Thursday, December 23, 2010

What Is The First Night On-Call Like?

This common question is answered by an internal medicine intern's experiences on her first night. The text below is a repost of the entry "First Night On-Call", first published on the blog Life In A Q4 World.

October 7, 2010 - In our residency program, like in most others in internal medicine around the country, life revolves around a “q4” call schedule; that is, overnight 30-hour “on call” shifts every 4th night. As an intern, a first-year resident, our “on call” day starts at 8 AM, and we stay overnight in the hospital admitting patients and cross-covering for the other teams who aren’t in the hospital overnight until 2 PM the next day (i.e. 30 hours.) If we’re lucky, we can sleep for an hour or two, but usually cross-covering for 30-40 patients means getting paged constantly about every fever, request for sleeping pill or pain medication, or anything else that goes wrong in the middle of the night, and the little sleep you do get is interrupted and unsatisfying (not to mention the fact that we share a call room with the other intern on call who’s concurrently getting paged about her own separate patients.)

Anyways, the first night on call is sort of a rite of passage for interns, i.e. it will suck, but we survive it, and once that’s over with, the next 6 calls until the end of our one-month rotation (for a total of 7 calls per month) are usually not as bad, or at least not as shocking to the system. My first night on call as an intern was actually in the intensive care unit (ICU), which is generally a bit more stressful than the internal medicine wards, because the patients who are admitted to the ICU (the “unit”) are sicker than those admitted to the wards (the “floor”.) So while I was expecting that first night on call to be overwhelming, stressful, and exhausting, I was not expecting the very first patient I would admit that night to be one of the strangest and saddest cases in our residency program’s history.

She was a 23-year-old girl who came to the ER for shortness of breath, not an uncommon complaint. Her symptoms were way out of proportion to her physical exam or chest X-ray, which looked not quite normal but not like a horrible pneumonia or collapsed lung either. No matter how much oxygen we gave her through a mask, she continued to have more and more trouble breathing, and the oxygen saturation level in her blood continued to get lower and lower—not a good sign. By the time the ER doctors called us, the ICU team, about her, they already had the intubation tray set up and were planning to intubate her (put a tube down her airway so that she could be mechanically ventilated) in the ER. Given the rapid progression of her symptoms, they were able to get very little history from her, but it seemed that she had been completely healthy previously, and had not recently had any cough, fevers, or sick contacts. We gave her everything we could think of—a slew of antibiotics, antifungals, and antivirals to treat her for possible pneumonia or an early-in-the-season H1N1-type flu, all to no avail. We got a CT of her chest, thinking she may have had a massive pulmonary embolism, but that was not the case either, although like the chest X-ray, the CT wasn’t completely normal—it showed some collections of junk in her lungs, sort of like a pneumonia but not quite consistent with the classic pneumonia picture. In the ICU, she continued to deteriorate right before our eyes, her heart and kidneys started failing so that her blood pressure continued to be dangerously low even with maximum vasopressor medications and her kidneys had stopped making urine. Her husband and family members who were there with her could not give any more information about what had happened—she had been completely fine earlier that morning. The only other finding we got from examining her was that she had two cotton balls on her buttocks, covering what looked like recent injection sites. Neither her husband nor her family members could tell us what those were from—she had a couple tattoos on her legs but not recently and not on her butt.

Finally, after tracking down several of her friends on the phone, it was confirmed that she had gotten silicone injections in both her buttocks earlier that afternoon. At that point, we realized what had happened, or at least had a working theory—the injections had gone into her blood vessels and migrated into her lungs, basically turning her lungs into a solid chunk of rubber. This phenomenon apparently had been reported before, though extremely rarely of course, and was known in the literature as “silicone embolism syndrome”, which we spent the next 2 hours on Google trying to find case reports for. We looked for reports on how other hospitals had treated cases of suspected silicone embolism, only to find that basically nothing worked—it was just supportive care and waiting to see if the lungs would recover on their own, which they usually didn’t. One case report said steroids seemed to help, so we gave her a huge dose, but to no avail. She continued to worsen, and finally as the renal team was starting emergent hemodialysis on her to try to save her failing kidneys, her heart stopped beating and could not be restarted despite over an hour of CPR. She was 23 years old, had a husband and two small children, and had been completely healthy 12 hours ago before she decided to have cosmetic silicone injections in her butt.

The other wrinkle in the story was that the injections were performed illegally by an unlicensed doctor from Mexico who had been traveling around the LA area with his two Mexican assistants advertising these cosmetic butt injections. They had just been released from jail a few weeks prior, and had been posting flyers in the area, surreptitiously advertising these services for a mere $800 per injection. We were informed of this around 3 AM when a team of at least five members of the LAPD came in and started questioning us, informing us they were searching for this doctor and his two assistants, who were being charged with fraud and what it seemed like would soon be involuntary manslaughter as well. At that time we were all too stressed and exhausted to fully take in the horrible irony and moral injustice of it all—paying over $800 to die of complications from a cosmetic procedure, something that seemed almost too typical to witness in Los Angeles, especially within my first two months of moving here from Chicago. As I was writing the death summary for the patient the next day, thinking about how it would probably show up in court someday, the sadness and unfairness of it all did start to sink in some more, but I wasn’t as devastated or fraught with nightmares as I had feared I’d be. My first reaction was actually to email the story to all of my friends so that they would never get butt injections. Maybe medical school had prepared me better than I thought for psychological and emotional strains of residency.

Check out the blog Life In A Q4 World for more insights from a resident in a categorical internal medicine program in Southern California. Share your passion by publishing your writing on Scrub Notes today!

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