By Chance a fracture?

As usual, just when my night ER call coverage is about to expire at 8 am, I get a call at 7:55 am for a patient who walked in complaining of backpain. Great! "Can you send him to be seen in the office? we open at 8:30?" Nope, once they are registered for ER they have to be seen in ER. DARN IT@!

I go in and it was an obese patient, young guy in his 30s. I have seen so many people coming to the ER for pain meds and it has made me suspicious of everyone. "what happened sir? How can I help you?" I asked.

"I jumped off the back of my truck and when I landed I had severe mid back pain. I always have back pains and see an orthopedics regularly but now it hurts". And that my friends, is the typical pain med scenario. They have had back pain forever, seen many specialist, nothing works....etc etc etc.

"Do you have any medical conditions?". No nothing except for Ankylosing Spondylitis (AS). Now that perked my ears up. For us in the medical field, when we prepare for the boards, we learned that AS=Bamboo Spine. I have seen a few of these patients during my sports med rotation. Their spine x-rays look like large Bamboo stick. "Is that why you see orthopedics often?" yes.

I examined his back, there was no swelling, no skin redness or bruising. He pointed to his mid back and when I touched his spine at that spot, he squirmed in pain. I called radiology and had them take him for x-ray of spine. It took us a while to fit him on the x-ray table due to his large abdomen and his pains but we did it.
I went to my office to check my computer and see what time my first patient was coming in and then returned to the x-ray department.

His x-ray looked normal, not sure I could call it to a bamboo spine but right at the very top of the x-ray, the disc looked like it was split open, to the outside but it was very faint and difficult to see. I had them get a radiologist for me and he confirmed that finding and requested that I get a CT scan of the spine as that looks like a CHANCE FRACTURE. A what? he explained that a chance fracture is a fracture through the spinous process and vertebrae. Meaning that there is a serious risk for paralysis. OH NO. My patient was walking around without any spine protection.

I ran back to the ER and the patient was not there! I called and the nurses had brought him up to the nurses station so that they could do their morning sign outs. He was standing around waiting for me.

I literally had to force him into the bed and immobilize him, then called around to several spine centers in Minneapolis and found a spine surgeon who accepted him as a patient to operate on. I shipped him out that morning.

Apparently people with AS have very brittle bones and their spine is fused and not flexible so a simple fall can lead to devastating fractures. But he walked in to the ER by himself so I was not suspecting much. My definition of a chance fracture? its a chance that you can become paralyzed.
Here are some pictures that I found on the internet:

http://img.medscape.com/fullsize/migrated/545/253/ajr545253.fig4.gif
http://img.medscape.com/pi/emed/ckb/radiology/336139-386639-1998.jpg

Mister, you smell good

I was speaking to one of my patients during an office encounter when my office door suddenly opened and the office manager popped her head in and angrily said: Dr. I need to talk to you. I had never seen her mad before so I apologized to my patient and stepped out.
She was steaming. She led me to the next door room and said that a mother had brought her child in for an office visit and she is now in a wheel chair and hardly conscious. She was pissed at the mother of the 13 year old child as she had neglected to get a refill on her type I diabetic meds and had also stopped giving her child her thyroid meds last month for no apparent reason. She wanted me to teach the mother a lesson.
I walked into the room and a nice looking child was slumped in a wheel chair, sweating and her eyes were closed. I sat beside her and felt her pulse, she was clammy but pulse was normal. I nudged her a little but she did not open eyes. I looked at the mother, and I admit that I probably looked at her in disgust from what I had heard. I asked her what happened and she said that its been so hard keeping track of her childs issues and she ran out of her insulin and she has been acting sick the past few days. I sat up and wheeled her to the hospital (our office is connected to the hospital) and got STAT blood works on her and had the nurses start her on IV fluids as the finger stick blood sugar test that we did came back HIGH (which means that its over the limit that the unit measures, which is usually over 450).
I returned to the office to finish up with my other patients but my mind was swirling with questions regarding this innocent little child. How could someone be so careless regarding such a serious issue? I was now steaming mad too. I returned to the hospital and by now she had received over 1 liter of IV fluids. She seemed more comfortable. Her bed was surrounded by other nurses and the office manager was there as well. They were all scared as she still was not responding to anyone (I had already called the twin cities to have her transferred with a helicopter to children hospital). The helicopter crew had arrived. I leaned over the child to take a closer look at her breathing pattern. She seemed comfortable and was not sweating anymore and her repeat blood sugar values were now in the 400s.
As I was leaned over her I asked her if she can hear me as her eyes were still closed. She answered "Mister, You smell good". The whole room burst in laughter and for a brief moment, we all forgot that this is a sick patient.
She did well at the children hospital and was sent home in 3-4 days but from that day forth.....I still get jokes about how good I smell!!!!!!!!!

To heim or not to heim

As a family practice resident I was in to do a physical on a 7 year old boy, with mother and two other siblings who were 3,5 years old present. As I walked in I noted that the 3 year old brother to the patient was sucking on some candy and drooling all over his shirt and floor. The upper half of his shirt was completely soaked.
I kept on questioning the mother regarding the 7 year old but kept looking at how intensely the 3 year old was sucking his candy. All of a sudden, when I had just started the physical exam, the mother screams "Oh my god my child is choking". I swirled my head and sure enough the child had a blank face, mouth wide open, gasping. I stormed out of the room to ask for help but no one was there. I ran back in and instinct took over. I grabbed the child and flipped him stomach first on the palm of my hand and with his back facing me, I started to slap his mid back. He responded by covering the whole of my office floor with vomit. Within that vomitus was a large piece of red color plastic matter, roughly the width of a golf ball.
My heart was pounding out of my chest and then I noted that the mother seemed to be talking to me. I looked at her trying to follow her conversation. She had started exactly where we left off prior to this incident. Unbelievable. Did I miss something or did your son almost choke to death? was the question that I kept thinking about. Oh well. Maybe this was a regular issue at her home, kids choking on food.
The next week, I had an in-service exam and one of the questions, was almost my exact scenario. The choices were, back thrusts, Heimlich maneuver, finger swipe and something else, that I don't remember at this time. I answered back thrusts since I knew first hand that it actually works. WRONG. The correct answer is that anyone over 1 year of age gets Heimlich maneuver.

If you don't ask, you will never know

Recently I saw a 7 year old girl in my office with his father. She was here because they had found blood in her stools. The kid seemed every embarrassed and admitted that months ago this happened as well. The father said that she always goes to the bathroom and takes a long time but her stools are always soft and there were no worries for constipation. The kid denied straining when pooing. On top of my list of things that could be wrong were hemorrhoids or an anal fissure so I told the kid that I would have to take a look and poke around a little. She was nervous but with the help of the parent, I examined her.
No signs of any external hemorrhoids and I could not feel anything internally. No signs of any fissures or blood as well. I explored any chance of sexual abuse but the parent and kid denied it. I pulled the father aside and asked if I can speak with her alone. He left us alone. I asked the kid more questions to explore for any sexual abuse and I felt very comfortable that nothing was happening on that front.
I asked the kid how does she wipe herself and she said that she itches a lot so she has to wipe herself differently than others.
That was an interesting answer! I cut out a piece of paper from the sheet that she was sitting on and gave it to her and ask her to show me. She rolled the paper into a ball and then said that she has to stuff it in her anus and move it to stop the itching. "Do you do this everyday?", she said yes. That was so cute and was probably the cause of her periodic bleeding.
I called the father back in and told him the good news. Kids can be so inventive.

5 parts to a last name

Its funny going to a small town. Sometimes you standout due to your accent, sometimes due to your looks and these days, if your name sound foreign. I had an interview for a position in Maine and boy oh boy.....I ran out of there as fast as I could. The airport security people acted like they had never seen a foreigner and had a hold of a terrorist. They did everything but an anal exam on me. It took him just over 5 minutes to give back my driver's license. I apologized to the hospital CEO but said that I could never come back there again.

Now here, in my little town, I stand out too but, its been a pleasant standout. People are more curious than anything. When I originally set-out to come to the US for my residency I told my dad that I am going to be called Dr. Mo because no one can pronounce my last name. He scolded me and told me that if I allow people to do that, it would be like they were insulting me every-time they called my name. He insisted I force everyone to call me by my full name. Hmm. That did not go well during my residency training and Dr. C is what most nurses ended up calling me. My Attendings were much better at it though.

When I started here in MN, again, I forced the issue that I should be called by my full name. Guess what happened! Everyone is calling me by my full last name and doing a darn good job of it too. Of course I found many funny cheat sheets hidden here and there where nurses had broken down my last name vowel by vowel phonetically. My last name is 14 letters long and is divided into 5 parts...Che leh ......won't post it all since I do believe in some discretion when posting on the internet.

The power of tears...the magic of distraction

One early morning at my new job, while I was switching from one patient's room the next, I noticed a nurse bringing in a child in a wheelchair, followed by two concerned parents. I finished seeing my other patients and I made my way to the child's room. She was in tears.

This 9 year old girl was apparently doing cartwheels in the school yard when she suddenly felt pain in her right knee then stopped moving. School nurse called the parents and she was brought in. I had a lot of thoughts crossing my mind while they were describing the event to me, as there are few medical cases that are specific for children in this age group that we as doctors need to be on the lookout for and had already drawn up plans in my head to get a series of x-rays.

I sat in front of the child in the wheelchair, she was already teary eyed. I examined her knees together side by side, they looked the same, no evidence of any swelling or redness. I then reached out and touched her right knee......she screamed in pain and I jumped. wow. I reached and touched her right hip she cried out loud again. This time I thought something was odd. I had barely touched her. I moved behind her and then touched her mid back...she screamed again. Hmmm.

I looked at her parents and they seemed horrified. I moved in front of her again and then I asked her to point out with her left index finger and then I gently pulled her finger. She screamed in pain again. I could barely stop myself of chuckling. This kid was fooling us all. I looked at the parents again and from the look on their faces they had realized it too.

"tell me, what do you want to be when you grow up" and she immediately answered "cheerleader!". I shook my head and told her that she can't be a cheerleader and she perked up and angrily asked why not.
"Because cheerleader are very flexible and they can do jumping jacks" she immediately stood up and was mad and said "I can do jumping jacks too!" and started to hop up and down in the room. I told her that I still wasn't sure because cheerleaders can do the splits. Suddenly she went down on the office floor and did the splits.

I looked at her parents and told them I don't think we need to do any X-rays. They looked embarrassed and thanked me and they all left the office. That was one funny encounter. The next time I saw her (weeks later) she ran towards me yelling "Hi Dr. Chili". That last name of mine has been pronounced so many ways before, but never Chili.

A night as a resident: Death Is Coming

This is story from my residency that I wanted to share with people. It is medically oriented so if you don't understand medical terminology you might find it a hard read. I am pretty sure that all the rest of my medical cases will be in plain English but this one, is one that has some teaching points and maybe discussion points for anyone in the medical field and so I thought would be worth sharing. This is an actual event and I have changed the names of the real doctors involved in this story.

Enjoy.

2166….Not again!!!!!!!

I knew I shouldn't have commented to Dr. Blue it is so quiet out here. I knew it. How often do you walk into the doctor's lounge at 7:00 am and be handed a list with just 3 names on it?

3 admissions, a circumcision and a STAT delivery later, at 10:30 pm it was the damn beeper again. 2166. I slowly made my way to the ER, greeting mike the PA, something about a man with chest pain. I got the patients labs and information and made my way to the other side of the ER and spread everything on the table there. "You see it You write it" she said. I always remember that saying by Dr. Pell. She was my upper year on my first week as a resident at Montgomery hospital. Now that I am a second year resident, I try to tell all my interns that same saying. It seems to make admissions go slightly faster….

"Dr. Chelehehel.... and Dr. Sing STAT to room 232" screamed the speaker overhead. I am used to them mixing up my last name but they were getting better I thought. I jumped up and ran towards the stairs. As I was leaving the ER one of the Nurses commented "Its probably my patient". Why are they calling me? Let me see today is Sunday, I am not the house doc…oh that's right, my intern has to cover the 2^nd floor while I have to supervise her and take care of family practice patients. I was so glad that it was not a weekday because then I would be the house doc and I would have to cover the ICU as well. I needed to have some time to study for step 3.

Must be an urgent issue that they want me with my intern as soon as possible. The room was already buzzing with other nurses and supervisors as I arrived. A little old lady, who seemed out of breath, looking at us one face at a time behind an oxygen mask. Dr. Sing, the intern, arrived as well and followed behind me.

"whats going on" I asked…"I don't know, I just got this patient from the ER and I can't keep her O2 SAT elevated. We have her on 100% non-rebreather now and she is Satting 95%". "Mam. Hi. Are you in pain? No? any pain anywhere? Any chest pains? Do you feel nauseous or anxious? No?"

hmm.. Except for her rapid breathing, she was fully alert and denied any pain. Her Lungs were clear in all quadrants with good air entry.

"What was she admitted for? Can I see the chart please? And can somebody call the attending please" The patient, an 82 year old female with sudden back spasms 2 days ago as well as on day of admission, with Nausea and vomiting and fever, positive UA, admitted for Pyelonephritis. She was given a shot of levaquin 500mg IV, some dilaudid and compazine and was sent to Medsurg. I flipped to the H&P sheet it was not done yet. There was a CT of abdomen and pelvice: Diverticulosis…. No comments about the kidneys. Study limited due to lack of contrast…. I checked the labs, Cr. Was 1.3.. WBC 23, H/H 12.9/36.

"Do we have IV fluids running?" the nurse answered "NS at 80"

"Can you Up it to 150 cc/hr please"

PE was high on my list of differentials along with an MI.

"Do we have spiral CTs here?" I asked daught the Nursing supervisor. She said whats that. Never mind I said, can we get a V/Q scan please?

She went ahead to call the V/Q technicians but then I remembered that it is the weekend and on weekends we only get the V portion of the V/Q scan. How can you have a mismatch if you only do the V scan I don't know. I changed my mind again. "I want a Chest CT STAT with contrast. RIGHT NOW. And lets get her to the ICU"

I noticed a family member in the room. I asked her if she knew if her mother ever had any lung issues or complained of any chest pain. She said she didn't think so but took me outside to the waiting room by the elevators where the patient's husband and other family members were. They all said that she never had any heart or lung issues in her life but did say that the patient mother died of a pulmonary embolism. Otherwise a very healthy and active 82 year old female.

"Can I get a Chem 7 and CBC, Troponin I STAT as well please" As I was flipping through the labs I noticed all the liver enzymes were slightly elevated as well and repeat LFTs and RUQ U/S was scheduled for the am.

"Can you add LFTs to that STAT labs please"

The ABG's results had returned. The bicarb was 8 with a pH of 7.25. WOW I said and the nurse then handed me the phone with the attending on the line. It was one of the fornan doctors. I told them what happening and that I wanted to give bicarb. He said that look at the bicarb taken earlier in the Chem 7 in the ER. It was 24! Big difference. He said that he trusts that value more than the ABGs value. So I held off the bicarb. He said to call him back with the CT results. The only other abnormality on the labs was a WBC count of 23 and 88% neutrophils. I checked the ER records and Blood cultures were already taken.

I made my way to the ICU. I asked Dr. Sing a favor.. to return to the ER and do the admission, I had grown comfortable with her handling of patients through the last two weeks.. It was a straight forward case I thought, a 37 year old man with chest pain R/O MI, and I didn't think my attending would mind me not being there to supervise this one.

The patient was brought back at 11:45. She was now Satting at 90% on 100% NRB mask. What the hell is going on. I asked the nurse to give a couple of amps of bicarb now regardless of the chem 7 being more accurate. I was worried. She, the patient, reminded me of those asthmatic kids that end up taxing their accessory muscles then end up looking comfortable and that scared me that I might have to intubate this patient soon. I sat beside her. Held her hand and told her what we think it might be and again probed for any hint of anxiety or pain. She mentioned that her back still hurts, the same pain that had brought her in. But denied any pain with inspiration.

Dr. Mart the house doc also dropped in the ICU and I told her about the patient and she said that lets check the ABG again. The Bicarb was now 9.4 and the pO2 was 250, pH 7.25. She also agreed that we should correct the metabolic acidosis now while we wait for the labs. So I gave a few more amps of bicarb and then started a bicarb drip in Normal saline. Now she was receiving Normal Saline and bicarb with saline.

"Is she producing any urine?" There was no foley. "Can we put a foley please?" This was a sight that I was not ready to see. It was as if someone had turned on a switch. Instead of urine I got a steady stream of blood collecting in the foley bag. The hair on the back of my neck stood up…. Can pyelonephritis do this? I thought it could give blood tinged urine… but this looked like plain blood. I kept my composure and I covered the line so that the daughter would not see it.

"eh…mam, did you urinate today?" I asked the patient. She said that she went to the bathroom in the ER and it was not bloody and she did not have to strain to pee. Bloody urine 6 hours after entering the ER….what was going on here.

I went back to the computers and check the labs. There were not in the system yet! They were taken STAT at 11 pm I think. Why are they taking there time, I was thinking. The phone rang and it was the ER. They had received the fax with the CT result and someone was going to bring it up. I asked them to fax it up.

I hopping that I would see results indicating a PE. I didn't like the way this story was going forward. Normal Chest CT with contrast. Some evident of reflux. Is it an MI? where were the labs?

I called chemistry and they said that they never receive the sample…What? We all saw the technician taking the sample. The nurse that I was working with got frustrated as well and decided to take the blood herself to the chemistry. She came back up and said that the lab technician was trying to say something to her but she couldn't understand his accent but she thinks that he ment the sample was hemolyzed or something…....

Hemalyzed!!!!!!!! I looked at the patient again. She was alert and talking to her daughter through the facemask. Hemalyzed…. Pickedup the phone and called chemistry and said that I needed fibrinogen and fibrin split products STAT. Then I called the ER and spoke with Dr. Morr. He said that to watchout for sepsis and increase your antibiotic coverage. Good point I thought. I ordered Vancomycin and Gentamycin IV NOW and gave Nexium IV as well for the reflux that was seen in the CT.

I called the attending back and he said that to do an urgent consult to pulmo and hem-onc and don't be afraid to intubate.

"She is bruising all over her neck Dr. C" I went and checked her neck. Yes there were ecchymosis spots that were not there before. I also scanned all her IV sites and there was no oozing of blood from anywhere. But the IV sites did look traumatized and were blue. I held the patients hand and told her don't worry we will figure this out. I hinted at the daughter to meet me outside.

"Your mother is breathing so fast that she will get exhausted soon and might need to be intubated. Can I discuss that with her? It is only so that she doesn't die from being too tired to breath until we figure out what we can do."

"She has a living will. Does that fall under extraordinary measures?", I think so I said. "She is alive right now and she is alert. Do you mind if I ask her?" She said that lets go and ask her. Now I realized why its important to get the level of care of a patient in the ER before anything happens. "Mam, I am afraid soon you will become really tired of breathing so fast and you might suddenly stop breathing. In order to help you breath, I can put a tube from a machine in your airway to breath for you so that you want be tired. I would give us more time to figure out what is happening. Would you allow me to do that?"

She looked at me, then at her daughter. Her daughter said "Mom, at any other time I would say no, but we have a wedding in two weeks that we want you to be at, please say yes this time." She then nodded with her head and then said "Dr. Do what you have to do", I told her I will.

I went back to the phones and asked the nurse to get a hold of someone from pulmonary and I called Hem-Onc. I got a hold of Dr. Trop. He sounded sleepy..."did you get new labs?" no everything coming out of this lady is clotting right away. While discussing the case with him we concluded that its either a weired allergy to Levaquin, the first new drug given to her in the ER or, its overwhelming sepsis that is causing a DIC (disseminated intravascular coagulation) type reaction. He said that to start the patient on steriods so I began with 120mg solumedrol IV. I told the nurse to call anesthesia and let them know we have to intubate a patient.

Meanwhile the nurse got a hold of Dr. Pate from Pulmo so I switched phones and told Dr. Trop I will update him. Dr. pate agreed that the patient should get intubated. I got the vent settings from her and hung up. I asked the nurse are the anesthesia guys coming? and she said NO..

"What! Why not?" I said

"They weren't sure if you really wanted it or not and I told them you were still discussing it with pulmo"

"call them back and tell them that Pulmo wants the patient intubated". They then said that they will come.

I finnally sat down for a minute. I realized that my back was aching. It was like I was in the eye of a storm.

"Thank You Dr." I looked up and it was the daughter. "And you too" she said to the nurse sitting by the fax machine. "You guys have been really caring and really great. My whole family really appreciates what you guys are going through."

I couldn't bear hear those thanks. What had we done for this lady? nothing yet. Just hopping that things would somehow turn around. The lab lady who somewhere down the line had come to take more blood samples showed me one the patients blood vials. Amazing. The recently drawn blood had already separated into cells at the bottom and plasma on the top. Unbelievable.

It was then that the nurse I was working with throughout this ordeal turned to me and madly said"I cannot believe you want to intubate her, we should just keep correcting her acidosis with bicarbs. look at her, ever since we started the bicarbs she looks better and calmer. You doctors keep ordering intubation's for no reason and put these patients in more harm and torture"

She was soo livid and mad at me. I told her I think she is wrong. The patient will soon tire out and stop breathing. She disagreed and seemed disgusted at me.

I stood up and walked away from her. am I wrong? Isn't the patient getting tired?

The patient was now surrounded by a few more of her daughters and grandchildren. She looked somehow, calmer, more relaxed. My instinct told me that she is getting tired but.....what if I am wrong? what if these ICU nurses experience is what I should be listening to?

The anesthesia nurses arrived and the nurse let them know how she felt. They surveyed the patient and spoke with her. She was fully alert, oriented and answered questions properly. Her O2 Sat by now had dropped to 79%. The anesthesia group said that they don't believe that reading. "See how good she looks, she is alert and has a pO2 of 250. Are you sure you want to intubate her? maybe the bicarb is fixing her acidosis."

"Mam, do you feel tired" the anesthesia nurse asked. yes, she answered. "Do you feel tired because its 3 in the morning and alot is happening or because you are tired of breathing" No she answered, she was not tired of breathing she said.

I was getting really submissive by this point. How come I was the only one thinking this patient needed to be intubated? even the respiratory tech somehow managed to show some disgust towards me for thinking this way but he unwillingly was setting up the vent with the setting that I had given.

The Anesthesia nurses called their supervisor and they all decided that the patient does not need intubation.

I backed out slowly, and I called Dr. Pate.

"Nobody here wants me to intubate. And the patient does look better, and she did say that she was not tired of breathing. Can I just monitor the vitals and if she gets more shallow breathing to intubate?" She sounded mad at the anesthesia people but said ok, Just follow very closely please. I said that I will. She even offered to come to the ICU herself to helpout, but I said is there anything you can do more if you were here and she said not really. I told her to stay put I will contact her if needed and thanked her for the offer.

I finally received a set of labs. Fibrin split products were elevated....DIC it was. I called back Dr. Trop. Nothing can be done he said. We could give blood, FFPs or platelets but if the root cause is not removed, they will just be fuel for the fire. Just manage supportively.

I sat back down again, lay my head on the table thinking. In the corner of my eye I noted Dr. Mart was looking at different patients charts and wondered what she was doing 4:30 in the morning in the ICU. It then hit me. I AM NOT THE HOUSE DOC. I didn't have to endure this sad adventure. I could have been on the floors or in my call room studying. But I am glad that I didn't. I hope that I never see DIC again, but I was a solid learning experience that I shall never forget.

The phone rang asking for me. It was the ER. Another admission at 5 in the morning. There was nothing else that I could do at this point so I told the ICU nurses that I will be in the ER call me there if you need me. Said a few words the family and I left.

I couldn't stop thinking about my patient. I had told her to be strong and she had told me to do what you have to do.

As 7 am approached and I started to signout to the morning team, there was a call to house doc stat to the ICU and I knew this was my patient. I ran upstairs with the morning team and indeed it was her. She had stopped breathing. I almost burst into tears. I looked at the nurse and the anesthesia team, they both tried to avoid looking at me. I was so mad. I just walked out. I asked the team to walk out from the other side so that I wasn't get confronted with the patients family. We made it back at the doctors lounge and I continued my signout, but I couldn't hold back my tears.

Dr. Pate the pulmonologist came to the lounge a little later and said that the patient was stabilized. I felt a glimmer of hope and after signout I made my way back to the ICU and spoke with the family one last time. Somehow it looked like they were ready for the worst or that they knew the end was coming. I gave them as much comfort as I could and I told them to prey. As I turned to leave the guest lounge by the ICU, there was a priest waiting by the door. They knew what I didn't. The ICU nurse told me what DIC stands for.

Death Is Coming.

As I left the building at 9:00 am, through the revolving Mont. Hospital doors, I faintly heard "Code Blue ICU" and I left.

She passed away that morning leaving me with a lot of ifs and buts. I thought that I will be mad at a few people but in the hind sight, it was probably for the best that we didn't intubate her. It could have caused more trauma and severe bleeding into her lungs and killed her sooner. Then I would have been a lot more upset.

Note: Now, 4 days past the event, I found out that the blood cultures grew Clostridium Perfringens and that the patient had eaten a yogurt that was dated to expire on august 2nd and had felt nauseous and vomited before coming to ER. I also heard from the attending that the nurse putting in the Foley had told her that "It Stunk down there". On further research I found out that she had a pessary put into her vagina over 1 year ago that she was not cleaning. They are supposed to be taken out and cleaned regularly. I brought this up with the OBGYN doctor in the hospital who said that there are known cases of pessary's actually ulcerating into the bowl and bladder when not cleansed frequently and because of this, they do not recommend pessaries for older ladies who are less likely to wash it. That is what I think happened to my patient as clostridium perferingens is an anaerobe, which is very unlikely to be found in the blood...but it can get there if the pessary perforated the bowels and bladder, introducing it to the blood stream. I don't think that my patient had an autopsy so I really don't have the definitive final conclusion as to the cause of her sepsis with Clostridium Perfringens, to this case.

The Chronicles of Dr. C

Hi
I am a newly graduated family physician that has started to work in a very small town in Minnesota, with a population of 2570....err, correction, 2572 when you included my wife and I. It has been a little change for us living here, considering we have lived most of our lives in other small towns such as Toronto, Philadelphia. Anyways, I have had a blast working here as I am IT. I mean really IT. I cover the ER, admit patients into our inpatient service, which is myself again, and then discharge them to be followed up in our clinic.....by myself again. AND, I do deliveries too. Its the ultimate physician continuity deal. Did you ever see the show "little house on the prairie?" that's where I am and I am that doctor. I cannot go into town without bumping into someone thanking me for doing this or doing that or saving an uncle, dad, aunt, cousin....etc etc. I almost feel like I should be wearing a tie just to go to the market and pickup some milk.

Now, to the reason for this blog....I have come across some interesting stories, case scenarios and issues that I was sharing with some of the nurses I work with and one of them mentioned "You should make a website called the Chronicles of Dr. C". I thought that was cute....and then I got more cases that were fun to talk about. So here we are. I will write them in plain English for everyone to enjoy. I have one story from my residency that I wanted to share with everyone too, but I fear that it will appeal more to the medical community than the general community, but its worth posting.