The On-Call Diaries / Blog

[Anasazi23]

Tonight's been a relatively slow night. I'm afraid to say it out loud....it's akin to a player telling a pitcher he's got a no-hitter going in the 7th inning.

I've got to go draw a CBC and T&S on a guy who I think might be bleeding into his spine (long story). Guess I should order another T&S for the am so that my fellow PGY-1 doesn't have to draw it if the guy gets transfused.

Besides that, I've got a r/o ACS on tele; need to draw the 3rd set of enzymes and have to do the ekg myself also...for some reason they annoy me.

As I write this I'm being told a guy hasn't peed since 12 noon today. Yay, another foley.

You figure I'd have memorized the water deficit formula by now.

Feel free to contribute if you've got time.


.....to be continued

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[50960]

For what it is worth I haven't peed since 12 either...

 

[Anasazi23]

Do you have a obstructive uropathy also?


Want a foley?

 

[50960]

Flowing free now thanks!!

 

[Anasazi23]

So a friend of mine came up to the floor to visit, who was also on call, and I was telling him how quiet it was. Like clockwork, my pager goes off for a code on telemetry. So much for the quiet night.

I wound up starting the code, doing compressions, and praying for the 3rd year medicine residents to show up, which they gratefully did quickly. Needless to say, I wound up getting out late by the time all the work was finished that got backed up.

I really can't stand it when lazy attendings, who have their own access to the computers orders, and who know damn well where the order sheets are, write things for the interns to do when they could have done the same themselves with as much or fewer pen strokes.

One week left of scuternship.

 

[Anasazi23]

Busy night...but I got a few free moments.

Found a lady on the floor with what looks to me like an acute abdomen. Medicine agreed...transferred her to the medical floor. Also admitted someone with the largest scrotal hernia/hydrocele I've ever seen (size of a basketball, at knee level) last week.

Had a real nice drug lunch today though...that yellow Vietnamese chicken stuff and lots of other goodies...yummy.

Newsflash: $200 of PCP use daily can give you a labile mood. My ER patient didn't know this apparently.

 

[OldPsychDoc]

Newsflash: $200 of PCP use daily can give you a labile mood. My ER patient didn't know this apparently.

Shouldn't you just diagnose it as bipolar? That's what the ER does with all my meth addicts...

 

[Anasazi23]

Our ER is usually saved the trouble. They come in with that diagnosis already (acc'd to them).

I was called at 1:30am for agitation on the medical floor...guy was transferred from ICU where they didn't see a problem in stopping an ativan 5mg/hr drip and replacing it with 10mg PO q8h. Their intentions seemed good at least.

I had to do some significant tweaking to tune things up.


(thanks for listening)

 

[Anasazi23]

Is it me, or are people sick and tired of working up medical problems on the psych floor? My intern skills kicked in while trying (successfully, thank God) to place an IV for contrast abdominal CT on a morbidly obese patient that delightfully wasn't signed out to me.

Back pain, cough, shoulder pain, vomiting, chest pain, palpitations, acute knee swelling, blurry vision, belly pain, headache, demands for Tylenol #3, hiccups, not peeing, peeing too much, burning when I pee, vaginal bleeding, constipation, diarrhea, "heart pain," heart-burn, back pain, "broken ankle," etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc, etc.

All this in one day. And it's only 9pm. No joke.

I mean for God's sake people. Toughen up and live a little. When was the last time you coughed one time and ran to the drug store looking for cough medicine? The somatic complaints are killing me.

Remember, this is the on-call diaries. So I'm already miserable and don't what to hear "You figured a psychiatry resident would understand that anxieties are manifested by blah blah blah blah." I need just to vent.

Back to work...pager's going off again. Wonder what it is this time...
Thanks.

 

[50960]

Hey I have fibromyalgia, and my doc says I need norco 10/500 q4hrs so start writing.
Actually, how about you give me your pager number anasazi, so I can get my xanax filled at 1 AM. Remember they are all people like your mom, dad sister etc.. They are crazy, and that is what neurontin was created for....not addictive, safe for liver, treats everything (ya right), and puts most of them to sleep so another resident can deal with it.

 

[Anasazi23]

Yeah, really...

Got called also for stroke symptoms, and even better, "severe, unrelenting and excruciating chest pain with shortness of breath." The latter turned out to be a young woman who "just was upset that her fiancee didn't call her tonight, and that she might have pneumonia."

The chest x-ray earlier that day was negative for acute disease.

 

[OldPsychDoc]

Yeah, really...

Got called also for stroke symptoms, and even better, "severe, unrelenting and excruciating chest pain with shortness of breath." The latter turned out to be a young woman who "just was upset that her fiancee didn't call her tonight, and that she might have pneumonia."

The chest x-ray earlier that day was negative for acute disease.

Where DO these people learn their coping skills????

 

[NewRawTick]

Yeah, really...

Got called also for stroke symptoms, and even better, "severe, unrelenting and excruciating chest pain with shortness of breath." The latter turned out to be a young woman who "just was upset that her fiancee didn't call her tonight, and that she might have pneumonia."

The chest x-ray earlier that day was negative for acute disease.

Sounds like a case of a broken heart. Awwww. (hehe, I couldn't resist)

 

[Anasazi23]

Diagnosed Sarcoptes scabei on top of drug rash (I think quetiapene was the culprit) in the inpatient unit. Quite tricky. Complicated by TD, unable to give typicals and other neuroleptics due to heart condition. Very bad pruritis with excoriation and bleeding. Scabies tunnels like I've never seen from a previous infection.

Of course, the patient is benzo seeking on top of it and appears "organically paniced."

8 more hours to go...

 

[Anasazi23]

I wasn't on call today, but wanted to vent after dealing with a:

1. Real seizure (with head injury)
2. Pseudoseizure
3. ACS x 2 (both r/o'd)
4. New onset Hemoptysis with white count
5. Discovery of pseudomonas infected stasis ulcer
6. Acute ms change x 2
7. What wound up being clozaril toxicity

A nice, quiet day at the office.
And I'm not even on this weekend!
2 more weeks on geripsych baby...

 

[OldPsychDoc]

I wasn't on call today, but wanted to vent after dealing with a:

1. Real seizure (with head injury)
2. Pseudoseizure
3. ACS x 2 (both r/o'd)
4. New onset Hemoptysis with white count
5. Discovery of pseudomonas infected statis ulcer
6. Acute ms change x 2
7. What wound up being clozaril toxicity

A nice, quiet day at the office.
And I'm not even on this weekend!
2 more weeks on geripsych baby...

Sounds like you need to stir youself up a nice tall glass of Metamucil and wash down a couple of Xanax.

 

[Anasazi23]

Don't you miss those days OPD. I remember you telling me months ago that you're glad you have folks to do the "heavy lifting." That phrase just stuck with me.

6 more months, and I'm a 3rd year. Life gets muuuuch better.
I'd like to welcome the psych interns! I'll be supervising you on call over the next year. Here's my pager number.... You'll be receiving calls from the pharmacy, the psych floor for various somatic complaints, serious medical issues, and also outside crisis calls throughout the night. Let me know if there's something you can't handle, and page me if you get a floor consult or when someone comes to the ER.

 

[Anasazi23]

On call tonight. And this Saturday, and this Monday, and the following Wednesday again. Should put me in a real great mood.

The good news is...the beds got filled today. The bad news is...I filled them and am only now catching a break for a quick bite and some SDN. I'm sure it won't last.

Oh by the way, I feel sick as a dog, and look worse than most of the patients. I'm sure my white count is higher than half the people in the ER.

I've rarely actually seen sick dogs. Hmm...

Again, somatic complaints tonight....
"My liver is too big. Feel it here. I've been drinking like a fish and have hepatitis. I'm supposed to get a liver transplant. Find out if they can do it here so I can start drinking again."
"Can you tell me my lab results? I feel sick."
"I haven't had a bowel movement in 5 weeks."
"I need my Lasix now and you *******es haven't prescribed it. I take 20mg daily and my feet are blown up like balloons!"
"It says here on the wall that I have a right to dental treatment. I've had stitches in my mouth here (sticks open mug in my face) for 2 months. Take them out now."

 

[Poety]

Sazi, are you doing medicine CALL? MY GOODNESS - hmmm some places I've visited said they have no overnights, actually a few... hmmmm you seem to learn a lot - or is this the psych ward at a VA or something?

 

[Anasazi23]

Nope...regular psych call.

You'll see that psych patients are the most somatic beings on the planet.

 

[Anasazi23]

A lot has to do with nursing. Many will deflect demands to see the dr. for you, but many just won't no matter what, and page you telling you they said the dr. would see them. Then they write your name in the chart ratting you out so that if (God forbid) something happens, you're screwed.

 

[Anasazi23]

Well, I was on call last Saturday, and the past Monday, the holiday. I didn't feel the burn at the time, but did the remainder of the week.

Looking forward to sleeping tomorrow.
Had a midnight emergent consult.
55 yo AA male, BIBA after family called 911 secondary to unresponsiveness. Found to have AMS in ER. Given glucose, labs drawn:
WBC 11.2
Neutrophils = 67%
HR = 110-120
BP = 185-210/110-135
O2 = 98% on RA
CPK = 1180
BUN/CR = 18/2.1
CE's = neg
EKG normal except for the tachy
Periods of brief lucidity
Admitted to CCU
Became agitated, attempting to punch/hit nurses, more confused
Psych consult called for eval and recommendations for ams and agitation.
Family split out, and isn't around.

I put him in 5 point restraints...screw the CPK.
Any ideas?

 

[Poety]

Well, I was on call last Saturday, and the past Monday, the holiday. I didn't feel the burn at the time, but did the remainder of the week.

Looking forward to sleeping tomorrow.
Had a midnight emergent consult.
55 yo AA male, BIBA after family called 911 secondary to unresponsiveness. Found to have AMS in ER. Given glucose, labs drawn:
WBC 11.2
Neutrophils = 67%
HR = 110-120
BP = 185-210/110-135
O2 = 98% on RA
CPK = 1180
BUN/CR = 18/2.1
CE's = neg
EKG normal except for the tachy
Periods of brief lucidity
Admitted to CCU
Became agitated, attempting to punch/hit nurses, more confused
Psych consult called for eval and recommendations for ams and agitation.
Family split out, and isn't around.

I put him in 5 point restraints...screw the CPK.
Any ideas?

no , tell me

 

[Anasazi23]

Update to above.

Vitals contine to be unstable. Pt. remains lethargic with periods of agitation. Manages to pull out 2 IV lines.

I recommended .2 Narcan IM with some effect. Remember, the Bun/Cr could have been better. Another .2 woke him up, but then personality disorder kicked in, and like many awoken addicts, was pissed we took off his obtunded high.

Went home the following day.

 

[Poety]

Update to above.

Vitals contine to be unstable. Pt. remains lethargic with periods of agitation. Manages to pull out 2 IV lines.

I recommended .2 Narcan IM with some effect. Remember, the Bun/Cr could have been better. Another .2 woke him up, but then personality disorder kicked in, and like many awoken addicts, was pissed we took off his obtunded high.

Went home the following day.

Yeah well, I'm not appreciating all this "work" stuff thats been taking you away from your SDN duties - its like "I'm on call" oh "this patient almost crashed" WHAT ABOUT US SAZI? HUH? DO WE NOT MATTER ANYMORE? DO WE NOT HAVE THREADS THAT NEED TO BE STARTED? Don't leave me to start another one again - or I just may show up.....at your doorstep

 

[Anasazi23]

Called tonight for acute agitation in the psych unit. Arrived to find a woman who was admitted a couple days ago yelling, making a fuss, and vomiting at will. PRN given.

Chart mentions history of bulimia, but admission labs are unremarkable except for hypokalemia (3.0).

I was given sign-out to watch the K+ tonight. Drew labs that showed K+ 2.2. Redraw a K+ level at 10pm after four runs of 40meq Kdur. Repeat in a few hours was 3.3.

EKG shows NSR at 66bpm.

 

[Anasazi23]

6 admissions tonight. I can barely stay awake even though it's only 1:15am. I'm thinking I might have to envoke the often misunderstood Tarasoff rule in the morning. Since the patient is admitted, it's not mandatory. I'll sleep on it.



Very successfully treated a man's concomitant anxiety and tic disorder using one medication (well, two really) this week. Better results than what the neurologists could get, acc'd to the patient.
Here's a hint....

 

[Poety]

6 admissions tonight. I can barely stay awake even though it's only 1:15am. I'm thinking I might have to envoke the often misunderstood Tarasoff rule in the morning. Since the patient is admitted, it's not mandatory. I'll sleep on it.



Very successfully treated a man's concomitant anxiety and tic disorder using one medication (well, two really) this week. Better results than what the neurologists could get, acc'd to the patient.
Here's a hint....

BUMP!

 

[Anasazi23]

Ok, so I've seen four patients tonight, and there's a break in the action. I retreated to the call room to have some chicken nuggets and provide an update.

Saw a 71 year old man in the ER with cc: "hearing voices"
Dx: Wernicke encephalopathy

Saw a 45 year old chronic schizophrenic who had classic 1st rank Schneiderian symptoms. Admitted him naturally.

Saw a 66 year old agitated schizophrenic woman in the CCU with cardiac conduction defect and QTc = 510 and history of Torsades de pointes, crazy high CPK and ESR. Posed an interesting quesion. What neuroleptic to give someone with documented QTc prolongation and conduction defect?

Here's a link to a nice little article:
http://ps.psychiatryonline.org/cgi/content/full/52/5/607

And another, older, but more thorough one:
http://www.ajp.psychiatryonline.org/cgi/content/full/158/11/1774

 

[Poety]

Ok, so I've seen four patients tonight, and there's a break in the action. I retreated to the call room to have some chicken nuggets and provide an update.

Saw a 71 year old man in the ER with cc: "hearing voices"
Dx: Wernicke encephalopathy

Saw a 45 year old chronic schizophrenic who had classic 1st rank Schneiderian symptoms. Admitted him naturally.

Saw a 66 year old agitated schizophrenic woman in the CCU with cardiac conduction defect and QTc = 510 and history of Torsades de pointes, crazy high CPK and ESR. Posed an interesting quesion. What neuroleptic to give someone with documented QTc prolongation and conduction defect?

Here's a link to a nice little article:
http://ps.psychiatryonline.org/cgi/content/full/52/5/607

And another, older, but more thorough one:
http://www.ajp.psychiatryonline.org/cgi/content/full/158/11/1774

How come when I read your blog I get very very afraid of internship? Please God, don't let me kill someone!

 

[OldPsychDoc]

Saw a 66 year old agitated schizophrenic woman in the CCU with cardiac conduction defect and QTc = 510 and history of Torsades de pointes, crazy high CPK and ESR. Posed an interesting quesion. What neuroleptic to give someone with documented QTc prolongation and conduction defect?

So did you go with the combination of Mellaril and Geodon?
You could always throw on a little amitriptylline if the Geodon causes some insomnia...

 

[Anasazi23]

So did you go with the combination of Mellaril and Geodon?
You could always throw on a little amitriptylline if the Geodon causes some insomnia...

Exactly. The Mellaril is what cured her ultimately, I think.*

Like they say, "all bleeding stops eventually."



* Please do not attempt. Professional driver on closed course.

 

[Poety]

Exactly. The Mellaril is what cured her ultimately, I think.*

Like they say, "all bleeding stops eventually."



* Please do not attempt. Professional driver on closed course.

I'm always gunna prescribe Mellaril for prolonged QT interval syndromes - don't you? And also, I think I'll up the dosage while the patient is on thorazine while I'm at it - that way I can BE SURE its working

 

[Anasazi23]

Complete nightmare...

In the ER almost continuously since 8am. Saw 10 patients there. This is also interspersed with two agitation episodes on inpatient, 3 floor consults, and other crap.

Someone mentioned today that the hospital census is so low because of the nice weather that finally arrived in New York. Their theory is that the census drops in New York in the Spring every year because people don't want to spend the nice days admitted to the medical floor. Then, they asked me when the slow time was for psych....my answer was something to the effect:

Summer: Bad for the hot weather, which causes agitation, fights, drinking. People are out longer, drink more, and develop substance-induced psychotic/mood disorders
Fall: Bad because people are beginning to become depressed as daylight fades and SAD and winter doldrums kick in
Winter: Bad because homeless want out of the cold, and are prepared to fire up their Ganser's syndrome act; winter depression is in full gear. Others depressed from lack of physical activity. Somatization increases
Spring: Bad because bipolars typically become hypomanic to manic during this time, preparing for their summertime full blown mania.

 

[Anasazi23]

Also, hemmed an hawed over restarting someone I admitted on ziprasidone after discovering ST elevations in all leads, with a flipped T in III. I finally determined that it was either early repolarization and/or pericarditis (no symptoms of the latter). The cocaine on board complicated the matter.

 

[Poety]

Also, hemmed an hawed over restarting someone I admitted on ziprasidone after discovering ST elevations in all leads, with a flipped T in III. I finally determined that it was either early repolarization and/or pericarditis (no symptoms of the latter). The cocaine on board complicated the matter.

<singing Eric Clapton> ba ba ba ba... cocaine. I don't know any other words to that song except "cocaine" thats sad.

 

[OldPsychDoc]

<singing Eric Clapton> ba ba ba ba... cocaine. I don't know any other words to that song except "cocaine" thats sad.

"She's alright, she's alright, she's alright....Co-Caine."

 

[Anasazi23]

Second wind post call euphoria!

"Cocaine", as sung by Eric Clapton (a hell of a lot better than "tears in heaven")

If you wanna hang out
You've gotta take her out
Cocaine
If you wanna get down
Get down on the ground
Cocaine

She's alright,
She's alright,
She's alright,
COCAINE

If you got that lose
You wanna kick them blues
Cocaine
When your day is done
And you wanna ride on
Cocaine

She's alright,
She's alright,
She's alright,
COCAINE

If your day is gone
And you wanna ride on
Cocaine
Don't forget this fact
You can't get it back
Cocaine

She's alright,
She's alright,
She's alright,
COCAINE

She's alright,
She's alright,
She's alright,
COCAINE

 

[Poety]

"She's alright, she's alright, she's alright....Co-Caine."

THATS IT!!!! she's awright she's awwwright..... coooooo caine!!!

speaking of which, "riding that train, high on cocaine, da da da dad adada, soothe your mind, trouble ahead, trouble behind, la al ala lalalala"

Sorry for the thread hijack Sazi -

 

[Poety]

Hey sazi, what does this image mean? It looks like it depletes the dopamine in 10 days or whatever that lighting up part is, and then it goes back to half of normal - is that chronic or is that with 100 days of use? And is that permanent?

 

[Anasazi23]

THATS IT!!!! she's awright she's awwwright..... coooooo caine!!!

speaking of which, "riding that train, high on cocaine, da da da dad adada, soothe your mind, trouble ahead, trouble behind, la al ala lalalala"

Sorry for the thread hijack Sazi -

I'll never complain about a Grateful Dead-inspired thread hijack.
I have a Steal Your Face Pin on my white coat lapel. You'd be surprised at the rapport I get out of it at times!

 

[Anasazi23]

Hey sazi, what does this image mean? It looks like it depletes the dopamine in 10 days or whatever that lighting up part is, and then it goes back to half of normal - is that chronic or is that with 100 days of use? And is that permanent?

-From the Brookhaven National Laboratory-
"This slide shows images of a healthy brain (top row) and the brain of a cocaine addict taken at 10 days (middle row) and 100 days (bottom row) after the last cocaine dose. Working from scans like these, taken at the Brookhaven National Laboratory, on Long Island, New York, Dr. Nora D. Volkow studies the long-term effect of cocaine use on the brain. Even 100 days after a cocaine addict has stopped using drugs, the decreased metabolism in the brain's frontal area remains visible. This region of the brain influences behavior such as regulating impulsive and repetitive behavior, planning and organizing activities, and critical thinking. "

 

[Poety]

-From the Brookhaven National Laboratory-
"This slide shows images of a healthy brain (top row) and the brain of a cocaine addict taken at 10 days (middle row) and 100 days (bottom row) after the last cocaine dose. Working from scans like these, taken at the Brookhaven National Laboratory, on Long Island, New York, Dr. Nora D. Volkow studies the long-term effect of cocaine use on the brain. Even 100 days after a cocaine addict has stopped using drugs, the decreased metabolism in the brain's frontal area remains visible. This region of the brain influences behavior such as regulating impulsive and repetitive behavior, planning and organizing activities, and critical thinking. "

wow, well if this isn't some great information I don't know what is! Now we're seeing WHY its so hard for a coke addict to get off the drug - I'd like to see some follow up studies at one year and two years - wonder if they have any subjects that stay clean long enough to follow them!

 

[OldPsychDoc]

-From the Brookhaven National Laboratory-
"This slide shows images of a healthy brain (top row) and the brain of a cocaine addict taken at 10 days (middle row) and 100 days (bottom row) after the last cocaine dose. Working from scans like these, taken at the Brookhaven National Laboratory, on Long Island, New York, Dr. Nora D. Volkow studies the long-term effect of cocaine use on the brain. Even 100 days after a cocaine addict has stopped using drugs, the decreased metabolism in the brain's frontal area remains visible. This region of the brain influences behavior such as regulating impulsive and repetitive behavior, planning and organizing activities, and critical thinking. "

It would be interesting to see if this changes if you've got them on bupropion during this period. There's some interesting new evidence (consistent with some of my clinical experience) that that weak DA agonism helps coke & meth addicts to stay abstinent in this critical early recovery period.

 

[Poety]

It would be interesting to see if this changes if you've got them on bupropion during this period. There's some interesting new evidence (consistent with some of my clinical experience) that that weak DA agonism helps coke & meth addicts to stay abstinent in this critical early recovery period.

I was thinking about this the other day during my neuro rotation - they should do some research on it. I was also wondering if snri's would be more helpful as opposed to say - ssri's.

 

[Anasazi23]

Since we're talking abou countdowns (on the other thread), I have three (3) more Saturday calls for the rest of my residency career.

 

[Anasazi23]

NOthing like going to the ER and seeing a 25 year old guy who's on SSI because he has OCD which is manifested "by taking long showers." (15 mins, I asked).

Demanding that I admit him to restart his zoloft, which he hasn't taken for a year, which he only now was told by a shelter buddy that it didn't work because of his extensive cannabis abuse.

So much respect - being this doctor thing and all....

Then, having a flying, ketchup and coffee soaked (don't ask) double quarter pounder with cheese flying toward your head after telling said patient he wouldn't be admitted - then having obscenities screamed at you until you leave the room and on the way to tell security to help discharge the patient.

Then even more fun to go up and find another patient with no BM for 1.5 weeks, hardened abdomen filled with stool and making a diagnosis of atonic ileus.

Oh the glamour.



One more Saturday call for the rest of my God-forsaken life.

 

[Anasazi23]

Today is my last Saturday call ev-er!

Hear that ?

EV - ER !

 

[Poety]

Today is my last Saturday call ev-er!

Hear that ?

EV - ER !

And there he goes, with the dancing pe..., errrr bananas

CONGRATS SAZI!!!!!!!!!!!!!!!!!! How many more calls do you have?

 

[fiatslug]

I am coming up on the delightful end of weekend/holiday call too--only a couple more left.

The downside is--b/c I'm pregnant & want to get ALL call over with before the 2nd tri ends--is that I'll be on q3/q4 weeknight call for the next 12 weeks. Lucky girl!

Got paged to ER at 3:48 am this morning. To re-admit a pt the unit had d/c'd at 12:30--he asked for a TAR (Tx Auth Request, for Medi-cal pts, for non-formulary meds... how is Prozac non-formulary?) for his Prozac before d/c, they said, "uh, you probably won't need it," he spent 6 hrs trying to get it filled w/o success, then presented to ED with the tiniest "hesitation marks" on his wrist (I've had worse shaving injuries...). Yeah, I wasn't too happy with my fellow resident for booting this guy w/o the TAR--I coulda slept all night otherwise!