Newbie

My name is Mildred Admittalot. You might have been my doctor once, or a doctor to someone like me. I'm 78 and have diabetes, congestive heart failure, atrial fibrillation and chronic kidney disease. I'm on a bucketload of medicines. I've tried to take care of myself, but when I was young there were no fancy insulins or glycohemoglobin levels, and everybody smoked. I was too busy having fun, being a mom and working to worry about how healthy I'd be when I turned 70. That's just the way it is, spilt milk and all that.

It seems like I'm always getting admitted to the hospital. You might call me a frequent flier, but nobody's offered me any points so far, and believe me, there are plenty of other places I'd rather travel to than a hospital.

The emergency department seemed unusually busy as I was rolled in this last time. I'd gotten short of breath after a weekend with my family. Probably too much ham and other yummy but salty items. I'd taken an extra dose of furosemide, but I could see the writing on the wall and figured I'd better get seen before it was too late. I'm a full code girl—no bones about it.

There was a sense of havoc in the ED. The nurse checking me in rolled her eyes when I asked why things seemed so chaotic. The answer was simple: new interns. It was July.

Soon an intern stood by my bed. She looked frazzled, and like a deer in headlights. I waved her over. I was glad to have oxygen running, since the nurse had put me on a 3-liter nasal cannula. I asked her if she wanted to take my history. She stepped closer. She asked what brought me here, and I laid it out concisely for her. I was short of breath and had also noted some dysuria. I made sure she had my history and meds straight.

Then I suggested she examine me. She wrapped the cuff really tightly around my arm and pumped it up so high I thought my hand would explode. She fumbled with the cuff. I told her to turn the little wheelie-knob. She did and the pressure slowly dropped. I asked her if she heard my bibasilar rales, my irregularly irregular rate and my systolic murmur, and whether she had noted my pedal edema. She scribbled notes furiously.

Then I suggested she give me some IV furosemide, since I was feeling pretty bad. She dropped her notebook as she pulled it from her pocket. She began looking up the dosage. I suggested 80 mg. While she was at it, I suggested she check my INR and electrolytes, and get an EKG and a chest X-ray. My potassium was not in the just-right zone, and I was admitted.

I arrived on the telemetry unit. The transport person was new, and at first we took the wrong elevator, but I eventually directed him to the right ward. Thankfully the nurse was experienced. She had taken care of me before and greeted me warmly but with a slight tone of disappointment. She asked if I had been compliant with my meds and diet. I tried to change the subject.

An intern stalked in, interrupting the conversation. He did not introduce himself, but leaned over me and began to auscultate. I stopped him cold and looked him in the eyes. I told him my name and asked his. He grumbled “Doctor Something or other.” I could not catch it. And again he leaned over me, pulling my gown aside to listen to my heart...and again I stopped him with a hand wrapped around his stethoscope. He was stunned. I had touched his scope! I could see his thoughts playing across his face: He was the intern and he was in charge.

Eventually he told me my potassium was high, and we needed to urgently treat it. I asked how high; he told me 6.9. Not too bad; I'd hit 7.3 once. He seemed frozen by indecision about what to do. I gently suggested he check my EKG and see what my T waves looked like. I remembered something about high potassium and T waves being peaked the last time this had happened. Still he stood there, poking at some kind of handheld device over and over. His battery died. He was immobilized.

I took pity on him, and myself. I told him last time they gave me insulin and glucose, calcium, fluids and furosemide and a nebulizer treatment, followed by a good slug of Kayexalate. He scurried off to place the order, but popped his head in and sheepishly asked if I knew the dose of Kayexalate. I didn't.

Things were going well. My glucose was 140, my INR 3.2, my K down to 5.4. A medical student came in to tell me my urine was growing E. coli, and I would be starting an antibiotic. My internal alarm did not ring. I'd been on antibiotics before. The nurse came in with trimethoprim-sulfamethoxasole.

I was about to swallow the large tablet when something began to tickle my brain. I asked the trade name of the antibiotic. It was Bactrim. I knew it. This had happened when I first started warfarin and had a urinary tract infection. I wasn't about to let it happen again. I asked the nurse to call in the team. I told her I'd wait to take the pill until I spoke with them.

Half an hour later the team descended on my room. There were no introductions. Everyone seemed tense. They stood by the door not really entering: new consultant, new resident, new intern, new student. Oh brother. Again I waved them in. Nobody spoke. I gave them the update. My potassium was better, my creatinine down, my glucose controlled.

I was ready for discharge, but I wasn't going to take Bactrim. Hackles began to rise. I could smell the tense static of confrontation, something I wanted to avoid. I looked at the student. I told her that, as I was sure her consultant was about to tell her, warfarin was a dangerous drug with lots of drug interactions, and that trimethoprim-sulfamethoxasole was one of the strongest interactions. So perhaps they could consider a safer antibiotic choice.

I was discharged later that day, but sadly, I knew I'd be back.

Four months later I was readmitted. A COPD flare led to steroids, which led to loss of control of my diabetes and a slew of other problems. I recognized the intern, but she did not seem to recognize me. She was thorough, competent and self-assured. She'd been taught well. Nonetheless, I promised myself that no matter what, I'd really watch my diet next July.