Respiratory distress, anyone?

1/12/2010
Day 7

I am currently in the midst of my call night. We live so close to the hospital that we can duck away if there’s a lull. I am planning to go back soon and am sure I will be paged before then. My intern is the first line of defense (she gets all the pages from the ward nurses and any new admits) but then I’m second line. The interns are, for the most part, a bit tentative and quick to page.

We had a busy day that flew by. I got a new patient this morning, a 2 yr old boy with pneumonia. He was diagnosed clinically without a chest xray (very common here, though unheard of at Swedish). We started him on antibiotics and I decided to give him some IV fluids this morning since he looked a bit dehydrated. Shortly after the bag of fluid finished he decompensated and became hypoxic (low oxygen) and tachypneic (fast breathing) with a respiratory rate in the 80s. A chest xray done then showed cardiomegaly (big fat heart) and pulmonary edema (fluid on the lungs). I likely tipped him into failure with the fluids. Oops. But honestly, what are the odds that I’d have 2 patients in a row with heart failure? I’ve quickly learned that it’s not at all about odds around here. Anything is fair game, at anytime.

My other heart failure patient decompensated today as well. Truthfully, she was looking terrible from the get-go with tachypnea and an oxygen requirement of about 11 L by facemask. We were concerned she needed to be intubated, so got transferred to the ICU. Before that could happen, though, the ICU staff had to play the ol’ musical beds game to get people out of the ICU to open up a spot. The ICU has been a hotbed of peds activity lately. Once she made it to the ICU she got a few whopping doses of lasix, some morphine, and actually started to look a bit better. We jimmy rigged this portable ultrasound machine to look at her heart bedside (there isn’t anyone who is actually trained in echocardiography, and no one really knew how to use the machine either). It confirmed what we already knew from her clinical presentation and her chest xray: her heart is huge and working poorly.

Then I got pulled into casualty to admit a 13 yr old girl with (guess!) respiratory distress. She was diagnosed with TB a few months ago, and has continued to have cough and fever. Her chest xray is suspicious for pneumonia. She had a negative“spot” test (translation: HIV test) which narrowed our differential a bit. I was putting my money on PCP but it’s pretty unlikely if she’s immunocompetant. I never was a good gambler. When I came to see her she looked terrible with oxygen saturations in the 60s on room air and tachypneic (are you beginning to see a theme here?). She’s now on the peds ward and actually looking a bit better (for now…).

I then got called to the men’s ward to meet my fellow on call intern. An adult patient was having severe abdominal pain and distension. My call duties cover both the adult and peds services, despite my never actually having set foot on the men’s ward until tonight. Looks like a bowel obstruction to me. My intern attempted a few times to insert an NG tube without success. She looked to me with big question marks in her eyes (and also pleaded “we have to do this because I CAN’T call a surgeon to place a tube!”). I grabbed that sucker and got it down into the stomach (with a bit of nose bleeding, gagging, and retching – the tubes here are torture devices - stiff, hard plastic!), asked for suction (there isn’t any), and settled for NG tube to gravity. We’ll see if that helps. If not, it’s on the surgeons for tonight.

Then it was up to the ICU to check on heart failure patient behind door number one (doing ok actually), down to the wards to check on heart failure patient number two (still a bit tenuous, most likely secondary to not ever getting a dose of lasix that I ordered hours ago), and down the hall to make sure no major disasters were unfolding (not yet!). I’m sure there are still plenty of those in store for me tonight!