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Newbie

From the July ACP Hospitalist, copyright © 2012 by the American College of Physicians

By James S. Newman, FACP

My name is Mildred Admittalot. You might have been my doctor once, or a doctor to someone like me. I'm 78 and have diabetes, congestive heart failure, atrial fibrillation and chronic kidney disease. I'm on a bucketload of medicines. I've tried to take care of myself, but when I was young there were no fancy insulins or glycohemoglobin levels, and everybody smoked. I was too busy having fun, being a mom and working to worry about how healthy I'd be when I turned 70. That's just the way it is, spilt milk and all that.

It seems like I'm always getting admitted to the hospital. You might call me a frequent flier, but nobody's offered me any points so far, and believe me, there are plenty of other places I'd rather travel to than a hospital.

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Courtesy of James S. Newman.

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The emergency department seemed unusually busy as I was rolled in this last time. I'd gotten short of breath after a weekend with my family. Probably too much ham and other yummy but salty items. I'd taken an extra dose of furosemide, but I could see the writing on the wall and figured I'd better get seen before it was too late. I'm a full code girl—no bones about it.

There was a sense of havoc in the ED. The nurse checking me in rolled her eyes when I asked why things seemed so chaotic. The answer was simple: new interns. It was July.

Soon an intern stood by my bed. She looked frazzled, and like a deer in headlights. I waved her over. I was glad to have oxygen running, since the nurse had put me on a 3-liter nasal cannula. I asked her if she wanted to take my history. She stepped closer. She asked what brought me here, and I laid it out concisely for her. I was short of breath and had also noted some dysuria. I made sure she had my history and meds straight.

Then I suggested she examine me. She wrapped the cuff really tightly around my arm and pumped it up so high I thought my hand would explode. She fumbled with the cuff. I told her to turn the little wheelie-knob. She did and the pressure slowly dropped. I asked her if she heard my bibasilar rales, my irregularly irregular rate and my systolic murmur, and whether she had noted my pedal edema. She scribbled notes furiously.

Then I suggested she give me some IV furosemide, since I was feeling pretty bad. She dropped her notebook as she pulled it from her pocket. She began looking up the dosage. I suggested 80 mg. While she was at it, I suggested she check my INR and electrolytes, and get an EKG and a chest X-ray. My potassium was not in the just-right zone, and I was admitted.

I arrived on the telemetry unit. The transport person was new, and at first we took the wrong elevator, but I eventually directed him to the right ward. Thankfully the nurse was experienced. She had taken care of me before and greeted me warmly but with a slight tone of disappointment. She asked if I had been compliant with my meds and diet. I tried to change the subject.

An intern stalked in, interrupting the conversation. He did not introduce himself, but leaned over me and began to auscultate. I stopped him cold and looked him in the eyes. I told him my name and asked his. He grumbled “Doctor Something or other.” I could not catch it. And again he leaned over me, pulling my gown aside to listen to my heart...and again I stopped him with a hand wrapped around his stethoscope. He was stunned. I had touched his scope! I could see his thoughts playing across his face: He was the intern and he was in charge.

Eventually he told me my potassium was high, and we needed to urgently treat it. I asked how high; he told me 6.9. Not too bad; I'd hit 7.3 once. He seemed frozen by indecision about what to do. I gently suggested he check my EKG and see what my T waves looked like. I remembered something about high potassium and T waves being peaked the last time this had happened. Still he stood there, poking at some kind of handheld device over and over. His battery died. He was immobilized.

I took pity on him, and myself. I told him last time they gave me insulin and glucose, calcium, fluids and furosemide and a nebulizer treatment, followed by a good slug of Kayexalate. He scurried off to place the order, but popped his head in and sheepishly asked if I knew the dose of Kayexalate. I didn't.

Things were going well. My glucose was 140, my INR 3.2, my K down to 5.4. A medical student came in to tell me my urine was growing E. coli, and I would be starting an antibiotic. My internal alarm did not ring. I'd been on antibiotics before. The nurse came in with trimethoprim-sulfamethoxasole.

I was about to swallow the large tablet when something began to tickle my brain. I asked the trade name of the antibiotic. It was Bactrim. I knew it. This had happened when I first started warfarin and had a urinary tract infection. I wasn't about to let it happen again. I asked the nurse to call in the team. I told her I'd wait to take the pill until I spoke with them.

Half an hour later the team descended on my room. There were no introductions. Everyone seemed tense. They stood by the door not really entering: new consultant, new resident, new intern, new student. Oh brother. Again I waved them in. Nobody spoke. I gave them the update. My potassium was better, my creatinine down, my glucose controlled.

I was ready for discharge, but I wasn't going to take Bactrim. Hackles began to rise. I could smell the tense static of confrontation, something I wanted to avoid. I looked at the student. I told her that, as I was sure her consultant was about to tell her, warfarin was a dangerous drug with lots of drug interactions, and that trimethoprim-sulfamethoxasole was one of the strongest interactions. So perhaps they could consider a safer antibiotic choice.

I was discharged later that day, but sadly, I knew I'd be back.

Four months later I was readmitted. A COPD flare led to steroids, which led to loss of control of my diabetes and a slew of other problems. I recognized the intern, but she did not seem to recognize me. She was thorough, competent and self-assured. She'd been taught well. Nonetheless, I promised myself that no matter what, I'd really watch my diet next July.

Dr. Newman is a hospitalist at Mayo Clinic in Rochester, Minn., and ACP Hospitalist's editorial advisor and humor columnist.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated