Archives for September 2006

Change of Shift 1:6

It’s up: cooltext190913551.jpg

Welcome to the latest edition of “Change of Shift: A Nursing Blog Carnival”!

Letting the Cat out of the Bag

Recently, I let the cat out of the bag.  (I looked that up on Google and found several definitions / explanations, and they agree on ‘ letting out a secret’, but cannot agree on an origin; no matter.)  The result was uncomfortable, for all of us.

So, it’s about 1AM and the place is packed, as usual.  I pull the chart of a very young female, with the chief complaint “abd. pain”.  No worries, probably a UTI.  To the room.

Patient is pleasant, cooperative (a big plus).  Mom is nice, but lets the patient give the history, which is less complicated and easier for me (bonus!).  Patient able to give chief complaint in less than 2 sentences (on a roll!).  Pain is in low pelvis, intermittent, worse sitting up, better lying down, maybe better after urination.  No fever / chills, no NVD, etc.  On the the physical exam.

Patient lies supine.  As it’s an abdominal complaint, the first place my hand goes is the upper abdomen.  It’s where I start, and where patients are comfortable with me starting (don’t just go to the the pelvis student docs, it makes patients tense up very quickly).  And, this isn’t a normal abdomen.

If you’ve handled many bellies one of the things you know instinctively is that they’re normally soft, and there aren’t any really hard or lumpy spots unless something is wrong, or you’re examining a body builder (and that hasn’t happened in my practice).

When I palpated something really hard in the upper abdomen, surprise went through my arm, and my brain wasn’t far behind.  I continued the examination of the abdomen, knew what this lumpiness meant, and said completely without thinking “…when are you due”?

The instant fear in the patient’s eyes got my attention, just as the sound of mom’s gasp reached my ears.  I felt a bit more of the  abdomen to be sure, and awkwardly excused myself with ‘ let me go get the sono machine, I’ll be right back…’.  Oh, I got to make the Big Announcement.  Great….

The sono machine preceded me into the cubicle, and a show and tell of baby parts was made to a completely unappreciative (or just stunned) audience.  About 34 weeks gestation by the machine calculations.  The now older mom was teary but in control, and the now-outed very-young mom was unhappy, but more in the loss-of-denial way than any anger or defiance.

The lower abdominal pains were contractions.  Early teen pregnancy isn’t the diagnosis I’d thought I’d make.

I felt about 2 inches tall the rest of the night, because I had let the cat out of the bag into the wild rather than facilitate the release under more controlled circumstances.  The patient and mom went to the Labor Deck to meet with the nurses there, and the social workers.

I blog this as a warning to other docs: you’re going to get surprised, eventually.  Keep the cat in the bag until everyone is ready to catch, including you.

Medblogs Grand Rounds 2:50

Ves at Cinical Cases (Cleveland Clinic, maybe you’ve heard of them?) brings the latest:

Grand Rounds is a weekly summary of the best posts in the medical blogosphere. Pre-Rounds is an article series about the hosts of Grand Rounds on Nick Genes of Blogborygmi, who writes the Medscape column, is the founder of Grand Rounds and he maintains the archive.
This week’s Grand Rounds is loosely structured in a “medical journal format” using the table of contents of one of my favorites — the British Medical Journal:
Editor’s choice
Clinical review
Analysis and Comment
Career focus

I usually say something pedantic like “It’s up”.  Here’s what this deserves: This is how a Grand Rounds should be.  Refer to it when you host.

Here’s my must-read post from this grand rounds.

Labor Day: A Day when I liked my job

Labor day was spent in my particular labor, the ED, doing my thing to save disease and stamp out lives (joke).  I was at my part-time gig, which is a very nice ‘community ED’, a departure form the inner city referral-center ED that’s my real job.

At the real job I don’t see kids under 12 much, as we’re in a  complex with a huge peds referral center.  At the real job I see inner city problems and patients, and a lot of exacerbations of chronic diseases.  Oh, and a terrific lot of blunt trauma.  It’s good emergency medicine, and I help the team make a difference, but it’s a pretty well defined patient population.  A lot of acuity, a lot of sick patients, a very high admission rate.  Not bad or good, just different.

The part-time gig, on the other hand, is on the edge of the big metroplex, and as such is much more of a ‘real’ ER: kids with colds, ankle sprains, and the occasional really sick patient.  Lots of patients, but as a rule they’re not as sick and not as chronic.  Trauma is steered away by EMS, but they get MI’s, etc.  And nursing home patients, but not nearly the volume of the Big Joint.

Today I got to talk to my patients a little bit more.  I got to get a bead out of the nose of a kid (10 Fr. foley plus a little etomidate worked the charm in a rambunctious and completely uncooperative toddler), I did a diagnostic and therapeutic thoracentesis in a nice little-old-person who felt miserable trying to breathe with one diseased lung rather then the usual two; the change was dramatic.  And appreciated, by both of us: the patient for a life made better, and me for a renewal of energy.  I used judgement, skills and hands to make a patient comfortable, facilitate a diagnosis, and prove to myself I cold help.

Yes, they’re common procedures for an EM physician, but today it felt different.  Good.

I’m like you, I need good days, and love them when I have them.  Today was one.


Rain is one of those all-or-nothing phenomenon here and we’re finally getting a little of it here in North Texas.  After a ridiculous number of dry days, and an even more ridiculous number of consecutive days greater than 100F, we’ve been given a reprieve by the Rain Governor: water is falling from the sky.  Temps are down, sanity has begun to return in the ED (okay, it’s relative there).

Oh, our reservoirs are still fantastically behind, and the ground looks like Apollo 11 moon dust  when trodden upon (just like it does in Fort Stockton; story some day), but at least we’re getting some water.

Weird how the end of a drought can make your week.

(picture from the WeatherBug)

Steve Irwin Dies

The Crocodile Hunter died, and not by a croc.  By a stingray barb:

BRISBANE, Australia (AP) — Steve Irwin, the Australian television personality and environmentalist known as the “Crocodile Hunter,” was killed Monday by a stingray during a diving expedition, Australian media said. He was 44.

Irwin was filming an underwater documentary on the Great Barrier Reef in northeastern Queensland state when the accident occurred, Sydney’s The Daily Telegraph newspaper reported on its Web site.

The Australian Broadcasting Corp. said Irwin was diving near Low Isles near the resort town of Port Douglas, about 1,260 miles north of Brisbane.

A helicopter carrying paramedics flew to the island, but he died from a stingray barb to the heart, ABC reported on its Web site.

Pericardial tamponade is the diagnosis that jumps to mind, though there are several others. 

Update: Dr. Rangel has the analysis covered here. (via Kevin, MD)