ER doctor, pediatrician, intensivist...

Dr. Chang Noi facing the nursing station. Behind him is the "ICU" where our sickest patients are placed. We currently have two patients being monitored there. 

This week has already been entirely different than last. For some reason I think the world decided it wanted to test me when Jen was gone and Mew and Yot decided to leave, and now things have calmed down a bit again. Not to say that this week has been entirely uneventful. We have had some very sick patients this week, which has kept us on our toes.

First thing Monday morning during rounds I was told there was a patient in the ER "vomited blood". Now we all know that can mean literally anything--from some blood streaks in the sputum to frank massive hemoptysis. Well, in this case it was the latter, and I knew it pretty quickly when I saw a puddle of blood in the ER doorway entrance. There was blood everywhere. Fortunately, the patient was stabilized with IVF and TXA, only had one additional episode of frank hematemesis, and Jen was able to emergently get him to EGD. He was able to clip his bleeding varices, however due to his risk of rebleeding and the fact that he was Thai, we transferred him out to the local government hospital. FUN. 

The rest of the day was actually a calm Monday- just like apparently everywhere else in the world Mondays are the crazy days here, and the rest of the week tends to taper off. Monday this week was calm, which was a nice break from last week's chaos. 

We have however had a few very sick pediatric patients, one a 2 month old ex 32 week preemie with respiratory issues at birth who presented grunting with an O2 sat in the 80s. We presumed bronchiolitis, and treated him as such, and fortunately he did well, but managing these tiny humans is far more frightening here than at MMC where we have a PICU and endless resources. We are fortunate enough to have a visiting neonatologist here from Singapore this week who was very helpful in managing this infant, who overall did well. 


Unfortunately we have other patients right now who are not doing so well. Yesterday I admitted a woman from Burma who presented after having a flaking/peeling rash for an unknown amount of time, altered mental status, significant weakness, and no urine output x 5 days. To put it bluntly, she looked like she was dying. Her labs however were remarkably okay- she was hyponatremic, with normal renal function, slightly low potassium, and normal LFTs. Her albumin however is 1.1- which is very low. She has diffuse pitting edema and worsening ascites, likely due to her profound nutritional deficiencies and hypoalbuminemia. Today her blood pressure has been cycling downward in the 60 systolic range despite being on increasing doses of norepinephrine. We dont have any albumin to give her or anything else that might help to expand her plasma and allow for the fluid shifts that she needs. She still has not made any urine despite lasix. We are not sure where else to go. She is from Burma and thus does not have access to the Thai government hospitals, so we will do our best. 
The visiting Singaporean anesthetists attempting an EJ. I placed a femoral central line after we were unsuccessful in obtaining peripheral access. 
The above mentioned patient resting. She did sit up today, but I am concerned we have nothing else to offer her. 


The rack of current inpatient charts as of this afternoon at 1600. Not as many as last week...


oh and chicken pox! or pretty sure it's chicken pox...

AND FINALLY, THE HIGHLIGHT OF THE WEEKEND:

PIZZAAAAAAAAA

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