Former KCUR intern Stefani Fontana, now a fourth-year medical student at the University of Kansas School of Medicine, spent last summer doing a clinical rotation in western Kansas. We asked her to keep a journal of her experiences. We’ve edited out actual names of people and places to protect privacy, but otherwise present her journals largely as she wrote them.
Part 3 of 4: Thank goodness for nurses
It was one of my last nights in the emergency department with Dr. O. I was looking forward to getting back to Kansas City, but I was also hoping my last night in the ED would be extremely busy. I liked how staying up all night made me feel strong and powerful, superhuman almost, to my friends outside of medicine and to the other med students who hadn’t pulled all- nighters yet.
I know it sounds morbid when doctors hope for a lot of excitement in the ED, and I don’t mean it like that. I’m not hoping that someone gets hurt. I just hope that when someone gets hurt, because it’s inevitable, I get to be there to practice my skills and possibly save someone’s life.
Eight o’clock rolled around, Dr. O was looking over charts and finishing notes from patients she’d seen during the day. Then the sliding doors opened and someone walked up to the glass front of the nurses station. I couldn’t hear what was being said on the other side of the glass, but whatever the problem was, it was sufficient to get him a room in the emergency department.
I began to get anxious as the nurses roomed this patient and started the initial work- up. I knew it couldn’t have been a major trauma because the patient drove himself to the hospital. Finally, one of the nurses came back to the desk where Dr. O and I were sitting.
“He says he has a rash on his legs and his skin on his feet is irritated because he was using a chemical remover to wash his mom’s floor,” she said, handing us the intake sheet where she’d recorded his vital signs: heart rate, breathing rate, blood pressure and temperature.
Dr. O took the sheet and stared at it intensely. I leaned over her shoulder and tried to look intense too, attempting to get as much information from it as I could. He was a middle-aged Caucasian male. His blood pressure was high. His heart rate was also pretty high. His temperature was almost what we’d call a fever, but not quite. Many people think anything over 98.6°F is a fever, but in medicine it’s not considered a fever until 100.4°F. His breathing rate wasn’t impressively high. He had a low BMI, 21, and was tall and skinny.
Before I could see anything else, Dr. O looked up at the nurse. “Chemically washing a floor?” She sounded skeptical. The nurse nodded and shrugged. I followed her to the patient’s room. Over Dr. O’s shoulder, I read the note stating “the patient appeared older than their stated age.” He did look 15 or 20 years older than his chronological age.
In the patient room, a nurse was trying to stick a needle in one of the veins of his hand. He already had a blood-pressure cuff on and blood-oxygen monitor attached. He was wearing cutoff jean shorts and a black, worn T-shirt. His skin was wrinkled and leathery, his muscles wasted away. He seemed excited to see us when we walked in. Dr. O started down her line of questioning, or “taking a history.” Oftentimes you can figure out what is going on with a patient simply from taking a good, thorough history.
I noticed his feet were red and blotchy. My first thought was cellulitis, an infection of the skin, but I thought surely that was too easy a diagnosis, and I couldn’t figure out how chemical washing could lead to cellulitis.
“What’s this?” Dr. O asked in the direct way I always admired about her. She had a way of being serious but also the kind of fun, talkative person who makes you feel like she’s your best friend. Oftentimes when women are direct like that, they get labeled as “bossy” or a more offensive b-word. But Dr. O managed to be to-the-point when necessary, and nobody seemed upset or annoyed by it. I hoped one day I could do that, command respect without demanding it.
“What’s this?” she asked again, pointing to a purple bruise on the inside of his left lower leg just over a prominent vein. I glanced up as the nurse was still struggling to get an IV line into his hand, which I thought was odd since he had such prominent veins in his legs.
“Oh yeah, I fell off my motorbike,” he said, rubbing his hand over the purple area. “And this other leg I got shot when I was 15 and it never healed.” We hadn’t asked about his right leg, but when I looked at it, there was a matching purple bruise over a prominent vein there too.
“Is that the truth? ’Cause if you’ve been injecting something, you need to tell me. It could change what I think is going on with your feet,” Dr. O said, still pointing a finger at his leg but looking him in the eye.
“No, I told this nurse here, I was just chemical-washing my mom’s floors, and the next day my legs looked like this.” Then he redirected his attention to the nurse, “You really shouldn’t be using the vein in the hand, I’ve got a good one in my elbow here,” he said, pointing to his elbow crease.
I watched the nurse try one more time to isolate a vein in his hand. She failed again, and with a large exhalation, untied the rubber band and tied it on his upper arm to pursue the vein in his elbow crease.
Dr. O and I headed back to the physician’s area to wait for the results of the blood tests. “Is that normal, to see cellulitis on both feet?” I asked her. Usually cellulitis will spread in a contiguous manner, to regions adjacent to the infected area. “No, the whole story doesn’t make sense. I think he may be injecting drugs into his leg veins,” she said.
I was surprised. After weeks in rural Kansas, I’d learned that a lot of our patients were drug users, but it wasn’t the first thing to pop in my head when trying to diagnose someone. I still thought of organic, biological-based problems, not self-inflicted or psycho-social ones.
“Why is he using the veins in his legs and not the one in his cubital fossa (elbow pit), like in the movies?” I asked, referring to the only times I’ve seen injectable drugs being used.
“Sometimes people will have jobs that allow them to wear short-sleeved shirts. If he has track marks on his arms, his boss will see them and fire him. So they use the veins in their legs ’cause they can hide those with jeans,” Dr. O explained.
She pulled up his chart and wrote an order to start him on IV Zosyn. I thought he had a penicillin allergy, but she must know something I don’t, I thought. It must be that Zosyn contains a type of penicillin that doesn’t affect people with an allergy. I watched her put in the order, afraid to question the doctor and be told that this is something I should know. We admitted the patient to the hospital. If someone has cellulitis, it needs to be treated with IV antibiotics, which has to be done in the hospital.
Admitting someone to be an in-patient in the hospital is one of most tedious activities. You have to write orders for every aspect of their life: What can they eat? Do they need IV fluids or can they drink fluids by mouth? If they can’t drink fluids by mouth, can they at least have sips of water with pills, or should all medicine be converted to IV? Do they need help going to the bathroom? Do they need to have their blood chemistries checked every day? Multiple times? And so on. Needless to say, it takes a while to write admissions orders.
We finished writing the orders and headed back to the room in the ED where he was waiting for us to treat him. The nurse had gotten the IV into his arm and was preparing to add the Zosyn to his IV line. She started to set up the attachment for the bag of clear liquid, which was labeled with the drug’s name. She looked at the bag and whipped around, spinning on the balls of her feet, her blonde ponytail flying behind her.
“He’s got a penicillin allergy,” she said with a note of concern in her voice. This caught Dr. O’s attention. “Really? Oh, hang on, I’ll write an order for something else.” I kept my mouth shut, but I was pretty upset with myself. I saw that! I even made a mental note of it! But I assumed there was something I didn’t know, assumed that I was wrong, not the doctor, and was too timid to speak up. And if not for the nurse’s vigilance, we could have caused an allergic reaction in this patient. I didn’t admit this to Dr. O, but I learned an important lesson that night: It’s more important to risk looking stupid or like you don’t know something than to risk a patient’s well-being. I’ve never made that mistake since.
“Okay, we need to find out what drugs he’s been using. Let’s run a UDS (urine drug screen),” Dr. O said to the nurse as we left the room.
We got the patient settled into one of the 20 beds in the hospital’s in-patient wing. After he was settled in, we got the results from his UDS. “He put some hand soap in it to try and confuse the test, but that didn’t affect the results. He’s positive for marijuana and meth,” the nurse said as she handed us the results. That always confuses me when patients test positive for a stimulant, methamphetamine, and a downer, marijuana.
Before going to bed, we ended up starting him on Zosyn despite his penicillin allergy. Because the hospital is small, they couldn’t keep every antibiotic on hand at all times. In those cases, if the allergic reaction is known to be mild – which the patient told us his past reaction had been a rash – then it is acceptable to give the patient a penicillin with Benadryl to temper the reaction. Due to our limited resources, the fact that this was the only antibiotic on hand that could fight this bacteria, we decided to do that.
Ultimately, my reluctance to speak up didn’t have an impact on our treatment plan for the patient, but the guilt I felt over not speaking up has stuck with me since then, and I am a more meticulous doctor for having been through that experience.
Round and round
My alarm went off the next morning at 7. Some of the other doctors liked me to round on their in-patients after the night. I knew I still had to spend the morning in clinic and wouldn’t get to leave the hospital until early afternoon, but I got up to go see the patients we had admitted. I went to the bathroom to brush my teeth and apply makeup. I heard the phone ring in the room that Dr. O had slept in. I heard her speak but couldn’t make out the words. Then she came out of the room, already dressed in her scrubs, and started to leave the lounge area where I had slept.
“Are we going to round now?” I asked, catching up to her in the hallway. I was concerned because, before rounds, I should have reviewed the vitals overnight to make sure they were stable, I should have talked to the nurses to make sure nothing major had happened over night, I should have looked at how many times pain medication was given so I’d know how much pain the patient was in, and I should have examined the patient myself. All of this before rounds. If Dr. O was going to round, I was completely unprepared.
“Last night’s patient is trying to leave AMA (against medical advice),” she said, turning and stopping in the hallway. “He keeps trying to go to his car for something, but the nurses said he’s not allowed to go on his own. So since we won’t let him go outside unaccompanied, and he won’t let us get whatever it is he wants from his car for him, he’s trying to leave AMA. You don’t have to come with me. I think this will be a tough situation to handle. I worry that people like this will be more belligerent if there’s an audience,” she said, turning to the in-patient wing.
One of the nurses later told me the patient was becoming combative because he needed to get high again. For some reason, he was still under the impression we didn’t know he was using drugs.
Thank goodness for the nurses. I never would have caught any of the subtexts of these conversations had they not been willing to explain them to me. The doctors were too professional to say anything that might sound judgmental, anything that was not precisely scientific and medical about the patient. Did they say the patient had used drugs? Of course, that had to do with treatment. But they would never say anything beyond what I needed to know to treat the patient. The nurses, however, weren’t bound by these constraints. Someone once told me that nurses are a med student’s best friend. I took that message to heart, and the nurses have never let me down.
Dr. O met up with me in the clinic about an hour later but quickly ducked into a nearby office to answer a phone call.
I tried not to look like I was eavesdropping as she talked on the phone. “No honey, I don’t think he’s going to come into the clinic, I think it’s okay. Babe, he doesn’t know where we live and we’ve got guns in the house and two big dogs, it’ll be okay,” I overheard her say.
I later found out that the patient, who ultimately did leave AMA, had become so aggressive he’d threatened Dr. O with physical violence if she wouldn’t let him leave.
