My first Hospitalito call night

On Wednesday, for the first time in my life, I was responsible for patients without an attending doctor on site with me.

I was responsible for the 2 bed ER, and the hospitalized patients (we have 4 inpatient beds here).

My resources:
People: one well trained nurse (aka "life saver") who speaks both Spanish and the local Mayan tongue, 2 staff with less education (maybe the equivilent of MAs?), a "guardian" (like, of the grounds), who knows which button to press on the xray so I can get poor quality xrays overnight.  
Labs: urine dip, a blood glucose and a urine pregnancy.  Period.
Other diagnostics:  EKGs, XRay, external fetal monitor and tocometer.  (The EKG machine works with metallic suction devices that leave bruises!)
Reference materials: A shelf of reference books, plus my own that I brought.  A computer.   
Basic supplies: stethoscope, otoscope, ophthalmoscope, trauma shears, sutures, intubation equipment, gauze, iodoform, lidocaine, needles and syringes,
IV fluids: LR and NS and D 2.5 1/2NS
Backup: The phone numbers of 4 other family docs who I can call in a pinch, and an OB.


My patients (details changed to protect their privacy)
1) A woman in early labor with a history of 2 cesarean sections who wanted a vaginal birth. 
Her first C-section was done after she labored at home for 30 hrs, came in with a dead fetus in her, finished dilating with the help of pitocin, suffered eclampsia (yes, she seized) and failed to birth her baby vaginally despite the aid of pitocin, forceps, and vacuum.  After this nightmare the dead baby was finally birthed by C-section, after which she had complications including endometritis and wound dehiscence.
Her second C-section was done preemptively, to avoid all of the above.  From that birth, she has a healthy child.
Now, she's here with her third pregnancy, wanting a vaginal birth.  She wants this because she's been told she can only have 3 C-sections in her life, and she wants 4 (living) children.  So she figures if she accepts a C-section this time, she's done bearing children.
She is only 1 cm dilated, and her contractions are still very mild, but the baby is having frequent decels (of it's heart beat) on the monitor.  Most of them are variable, to ~100 bpm.  There is one, however, that drops to the 50s for 3 minutes.  This makes me unhappy.
This, my first call shift as the only MD inhouse, happens to be a holiday, so the normal hospital staff are not here.  If I thought this baby or mother were dying and I recommended a crash C-section to them, and if they accepted it, I would have to call in the OB, the family doc who does the spinal anesthesia, and the surgical tech.  This would take at least 10 minutes, not to mention the time to administer the anesthesia.  This makes me unhappy.
They have not yet decided that they would accept a crash c-section if mother or baby seemed to be dying.  This makes me unhappy.
If her uterus ruptures (it is not in great shape, after 2 c-sections and the endometritis) and she is bleeding out internally, I cannot give her any blood, because we do not have any here.  This makes me unhappy.
The first baby, who was dead before she came in, was not especially large, yet she couldn't pass it vaginally with the help of pitocin, forceps, and vacuum.  Therefore, I have no reason to think that she can birth the current baby vaginally.  This makes me unhappy.
So, I find myself in the unusual (for me) position of trying to frighten a woman who wants a vaginal birth into accepting a cesarean section. 
I am not sucessful.  Neither is the family doc who's going off shift.  Neither is the OB who we call in.
The patient leaves to go to another hospital a few hours away with the goal of having a vaginal birth.  The next day I learn that they did a C-section there.

2) A baby girl with either pneumonia or bronchiolitis.  I admitted her to one of my 4 hospital beds so I could keep her oxygen level up.  Easy peasy.

3) A 12 year old girl here for a check back on her neck abscess, which was I&D'd a few days ago.  Looks like it's healing, I repack it and send her out.  Easy peasy.

4) A man walks in carrying his 11 year old son, who is seizing.  He has been seizing for 2 hrs.  (Suddenly I am treating status epilepticus, despite the fact that none of my patients have ever actually seized in front of me before.)  In the past 4 days, this boy has seized ~30 times, according to his mother's careful records.  He has not recovered from his post-ictal state between seizures at all in those 4 days.  He therefore has not eaten, drunk anything, or taken any of his meds in that time.  He usually takes 3 meds to prevent seizures.   Oh, and he has gastrointestinal tuberculosis, and is off of those meds too.   Before this all started 4 days ago he was in his normal state (disabled, developmentally delayed, treated for TB for the last 5 months) other than a little cough for 1 week.
The benzos I give stop his seizure for a few minutes.  Then I have to give more.  Then I have to give more.  By the third round, I have figured out which of the longer acting anticonvulsants we actually have here.  And which ones I can give IV, since oral meds are out of the question for this boy who typically (according to his mother) stays in a drowsy, post-ictal state for 3-4 days after a seizure.  And I have managed to calculate a pediatric dose for him after cross referencing several sources, all of which give slightly different numbers.  They do all agree that one should adjust the dosing based on serum drug levels.   Very funny.   We proceed to hydrate him with IV fluids and wait for him to wake up enough to take his oral meds so his parents can take him home.  2 days later, we are still waiting, but at least he hasn't seized again.

5) An utterly hysterical man with gastritis.  He went to a clinic this morning, and says they did an ultrasound and saw a gallstone.  They told him to come back if his symptoms got worse.  His gastritis symptoms got worse and he is now terrified of "the stone growing in me".  He is very melodramatic and all the staff are laughing at him behind the curtain.  He wants another ultrasound.  I treat his gastritis instead.  Eventually he is calm enough to understand my explanation of why the gallstone has nothing to do with his gastritis.  He goes home.  Easy peasy.

6) A young woman with vaginal hemorrhage.  Last period 3 months ago, but it was always irregular.  She has no idea if she's pregnant.  For some reason we don't have any pregnancy tests at the moment (I thought that was one of the 3 labs I could do!)  Yes she feels lightheaded and dizzy.  Conjunctiva are quite pale.  No, I still don't have any blood here.   Methergin and IV fluid bolus have been ordered.  Vital signs are not too scary at the moment.  Speculum exam: I go through a lot of gauze trying to clear the blood enough to see the cervix.  I remove several large clots, and then the blood just keeps flowing.  I am unhappy.  I switch to manual exam, since I can't see a damn thing.  Her cervix is 2 cm dilated, and something is sticking out of it.  It's soft, squishy, and vaguely tubular.  Is that another clot or is it the "products of conception"?  I am afraid to try pulling on it, because sometimes that can make the bleeding worse, and then what the hell would I do?  I think she's lost about 500 mLs of blood since I met her 10 minutes ago.  I end my exam and call the OB.  He comes in, repeats the speculum exam, and uses the ring forceps to pull what turned out to be the products of conception from the cervix.  Maybe after my Planned Parenthood rotation I'll feel confident enough to do that.  She stops bleeding and we relax.  She stays overnight for observation and some labs and an ultrasound in the morning. 

7) I am awoken in the middle of the night for another seizing patient.  This is a middle aged man.  Family says he seized at home.  Nurse says he seized again here, but it stopped on it's own before I got downstairs.   Post-ictal for a few minutes, then coherent and obnoxious.  Demands meds, refuses to stay for observation.  Didn't bring in the meds he's already on, and has no idea what they are.  Belly looks like a drinker, but denies any alcohol for the last 2 years.  30 year history of seizures, and a long history of coming into our ER with seizures and then leaving AMA.  He's been told to see a neurologist many times, but never does.  He leaves AMA again.  We go back to sleep.

I sign out the three hospitalized patients in the morning, and go home relieved that both I and all my patients survived the night.

I'm on again tomorrow.