Intuition + knowledge

November 24, 2009 at 12:02 am | Posted in Uncategorized | Leave a comment

My most recent call night was one of the easiest I’ve had since I started here.  Not because nothing happened (it was actually quite eventful), but because I knew what to do about everything that did happen.   Also because the calls I got involved, for the most part, real problems.  Our floor nurses are notorious for hammering us with pages about clinically unimportant issues, simply because they feel neglected.  So “crying wolf” is always on the differential.  But for whatever reason, this last call night I somehow just knew the problems were real.

Parenthetically, this is why I like EMRs when dealing with floor patients.  Nothing surprises the floor nurses like YOU calling THEM about an issue before they get a chance to page you.  Not that I’m able to do that often, as the ICU and ER patients generally take up all my time.  But it’s fun when I can.

Anyway, that night was a steady stream of badness, all across the hospital.  First, we got a subarachnoid hemorrhage that actually turned out to be aneurysmal.  It’s always more satisfying to find an aneurysm, because at least then there’s something we can do about it, besides just sit around twiddling our thumbs with medical treatments, waiting for the patient either to get better or go into vasospasm.  I also like spontaneous subarachnoids because they’re an automatic two-fer, procedurally, since they all  get an arterial line and a central line.

The poor lady’s husband was beside himself with worry, though.  I nearly cried, myself, while I was getting consent to clip it.  Mostly because I had to bring up all the complications that could happen, and was unable to reassure him beyond saying that her surgeon was excellent and that we would do everything in our power to ensure the best possible recovery for her.

And then another patient who was scheduled to be discharged to rehab the very next day developed a massive hemorrhage, and lost all brainstem reflexes within an hour.  She had been talking on the phone to her husband just a couple hours prior, and then she was comatose when the nurse came in for her next neuro check.  Another difficult family conversation.

Then  another patient had a urethral injury due to inadvertent traction on his Foley catheter at some unknown recent point, with about 2 liters of hemorrhage into his bladder.  It presented in a benign manner, with somewhat decreased urine output, but not below the 30mL/h threshold that triggers clinical alarms. But it had become bloody as well, for no apparent reason.  So I asked the nurse to flush the tube, and she reported back that she was only able to get a small amount of output after doing so, and that it was full of clots. She then scanned the bladder and found >500mL of volume still inside, and noted that he was bleeding around the Foley.  So I came over to examine him, and found that his abdomen was also very firm and distended (I know, a neurosurgeon actually examining an abdomen…surely a sign of the coming apocalypse).  It was definitely time to call urology.  So I did, and the urology resident came over, made sure the bladder wasn’t ruptured, took out the Foley, placed a Coude, and irrigated the bladder until all the blood came out.  Thank God that nurse caught it when she did.

And then two peds patients with head injuries.  One, the teenager, was not seriously injured but was dramatizing the concussive symptoms a bit.  (When you deal with the whole spectrum of deceit, from simple disingenuousness to outright lying,  as you do in retail pharmacy, the BS sensor gets very acute.)  I decided to let it go, as we would be watching him overnight regardless of his mental status.

The other pediatric patient was seriously injured.  It was unclear at the time I left how serious the injuries were, but to me they did not seem serious enough to require surgery, or to result in diffuse axonal injury.  But anytime there’s a child involved, people get excessively worked up over it, and I’ll admit the mechanism of injury was quite dramatic.

On a more mundane note, we are all still adjusting to writing our notes electronically.  Some are adapting more quickly than others.   Despite the system being the same as at UW, this place hasn’t developed any note templates  to automate things at all.  So we each have to make our own templates, and every day we have to manually import the latest vitals, meds and labs.  IMHO, this is a direct result of having an IM person in charge of implementation.  Those medicine people have a much lower patient-to-resident ratio than we do, and they have much more time to write their notes, as well.  Our usual MO is to write notes and round as quickly as possible, so we can get to the OR/clinic/bedside procedures/whatever as quickly as possible.  The extra time required to write notes and import data by hand doesn’t affect their ability to function effectively nearly as much as it does ours.

Meanwhile the VA remains as slow as ever.  I feel a bit guilty being over there, knowing how short-handed it leaves the university hospital.  But I’m getting a lot of studying done, and my current goal is to be able to distinguish reliably between a radiculopathy and a peripheral nerve issue based solely on the clinical exam.   I have a general grasp of it already, but I want to be able to simply look at a bunch of exam findings, and remember them as a unit–the diagnosis they represent–rather than as individual pieces.   Which requires spending some quality time back down in the weeds of 1st and 2nd year, and integrating all of that with the hundreds of patients I’ve seen and will see in clinic with undifferentiated back pain, weakness or numbness.

I’m not a fan of the spine aspect of neurosurgery.  But if I have to learn it, I’m going to learn it like the back of my hand.