Monday, December 31, 2007


My hospital is an odd combination of old and new technology, because physicians hand-write orders, but then the nurses enter them in a computer. It's a bit ridiculous, but for some reason some paper pusher somewhere figured it will save money.


Recently I admitted a patient with vague abdominal pain, and since the surgeons decided not to cut him open and the ER attending wouldn't let me send him home, the guy was admitted. (That's another whole story) We gave him a laxative and some Motrin, but figured we'd also try to figure out if anything else was going on, so among other things I wrote for an anti-S. cerevisiae level, as this antibody is elevated in Crohn's. The nurse taking off the orders was new, and unfamiliar with the computer, which will auto-complete the orders as they are written, and instead she sent an Ascaris lumbricoides battery. I've had similar problems with the computer before, and as both of the computer abbreviations for these labs begin "ASC..." it was an easy mistake to make.

Ascaris, for the one or two non-medical readers out there, is a roundworm which is very common in third world countries, but not so much in the yuppie demographic my patient belonged to. I saw the order in the computer later on the night of admission, and went to change it, but the original had already been sent. So we sent the Crohn's lab and thought no more about it.

Flash forward a week. The patient is discharged, and as far as I know still having the vague abdominal pain when his labs start to come back. And though he doesn't have Crohn's, he does have roundworms. It's an easy disease to treat here in America, but we never would have caught it if the nurse had had more training.

Friday, December 21, 2007

To line or not to line?

This month I'm back on the inpatient wards, and for a variety of reasons (not least of which, I flatter myself, is my outward impression of competency) my senior resident has been very hands off in dealing with me. She lets me know if there's a patient in the ER to see, and then swings by about 45 minutes later to see what my plan is. The confidence is good for me, because I'm realizing I actually have learned a lot in the past few years. Pulmonary embolism? I know what to do. Diabetic ketoacidosis? I'm all over that. But only recently have I started standing up for my ideas against those of my seniors.

From my perspective as an intern, desperate for procedures and learning opportunities, it might have been a bad idea. Mrs. Wilkins was a 70-something year old diabetic with renal failure, and the ER was unable to get IV access on her. Normally they would just stick a central line and call us, but we weren't particularly busy and admitted the patient before they had the chance to. Once we got her up to the floor, my senior told me to get consent and then put in a central line. I was fairly excited about the prospect, because I'm getting close to having done enough not to need supervision for this procedure. But I'm trying to be an internist, so I sat back and considered for a minute. Mrs Wilkins didn't need a central line, she needed maybe a little fluid and the occasional lab. Since we hadn't gotten an IV downstairs we didn't have coagulation labs, and for all I knew she had an INR of 4. So instead I grabbed one of the techs from peds and he got a nice peripheral line on the first try. We gave Mrs. Wilkins her fluids, readjusted her insulin regimen, and sent her home two days later.

It's not a particularly moving story, I know. But it stands out to me as one of the first times I went for something less exciting because I was thinking for myself, and for the patient, rather than for a check box in my training. It was a small step on my road from technician to physician. And even if I still need another central line or two, that step was the more important one.