IM: Changing Residents in Midstream

This morning I got to the hospital by 6 a.m. to see all my patients before the EKG class at 7:30 a.m. The other two teams aside from Jacob and Phuong were there, and later Annie showed up b/c Andrew told her about the class. "Was this required?" she said, and I said I didn't know; I just followed Sherif's instructions to attend. I hope Annie doesn't think I tried to screw her over, because I'd asked her yesterday if she planned to come early to round on patients and she said no. Heck, if Sherif hadn't told me about the lecture, I wouldn't have gone, either. Still, I was pleased that I was able to see all 3 patients in 90 minutes, and everyone on the team was happy that our psych patient, who'd been "chilling" at the hospital for the last week or so b/c no other psych hospital in town would take him, finally got discharged yesterday.

It's the end of the month, and Keira, Sherif, and Dr. M are leaving the team. Keira's going to another team, so I'll probably see her around, but not sure about Sherif and Dr. M. I did meet our new 2nd year resident though (I forget his first name so I'll just call him Patel), and he is nothing like Sherif. First off, when he saw Annie and me making the patient list, he told us not to do it anymore, that he could do it himself, faster. No real complaints there, since making the list keeps us at the hospital later than other people, but then he said he didn't want us seeing more than 2 patients at one time. Considering how Sherif wanted us to see six by the end of our rotation (I was curious to see just how many I could handle), this is a bit of a letdown. *sigh* Now I can see why some people loved this hospital while others hated it; it's all about the team.

IM: The things we don't want to be

As usual, we rounded on patients before 9:00 a.m., and on the 6th floor I ran into Chris and we went to see our 29-year-old CHF patient together. He's in pretty bad shape; has an ejection fraction of 15-20% and nothing in his history except HTN and a recent viral illness that could point to a cause of his CHF. Chris showed me how to read his EKG, which showed right atrial enlargement (look for P waves that look like a "sine" wave) "See, you're learning something," said Chris, and I'd glad; cardio was never one of my strong points and I can't read abnormal EKGs to save my life. Andrew stopped by to say hello; he wondered why we arrived at 7:00 a.m. each morning while the rest of them arrive at 6:00 to round. It really depends on the attending; Dr. M likes to round at 9:00 while others round at 8:00.

One of the last patients we saw today was a man with metastatic liver cancer who came to the ER with chest pain, SOB, and a UTI. He was a "bounceback" who had originally been sent to hospice, yet somehow ended up back here. He was on a morphine drip when we went to see him, and we learned that he "shot up" on heroin 2 days ago. Dr. M proceeded to check the patient's back to check for costovertebral tenderness, except he didn't tap, he pounded. The strength he used to hit the patient's back was audibly harder than the strength we'd use for tapotement, and the patient almost screamed from the pain. "Stop...stop!" he gasped, and quickly explained that he had a spinal cord injury. "Oh, sorry," Dr. M said shortly, and left it at that. Annie looked as horrified as I felt, and I thought, That's it? You hit someone's back and cause them excruciating pain, then say, "Oh, sorry" and leave? That patient's back pain was probably secondary to liver mets and why he went out to "shoot up" on morphine in the first place! That was bad. Annie was furious by the way our patient was treated, and I didn't blame her. I mean, I know our residents told us that Dr. M has lousy bedside manner, but this was ridiculous. I know which program in Chicago he trained at, and I don't know what kind of training they have there, but I know one thing: I want to go to a residency program that'll teach me to be compassionate to my patients, not brush them off like dirt, even if they are druggies. I do not want to be like Dr. M, ever.

After lunch conference I asked Sherif what time we should see our patients by tomorrow. He said, "I'd like you to get done earlier, by 7:30, so you can go to lecture with the interns and learn how to read EKGs." I asked Annie if she was planning to go, and she said no. But after working for one call day with Sherif, I know that if he tells me to do something, I'd better do it. So...looks like I'll be rounding on my patients earlier tomorrow so I can go to lecture.

IM: First Patient Lost

This morning I got to the hospital as usual to round on patients, and when I looked up my 82-year-old A-fib patient, his records said that he was discharged yesterday. I knew that couldn't be right; he was in no condition to go anywhere. So I looked through the patient's notes, with the latest one reading, "Patient cleaned and taken to the morgue." Oh. That was how I found out my patient had passed away =( Going backwards in the notes, I read that around 2:40 pm yesterday, his HR shot up to 160-170 and wouldn't stabilize (I doubt his dyspnea and tachypnea helped), and his son, after being briefed on the seriousness of his father's condition, decided to sign a DNR. My patient was pronounced dead at 15:09. Did I know when I rounded on him that morning that he had only nine hours to live? I didn't, but I'd like to think that the small things I did for him (adjusting his oxygen mask, giving him some water even though he was NPO, wiping his face after he finished drinking) helped him in the end, even just a little. I remember he thanked me before I left the room. =(

This is the my first real patient to pass away. The trauma patients from the ER and the little boy, AJ, back at Driscoll didn't count because they were already near death and my role in their care had been minimal if anything. But this man, I saw him in the ER, and I saw him the following morning and had hoped he'd eventually get better. I think I have to start realizing that not every patient who comes to the hospital will be able to leave by their own accord. Jacob has already seen 3 codes and I've yet to see one. Annie had one code happen on Saturday/Sunday night but didn't know about it until afterwards. I think I'd like to participate in at least one code if it comes my way.

So with two of my three ER patients gone, I had to pick up two random patients, and when time came to present to Dr. M, I was less than stellar in my presentation. I told him I'd just gotten the patients this morning b/c I lost two, and he asked me if I was choosing my patients. I said, "No, one of them passed away yesterday" and he joked, "You didn't take good care of him?" No, but everyone had a good laugh over it. At lunchtime Jacob started talking in Chinese (he's learning), so when I answered back, Dr. M asked the difference between, "Ni hao" and "Ni hao ma." I said that with the latter, it's a question form that expects a response, and Chris (who's from Taiwan) said, "That makes sense." Our lecturer today was a neurologist who stressed that we should never tell a patient's family that a patient will not wake up if there is even a small part of the brain that is still alive. It made me think of the elderly lady I saw at JPS who had a midline brain herniation and had lost most of her reflexes. To me, she had no hope of a full recovery, and JB had told her son that she would not wake up, yet later she opened her eyes. Did that constitute waking up? I would say no, but a family member would most likely say otherwise.

IM: Sunday Post-Call

The hospital was a very lonely place at 5:00 a.m. It took me a while to even find an unlocked door (had to press the HELP button in the parking lot for advice) to get into the hospital, but I was able to see my patients before rounds. My N&V lady felt better, my rectal bleeding lady was still afraid to have a bowel movement for fear of "bleeding out" (even though her H&H was stable), and my A-fib guy was more lucid than yesterday. "I need some water," he said, and seeing a cup of water on the counter, I gave some to him. Then I left his room and saw a big "NPO" sign on the door that I apparently didn't notice when I went into his room. O.O Oh crap. I later reported my faux pas to Keira and she asked me if he'd choked on the water. I said no, and she said it's fine; apparently he's NPO to avoid potential aspiration. Our attending this morning was a lady who brought pigs-in-a-blanket and donuts for our breakfast, which we were all grateful for. Later Sherif asked me if I looked up the A-fib article yet. I said no, and he handed me a copy that he'd taken the liberty of printing. "You gave her a reading assignment? How mean!" said Annie, but Sherif said it was pertinent to my A-fib patient and that Dr. M loves that sort of thing. "And someone has to channel him when he's not here," he said. How true.

Annie and I each had three patients to present and I thought I did pretty well in my presentation (with occasional input from Keira; we all got a laugh over my rectal bleed patient b/c she kept saying her stomach was "griping" her); Chris later said I did a good job. *feels pleased* Chris had some back pain and Sherif said he could do some OMM on him, but never got around to it; Annie and I offered it again at the end of rounds and Chris asked if we were being serious (then turned us down). We did an orthostatic test on one lady (take her BP supine and then sitting), but it was nothing significant. I think I like weekend rounds b/c you don't have to stick around for lunch conference. But...I need to stop blogging and go read that article =P

IM: First Day Call

Ahh...how nice to sleep until almost 7:00 a.m. =) All my patients got discharged yesterday, so I rounded on Annie's patients before meeting the rest of the team at around 10:00 a.m. Keira let me present one patient to our attending (who was here for the weekend), but when I started rambling (since I'd just picked up the chart this morning) and not knowing what I was talking about, Keira quickly took over. *sigh* The attending didn't even see the patients, just took notes on them and left. "That's it?" I wondered. After rounds, I was free to myself from about 11:00 a.m. to 1:00 p.m., where I stayed in the library so that Sherif could reach me if a patient came (I forgot the cell phone again). I grabbed lunch at the cafeteria downstairs; amazing how much a $7.50 ticket can buy =)

The first patient I saw was a 79 yo lady with a two-day history of nausea and vomiting that's most likely GERD-related; we're keeping her for 24 hrs to see if it resolves. Keira let me write the admit order, which took a lot of thinking and confusion on my part, but I'm glad I got to do it b/c it got me thinking more about what to do for the patient. Sherif, too, asked me the differentials of nausea and vomiting associated with stomach pain, and I named several that we were able to rule out with the Chem-14 alone. My next patient was an 82-year-old man with altered mental status and a-fib. When I went to ask him what brought him to the hospital, he yelled, "I have no strength!" and either couldn't hear me or refused to answer my questions. Keira and I managed to get more answers from his son, but not much, since this man lives alone (son lives in SC) and had fared pretty well until recently, so no one knew what meds he was taking or what medical problems he had. We didn't know if his a-fib was new or old, what allergies he had, or what medications (if any) he took for HTN. *sigh* So he was a challenge for everyone. My last patient was a 74-year-0ld lady who has had bleeding from her rectum for 4 days; she knew this b/c there was blood on the toilet paper and in her underwear, but she never once looked in the toilet bowl to see how much blood there was. Then she'd say that she had diarrhea and increased frequency in bowl movements but when Keira asked her how many BMs she had, she replied, "One." Apparently she tries to "hold it in" b/c having to see bloody toilet paper freaked her out. She also had a long history of abdominal cramps in the morning after drinking coffee and eating sweet things for breakfast, cramps relieved by defecation, yet morning after morning she eats the same stuff despite the pain. Heck, even I get sick having coffee on an empty stomach (my Corpus roommates can attest to that), so yeah, she was kind of nuts too. Later, when Sherif was talking to her, her son came in to tell her that her grandson and his girlfriend/wife crashed into a telephone pole and weren't wearing seatbelts, and EMS had brought them to this exact same hospital. Needless to say she got upset and sent Sherif out of the room. Man...talk about awful. She was the last patient of the day and I got to go home at 7:30 pm, but...have to be back at the hospital at 5:00 pm to round on my pts. Argh...

IM: Not Proactive Enough

Yesterday Dr. M had told Annie to go to the pathology lab to "put a rush" on finding out the FNA results of one patient's neck mass. Annie had not gone b/c she thought it wasn't the place of a medical student to tell the pathologists which slides to look at, and this morning the FNA results came back positive for "colloid growth" that was most likely benign. When Dr. M asked Annie if she went to the lab to find out those results, and Annie said no, he asked why not. "I guess I'm not that ambitious," said Annie. That did not sound like a good response (certainly not something Dr. M wanted to hear), and after rounds Chris sat us down and told us that when Dr. M tells us to do something, we should do it. Annie responded that doing something that Dr. M told her to do for the sake of doing it felt fake, and that the pathologists would see right through her, whereas Chris was a real doctor and the pathologists would have listened to him. Chris argued that the pathologists like it when med students stop by and that they wouldn't have minded Annie asking about the FNA results. Annie said if it was a matter of life or death, she might have done things differently, but the neck mass had been present for ages so it was probably not a life-or-death thing.

Chris said that the key was to say something like, "Hi, I'm following up on a patient who got a FNA done today, and I want to see what the results are" without mentioning that you were there on the attending's orders. Knowing me, had I been in Annie's shoes, I probably would have blown my cover by saying something like, "Hi, I'm one of Dr. M's students, and I'm here to follow up with Mrs. C's FNA for him." Yup, I'm too honest for my own good. Annie and I discussed our fears about the residency application process with Chris and Keira (i.e. not matching), and our interns said we should be fine. Easy for them to say; we have no idea how competitive their scores were, so maybe the match was a piece of cake for them.

The rude general surgery intern struck again by leaving a progress note that offended Dr. M. The final comment: "Medicine consult appreciated." Dr. M got mad and said, "Is he being sarcastic?" before slamming the binder shut. Chris and Keira thought he was reading too much into it, but since Annie and I have seen that intern (whom I'm tempted to nickname "that a**hole") at work we kept our opinions to ourselves. *sigh* At any rate, I'm on day call tomorrow, but no complaints there. I did plenty of 12-hr day shifts in ob-gyn so I'm used to it. But night shift...that's something I can't get used to b/c I value my sleep. Andrew positively looked like a zombie this morning b/c he got no sleep at all (his team "capped" last night), but it turns out that was his doing and not b/c his residents worked him all night. Elizabeth said that his residents had joked about deducting points from Andrew b/c he didn't go to sleep when they told him to. Heck, if residents tell me to go to bed, I'll gladly go to bed.

IM: Doing OMM?

This morning I found that we only had seven patients left on our service, so instead of our usual three, Annie and I only saw two patients each today. Dr. M wondered why we didn't see all seven and asked Sherif how many patients we were supposed to see. Sherif's response: "Start with 3 or 4, have 5 to 6 by the end of the month." Good to know. Sometime before rounding, Annie and I were in the library when she said she felt like her sacrum was out of whack. The conference room was empty, so I treated her shear with a leg tug and fixed an anteriorly-rotated innominate before it was time to start rounds. When we left the room, an anesthesiology intern asked us what we were doing, "Massages?" Annie said, "She was fixing my sacrum" and I said it was manipulative medicine, which we learn at osteopathic medical schools. I don't think he really knew what to think of it, but one of the other anesthesiology interns here went to our school so I figure if he really wanted to know what OMM was, he could ask his classmate. Annie and I tried explaining what we were doing to Chris but he said that sort of anatomy was beyond him.

We got lunch at the cafeteria today b/c there was no lunch conference, and while their food selection is nothing like Plaza, it still beats JPS. Then Elizabeth, Annie, and I had lunch in the library, where Elizabeth and Annie talked about specialties. Annie's still undecided, so Elizabeth was telling her about pathology and what it had to offer. My team got to go to the pathology lab today to see a patient's blood smear after seeing "1+ schistocytes" on his lab report (in reality he only had one or two negligible schistocytes, hardly 1+), and that got Annie thinking about pathology. Sherif had told us that he wanted to be a pathologist until he did a rotation at UTSW and learned that you spend 3 months doing nothing but autopsies during the training. "I couldn't even handle it for a few days," he said, giving gory details about men who blew a hole in their heads or cutting into bloated, decomposing bodies found 3 weeks postmortem to find a swarm of maggots in the body. "The smell was so bad it went all the way up to the sixth floor," he said. As much as I love CSI, maggots and rotting flesh are enough to keep me away from pathology. Elizabeth has a lot of passion about pathology, so I know she'll be great at it, but it makes me wonder when I will find something that I can be passionate about, too, in the same way.

Later Sherif sat down with Annie and me and asked if we were having any problems with Dr. M, the interns, or anything about the rotation in general. "Dr. M's nicer to you than he was to the guys (preceding us), and he hasn't said anything bad," he said. Sherif also said that Dr. M loves gunners (which Annie and I are not) and wants us to be interested, engaging students, so I'll have to up my "engage-o-meter" somewhat =P Speaking of things that bother us, there's this one general surgery intern I keep running into that some of us don't like too much. He thinks he's all that even though he's only an intern and talks to us like we're lowlifes, not even letting me use the phone to page my intern b/c his call was more important. *sigh* Someone made an excuse for him saying he was trained at UTSW and has that sort of ego, but Chris trained there too and he's pretty down to earth. Whatever...

IM: A Typical Day?

This morning we were told to finish seeing our patients by 9:00 a.m., so Annie and I arrived shortly before 7:00 a.m. to see our 3 patients. It took me way longer than I thought and I just barely finished seeing my last patient (whom, as it turned out, I didn't have to see b/c she was transferred to the care of ob-gyn) at 9:00 a.m. It was an interesting case; a 16-year-old came to the hospital with an acute abdomen for no clear-cut reason (CT just showed diffuse thickening of the bowels, which point to IBS), so surgeons did an exp lap on her and found out she had an infection in/on her uterus that had spread to her bowels and appendix. Possibly a bad case of PID? At any rate, ob-gyn was taking care of her now, and I had to remove my progress note from her file since we wouldn't be seeing her again.

Based on what kind of patients we saw, Dr. M gave us assignments to look up tonight (i.e. parotid gland masses, Kussmaul breathing in constrictive pericarditis, etc) and asked me to tell him about jaundice. I started out good but grew rather disorganized, so I have to work on my presentation skills b/c I think the knowledge is there (I read the same jaundice article at least three times). Jacob and Phuong were on call yesterday and were kept pretty busy, but Jacob said it was still much better than surgery call. I agree completely; q5 beats q4 anyday. And I got my CD back =)

IM: First Night Call

After meeting up with friends (you know who you are) for dinner at Panera Bread, I drove back to the hospital for my first night call. There I met up with the night resident, Amie, and she told me that since it's my first call, she doesn't plan on working me too hard. "You have all of residency to do that," she said, and told me to go study until a new patient comes in. Sounded good to me, so I gave Keira (intern) my phone number and went upstairs to lie down/do questions. About 90 min later Amie knocked on my door (apparently the phone call didn't go through) to tell me I had a patient. This lady came to the ER b/c she'd had myoclonic seizures all day, then had a grand mal seizure as soon as she came to the ED. Oddly enough (or maybe not), she had a similar seizure last week in which several of her teeth got knocked out when she fell to the ground. This time she bit her tongue so hard it looked bruised and swollen on one side, and she complained of post-ictal dizziness. I wrote a detailed H&P on her and thought I did a pretty good job (Amie thought I did well, too), but it turned out my team would not be admitting her. She was a "bounceback" patient, meaning that she'd been seen in the ER in this same month for the same reason, and because of that, the team who took care of her last week will care for her now. Fortunately there was another patient available for me to see.

This second patient came in for a HA and knee pain secondary to a fall but when she got to the ED she was found to have a BP of 240/140. Yikes! Further questioning revealed that she'd been out of her HTN medications for 3 weeks, and that she had a history of being noncompliant with meds. She was given nifedipine in the ER and it began dropping her BP down to 170/90, at which point I retired to get some sleep before rounds at 6:30 a.m. The time: 1:40 a.m. Despite how "comfy" the room appeared, it was still too cold for my taste and I had trouble sleeping. Total hours of sleep, I'd estimate I got about 2-3 hrs. Then there was no time to get breakfast before rounds at 6:30, so I ate some cake from home and hurried down to the ER.

The attending, Dr. M, was nice, but had a somewhat brusque bedside manner. There were many times where he just left the patient's room without saying goodbye and it was up to Sherif (the third year) to say, "Let us know if you need anything" before leaving the room. He also likes to pimp, and the interns already warned us that if we don't know the answers, then he asks the interns, so it's best if we know the answers beforehand =P Today he asked us causes of pulsus paradoxus, and tomorrow I'm to tell him everything possible about jaundice. Oh boy...that's going to be a broad topic. We had a total of 13 patients today. It took about 2.5 hrs to round on all of them. One patient had attempted suicide and mentioned that he once stayed at TSH. "Where's Terrell?" Dr. M asked, and I was able to tell him where it was (sort of). On another floor, the chief medicine resident saw me, Annie, and Chris standing together and joked, "Man, what's with all the Asians here? It's like we're breeding like crazy" (he's Asian himself) He also offered Annie a free lunch coupon but not me or Chris; I had to wonder if it's b/c she's the only one on our team who was dressed up and not in scrubs (and therefore more presentable).

When we got back to the library, Annie and I were given the task of typing out our checkout list to give to Jacob's team (they're on call today). Using a sample list that Sherif left us and our own notes, we were able to compile a pretty good list with pertinent information; Sherif gave us an A for effort and commented that our predecessors (who'll remain nameless) had gotten an F on their first list because they'd had no clue what to do. I was pretty exhausted when I left the hospital at 12:30 but halfway home I realized I'd left a brand new CD that I got last weekend in the call room =( Fortunately Jacob found it and I'm hoping he'll store it in the cabinet for safekeeping until I can pick it up tomorrow.

Later I checked my email and was saddened to learn that Dr. Bailey from OB had passed away. He was the attending on call for at least two or three day shifts during my OB rotation, and he was infamous for not allowing the residents to use the Bovie during C-sections (though Dr. C has been known to bring out the Bovie once his back was turned). I was just telling the others about him yesterday at dinner, and now this happens =( Still, he'll be missed by many for sure.

Goodbye Family Medicine, Hello Internal Medicine

The shelf exam on Friday wasn't too bad; some of Dr. RR's mini pimp-sessions really came in handy (otherwise I wouldn't have looked up stuff like cauda equina syndrome, which appeared on the exam). I had a pretty good weekend, too; my sister and brother-in-law came to visit and they brought their Wii, so we had fun playing Super Smash Bros, Mario Party, and Bleach: Shattered Blade (me). My arms are still sore from waving the Wii around like a sword, but it was worth it.

My first month of IM was at Dallas, so seven other classmates and I drove over there this morning. I'm paired with Annie on the Blue Team. The residents there are Chris (anesthesiology intern), Keira (IM intern), and Sharif (IM 3rd year), and I've yet to meet the attending. As luck would have it, my team is on call today, but I worked it out with Annie so that she takes day call today while I take night call this evening. *sigh* Fortunately MDMC is only 15-20 min drive from my house, no farther than the other hospitals, so I can drive home easily and don't have to find someone in Dallas to stay with until the next time I work. As nice as the call rooms might appear, I have no desire to spend more time in them than necessary. More on my call night tomorrow.

Family Medicine: Memorable Last Day

Today was my last day of Family Medicine, and it was definitely not an ordinary day. A 15-year-old girl came to the clinic with her mother and two siblings for a well-check, and among the tests they wanted to run was a pregnancy test since her last period was back in January. She went to give a urine sample, but what she gave Shari (the lab tech) in the specimen cup was clear, colorless...and cold. That's right, there was nothing in that specimen cup but tap water. Shari came to the nurses' station to tell us and said, "Does she really think we're that stupid?" At the very least, the girl could have tried to make it realistic by heating the water; there's no way a urine sample is going to be cold. Still, she's a scared teenager with her mama in the room (the mother refused to leave her daughter alone, she wanted answers), and probably thought that was the best way to trick us. Still, Tawanna went to the room and gave the girl more water, saying the last sample was "too clear" for analysis. The girl didn't fess up, even after I went to her room to do a physical on her. It was hard to tell whether or not she was pregnant (13 weeks along based on her LMP) I did notice during the abdominal exam, though, she kept covering her lower abdomen protectively when I was pushing around. Finally at one point her sister said, "Can you hear a heartbeat? She thinks she might be pregnant."

Now we're getting somewhere, since she hadn't fessed up to the nurses. I then asked her about her sexual history (her mom doesn't speak English), and she said she'd been having unprotected sex with her boyfriend for six months. Hmm, well there you go. The girl knew she was probably pregnant; but as long as she didn't know for sure (and the urine test would have clinched the diagnosis for sure) then she could still be in denial and pretend nothing was wrong. I told Dr. RR what she told me (and Tawanna told him about the "clear" urine), and Dr. RR said, "You're nicer than me" because he would have gone in there and flat-out accused her of trying to fool us by substituting water for urine and say that she needed to get tested pronto so that she can start her prenatal vitamins and see an OB (her first trimester is just about over after all). We were all curious as to how he'd handle the situation, but he just told the girl that given her history he's 99% sure she's pregnant, and that they'd draw some blood today and he wanted to see her back tomorrow. She was surprisingly fine with it; maybe being told "You're pregnant" has forced her to take responsibility for her actions. Some of the MAs commented that she must have wanted that baby, because based on their own experience, if they wanted a child, they nixed the OCPs.

We had a few interesting cases today; a woman has come in several times in the last month with hematuria; there's only so many times it can be blamed on pyelonephritis so she's going to get a urology appointment. Another kid came in with a stomachache that all but vanished by the time he arrived at the clinic? The culprit? Spicy Hot Cheetos, which he apparently ate too much of. So in his assessment, I wrote, "Stomachache secondary to too many Hot Cheetos =)" Dr. RR laughed when he saw the smiley face. At the end of the day, Dr. RR said that I was an "excellent student" who was an asset to the clinic, and that if I ever need another rotation I can always come back. Lupe and Tawanna gave me hugs and I wish I could have said goodbye to Sue, but yes, I was sad to leave the clinic. From here on out, things are going to be harder.

Family Medicine: Wrapping things up

Last Tumor Board of the rotation (and free breakfasts at Plaza). The cafeteria ladies really do take the $6.00-and-below rule for students very seriously; Lori wasn't wearing her badge and the lady at the cash register made her pay up. The clinic day was pretty ordinary. Dr. RR was informed that he had a meeting that he didn't know about ahead of time (again), so the morning ended at 11:20. Then I went to school and used the computer for a while. There was an older man in his late 50s or 60s sitting beside me, and I think he might be homeless or destitute b/c his clothes were rumpled and he smelled like he hadn't showered in days. =/ You can't work at a JPS clinic and not know that smell. It made me wonder, was this man trespassing by using our computers? Other universities require a log-in at all their computers; ours do not, and so anyone and their mother can go online. It reminds me of the time during my OMM rotation where a doctor was arrested for using our computers and not wanting to "vacate the premises." Yeesh.

One mother who brought her 12-year-old to the clinic works at the ICU in the main hospital, and she said that she and Dr. RR go way back from his days as a resident there. "He's gonna kill me," she joked about bringing her daughter in for a breathing treatment when she barely had any wheezes. Dr. RR was nice about it, though =) One of the last patients of the day was a 9-year-old girl with a high fever and sore throat who couldn't stop crying. Then she started screaming when Lupe tried to swab her nose for a flu test (she thought she was going to get a shot), and Dr. RR apologized when Lupe left the room and gave us a Look. When the actual shot came, she began screaming and crying really hard, and at times it was hard to believe that she was a nine-year-old. I commented that my parents would have busted me for screaming or misbehaving at a doctor's office, and Dr. RR shared a story where, as a five-year-old, he ran for his life after learning he had to get shots and it took a 200 lb nurse to corner him, catch him, and sit on him (his words, not mine) while the other nurses gave him the shots. And after he got home, his parents punished him severely for bad behavior. "But...I didn't cry," he said. The main point was that parents these days don't punish their children the way they used to =P

Family Medicine: Return to the Anatomy Lab

*sigh* Notice how my posts are getting later and later? These days I really don't feel like blogging much because nothing's really going on. Clinic didn't start until nearly 9:00 today due to a staff meeting (during which I did 50 Kaplan questions), but after that things got rolling pretty good. My class was supposed to meet at the Anatomy lab at 2:00 pm so Dr. RR originally said I didn't have to come back after lunch, but our morning didn't end until 12:30 and drug reps brought lunch so I never actually left. I ended up seeing 2 patients before driving to school.

I definitely don't miss the smell of the anatomy lab. To my dismay, many people wore scrubs while I was still in my white coat and sort-of business casual clothes, so I left the white coat in the lockers. There were two cadavers waiting to be intubated (Dr. T from Plaza was there with some interns to teach us how to intubate). One of them was an obese woman (one of the BONES of making intubation difficult), but because the interns had already practiced on her and made an indentation in her tongue, I was able to intubate her fairly easily. "Are these any of your patients?" Dustin N joked, and I was glad to say no. I had one elderly lady as a patient who didn't think she'd live another year, but she was tiny.

*sigh* I really don't know how to study for this shelf. I hope I don't fail =(

Family Medicine: Winding Down

Last week of family medicine! It's been an interesting eight weeks, and I have to admit I've gotten accustomed to the 8-4:30 hours and weekends "off" (when I wasn't reading for those quizzes). I get along pretty well with everyone in the clinic, and it'll be sad to say goodbye at the end of the week. I've learned a lot on this rotation, mainly how to think like a doctor (thanks to Dr. RR saying, "Tell me what you want to do" with every patient we come across), and hopefully that'll prepare me for IM. I'm going to Dallas first and then JPS, so if anyone has any useful survival tips, please email them to me! =D

Although Dr. RR said that my observation skills have improved greatly these last two months (he told me to pat myself on the back for IDing cobblestoning, even though it wasn't the first time I saw it), my diagnosing skills still leave much to be desired in some aspects. One girl came in today with all the findings of a potential pyelonephritis except she had no fever. No fever pretty much rules out a pyelo, and with careful questioning Dr. RR managed to learn that she hurt her back from doing flips on a trampoline on a regular basis. *sigh* Got to remember the musculoskeletal (and OMM) No more nightly assignments; this week is strictly for board review. Not too sure what to review though. Ran into Ben today and he said MKSAP was too easy. Maybe I should do more Kaplan questions =P

Family Medicine: Mock Ethics Committee

This morning was a slow morning. There was a period of about 1 hour where we had only 1-2 patients come in; Dr. RR even had time to engage in a game of Connect Four with a 10-year-old patient (her mom comes in for Matrix treatment for carpal tunnel; they're really fun people to talk to) without worrying about another patient coming in. The little girl told me that she got to dissect an owl pellet in class the other day; I did the exact same experiment at her age =P Dr. RR had to get to a meeting by noon, but at 11:45 he still had two patients to see (the last few decided to crowd in all at once), a pap and a well child. I saw the well-child while he did the pap; fortunately the kid was healthy with no problems so it was a quick visit.

This afternoon we had a mock ethics committee with Dr. M at school. We were told to split into groups and "roleplay" what would actually happen at an ethics committee based on the case we were assigned. I was in a group featuring "Mr. B," an elderly man in chronic respiratory failure who wanted to be taken off the ventilator and go into comfort care, but the hospital refused b/c it went against their Christian beliefs to preserve the sanctity of life. My group managed to throw something together and I was given the role of Mr. B's PCP, where I argued on his behalf that he be allowed to choose how to live the remainder of his life. Lori and Jeff W stole the show with Lori acting as Mr. B's Southern-accented, smart-talking lawyer and Jeff being "Mr. Hospital," or the hospital people advocating to keep Mr. B on the ventilator. The other group, which debated whether or not a Hispanic girl with AML should be forced to get a BMT, did an excellent job too, with Deanna and Jacob speaking Spanish to each other as the girl and her father to make the case more realistic: interpreters are very important in health care, after all.

Family Medicine: Same old patients

After almost seven weeks at this clinic, there are a few patients that I've seen at least three times, and some of those came here today. One was a 10-month-old toddler who had fever and vomiting; he was pretty quiet until I started examining him, and then he couldn't stop screaming. Another was a lady who'd been here several times before b/c she had low appetite and sinus problems (same lady who burned her breast on a stove once). The last time I saw her, she'd said she hoped she wouldn't have to see me again (b/c there was a time she came 3 times in seven days and she knew that Dr. RR was probably fed up with her), so when she saw me today, she said, "You're still here?" Sure am. Today she presented with an open abscess on her butt; it smelled pretty awful. Even still, because it was open and draining, Dr. RR made no effort to I&D it. I diagnosed my first case of herpangina today; I saw blisters on the roof of the mouth but not on the hands or feet, and I remembered that hand-foot-mouth disease was caused by the Coxsackie virus so...I consulted Up-to-Date and herpangina popped up=)

My faux pas of the day: Dr. RR said that one of the presidents in his time had hyperthyroidism brought about by A-fib but didn't remember which one, so I started naming random presidents from the 40s and 50s. I think Dr. RR was born in the 50s though, b/c when I said, "Roosevelt," he exclaimed, "I'm not that old!" Uh oh. I hope he wasn't too offended.

Family Medicine: Ending with ethics

Back to the clinic today. We had a lot of four-month-olds come in for well child exams and shots today. I also saw my first case of plagiocephaly (misshapen head) on a baby; fortunately this is easily corrected by a head brace since babies have soft skulls. *sigh* I missed a lot of things on diagnosis today (the plagiocephaly, a 3-day-old with a left hip click), but later redeemed myself with the last case of the day. A 10-year-old girl came in looking absolutely awful (lying on the exam table, not moving) with a 103 degree fever, swollen lymph glands, and generalized aching pain. It looked to me like she had both strep and flu, but after last week's strep-test-for-nothing incident I was hesitant about diagnosing her with both (and who wants a double-whammy like that?) Dr. RR agreed with me about the strep but not so much on the flu; still, he went ahead and ran a flu test. Lo and behold, it was positive =) I also did well on today's topic on spinal stenosis; thank you, Simmons Manual, for being a great source of info.

After work I had an ethics meeting at Baylor. Also with me were Lauren, Elizabeth, Phuong, and Kim. We got there early and chatted with Dr. M for a while; imagine my surprise when he said he enjoys watching anime! (I imagine he means the Miyazaki movies and not specific series). Coolness =) The ethics case itself debated on whether a baby born at 23 weeks gestation (where survival is poor) should be allowed to die or should every effort be made to save it even though its quality of life would not be great if it survives. I'll have to think more about that one.

Family Medicine: Hospice Day

Today was my day to go to the hospice center, except there really wasn't much to see. Aside from me, there were five fourth years at the center, and there were only two patients to see b/c a third passed away just hours before I arrived. And they'd lost three more patients over the weekend. I also arrived too late (thanks to taking a quiz in the morning) to go on a "ride-out" to see what home hospice care was like, so I was left to follow the fourth years around. There were two guys and three girls; the girls pretty much kept to themselves but the guys took me into the patients' rooms with them and taught me what signs of imminent death to look for in patients (i.e. buccal and temporal wasting, hyperextension of the neck, relaxed pinna, and death within 4-6 hours after radial pulses disappear). The patient who'd just passed away was still in her room and family members walked in and out of the room to say goodbye before her body, covered with a colorful quilt, was wheeled out of the room. One of the doctors told me that usually, patients arrive during the week and pass away over the weekend. =/

Family Medicine: Ignorance is NOT bliss

One of the first patients who came today was a couple with two sons, a four-year-old with spastic encephalopathy (his legs are very weak and he can't stand without support) and a seventeen-month-old toddler. And they were both behind on their shots; the four-year-old was due for his six-month shots and his four-year-old shots and the toddler was due for his four month shots only. The only reason their mom brought them in for well-child visits today was because that was the only way they could qualify for food stamps; before that, they hadn't been seen in a year. Now, it's one thing to give a little baby 3-4 shots in one day because there's only so much they can struggle, but to give a toddler 3-4 shots was a nightmare in the making. We could hear the kid screaming throughout the entire nurses' station (which is very large), and finally Tawanna (the nurse) left the room and yelled, "Dr. RR!" Dr. RR was in the next room seeing another patient, and he immediately came outside to see what was going on. "I can't do my job," said Tawanna. "He keeps pulling the needle out, and she (the mother) doesn't want me hurting her child!" Dr. RR had to go in and explain things to the mom, and I think the kid ended up getting those shots in the end, but Tawanna was pissed. "Ignorance, girl," she said to me. "It's plain old ignorance. She should have brought them in a long time ago." I agree; it would have made everyone's job easier. There's a reason why you give most kids shots when they're babies.

One of my patients today had a clear-cut case of strep, but I ordered a strep test anyway just to be sure. Later Dr. RR took me aside and told me that if it looks like a child has strep (fever, headache, exudates on the tonsils, red throat), then it's all right to go ahead and treat it like strep. "There's no need to run a strep test if you're fairly sure it's positive," he said. "It's a $50 test." Oops. =( I guess this is what I get for trying to be more productive in the clinic. We discussed knee pain again, and this time I mentioned different exercises and Dr. RR talked a little about muscle activation vs muscle energy. I brought up Dr. KR from TSH (psych rotation) because they'd graduated in the same class. He didn't know that she was working at TSH, and he commented that she was well-suited for it. Yes...she definitely is.

Family Medicine: Down Again

*sigh* Today was made of all sorts of wrong. I am falling into the bad habit of diagnosing every kid who comes in with a runny nose and cough with the same three drugs Dr. RR normally uses based on age group, but each time Dr. RR crossed out my assessment and wrote something else in its place =( I read online that kids aren't usually given antiemetics, but he still gives some kids a Phenergan suppository after they've been vomiting for a while. One kid who came yesterday for vomiting came back today with a higher fever, stomachache, and pharyngitis, so I said we should do both a strep and flu test on him. Later Dr. RR changed it to flu test only; he said if the flu test is negative, then we can give the kid some Amoxil. The test was positive for flu, and we both wondered how we didn't catch it yesterday. We also had a teenager come in with a suspected testicular torsion after getting kicked in the groin during a fight; I wasn't allowed in the room, but Dr. RR told me that his swollen testicle was three times its normal size. Yikes.

The downer came when Dr. RR pimped me on knee pain. I'd gone on UpToDate yesterday and looked up all sorts of knee pain, but didn't think I'd need to know the treatments in detail (stupid me). Apparently there's a lot more ways to treat knee pain than NSAIDs, rest, and steroid shots (as commonly seen in the ortho clinic). *sigh* Then Dr. RR had me to a knee exam on him, i.e. how would you diagnose meniscal tears (McMurrays) or ACL tear (Lachman vs drawer test); for a while I thought I was in OMM again. So now I have to "remediate" again on certain knee disorders. =( This downward trend has got to stop.

Family Medicine: Redemption (sort of)

I listened to the CDs that Dr. RR told me to listen to, and a great deal of what they talked about, he already told me yesterday. The one thing I threw in that he did not mention was that Mirena (the IUD) can be used to treat menorrhagia b/c it gives off progesterone, so at least he knew I did my homework. We then got a kid with growing pains in his knees, so that turned into my assignment of the night: knee pain. We'll just see how much I remember from ortho about torn menisci =)

So yeah...nothing much to report. We've had a girl come in for the third time since my rotation, this time for purulent rhinitis (last time it was pityriasis rosea); needless to say she started screaming as soon as she saw me. =/ Gotta love kids and white coat syndrome =P

Family Medicine: Remediation

Last night I was assigned to read up on dysmenorrhea and menorrhagia by Dr. RR, but when time came for me to tell him what I knew, I found out just how little I remembered (or studied) from obgyn (didn't study much last night). Dr. RR could tell I didn't know what I was talking about, b/c he gave me some CDs to listen to about dysmenorrhea and said we'd talk about it more tomorrow. =/ The interesting thing was, later today I did get a 17-year-old patient who had heavy periods lasting 2 weeks each time, about 2-3 months apart, and had cramps so bad that she couldn't go to school. The solution for her: birth control pills. *sigh* Obgyn was definitely not one of my better subjects. Here's to tomorrow being a better day.