Filling in the gaps

On a more serious note, in terms of work, we are getting used to the hospital system and have been working throughout the hospital, including the wards and the admissions room (equivalent to the Emergency Department in the US). Due to the general attending staffing shortage and lack of systematic coverage for interns/residents who are sick or on leave, we have found that patients often are not seen by a physician on a daily basis.

For example, when a patient is decided to be admitted by the intern in the admissions room, they will often sit in the waiting area for 1-4 days before a bed becomes available for them in the wards. During this time, it is rare if they are seen again by another physician, let alone started on the appropriate medications or interventions. During this time, it is not uncommon for patients to die. What we have found to be the most helpful is to round on patients throughout the hospital who otherwise wouldn't be seen by an attending or intern. We have had minor successes... starting IVF on a man who initially presented with altered mental who has become so dehydrated due to lack of access to fluids that he was hypernatremic to 167(!), ordering blood and a PPI for a patient whose down-trending Hgb was left unnoticed by the scurrying interns and nurses around him, and repleting the potassium of 1.2 in a HIV+ male with cyclical vomiting and diarrhea....though all minor interventions, they are ones that hopefully prevented their demise.

One of the sadder cases we have seen this week, in which our interventions were too late pertained to a previously young and healthy man without HIV who presented with altered mental status. He underwent a lumbar puncture and results returned with +India ink stain suggestive of cryptococcal meningitis. He was treated empirically for crytococcal and bacterial meningitis for 3 hospital days. His mental status had worsened to a near comatose status, but despite lack of inprovement on antibiotics, his treatment plan did not change due to lack of physician follow-up over the weekend. (Here, only pre-determined "sick" patients are seen on the weekends.) By the time Nicole and I met the patient, we were extremely suspicious of this diagnosis as his CD4 count was in the 1000's and his negative HIV status was confirmed. Furthermore, his CSF cytology was fairly bland other than the India ink stain. We repeated the lumbar puncture which returned with no crytococcal organisms seen, and it was felt that his prior results were likely due to lab technician error. We ordered a head CT which took 3 days to obtain. It demonstrated a subdural bleed with overlying abscess. 1 hour after the correct diagnosis was made and while attempting to get a hold of the neurosurgeons, the patient expired with the family at the bedside.

-f