Sunday, January 12, 2020

But it’s a Cat Bite, not Cancer



What started out as a challenging emotional time in our first week of 2020 morphed pretty quickly into a challenging health care time. I’ll preface it all with, I am now fine and, the short story is, I have an infection that I needed some help combating.

If you’re interested in the longer version of the story, complete with healthcare frustrations, wins and ridonkulousness please feel free to read on. But please know, it’s a cat bite, not cancer.

As many of you know, our 12 yo family cat, Polymer Fishbone died on January 4th, right after we returned from a family vacation to Colorado. 



Even that is a much longer story but, when we landed at SJC, a friend picked me up from the airport to take me directly to the vet. My hope was that we were picking up our family cat who had become dehydrated in our absence. Unfortunately, things were much worse than dehydration and the prognosis was grim. Brandon and the kids met me at the vet and we decided to take him home for one more night. He was not very lucid and we placed him in our bed that night where he's slept for the past 12 years.  At 3am he suddenly woke and was highly agitated. He began to move wildly and, as I cradled his head to move him to a more comfortable position, he bit me on my left index finger. 

I didn't think too much of it, rinsed it, wrapped it and went back to caring for the cat. He died in my arms as we entered the vet clinic the next morning.

As you might imagine, our house was, and continues to be, quite sad over this loss. 

Saturday afternoon, my finger started to throb and I took a quick look under the Bandaid. Eww. Worse than I thought. My husband and daughter said, “Hmmm… when are you going to the doctor for that?” I explained that it was fine and I was going to my oncologist on Tuesday for a six month check-in, so she could let me know if I needed to see someone.

On Saturday night, I tried to go to bed early since the evening before had been so fitful, but the pain in my finger was then unbearable. Truly unbearable even when compared to the myriad of other surgeries, procedures and recoveries I have experienced.

I recognized this wasn’t a great sign.

At 11pm, after my husband was in bed, I took myself to the emergency room. To the friends who have heard this part of the story and suggested, “You should have called me,” I offer my sincere thanks. My husband would have taken me too.

I didn’t ask.

In all honesty, I was embarrassed going into the ER for something as simple as a cat bite and knew my family needed some rest.  

As embarrassed as I was going in for “just a cat bite,” I became even more embarrassed when I was triaged, immediately given a room in front of all those sick people and told that I should have come in right away. Since I am allergic to penicillin, I was given two broad spectrum antibiotics Doxycycline and Clindamycin and told to come back to the ER if anything worsened. 

A truly efficient and, dare I say, delightful ER experience which feels like a rarity these days.

I was home before midnight and took my first dose of both medicines.

In the morning, I again happily took my dual meds thinking all would soon be well – my only concern the gut issues that would soon follow a rigorous course of antibiotics.

Sunday was a very slow day and I assumed much of my slowness was due to sadness and lack of sleep but, late Sunday night my hand began to look worse. I combined Advil and Tylenol and tried to make an appointment for Monday morning, wanting to avoid the sicky waiting room of the ER.

When I tried to make an appointment online, I was told the first available was a Wednesday 1/8 morning time. Even after I opted to see “any provider” the first appointment the system offered me was on Wednesday. I assumed it must just be a glitch with the portal, so I chose to call first thing on Monday.

I drove into work and called as soon as the office opened and requested a same day appointment. I was told the earliest I could be seen was Wednesday. After I explained the situation, the scheduler said she’d speak with my primary care physician and call me back. Three hours later, she called me back and let me know I could come in at 2pm to the Internal Medicine Clinic.

Honestly, I’m not sure what I expected but I definitely didn’t expect what went down next. As I explained the happenings of the past three days, the physician looked at me, looked at the wound, called the hand surgeon and said she was giving me “an e-consult to the ER.”

“The ER?!?” I was not a fan.
“You need to have intravenous antibiotics and you have to be in a bed to get them,” she said.
“Can’t I just come back later, when there’s room somewhere?” I pleaded.
“No, this is the way we have to do it. I’m sorry. But you’ll have an e-consult so they’ll be expecting you.”

They were expecting me alright but I was NOT expecting a completely full emergency department. And I was NOT expecting the level of illness I was going to be sitting with while I waited to be triaged.

This was the last full day of my son’s winter break and my daughter was home for a few more days before heading back to college – this was NOT AT ALL the way I wanted to spend my time. I asked whether I could just come back, “when it is less busy.”

The otherwise nice woman laughed, “Unfortunately no, let me get your vitals.”

“I just had my vitals done 50 minutes ago. Can we just use those?” I asked eager to get into the queue at least.

“No, we have to do them again. We have to do everything again. If you had an EKG upstairs, we’d have to do another down here,” she explained.

“That’s ridiculous,” I pause, remembering I needed to make nice with the people who get things done down here. Like prison rules, or so I imagine, but different.

“So, if I can’t leave and come back when you’re ready for me, could you give me an estimate of the wait so I can tell my family? We didn’t expect I’d be staying.”

“Well?” she looked up a bit, squinched her face and said, “people have been waiting for a couple of hours.”

Thinking that most, if not all, of the patients she sees are at least as impatient as I am and likely much sicker, I gave her an empathetic smile and deep sigh, “It must be really hard to work here some days.”

No response.

Temp, blood pressure and check-in complete, I was sent to the big room where 30+ people were sitting/lying in various states of concerned illness. They ALL looked sicker than I felt.

I chose a place in the corner of the room where there were few people and as far away from the individual who sounded like he was simply waiting to be diagnosed with tuberculosis.

I need to pause here to say, as a general public service announcement, “Cover Your Damn Mouth When You Cough” because guess what? There are some grown arse adults, who are most definitely very ill, who do not cover their mouths when they cough.

To pass the time and find validation, I took to Twitter sharing that, after all the talk of how misuse of emergency department resources is a huge issue (i.e. people going to the ER when they should make an appointment with their primary care doc), I had played by the rules and the ED was about to be misused anyway.


After one hour of waiting, and immediately after the newest vomiting patient puked, I began composing a letter to the leadership of the hospital, sharing my frustrations at this operational nightmare.

I sent it off at the two-hour wait mark.

Within 20 minutes, two things happened. I was called into the screening room and I received a message from one of the individuals I’d emailed. She was sorry to hear about my cat; sorry about the health care inefficiencies and that another member of the leadership team was checking with the ED director.

It felt good to be heard. You shouldn’t have to know someone to get quality timely care but, in the end, I’m glad I know some people.

Screening was screening - blood draws mostly since all the details were in the e-consult. The nurse working with me was a visiting nurse and had only been working there one week because the caseload was overwhelming the regular staff. He was going to put my IV in since we knew I was going to receive IV antibiotics but some discussion behind the curtain made it clear I would be sent back out to the waiting room until a room was ready.

Queue my not happy face.

He took culture vials and then I heard another backroom conversation – I was being taken to a room and would not be sent back to the room of unfettered contagion waiting room. I think my email was making the rounds.

I was taken to room 31. It had a door, something I would soon learn is an absolute gift in the ER.

It was 5:35pm. Four hours had passed since I’d entered the hospital parking lot that afternoon.

Right about that time, my husband finally read the text I’d sent hours earlier,

“Went to the doc. They've sent me back to the ER... I hate healthcare ridiculousness like this”
His response, “Oh my! I just saw this. Where are you now?

I don’t know about you, but I can’t just text, “I’m in the ER dammit,” without adding more context so I was getting ready to call him when the doctor came in to explain what would happen in the next several hours. First and foremost, I’d be spending the night – likely in this very room since there was no room at the inn upstairs on the ward. I would be given a couple broad spectrum IV antibiotics, as yet to be determined, since cultures wouldn’t be back for days. And he was going to lance the ‘felon’ in my finger.

Yep, it’s actually called a ‘felon.’
And this was really beginning to feel even more prison like.

I called Brandon as soon as the doc left, “Hey where are you?” he asked innocently.

“I’m in the ER dammit,” I choked out and started to cry.

Whether it was fear or frustration or just finally having someone to lean on that did it, I’ll never know but letting some of that out felt good. We talked briefly, I caught him up and he asked what he could bring me since I was having a sleepover in the sicky house.

I ended our call when the nurse walked in to start my IV. As I’m getting my mainline installed, my daughter, who had been out with a friend all day, texted, “Yall dead?”

I had been texting with my son letting him know I was still at the hospital so he didn’t worry and until I had something concrete to share but I hadn’t talked to my daughter all day. She’d just come home to an empty home

“No one’s dead. I just had a little {healthcare facility} speed bump and Dad's bringing me some food.”

Then the phone rang. I asked the nurse to hold off a sec, picked up my daughter’s call and explained everything quickly. She asked if she could come by and told her to wait 15 minutes or so before heading over because they were going to “lance my felon.” My children (and husband) aren’t nearly as into the surgical/blood/procedure thing as I am.

IV was inserted and the nurse came back in with a bag of antibotics to get the show on the road. I was hopeful I could be out before dawn. But, when she scanned my wristband and the bag, antibiotic #1 was a non-starter – they’d already changed my prescription. One wasted bag of IV antibiotics. 



My husband and son arrived with food at the same time the doc was injecting my finger with some lidocaine in order to go after my finger felon so I suggested they wait in the hall before we started dinner. My daughter arrived shortly after, as I was being bandaged up.

As the bloody detritus of that little procedure was removed from the procedure tray, we converted it to a mini table of sorts. Dinner was served. A few spoonfuls of Tom Yum soup was all I could really handle but oddly had a moment of gratitude having my whole family together despite the circumstances. Neither of my children enjoy, or even can really tolerate, the hospital so it meant a lot that they had come. My son, none worse for the wear, or so it seemed, ate voraciously but my daughter declared “I do not eat in ERs.” Wise young woman.

My 7pm – 7am nurse arrived, introduced himself and brought me my first dose of cefepime. The IV pump was low on batteries, and he couldn’t find another, so we let it free pour. One dose down in ~20 minutes.

When I mentioned the “unbearable” pain I’d experienced Saturday night that drove me to the ER, I hadn’t actually experienced a “felon lancing.” A double shot of lidocaine took some of the edge off as he was digging around and “opening the pocket” but it was short lived. As in, we didn’t make the hour.

My good humor started to wane and Brandon found the nurse.
“I’m pretty uncomfortable,” I explained. Cheerfully he said, “I’ve got morphine, Tylenol and Ibuprofen.”

I said, “I’m pretty uncomfortable, but I don’t think I need morphine.”

He went through the standard rigmarole about “getting on top of the pain” and being wary of “breakthrough pain.” I relented and he said he would be giving me 4mg of morphine via my IV.

“Wait. Wait. WAIT!” I said, “I’ve never had morphine before, can I have a half dose instead?”

A lot of blah, blah, blah as he re-explained getting on top of pain but he agreed to give me 2mg and then I could “have the rest” if that didn’t work.

I hate the sensation of pain meds via IV – it comes on fast and I always feel like my heart is going to stop with the injection. And then it spreads out. Morphine is no different in this way.

Fifteen minutes later I ask for Tylenol. “I’m still uncomfortable,” I explained.

I watch my husband leave the room and explain to the nurse that, in my vocabulary, the word ‘uncomfortable’ means I’m in pain. The nurse walks back in to ask for my pain number 1 – 10.
When I cannot answer right away, my son points to the handy dandy facial expressions on the rubric. “Mom, your face is all scrunched up like that…”

“Okay, I’m a seven,” I say.

“I’ll bring you the other 2mg.”

“But the first two didn’t really fix the pain, they just made me feel drunk,” I said.

“Morphine changes the way your body thinks about pain,” he responded.

To my narco-ed out brain, this statement was pretty profound.

I will not go into detail about the conversations I had with my family on the full 4mg of morphine but they all sure thought it was amusing.

My family left to let me try and get some sleep and I was soon attached to my first dose of Vancomycin, another broad-spectrum antibiotic.

My time recall is likely a little off on this one, blame the morphine.
But I do know that within minutes after the drip started, I shifted in my little gurney bed to take a little snooze but soon realized I was scratching my head and the back of my neck. I remember thinking, “Weird. Did I get lice from the ER?”

It took me a few minutes to register what was going on and to press the call button, “Can I help you?” said the voice in the wall.

“Um… I’m crazy itchy.”

“Someone will be right there.”

My nurse came in immediately, “You’re having a reaction to the Vancomycin,” he said calmly as he stopped the IV drip. “Where do you feel it?”

“Just my head and neck,” I replied, actively scratching.

“I’m going to give you a dose of Benadryl.”

When he walked back in with a syringe, I was surprised and made some dumb comment about everything going through IV in the ER.

Dude.

My most profound learning? No one needs morphine if they have a dose of IV Benadryl. Lights were going out quickly but I grabbed my phone and texted my husband at 8:42pm:

Allergic reaction tonVancomy in. Hella itchy. Now have benadryl. Feels stronger than moorpjine

Lights OUT.

When I woke a bit later, I got to thinking about my reaction and a conversation I had years ago with a friend being treated for metastatic breast cancer. She found that some of her side effects went away when she was infused at a slower rate.

When my nurse came back I asked if he thought that my reaction was because of the ‘free pour’ and he said he’d talk with the doctor.

At 10:10 we restarted the Vancomycin at a very slow rate, which I shared with  my husband in case things went sideways:  



No issues and I went to sleep.

At 11:30 I was woken up by a sweet young woman, “Ms. Tinianov, I’m here to take you for your cat scan.”

It took me a minute but I responded, “You have the wrong patient.”

If you know me, if you’ve seen me in a healthcare setting, you know that I am an “ask-everything-all-the-questions-and-what’s-our-plan” kind of girl.

We’d had a changing of the rounding doc guard and the new physician had come to introduce herself but there was no mention of a cat scan.

My would-be radiology escort left and could be heard in the hall saying to the charge nurse, “31 says she’s not supposed to have a cat scan.”

The response voice said something about x-ray and the woman returned to my room, “Ms. Tinianov, I’m here to take you for your x-ray.” No mention or explanation of the earlier error, just a let’s-start-fresh kind of attitude.

Again, none of the docs I’d seen upstairs or down had mentioned an x-ray so again I balked.

My nurse came in and asked whether there was an issue and I explained. He looked in my chart and said, “Oh yes, looks like {new doctor} ordered an x-ray.”

“Okay”

When my escort returned, I followed her but, as we wound our way around the department toward radiology, I stopped.

“I still don’t understand. Why am I having an x-ray? Nothing is broken. I had full mobility until the swelling got really bad.”

“So, do you want to talk to the doctor?” she asked perhaps a bit incredulously.

“I do.”

“So do you want me to take you back to your room?”

“Yes please.”

At 1:05am {new doctor} walks in and asks why I don’t want an x-ray.

“I just don’t understand. I’ve seen four docs today and no one mentioned an x-ray,” I explained.

“Well {old doctor} thought you should have one to check and make sure nothing was left in there, like a tooth,” she said boldly.

We could blame it on morphine but that was likely long gone after 6 hours but I instantly didn’t trust this woman. Not as in a fear for my life kind of distrust but, to be clear {old doc} had been incredibly communicative about what was happening, why it was happening and asking if I had any additional questions. He had not ordered an x-ray and not told me. I am sure of this.

I deferred. And if, in a few weeks, a tooth pops out of my finger, well… that’s on me.

More sleep in my tiny sleeping space which, by the way, didn’t have bars. Had I enjoyed morphine, this could have been a problem. Just sayin.



At 3:15am I woke.

My hand hurt but really it was the cacophony in the next room that wrestled me from slumber.

The cast of characters, beyond the ones hacking up lungs, included an very irritated individual who thought they had swallowed fishbone; an individual who kept getting out of bed seemingly just so they could push their call button and have someone help them back in; an individual who had had a severe fall likely due to her continuous state of inebriation.

At 3:40am we started round 2 of cefepime and I took Ibuprofen and Tylenol.  

Not much to report after this, blood work for kidney functions required another stick. I was overtly fascinated that everything in the ER came in its own single use, plastic wrapped package. Sterile, fast and a ton of waste. Not complaining, just observing.

7am brought a new nurse and a new doc and a woman cleaning parts of my teeny room. During her quick sweep, she found the culture vial from the day before – no one had taken it anywhere.

“Please don’t throw that away,” I said. “Can you give it to the nurse, that’s my culture?!?”

No words. 

Everybody was waiting to see what was growing in my wound so we could treat it effectively and it almost ended up in the biohazard bin. Absolutely no words.

I was all out of good humor by this point and just waiting on the hand surgeon from yesterday so asked the new nurse, “What’s the plan and when can I go home?”

When the hand surgeon arrived, she explained that I would need to pack my wound three times a day because we needed it to “keep it open and heal from the inside out.” When I explained I didn’t know how to pack a wound she said, “The nurse will show you.”

If it hadn’t been my body parts that we were talking about, the next conversation that happened outside of my room would have been amusing.

Hand Surgeon to my nurse: “31 needs her finger cleaned out and packed.”

My nurse: “okay.”

My nurse to another nurse: “Can you take 31? She needs her wound cleaned and packed.”

New nurse: “I’ve never done that before. Can you show me?”

My nurse: “It’s easy. Just use the quarter inch packing strip.”

Me (in my head): Oh $hit.

When the new nurse came in and said, “I’m going to pack your wound.” I could not help but respond, “So… we’re going to learn together?”

When we started soaking it, I noticed that the other puncture looked worse and wasn’t draining into the “big pocket” so I asked for her to have the doc look at it. There was much consternation at the nurses station since the hand surgeon had already left. I explained I didn’t care who looked at it but I wanted that second pocket lanced and drained before I went home responsible for keeping a wound open when it was very obviously closed.

Another long story shortened, ER doc #3 was a rockstar. I asked, he delivered.

Efficient, effective and with good humor. He also explained that, after several conversations with infectious disease, we were going to put me on oral Moxifloxacin, a Fluoroquinolone because, with my drug allergies, this looked like the best bet.

I balked, “But I had a reaction to Ciprofloxacin, it’s the same drug class.”

“I know,” he said. “But we believe that it is the best drug for you since you cannot take penicillin drugs. And based on your previous reaction, we think you’ll be okay. If you start to have a reaction, take Benedryl.”

My previous reaction (over 20 years ago) had been soft tissue swelling that affected the palms of my hand, the bottoms of my feet and edema in my knees and elbows. I was not a fan of trying this out but, based on my allergy history and typical pathogens in a cat bite, my choices were to be on this slightly scary oral or to have a PICC line for IV antibiotics at home.

So after the doxycycline, clindamycin and the IV cefepime and vancomycin, I'm now on oral moxifloxacin.

Thankfully, the misplaced and almost trashed culture vial must have ended up at the lab eventually because cultures came back positive for Pasteurella multocida Wednesday morning confirming I am on an antibiotic actually effective against this bacteria. The past five days have been filled mostly with naps and wound cleaning. Shout out to my daughter for being a fabulous discomfort distraction and streaming old episodes of Nailed It and The Voice as a great distraction during the yuckier parts of this week. Sorry that her last week home wasn’t filled with more fun but grateful for the love. 

In short, the new year has not unfolded in any way I would have expected or imagined that I could have enjoyed but I’m on the mend and have learned a lot:

  • I’ve learned that a simple cat bite is no joke.
  • I’ve learned that ED/ER misuse/resource drain is sometimes not at all misuse from the patient side.
  • I’ve learned a new meaning for the word felon and made the appropriate link between prison and the ER.
  • I’ve learned I hate morphine but Benadryl is awesome.
  • I’ve RE-learned that self-advocating is hard, especially at 3am when you’re wearing a hospital gown.
  • I’ve learned that I'm the kind of badass that can pack her own wound without vomiting.
  • I’ve learned that “massage” in the wound care clinic is NOT a comfortable thing. 

And, I've learned that I'm grateful for healthcare, and the people who work in healthcare, regardless of the imperfections

As I’ve told several people, I am winning at life and planning a do over of the first couple weeks of 2020.




SIDE NOTE: I’m the type of person that has to park in the same spot everyday or she forgets where she parks but, I shared my teeny tiny gurney bed with my computer bag and purse (as evidenced in the pic above). At every interesting and semi-conscious moment, I grabbed my phone and typed little notes into a draft email. Part of me wanted to just post that draft email itself since it is VERY clear, and pretty amusing, as to when I was being affected by morphine and Benadryl but there are way too many names and identity reveals so I’m just using that as notes.  That said, here are a couple that I pulled because I thought they were amusing and innocuous:
  • Cat scan for a cat bite? nono bo.
  • {name redacted} best nurs sEVAH
  • Another stick at 4:10am to check kidney functions. Iv only working one way flow.
  • 5:55 97/61 & no fever because tylenol and ibuprofen 
  • 7:15. New doc. Old doc didn't say goodbye.
  • 7:20 cleaned my room and she found culture from yesterday evening 
  • 740 hand doc came by. Soak and pack soak and pack
  • Nurse from the other room " I've never done that before. Can you show me how?"
  • Consult with unfe to us disease




1 comment: