Once again I arrived at the Palau hospital on Monday morning with no plan for the week. In a way I’m glad there isn’t a structure otherwise I might be forced to be in surgery, at least this way I can do things I'm interested in. I decided once again to hang out in the walk in clinic. I’ve now become a known face in there, as I mentioned two weeks ago they gave me a room with a stack of patients and I reported my findings to one of the doctors before deciding on a final plan. This time they were happy to see me and the Doctor in charge of the clinic gave me my own room, along with her provider code, instructed me how to work the color coded flags on the door, then disappeared back into her room and said to call her if I have any problems.
I knew they were cutting me loose, but I was still a bit worrisome about actually signing my own orders and prescriptions. As time went on I was still pretty careful and would do everything for the patient including writing all orders and scripts, but as they were walking out the door I would still typically tell the doctor in charge something along the lines of “I just had this patient and I gave them this”, just to make sure I wasn’t missing anything. The truth is there isn’t too much wiggle room with what kind of treatments can be offered. Most people came in with simple things like colds and flus, others had some kind of gastroenteritis. Medication options were also limited.
The patients were simple enough and the treatment protocols were inflexible enough that I eventually was flying solo not bothering the doctors with something I knew I could handle, or knew they would be forced to give the same treatment anyway. They pretty much expected this from me anyway, and it was really pretty amazing to be able to earn their trust like this.
In the midst of Gout and runny noses one elderly lady came in with the simple complaint of feeling weak and dizzy. It turns out she was a known diabetic and decided to not refill her medicines three days ago. Her blood sugar read “high” on the monitor, which meant it was over 400. She was a little confused, complained of a headache, and was thirsty. She wasn’t really that sick looking so I started working her up for a diagnosis of hyperosmolar hyperglycemia which if left untreated can become lethal. I ordered the labs I would need and decided to give her IV fluids as she was no doubt massively dehydrated. I started her with a simple bolus of normal saline and then started trying to figure out everything else she would need, what kind of electrolytes to replace, etc. Once I had all the formulas in place for how much her fluid deficit was and how much insulin I thought she needed I went to find the head doctor to discuss it. She was no where to be found. There was another doctor that only gave me a look of bewilderment when I started taking about calculating fluid replacements and insulin and potassium requirements.
I probably could have recited off the treatment for this without thinking 6 months ago. But, fluids and electrolytes shifting around is something I’ve never been very strong at, and I was really worried I would miss something big and send this lady into a worse position than I started with. I decided to wait for the head doc to show up before moving any further. The nurses were already a bit confused about how to run some of the things I was asking for. They never give insulin IV for example. As I was sitting there waiting for this doctor and searching the internet getting a crash review course on things like total body water and calculated vs. actual sodium levels the charts on my desk began to pile up as more patients were waiting to be seen. I felt a sudden wave of panic as I wasn’t sure if this lady could just be forgotten about for the time being while I saw other patients waiting for the doctor, or If I needed to do something emergent due to the treatment I had already started. It was the first time and surly nowhere near the last time that I felt someone’s immediate health and potentially life was solely in my hands, and I had no safety net.
Time went by and the IV I started was done. The lady was walking around the hallway waiting for someone to do something with her. I was forced to start seeing other patients, thankfully they were nothing too distracting, and ankle sprain, maybe an ear infection. The old ladies labs came back with a blood sugar over 850 and a whole array of lab values no where near normal, at least it confirmed my initial diagnosis. When the doctor finally got back from the meeting no one knew she was in I gave her the run down and explained what I wanted to do. She nodded her head agreeing with everything and modified a couple of things based on what they are used to doing, and maybe not what the Massachusetts General Hospital recommends.
The lady eventually got admitted and all over values returned to normal in the next day, and she went home only to probably be back another day. Of course there are conditions that I could have saw that are more life threatening, but the possibility was definitely there to screw things up. All it would have taken was forgetting something like adding potassium to the insulin and she could have spiraled downhill. I once had a roommate that graduated a couple of years ago from med school and in her final days she was no longer excited to be done, but scared she was going to kill people. I’m pretty sure I get where she was coming from now.