Cutting the cord

Today was a day unlike any of my other days here. Jen was gone, I was (and am still) alone with just Mew, and things were just a little busier than has been "normal"....

It started at 7am with a call in broken english about a woman who had just had a vaginal delivery "something, something 30 minutes". I show up in the L&D suite with a woman in the lithotomy position with a bowl of blood between her legs and a blood pressure ~60/40. "Retained placenta, 45 minutes". I quickly try to assess the situation and what I needed to do, which I knew was to get the placenta out. I called Jen, and through video call he walked me through the process which involved putting my entire forearm in the woman's uterus and peeling the attached placenta from her uterus posteriorly until I was able to remove it. It came out, thank god. Her BP stayed stable normalized with IVF, and she stopped bleeding. 

830 rounds, (after the daily morning worship). The inpatient department has been busy with all the pre and post op plastic surgery patients. Luckily no big surprises there. Everyone is good for now. 

930 see patients in the outpatient department (OPD). I am slow as hell given that every patient I see requires at least two conversations, me to the translator, the translator the patient, and then back to me. The translator I've been working with the most, Badura, is amazing. She speaks like 5 languages, and I'm not the only one that depends on her, so she never gets a break. I see as many patients as I can, but because of the language barrier, and the fact that I'm functioning as a family physician and have to look up stuff on Up to Date for nearly every single patient, my efficiency is quite poor. 

1030 or so, one of the anesthetists from the plastic surgery team finds me to tell me about an incident that occurred during their first case of the morning. A 1 year old female undergoing cleft palate repair under general anesthesia received 10mg IV morphine, 10 times the dose she should have received. Good news: she is stable and breathing on her own, Bad news: she is far too somnolent to extubate and might be like this for a prolonged period of time given the duration of action of morphine. "What do we do?" he asks me, meaning should we keep her here, should we transfer? Well shit...I dunno!? I've been here 3 weeks....and Jen is gone to Bangkok. Finally we get Jen on the phone and determine that we have to support her through this, that we cannot transfer her as this would be terrible for the Singaporean team, and so we come up with a plan. Before I left at 6pm, she was extubated and awake, however could decompensate overnight in which case maybe I'll have to intubate a post-cleft palate one year old with possible laryngeal swelling from already being intubated...I'll be checking on her shortly and throughout the night. 

By 3 pm, I'm still seeing patients in the OPD and haven't eaten lunch yet.  Feels like home:) Throughout the shift there are several patients that come into the ER with various complaints, all stable, but needing attention, and luckily Mew is able to manage most of this (or at least the ER nurses go to her first). I see the last patient, and just as I'm about to admit a patient with ? CHF exacerbation from the ER, the nurse runs in with a 2 month old yelling "doctor, seizure!". Fortunately, the baby was not seizing, looked great, was afebrile, but given his age I admitted him for observation, labs, etc. 


And now it's just after 11pm. As I was writing this post earlier I got two different calls to the hospital, one for the aforementioned 2 month old who had another "episode" with prolonged desaturation. Come to find out, I could have trusted the saturation probe in the ER when it was showing he was satting in the 80s, because once we were able to test three different probes the infant was in fact hypoxic to around 80%. No increased WOB or cyanosis, just straight hypoxia. On closer evaluation, he had some expiratory squeaking at the right lung, and in the setting of three days of viral URI symptoms, his presentation certainly could be consistent with bronchiolitis +/- apneic episodes. 

And the last call was for a 57 yo with HTN, CKD, and gout who had a right sided basal ganglia hemorrhagic stroke 11 days ago, and was reportedly admitted at an outside hospital, presenting now with persistent nausea and vomiting and hypotension with persistent left sided hemiparesis. Is it a worsening ICH? Is it renal failure? Is it a viral gastro? or is it the colchicine he is on for gout? For now, his renal function is stable at 2.5 and his BP is improving. He feels better with reglan and it's time to get some sleep. 

Hopefully they all feel better in the morning....


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