Sunday, October 29, 2006

The Case of the Internal Jugular Line

Last week, I received a page. It was not an ordinary page – not like the other million and one pages that I normally receive from nurses asking for Tylenol or from my students giving me an update on their patients. The extension that appeared on the tiny LCD screen of my Motorola pager indicated that somebody was paging me from the sixth floor, where all the offices of the administrators and attending physicians are housed. My heart skipped a beat. I braced myself and dialed the extension.

“This is Dr. Lee, I was paged,” was my automatic greeting. I immediately recognized the voice of one of my attendings from General Surgery. At that moment, a myriad thoughts flashed quickly through my mind: “I’m on Pediatrics now . . . Why is he calling me? Did I do something wrong? Am I in trouble? Did I violate my work hours by going over eighty hours per week? What could he possibly want?”

He began the conversation by firing a series of questions at me. With his characteristic southern drawl, he asked, “First, I just wanna ask you, were you on call for Trauma on September 29?”

I replied, “If my name was on the schedule for that day, then, yes, I was on call for Trauma on September 29.”

Without skipping a beat he asked, “Then, the next thing I wanna ask you is, do you remember if there was anything special or different about that day? I ask because there was a particular progress note with only my signature on it by the student’s note, but there was no intern or senior resident signature. Do you remember if on that particular day the senior resident was not present or if I happened to round with just the students or if there was anything else unusual about that day?”

I answered, “I honestly do not remember if there was anything unusual. I do know that a resident does not always sign the progress notes, but that does not necessarily mean that we were not present.”

He then asked, “And the next thing I wanna ask you is, do you remember a lady with an arm amputation and a C2 fracture?”

I replied, “There were actually several arm amputations that I took care of on Trauma Surgery that month, so can’t for sure say that I remember that lady in particular.”

My attending proceeded to tell me, “Well, the problem is that that patient died. And she was apparently discharged with a central line still in her neck. And she was also discharged after being on IV morphine here in the hospital without being switched over to oral medications. ” He continued, “Do residents on the SICU generally let you know when they are downgrading a patient to the floor if there is a central line in place in that patient?”

I answered, “No, they don’t.”

“Or are you aware of a policy somewhere stating that that piece of information should be relayed?”

“No, sir, I am not aware of such a policy.”

“And aren’t patients usually converted over from IV morphine to oral pain medications to see if they can tolerate it before they are discharged home?

“Yes, they are.”

The attending continued, “I am not in any way trying to say that you are at fault or did anything wrong in this case. I am simply trying to get a better understanding of what happened on that day. If you think of anything or have any more information after you take a look at the chart, call extension 01055. Anything you think of might be helpful in this situation.”

I replied, “Thank you for informing me of this situation. I will try to review my personal records as well as the chart to see if I can think of anything.”

“Thank you, Dr. Lee. Bye.”

Thoroughly confused and somewhat taken aback, I hung up the phone. A few days later, as I reviewed the chart and spoke with the administrative assistant who was investigating the case, I realized what had happened. The patient had been recently downgraded from the SICU to the Trauma service a few days before her discharge, and she still had an IJ line (central line in the internal jugular vein) in place under her C-collar (neck brace) at the time. My co-intern was assigned to this patient, but on that Friday, September 29, a new intern came on service and inherited the patient that day. She was discharged with her IJ line still in place. Later that evening at a motel, her husband noticed that she had something dangling from her neck, and so he brought her back to the hospital. At that time, it seems that they asked for some oral medications, and someone apparently prescribed her MS Contin in a dose that was three times what she had been taking at home for chronic pain. The mystery lies in who prescribed the MS Contin; the handwriting is clearly different from that on the discharge paperwork, and there is no documentation anywhere in the chart of anyone having given it to the patient. My question: could the night float intern have prescribed that when the couple returned to the hospital for the IJ removal? Only time will tell.

Anyways, after her discharge (I do not know how long afterwards), the patient subsequently went into respiratory failure. At first it was feared that it may have been a complication of having been given too large a dose of narcotics. Although the cause of death remains unknown, administrative secretary stated that the respiratory distress clinically fit the picture of a pulmonary embolism. The patient was taken to a nearby hospital, where she eventually died. And now the disgruntled husband is planning to sue.

What a disaster. Every surgeon's nightmare. I am just thankful that I was not the one who wrote those discharge orders (or any orders on the patient during her hospital stay, for that matter). I would just as soon stay out of trouble with the law this early in my medical career.

And I have learned my lesson always to check for central lines before I discharge my patients home.

Sunday, October 22, 2006

My Friend Nyein

Today, I had a wonderful time hanging out with my friend, Nyein. Nyein is a Burmese girl that I met during my freshman year at UCSD. She is currently working up in Northern California. Thoughtful and sweet as she is, she made it a point to fly down just for the day to visit and celebrate my birthday with me (I turn twenty-seven tomorrow!). Not only is she thoughtful, she is also beautiful (inside and out), intelligent, articulate, and loyal. I also respect her for her faith – that she was able to make a commitment to believe in Christ during her undergraduate years despite the strong cultural pressures of her Buddhist upbringing. She is a joy to be around, and I appreciate her friendship. I am privileged to have her as one of my bridesmaids in the upcoming wedding. Here are some snapshots that we took today. My poor technologically challenged self had a hard time figuring out how to set the self timer button, so we took pictures the old-fashioned way, extending our arms out as far as we could. hee hee. Try to guess who's holding the camera in each picture. ;)

Wednesday, October 18, 2006

Jukes and Aileen Tie the Knot!

The news you have all been waiting for. *Drum roll* I’m done with General Surgery! Last week on Thursday was my last official day. One thing I am sure of is that I will not miss waking up at 4 am every morning. Now that the weather has gotten much chillier in the early morning hours, I appreciate the fact that I can stay in bed until 5 or even 5:30 am! =)

Pediatrics has been fun so far. On Monday morning I started Newborn Nursery. My job is to assess and admit every baby born to the hospital (that is, if the baby does not go to the Neonatal Intensive Care Unit). We carry around a little pager akin to the infamous Trauma pager from Surgery. Every time there is a C-section or a crash delivery with complications (meconium or shoulder dystocia, etc.), the obnoxious pager goes off. *BEEP BEEP BEEP BEEP BEEP BEEP BEEP* “Crash C-section in OR 1! Crash C-section in OR 1.” I jump every time the pager rings (a result of PTSD from my Trauma days), but the workload is not too bad. It seems that in the last two days, however, there has been an overwhelmingly large number of babies. In fact, there were so many admits last night that the white board we use to keep track of all our babies could not even hold each individual, so we had to resort to pen and paper for the extra babies. Today, rounds seemed to last an eternity; we had to see 35 newborns (anywhere from 1-3 days old)! Why this sudden explosion in census? Counting back the days, I realize that this must be a product of New Year’s or Valentine’s Day.

Speaking of love . . . last Sunday (October 15, 2006), my friends Jukes Namm and Aileen Vitangcol were married! It was an intimate wedding at an exclusive estate in Palos Verdes overlooking the Pacific Ocean. Watching Jukes hold back his tears of joy triggered tears in even the manliest of men.

I participated in a string quartet with Leslie Kim (violin), my brother James (viola), and a girl named Joo (cello), who is doing her Master’s in music at USC.

Jukes and Aileen, being showered with petals after the wedding

Paul and me, exploring the estate grounds

For more pictures of the wedding, check out Renato's blog

Monday, October 02, 2006

Paul in Honduras

Ahhh…I’m back on Trauma Surgery again. Coming off of night float, it’s good to be able to sleep at night and work during the day. I have just two weeks left on this surgery rotation, and I will forever be done!!! Trauma seems like a vacation now. I only had 17 patients on my list this morning. Since I split those patients with one other intern, I only end up seeing about 8 or 9 patients each morning. That sure beats juggling 26! =)

During my week of night float, Paul and Ken were in Honduras on a Dental mission trip. I sooo wanted to tag along, but unfortunately I was stuck here taking care of my patients. Here are some photos of Paul on his trip.

Paul with the orphans

Getting drenched under a huge waterfall

Exploring the ancient ruins

Paul and Ken seemed to have had a wonderful time on the trip. They were able to serve the needy with their skills in Dentistry, and they were able to see a little of the natural beauty that Honduras had to offer. Oh, the joys of medical missions! One thing in this life that I am sure of is that I am called to the medical mission field. Ever since my high school years, I felt called to serve overseas. Currently, Paul and I are seriously praying about going to Africa after we finish our training here in the United States. That should be an adventure.

This past weekend I had the privilege of going to church for the first time in several weeks. It is unfortunate that my internship schedule prevents me from getting Saturdays off. During my two months on General Surgery I was only scheduled to have a grand total of two Sabbaths off! Nevertheless, I have learned to appreciate and cherish the Sabbath so much more now that I rarely get to go to church. This Friday evening I went straight from work to the "Freedom from Fear"evangelistic series with Pastor Randy Skeete. I felt so blessed to listen to a convicting sermon and to sit amongst fellow believers. On Saturday morning I went to church, and then I spent the rest of the afternoon hanging out with Paul. We listened to another sermon online before having dinner. Afterwards, we attended the final meeting of the evangelistic series. Although I went to bed a little later than I would have liked (it was so difficult to get out of bed at 4 am the next morning), I was thoroughly blessed to have had such a spiritually rejuvenating weekend. The Lord knows I surely needed it. =)