It is 2:35am and I am hunched over at the desk making notes in my latest patient’s file. The intern walks in and stops, startled at what she sees. All 4 bays in the medical admissions ward are filled, each occupied by a patient. Things had been a little clearer when she had gone off to get a little bit of sleep at about 22:30. We have both been on call since the previous morning, working pretty much flat out. Just before midnight the doctors at casualty down the corridor had offloaded a whole bunch of patients to us before the start of their new working shift. This meant that in addition to the packed admissions ward we had 4 patients lined up in the corridor outside, 3 of them on stretchers, one seated on the waiting bench squeezed in between the other patients’ family members. Organised chaos, or rather chaos that needs to be organised.
My intern on this particular night is a super smart, efficient doctor. She works through the patients fast, which the nurse in charge tonight loves because there’s nothing she likes better than to clear the patients out of admissions once we’ve seen them, to their designated places, either off back home, or the short stay ward or the in-patient wards. This is so we can have a relatively clear space to work in, in admissions. This night was not one of those nights however, as we had a couple of sickies on our hands. ‘Sickies’ as one of my registrars back in Bara days used to call them refers to patients who are relatively critically ill and need particularly close attention the entire time that they are there. They have to stay in admissions. Out of the 4 patients 2 were diabetics. They were the ones we were worried about. One was a 16 year old boy who had come in the previous afternoon in diabetic ketoacidosis (DKA). DKA is one of the worst things that can happen to a Type 1 Diabetic. Very simply explained, their blood sugar levels go very high, but because of a lack of insulin (they may have been skipping their doses or be on an inadequate regimen) the body can’t use that sugar, and burns body fats instead, producing ketones which are acidotic. The acidosis makes the patient feel very ill and they present at the hospital with stomach cramps, vomiting, and sometimes with decreased consciousness. In managing them the aim is to correct the acidosis. We were giving this young man a lot of fluids very fast in one intravenous line, and a slow insulin infusion in another IV line, while keeping his electrolytes in check. We were winning the battle with him, his blood sugars had been steadily decreasing, and his acidosis improving until one point the previous evening when the nurse reported a sugar reading that wasn’t in keeping with the trend, presumably because at some point in the evening while our attention was elsewhere, he had a snack! This was probably provided by his mother, who was there the entire time. The other patient was an elderly lady who also had high blood sugar, and all the features of DKA except acidosis, which had me kind of stumped. She was in fact in a metabolic alkalosis, her blood pH and bicarbonate levels were sky high. What on earth do I do to correct alkalosis? I mused to myself. How often does one see one of those…? Keep it simple, I decided. Get her blood glucose down and see how she does. I wrote up continious fluids for her as well and an insulin infusion.
I had to take a walk to the neonatal intensive care unit (NICU). NICU has one of only two blood gas machines in the entire hospital and I had a blood sample that I needed to run. Dora is a pretty big hospital and the walk is relatively long. It gave me some time to think about this lady’s situation. She was hypertensive so perhaps it was the diuretic medication that she had probably been on for years. These could be causing her to lose potassium, also making her alkalotic. Maybe…? I thought. But still, what do I do for it? At a loss for an approach, I whipped out my cell phone and tapped on the Medscape reference app. Chloride responsive and chloride resistant metabolic alkalosis came up. Jeepers I thought, as I started reading, it’s 3am and now I have to start conjuring up what I do (or don’t! ) remember about acid-base balance, or imbalance as it were. A sodium chloride infusion is what will help correct a metabolic alkalosis I discovered, so I may have been right to have ordered the IV fluids. If she did in fact have a chloride responsive alkalosis. I would only know after her next blood gas sample, which I had planned for a couple of hours later.
When I got back to the admissions ward I saw another new patient, a 50something year old man who turned out to be in mild right heart failure and had a lung infection. Relatively simple: admission, intravenous diuretics, and antibiotics. And also work him up to exclude tuberculosis. Then I saw a young man in his twenties, brought by his mother. He had ingested half a cupful of engine oil after having a row with his girlfriend (cue heavy sigh!). He was relatively stable clinically, and had no psychiatric history so we did basic blood tests and admitted him for observations. He was patient number 33 since the start of our call the previous morning. When I was done with him it was about 5.30am and I was ready to get a little bit of shut-eye so I retreated to the doctor’s room. At 7am the intern knocked on the door. I had asked her to wake me up, my cell phone battery was at it’s end and I couldn’t set an alarm. As I walked out of the doctor’s room she showed me the latest results of the blood gas samples of our 2 diabetic patients. The young boy was looking good, not quite out of acidosis but definitely improving, and while the older lady’s blood glucose had decreased somewhat her alkalosis was actually worse! Luckily the consultant would arrive soon for the ward round to see the new admissions. He would know better how to approach this.
The consultant strolled in just after 8am and we were busy until about 11.30 presenting all 35 patients we had newly admitted. You can learn a lot on a post intake ward round. The consultant might suggest a different approach to manage the patient, or suggest a diagnosis you had not thought of. Metabolic alkalosis is apparently not a medical emergency, so no need for yours truly to have been freaking out (here read: keeping cool despite being somewhat perplexed 😉 ) Of note, he asked us to discharge the DKA boy, even though his acidosis wasn’t quite corrected. He did look much improved clinically but the specialist physician’s last words “The DKA will resolve itself…” had both the intern and I gawking a little…
I got back to the flat in town in the afternoon and collapsed to a deep sleep. I was awake about 3 hours later. I have this thing about not sleeping all day post call because I feel it’s a waste, even though I’m usually too tired to then do any reading or hec, anything constructive really. I did get started on this latest blog post though, while I still had some of the patient details still relatively fresh in my head. Still later I finally fell asleep while watching a movie on my tablet.
Up early the next day (today, that is) and at work by 8am (8:10am I’ll admit I was a little sluggish this morning!) In a doctor’s meeting until about 9.30 and then on to the ward. I had to see all the ward patients on my own today. Normally this work would have been shared between 3 doctors, one other medical officer (MO) and an intern, but the MO was post call and the intern was off sick. “Do doctors have to hand in a sick note after being off sick?” my girlfriend asks me during a quick phone call while on my way to the ward… 😛 It’s slow tedious work seeing every single patient and trying not too miss anything. The blood results from the previous day, dealing with new symptoms etc. By mid-afternoon I was finally done. I walked across to the other ward to find the intern there also busy with her last patient. So I didn’t have to help her out. My work day was done. I went off home.
Not too long later I found myself in Stanley Street, and the waiter at Posh Eatery offerred me a seat at a table inside. My usual friday afternoon blog spot Yiayia’s, is closed for some reason. It is late evening now and I have just finished writing this post. The
weekend’s plans include running, and reading up on acid base disorders…
Eazy in the EC 