More Continuity of Care

When I first started ICU two months ago, we had a very sad case of a woman in her seventies who got hit by a garbage truck. She sustained an overwhelming number of injuries: multiple pelvic fractures, a femur fracture, a crushed foot, severe skin and soft tissue injuries of her lower extremities, and a transected vagina. It was horrible. She went to the OR for an exploratory laparotomy, to interventional radiology for an embolization of a bleeding vessel, to ortho for fixation of her fractures, to plastic surgery for an amputation of her foot, and to gynecology for repair of her pelvic transection. She was a serious trauma victim and given her age, her prognosis is very poor. Nevertheless, she is a fighter. She's managed to make it through an abdominal compartment syndrome, an E. coli sepsis, a Bacteroides fragilis bacteremia, a bladder leak (for which she got two nephrostomy tubes, a suprapubic catheter, and a Foley), pleural effusions and pneumothorax (she has two chest tubes in), and intra-abdominal fluid collections concerning for abscess. She's a really hardy patient.

Today we got re-consulted for a worsening picture of sepsis. She spiked a fever to 39.2 and her blood pressures dropped to 60/25, requiring a phenylephrine drip. This consult reminded me that I really like taking care of sicker patients; it's terrifying and sad, but I like that sense of gravity and responsibility. We looked at all the sources of infection for an ICU patient and broadened her antibiotics (vanco, mero, fluconazole - she has yeast in multiple locations). I hope she can pull through once more.

The other sort-of continuity of care is an interesting dermatology case. On dermatology, I met a woman with a rare disease called Darier disease or keratosis follicularis, an autosomal dominant disease affecting desmosomes and keratinocytes. It's really severe and debilitating, but it is rare enough that only dermatologists really know about it. Surprisingly, we got a consult on a gentleman who has this disease. He has hyperkeratotic erythematous verrucous-looking plaques with yellow crust and scale over 60-70% of his body. He likely has a polymicrobial superinfections of the soft tissue and is admitted for IV antibiotics. It was very educational for me to see a dermatology-related disease right after my last rotation.