Back for Week 2 at St. Charles

     Well, this is really a working vacation.  I get to spend every other week seeing friends and family in Portland, Springfield and Gleneden Beach, but the alternate weeks I'm working hard as a hospitalist at St. Charles Medical Center here in Bend.   It's the major referral center east of the Cascades in Oregon, so we get patients sent in from a lot of small towns.   My first week here, I was impressed with the interesting problems I saw--things we probably would have referred from rural Delaware to the  mega-medical center Mecca two hours away.   A couple patients stand out in my memory.  One was a middle-age man who suddenly became confused, agitated and even violent.  He had just returned from a hunting trip a couple days before, happened to work immunizing horses and counting mosquitoes for a county vector control department.  He had a bit of a fever.  The outlying small hospital had already done a spinal tap to rule out meningitis, though he didn't have a stiff neck.   He had a few lymphocytes in his spinal fluid, indicating a viral infection.   With all those potential exposures, we checked labs for West Nile Virus (from mosquito counting, though his wife said the first frost where they came from had killed all the mosquitoes weeks ago), Western Equine Encephalitis (what they immunize horses for around here) and Lyme Disease (he had been on a hunting trip, and the weather had been warm during the day so maybe some ticks were still around).   We gave him antibiotics for the potential Lyme Disease, anti-virals for Herpes Simplex Encephalitis, and waited.   I was very surprised and excited that he improved so fast.  By the time I finished my first week, he was awake and talking, though still a little hazy in his thinking.   I heard a week later that none of our tests showed a diagnosis, but maybe convalescent antibody titres will tell.  And his brain function seemed back to normal.   I'm convinced our treatment saved him.

    Another patient referred from an outlying hospital was referred to us because we have an MRI available around the clock, and cardiac surgery too.  This elderly man had a stroke just 3 hours after an epidural steroid injection for low back pain.  The stroke work-up included an echocardiogram, which showed a probable vegetation on a heart valve, which can throw little clots (emboli) to the brain causing strokes.  Sure enough, the MRI of his brain showed multiple strokes, consistent with multiple emboli.  Shortly after he arrived, he spiked a fever, so I grabbed several blood cultures and started him on triple antibiotics for probable endocarditis.  The next morning his blood cultures came back positive, and he had a transesophageal echocardiogram to get a closer look at that heart valve vegetation.    Usually, with embolic strokes, we'd order blood thinners too, but I learned that infected emboli are likely to bleed, so anticoagulants shouldn't be used.   Fortunately for this man, his stroke symptoms improved rapidly and he did well.   In several weeks he will be reevaluated to see whether he needs heart valve surgery, and he'll need follow-up to tell whether he had an infection around his spinal cord at the site of the epidural injection.  Meanwhile he'll get 6 weeks of i.v. antibiotics.

   I've taken care of a young woman with advanced Crohn's Disease, a middle aged woman with perioorbital cellulitis, an elderly man with newly diagnosed metastatic renal cell cancer, another with bleeding esophageal varices (varicose veins) from alcoholic liver disease...some really sick people, and not everyone does well.   Then there are the usual problems...COPD exacerbations, dehydration, abdominal pain, low back pain, but they're all interesting because of the personalities of the people involved.  We just had a woman with an intractable cough, even gave her antibiotics for possible Whooping Cough, though the culture was still negative by the time we sent her home.  The respiratory therapist suggested we give a nebulizer treatment of inhaled lidocaine 1%.  It worked to relieve the terrible tickle in her throat and the paroxysms of coughing, and I learned a new trick of the trade!

  I started this blog with the story of a woman with abdominal pain on the flight from Chicago to Portland, resulting in an unplanned stop in Billings, Montana.   She called today, finally back home in California.  It turns out she had a bowel obstruction which required surgery in Billings.  She was very grateful that I "stood up for her" and asked them to land the plane, told me I looked like "an angel looking down on me".   I was delighted that she called to let me know how she was doing, and since she herself is a physical therapist, I talked shop a bit about the woeful lack of medical supplies on the plane, and how I thought it would be impossible to start an I.V. in the back of a plane with all the vibration and jostling.

   So, I'm still struggling to learn the computerized medical record system at the hospital.  My orientation didn't cover all the ins and outs of the system, so I'm always having to call for help.  This week is better than week 1, but I still feel the quality of my work isn't as good as it should be.  It takes a lot of patience and concentration to get it right, more than I have at times.  So it was nice after work tonight to connect with Rob on Skype.  What fun to see him talking to me.  It's tough to find a time when we're both available since we're both working 12 hours shifts in time zones 3 hours apart.  I'm still asleep when he leaves for work in the morning, and he's falling asleep about the time I come home from work.   6:30 pm in Oregon which is 9:30pm in Delaware seems to be a good time for a brief Skype.  Then I still have time to go lap swimming at Juniper Swim & Recreation Center before I hit the sack.  Had a good swim tonight, and now I'm sleepy, so will sign off for now.