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Laurie Arrives and Lin Revisits St. Joe's ER and Room 314

While I was seeing my Tuesday morning patients at the office, Laurie arrived from Lincoln, NE, via Minneapolis, on Northwest Airlines. Lin met her at the airport and, by 1 P.M., we were eating a delightful lunch of egg rolls, spring rolls and soup at our favorite Viet Namese Restaurant (next to the Kosher Butcher) in Old Town, Tustin.
We caught up on the long interval since we had last seen Laurie, and then Lin mentioned that she needed to call Dr. Teddy (Coutsoftides), her colorectal surgeon. Quite casual, between bites of the wonderful egg roll. Her appetite was not affected, at least.

"Well, why didn't you tell me?," I said.

"Oh, I didn't want to bother you, and, you know, Tammy (Josh's wife), Myles and Danielle are coming over for dinner." Lin had spent the morning cooking up sukiyaki, Tammy's favorite, and ours, as well. When we got home, I took a look. She had two areas of redness at the incisional site, which was otherwise healed and two areas of fluctuance and edema, with tenderness in one area, but no peritoneal signs. No chills, no fever. I didn't like what I saw! She said she would see Teddy tomorrow since there was a dinner tonight. Her only symptom was a little itching in the inflammed areas, and the findings described.

When I think of cellulitis, I think of erysipelas http://en.wikipedia.org/wiki/Erysipelas. Not good, at all. That, and the fluctuance, suggested the need for a needle and antibiotics, even to an old nephrologist. So, dinner, or not, I called Teddy. Signed out for the afternoon, with the usual, overly protective (of the doctor, not the patient) secretary saying that he would be reachable in the morning. Not good enough. "Who's on call?" "Dr. Hamamji." "Fine, what's his number?" After a short conversation, gradding only lip balm and some aroound the eyes, wrinkle retardant.... no, that wasn't my idea of priorities.... off we went to St. Joseph's Hospital Emergency Room, the usual forms, a brief description of the problem to the triage clerk.... yes, clerk! Are cellulitis and abscess too "technical" to understand? The triage nurse, the second layer of defense, understood perfectly well and when the admission process was well underway, I returned to the Toyota Sienna (Lin is not quite up to Porsche rides, at this time) and drove off to Western Medical Center, Santa Ana, to see a hemodialysis patient of mine with a vascular access problem that needed a solution.

The gears ground merrily, and the ER M.D., whose first name is Christian, and whose last name.... naturally, I can't remember.... was very, very nice, and almost all the appropiate initial labs were ordered (I wanted to know about her magnesium and her serum albumin.) The usuals were all pretty normal, including a pretty respectable hemoglobin of 11.9, and a very reassuring creatinine of 0.8 Her potassium was a low normal. She is on potassium and magnesium supplements because of ongoing GI loss. She had a CT of the abdomen, with oral contrast, and later I learned that that was pretty negative. No obstruction and no fistulas. A fluid collection in the abdominal wall. Unfortunately (in my purist's opinion) a needle aspiration was not done in the ER, or in the first 18 hours, but antibiotics were started, quinalones avoided because they are not on her neurologist's approved list, because of the multiple sclerosis. Blood cultures were done. They were negative at 24 hours. Dr. Hamamji deferred to Dr. Teddy for a surgical decision, but the antibiotics were going. She was admitted. Several well intentioned venipunctures to get an IV going and draw blood. (The PICT line, via interventional radiology, only happens between bigger interventional procedure, during the 9-5 daytime hours, which, in my opinion, subjects those patients with crumby veins to repeated, sometimes futile, needle stabbings, until someone heroically inserts a jugular line, in desperation.... but then, I'm an old nephrologist, so they don't ask me!)

Teddy sees Lin, who is given her very same room, 314, where she spent 3 of her 4 hospital weeks in February and March. Teddy reviews the films, decides she does not need the operating room, and does the incision and drainage, and iodoform packing in the room. Great! No anesthesia and none needed. The cultures.... after 18 hours of antibiotics.... are negative. Dr. Ray, a very nice gentleman and excellent infectious disease doctor, had seen her on Tuesday evening and started the antibiotics, or approved the antibiotics that Hamamji started.

Lin seemed to feel better, immediately. In fact, I ran over to Carl's Junior, a block away, for a cheese burger and onion rings for Lin (the hell with Ensure Plus!), and she happily downed the burger and some rings. The mint chocolate malt, which I had sampled on the way over, was happily finished by Laurie, who learned an appreciation of this combo from her brother, Josh, who always had something mint-chocolate for his birthday or special occasions.

Laurie went home to entertain Tammy, Myles and Danielle, and share the sukiyaki Lin had cooked earlier in the day, and I went back to WMSA to see my patient. Of course, I had to communicate to friends that this was a very, very different hospitalization than February, and everything was going to be okay.

Yesterday, Thursday, at 11 A.M., after arranging to meet Lin in the emergency room parking lot, with Laurie and the Sienna, I had to park the car and go get her, as the usual paper work took three times longer than expected, with the nurse having to write down eight or so meds on the discharge sheet, and checking with the doctors about her medications, appointments, etc. I know how slow the wheels turn, so I knew it wasn't going to happen in half an hour. Laurie drove the minivan home, encouraged by my observation that it's not a Scion XB, and you have to slow a bit more at the corners because its top heavy, even though it rides like a dream. She did just fine... Laurie, and Lin. After dropping them off at home, I flew (in the Porsche) to the RAI clinic in Garden Grove, in time to see my patient with hyperkalemia, who requires Kayexalate for (suspected, but unproven) dietary indiscretions. His potassium was only 4.3! Wow! And his phosphorus was normal. So we talked about getting a kidney transplant in Mexico, because, undocumented, though he could be dialyzed forever in California at the taxpayer's expense, he can't get the more cost effective, and so much better, transplant. But, that's how it is with Emergency MediCal. Save a life, but don't really think about the quality of life, or even the cost effectiveness. But then, I'm an old nephrologist. They don't ask me.

Well, I had time on my hands before the 2:30 thursday afternoon patient parade at the office, so I called home and asked Lin if she wanted to have lunch, and where. Her favorite food is sushi! That, and the Porsche, and because I love medicine, is why I continue practice and deal with all the horseshit that gets worse every year. So, off I go at Mach 1, or thereabouts, safely of course, and beat Lin and Laurie to Lin's favorite sushi restaurant 3 miles from home, and 10 miles from RAI. I beat them by 2 minnutes! No tickets, and no crushed fenders, and even, no cursing.

Watching Lin down the sushi, and watching Laurie down even more, and leaving before the bill came.... what a pleasure. Just keep driving and working. So different from February.

Today, in an hour and a half, after I see a couple of patients at WMSA, we go off to Compton to see son, Geoff, in action at the Superior Court. That's Compton of Rodney King fame, where the city burned a few years back, and where Geoff brings justice, or what passes for it, as a Deputy District Attorney.


Tags: laurie, lin
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