My buddy the heroin addict

We're standing on rounds and the resident presents the following patient that was admitted to our team over-night:
John Doe is a 25 year old male presents with left sided facial/anterior neck swelling, left shoulder soreness and pain/parestheisas over the left buttock/thigh. He was skin popping heroin the night before last and woke up yesterday morning with these symptoms and presented to the ED…Febrile to 102 in the ED…cough, hoarse voice, a couple ulcers over his chest…CXR shows scattered infiltrate, cultures and some labs are cooking but he's got a white count and a CK>16,000. Yadda yadda yadda. This is a good case, why don't you cover him Bostonian??
I hate those words..."this is a good case" usually means that the patient will have a mildly interesting work-up but is such a pain in the ass that the residents didn't want to deal with him...

My prediction was right...he's cursed and swore through the H&P that morning. He kept telling us that he just woke up that way and was in alot of pain. He was even courteous enough to remind us that he has a tolerance to opiates. So my attending decided to throw me under the bus: "Alrighty, well we'll do our best to make your pain more tolerable and then Bostonian will be back in to talk a little later on". Thanks doc...I can't wait to work with this little ray of sunshine for the next 2 weeks.

So I come back later in the day and he's passed out, snoring away with a half finished breakfast tray in front of him...guess that extra dilaudid helped with the pain. I woke him up and got the whole story from his side of what happened. He ended up being a pretty nice guy underneath the gruff exterior and the pain was controlled. He had gone to a decent college was trying to keep his own business afloat, but he got mixed up with the wrong crowd and started using the hard stuff. I ended up having to do the patient education since I was covering him.

John: So this was pretty serious huh? I could have died from this, right?
Yep, if you had waited to come in, you might have been much worse off.
Hey, how old are you man??
Bostonian: 25
That sucks. We're the same age and you're here being a doctor and I could have died from heroin. That's scary man!
Yeah, we've had different lives. My parents were on my ass for the first 20 years of my life and your dad was an alcoholic who and won't even visit you 3 miles from home in the hospital. But the good thing is that you're young and still have your health and a business and a talent. You can change your life before the drugs kill you...alot of people don't get the wake-up call until it's too late.
You know I've been thinking about going back to school once I get clean. You've inspired me man, I want to do something with my life. I mean seeing you here making a difference, it's amazing. I don't want to waste my life any more.
Bostonian: I'm glad, I'll have the case manager give you some numbers for rehab programs.

Getting over your cynical preconceived notions of someone is a good thing sometimes
. It gave me one of the more rewarding patient interactions in my career, but I'll always wonder how much of that was him blowing smoke up my ass to get his dilaudid and how much was genuine. I'm hoping that he's clean and back in school!

I guess you gotta wear the rose-colored glasses sometimes to hope for the best, because reality sucks sometimes.

EM in the Village

My school is affiliated with a hospital in New York's Grenwich Village and they saw fit to send me there for a few weeks of EM. For those of you unaware, the Village houses some of the more interesting people in the City living alternative lifestyles. I don't mean "alternative" in the GLBT alternative...I mean the homeless, the drug abusing, and the clueless. Here's a few of my favorite chief complaints and quotes:

29 yo F with chest pain-
Had a history of panic attacks with chest pain when riding the subway. She started having a panic attack when I was on the subway and had some chest pain...wanted to make sure it wasn't a heart attack. Her panic disorder remains untreated.

34 yo M with fever and L testicle pain/swelling-
Bostonian: Do you use any drugs?
Dude: Officially, no. This isn't going in my medical record is it?
Bostonian: I need to know because certain drugs can cause fevers and infections. Unofficially?
Dude: I dunno, just little bit of Meth.
Bostonian: What happened on your arms there? (Pointing to the relatively fresh track marks)
Dude: Ok, I use a little bit of heroin too. But only a couple times.

25 yo F with BRBPR-
Bostonian: Any change in bowel habits?
Chick: Well...not really. I just moved in with my boyfriend a few weeks ago and I can poop with him in the apartment. I hold it, sometimes all weekend.
Bostonian: Honestly, I didn't know that girls poop until medical school.
Preparing for DRE
Chick: I usually don't let guys get to this point unless there are dinner and drinks first...
Me: Um...does that mean I owe you a drink?

23 yo F- with classical migrane and possible seizure D/O
Me- Do you always have seizures when you feel like this?
Her- No
Me- So why do you think you're going to have a seizure?
Her- Because I have a headache!!!
Me- How many seizures have you had?
Her- Like 15 since 2006. But no one believes me.
Me- Have you seen a doctor for them?
Her- I just started seeing one last month. He didn't believe me until my roomate yelled at him and made him order an MRI. He started me on Keppra a month ago which I didn't start until 3 days ago. And he gave me perscriptions for an MRI, EEG and CT scan, but I missed them all so they have to reschedule them.
Me- So you had 15 seizures and didn't see a doctor for 3 years and then you didn't follow up with your appointments or take your medication. Did you tell your neurologist about your headaches?
Her- No.

Cutting back on the drink...

A fairly put-together 30 year-old lady came in with some moderate epigastric pain and nausea for a few days. She said she over did it over the weekend before at a bachelorette party but no real other medical history besides some poorly controlled hypertension and a rapid tremor that she claimed had been there since birth. Oh...and by the way she drank about a bottle and a half of wine most nights. Labs showed elevated amylase and lipase, so we went with acute pancreatitis (alcoholic vs. gall stone). The enzymes came down after a few days of NPO and hydration and the GB U/S was clean, so we decided to send her home after she tolerated PO without pain or nausea and we were able to send her home with her tremor and hypertension. Well, the whole HTN and tremor history sounded pretty funny to me...but my attending brushed it off, so I did too...who am I to question the attending? I rotated onto the CCU team the following Monday thinking that she was doing well.

About a day after discharge, the poor girl has a seizure and spends 2 days in the ICU where she was suddenly hypotensive and dyspneic, placed on BIPAP. She got an ECHO that showed an EF around 20% due to alcoholic cardiomyopathy. Suddenly that hypertension and tremor looked a bit more noteworthy than before...I saw my attending rounding and all I could ask is "WHAT'D YOU DO???".

She ended up doing pretty well, fortunately. But missing a girl in alcohol withdrawl is kind of a big deal in my book and I hope the attending knew it. I felt aweful that I hadn't spoken up about my tingling spidey sense...not that my attending would have paid attention to me anyway.


Suck it third year

Sorry for the long lapse between posts...I was studying for my medicine exams, planning fourth year and moving, etc.

Finished my medicine shelf last friday and OSCE last Sunday...so I'm essentially onto 4th year of med school!!!!

Since then I've been couch-surfing down in Brooklyn while working in one of our affiliated ED's in Manhattan...more on that later though. For now I'm going for a nice long run in Prospect park, and I'm going to catch up on some of the non-medical parts of life...which involves a decent amount of driving around in circles up and down the east coast...I've got another week here in the ED then home for a few days next weekend, then down to see the GF down in DC for a few days. Then I've been conned into helping out with orientation for the rising third years...so it's back to NY for a few days and then my last few days of freedom before I spend the summer in some of the busier EDs in Massachusetts doing what I love to do!!! Oughtta be fun...

I'll try to get some of my better post ideas up before I'm stuck studying my face off for the summer and hanging out with my fam and the Boston crew.