Post-call

I was on call last night. Never a fun situation. I really don't like being on call.

The day started fine--all of our patients were either getting better (as is the goal) or staying the same, and several had improved to the point that we were comfortable discharging them. Unfortunately for me, all of those were patients I was following. It's unfortunate because it meant that not only did I have to fill out their discharge paperwork (I can't fill in discharge medications, but I can write summaries of the hospital course and lists of the procedures they had had while hospitalized), but that I had room to pick up more patients once they were gone. I was sure that meant that I would be up all night admitting new patients.

We did learn a few things about the patients during the day as well. We decided to take a field trip down to the radiology reading room to see about our TB patient's CT scans from the hospital he was at (they had sent a CD with the scans) to see if his disease was getting better, worse, or staying the same. We decided that his TB is getting better (his lungs were showing signs of healing), but he currently has a pneumonia, so it's not exactly an ideal situation. He's still hanging out in the isolation room until we can clear him. Another one of my patients had a new read on his lung culture. It turns out he's growing two different kinds of fungus in his lungs. One we knew about and have been treating him for; the other was a new discovery, and not a good one. For starters, the anti-fungal medicine we have him on doesn't cover the new fungus. For two, that particular organism is a pretty ominous sign in someone with cancer (he has chronic lymphoma), and the medicine used to treat it (amphotericin B, for anyone out there who watches House) is pretty hard on the kidneys, and his kidneys were already not doing great. In other words, this guy is a train wreck, and doesn't even realize it (he's always cheerful and comfortable when I come in and chat with him): he has cancer, kidney failure, fungus in his lungs, vasculitis in his skin, atrial fibrillation in his heart... The list goes on and on. He's being followed by infectious disease (my team), pulmonary (lung docs), nephrology (kidney docs), thoracic surgery (lung surgeons), rheumatology (for the vasculitis in his legs), and hematology (for his lymphoma). That's a lot of doctors for one guy.

Anyway, our census was pretty low at the beginning of the evening last night. We can have up to twelve, and we had eight, which meant that we had room for four more. We heard fairly early in the night about two that were supposed to come in: a woman with meningitis and another with possible TB. Neither of them came. We did get a guy from the ED with a newly diagnosed sulfa allergy, though. He had just been hospitalized, and during his last stay, it was discovered that not only was he HIV positive (with a CD4 count of 49--normal is about 1200, and AIDS is anything less than 200), but had two opportunistic infections. He was sent out on Bactrim, a sulfa antibiotic, to treat those infections, and came in with a massive rash and swelling in his face and airway. He didn't need to be intubated, but did get steroids and benedryl in the ED for the allergy. So we had to admit him to watch him and change up his medications. He's doing fine, although is still quite swollen and completely covered in this rash. Apparently, sulfa allergies aren't uncommon in HIV positive patients, which is unfortunate, because most get Bactrim to keep from getting the types of infections that HIV positive patients get.

As far as the calls from the nurses, allergies seemed to be the special for the evening. We have a girl (OSU undergrad) with bacterial meningitis who had been getting ceftriaxone for the past week. Well, last night, right after she finished her dose of IV ceftriaxone, her face got pretty swollen. I got the call from the nurse, who tried telling me that that was a medication for her, despite my insistence that she had been getting it for the past week. Well, we went in and saw her and, sure enough, her face was pretty swollen. We can't figure it out--most allergies would present a long time before a week after the medicine was started--but we gave her some IV benedryl, and she's looking better now. We're going to try to give her benedryl before the ceftriaxone for her next dose, and if that doesn't work, we're going to have to change her to another antibiotic that doesn't have as much data for bacterial meningitis (all of the studies on treatment of bacterial meningitis show that ceftriaxone is the best antibiotic for it).

I did manage to grab a couple of hours of sleep (on the world's most uncomfortable beds, in a room I shared with two other med students on call), between admissions and calls from the nurses, but I was still pretty out of it during rounds this morning (I'm fairly worthless when I'm post-call). Three more nights of call as a med student left, and after that, the next time I'm on call, I'll have actual responsibilities... kinda scary.