govern pretty much everything these days) are new to him. Huge handicap, and hardly his fault. Then follow it up with the fact that he still knows fairly little about dialysis...it's difficult for him, and I know that. But the thing is that I feel like I have no backup. However, it's wonderful what you can do when you have to. I took care of the patient, slowed down the heart rate some, made sure that the blood pressure was something that didn't make me shudder when I looked at it. And it turned out that no one (even the 2nd year fellow) really had anything to add. They just agreed that I had done what they would have done. And even when I made a suggestion about what the EKG rhythm might be, they thought that I might be right. And the patient's family member thanked me and said what a good job I had done.

Wow.

Because the thing is that even though I've been an NP lo these many years, a lot of the time I still feel like I don't know what I'm doing. And that I'm going to make some big mistake. I mean a BIG mistake. But maybe that's what helps keep me safe. I need to think about this some more...