I can't believe it's Wednesday. The days just seem to fly by so quickly. I haven't gotten homesick surpringly though. I've been pretty busy-as you can guess at the hospital this week. For the last 7 days I've been the attending on our team-as the person in charge was out for a conferance. Things got even crazier as the person in charge of the second team was away on vacation so I was kind of covering both teams and helping out when things are needed. It's been incredibly hard as we are very short staffed and the medical students who normally help out have been on vacation for the last 3 weeks- i haven't even met them yet. In any case, I've learned to accept the fact that I can't help everyone and i've now resorted to the, work as hard as you can till 4:30pm and then stop and pick up where u left off the next day.
I've seen a lot of interesting things and I"m learning tons.. especially when i'm forced to make decisions on very limited data. It was not too long ago-- maybe few months? where my mentor had brought a rack of ribs for our group to practice on how to place a chest tube. While i felt at that time it was an important skill to have while working internationally in underserved community I didn't really expect that I would be relying on this experience to help get me through.
I had just finished rounding on about 15-20 patients with my team. 2 interns, and a nurse that i have grown very fond of as he's excellent and just works with our team- i teach him and he helps us out a ton. After rounds, I walked which ended around 1pm I just walked through the outside balcony to see if i could help out in any way. There is always something to do. This one gentleman I passed by was laying curled in a fetal position. I stopped and looked for a moment and asked the guardan what the person's problem was. Not surprisingly the patient's chart was missing. The guardian of the patient could not speak english so I took notice of the patient's Chest X-ray just laying in a big manila envelope. Holding the x-ray up to the light and one glance at the left lung I literally let out a gasp of air. The patient had a huge left sided pneumothorax which literally compressed the entire left lung and there was tracheal deviation with midline shift of the mediastinal content. I quickly ran and asked a nurse to translate for me and apparently this patient had arrived the night before and had not been seen by anyone. The CXR was never even reviewed. I pulled out my stethoscope and placed the flat portion against the patient's chest. Wait a second why do I feel pops and why does the skin feel crunchy? palpating across the chest, into the neck and into the face it was apparent the patient had an air leak into the subcutaneous tissues. This patient had subcutaneous emphysema! A chest tube was necessary-this much I knew but I had never put one in before. I searched around to find someone anyone who could assist me. unfortunately everyone was out for lunch but i did find one intern who had put in a few during his surgical rotation. We wheeled the patient to the treatement room and a chest tube was found and a make shift pleuravac was constructed using a jar filled with water, one tube in the water 2 cm deep and a smaller tube that was just dangling in the water untouched and only exposed to air. this was thanks to my super intern who remembered how to construct one of these devices..
I decided to give the chest tube a try. a 3 cm cut into the 5th intercostal space midclavicular line and then dissection dissection dissection away until i heard a pop just like the cork of a bottle. the tube was inserted and attached to the tubing leading to the bottle. in an instance i saw yellow pleural fluid and air bubbles. it was a success.
the hardest part was suturing the skin as his skin was tough like sandpaper. I ended up finding only chromic gut sutures at the entire wards were out of sutures.
finally the chest tube was done and i was impressed and relieved I had done it successfully. the patient was actualy very calm during the procedure and granted i did lidocaine him he didn't complain at all.
Here's the kicker and the part that literally made me want to bang my head against the wall this morning. I was making rounds this morning to check up on my patient. Expecting the patient to tell me.. "i feel much better". I walk by him and my jaw just drops. His head was the size of a balloon literally. His eyes swollen shut. IN an instance i look at the bottle. The water had been emptied out and the tubing exposed to air... and unclamped!!!!! Who the hell did this. It finally became apparent that one of the staff members saw that the bottle was full and emptied the whole thing out leaving the tube not submerged with the chest tube exposed to atmosphere air and pressure. the tube was also left unclamped. Basically i was suprised the patient was alive.
Not knowing what to do,I just ended up asking the surgeons to help me out and one of them told me the subcuatenous air would just dissolve with time and just to refill the bottle. My anal retentive self opted to open up the suture wound and resuture the tube just in case the air trapped in the tissue had dislodged the tube. i was pretty mad.. spending so much time the day before putting the tube in and just b/c of one mistake the patient was worse off. I felt bad for the patient but I've also learned to accept that things like this happen especially due to lack of training.
I also took care of a heart failure patient today whose heart rate was in the 200s. he was so close to being discharged home from the triage area until i felt his pulse and it was super high. atrial fibrillation, a-flutter. given the heart rate i thought it was likely atrial flutter. I had him valsalva twice and did a carotid massage with no result. the only medicine that i could offer him was po digoxin or po propranolol. I opted for po propranolol and his HR came down a little. Let's see if he does okay.

In other exciting news, after talking to staff members, nursing, other doctors, I've decided to give a huge grand rounds presentation on heart failure and how to do and read and EKG on a very basic level. I find that the EKG machine is underutilized. It will take me 2 weeks i'm guesstimating to make a powerpoint presentation. apparently it has to be in 2 weeks because anytime after that one of the doctors who is the president of malawi's personal doctor won't be able to attend as he is attending the president's wedding ceremony.

I guess i had a lot on my mind today. I'm surprised. haha

by the way, I saw city of angels last night. not bad for a nicholas cage movie.