IM: Last Day with the Current Team

As usual I rounded on my patients in the morning. I talked to the IDA nurse about Mr. Roboto; he's still catatonic but can now sit up, respond to commands, and say, "I don't want to talk to you" in Spanish. We did hear him say "Andale!" a few times to no one in particular, but we think he could be talking to his schizophrenic voices. When time came to see our "mean" trauma patient, the first thing Jordan asked was, "Is he still naked?" Ryan said yes, and Jordan groaned. Even worse when Ryan said the guy's parents were in the room and apparently the mother is as messed up as she son, trying to draw attention to herself by stating what medical problems she had. Fortunately with his parents there, the guy's groin was covered with a large blanket.

Sarah, our new FP intern, was on call for peds today (catching babies), but when there was downtime she rounded with us. We soon saw she'd be an important asset to the team based on her fluency in Spanish alone; she'd spent a year in Venezuela doing mission work so from what I could tell, she spoke Spanish without an American accent. At the end of the day, I was a bit sad to see my old team go, but look forward to meeting the new team tomorrow.

IM: Crazy Call Night

Yesterday afternoon we had a GI lecture in which our professor gave us a scenario of a Vietnamese man with fatigue and asked us to work him up. Since I recently had a Vietnamese patient with Hep B induced liver failure at Methodist, I knew a good portion of which questions we want to ask (i.e. how long he's been in the US). When our prof asked us what specialty I wanted to go into, I was the only one who said IM (the others either played the I-don't-know card or said something else).

When Angela and I arrived at 1:00, we saw Jordan and his wife (an FP intern) playing with their sixteen-month-old daughter, who had a VCUG earlier that day and needed lots of comfort. Then our first patient came in around 2:00 so Angela went to see him/her, and I hung out in the lounge until about 3:30. My first case was certainly very interesting; a 19-year-old guy that Jordan dubbed "Mr. Roboto" was brought in with catatonia, a rigid body, and a CPK level of about 18,000 (VERY high). He was a schizophrenic prisoner on high amounts of haldol, and so we strongly suspected that despite the absence of fever (this wasn't the first time he had theses symptoms) he had neuroleptic malignant syndrome (NMS) and rhabdymyolysis. When I went to see him, he just kept staring at the ceiling with his arms and legs oddly flexed; I don't think he ever blinked. Dr. L just happened to be on site and he suggested we start Mr. Roboto on Benadryl and if that doesn't work, give dantrolene.

My second patient was a Hispanic lady surrounded by 3-4 adult children and some grandchildren in one tiny exam area, and they didn't speak English. Great. She presented with a headache and left-sided weakness; indeed, her presentation was classic for a right-sided stroke, just like my stroke patient from the last call. When I was testing her position sense, she got several answers right, but we saw her opening her eyes (cheating) or else rubbing her fingers together so she could tell if they were "up" or "down." When Nanette put a quarter in her left hand, she couldn't feel it and tell us what it was. She also lost her balance and fell toward the left after going to the bathroom. Initiate stroke protocol.

After seeing my 2nd patient I got a JPS sandwich for dinner. Big mistake; it make me sick. =( Then I saw my last patient: a middle-aged man with a bad case of altered mental status. According to the nurse's report, he was agitated, kept trying to climb over the bedrails, broke free of his restraints and drank water from the sink when he was thirsty, and "peed on the ER resident" (Jordan's words, not the nurse's). Jordan gave the case to me thinking it'd be something really exciting (mad cow's, maybe? hehe), but in the end, it was EtOH intoxication, pure and simple. The guy had a BAL of 332, which he claims came from drinking 4 shots of vodka but Dr. L and Jordan both think it was more like the entire bottle (the guy's a self-proclaimed alcoholic). When I saw him, he was a lot calmer, but had tremors, nausea, and dry heaves. Then one nurse told Nanette that she saw my patient sticking a finger down his throat to induce vomiting on several occasions, and Nanette said, "Great, a male borderline." I asked if that should go in the DiffDx, and she said no =P We were done before midnight, but I didn't get to sleep until almost 2:00 a.m. This was due to several factors, namely Angela not finishing until that time (I finally went to the ER to see what was up and she said her patient had 2L of "pea soup" fluid sucked from his gut during a paracentesis) and the fire alarm going off at 1 a.m. and scaring the crap out of me. Ben M was the student on surgery call, so we chatted briefly in the lounge. RB saw me at the computer and asked what I was doing up so late, I said I couldn't sleep. Hard to sleep in these call rooms, dang it.

In the morning, we found out we only had 14 new admits; one left AMA and the other was a chemo patient who never showed. Mr. Roboto improved slightly; he was still in and out of it most of the time, but his rigidity was more "waxy." Then we had a young guy who broke his hip in a MVC after getting high on meth; ho was reputed to be a "total ass" by nurses and doctors alike. He was in the same room as another patient, and when we turned away from the other patient to look at him, he was lying on his back, snoring, and totally naked except for his restraints and a Foley catheter. O.O "Whoa..." Angela, Nanette, and I said as we looked away, and Ryan joked, "What, never seen one of those before?" Jordan thought the sight was disturbing and threw a gown over the guy's groin, but it didn't help b/c as soon as the guy shifted his legs, everything became visible again. Fortunately, the patient wasn't too mean when we talked to him; when we asked him if he hurt anywhere, he replied, "I've had plenty to drink." Ummm, okay. Afterwards, Jordan complained, "That guy needs some clothes. I don't get these patients who like to lie around naked; he's the 2nd one I've seen. The first one I saw weighed 400 lbs and was always sweating." Lovely mental image there. When I was in high school, I never understood why patients had to be naked under their gowns, thinking it was an invasion of privacy and basic rights. And even though I know now, it doesn't mean we need to see blatant nudity in hospitals.

With the new shift change coming up, Angela and I are expected to work this weekend and educate our new team on our patients and how they're doing. "It's a big responsibility," said Jordan. I sure hope so, seeing how on post-call days, it's the med student's job to carry the donuts and make sure they don't get left on some random floor. I think I got Dr. L's attention today by knowing the conversion of Celsius to Kelvin (the things I remember from general chem...), but as far as medical treatments and plans go, I'm still in need of improvement.

IM: Getting feedback

This morning Nanette had the day off, so I went to see her three patients for her. We were hoping that one of our patients, a guy who had confusion and DTs after a vodka-drinking binge, would be able to go home today, but after talking to the night nurse and finding that he needed 2 and 4 mgs of Ativan to calm him down (he tried to climb over the railings of his bed), it was out of the question. On top of that, he can only eat if nurses feed him and his urine output really sucked; his banana bag was nowhere in sight. My stroke patient got his CT and MRI done yesterday; the CT showed no new bleeding, but the infarct has taken up a good 1/3 of his right hemisphere. It's amazing that the only symptoms he has are left hand weakness and left sided numbness. He's also a Vietnam vet, so with his VA connections he should be able to go to a good rehab center once he's discharged. I was supposed to see one other patient, an OB patient with HTN, but Jordan caught up with me and said he'd go see her instead. Funnily enough, he forgot which patients he was supposed to see, so he ended up seeing about 6-7 while Ryan only saw 3.

Rounds progressed as usual (though Jordan lamented that we were picking up more and more "rocks"), and afterwards Dr. L sat down with Angela and me to go over our H&Ps. Angela went first b/c Dr. L never went over her first round of H&Ps (but I told her what went on during my session), so there was a noticeable difference between her H&Ps from last Monday and her H&Ps from Saturday. "This is what I want to see," he said about one of her later H&Ps. When my turn came, he said that for my Wellbutrin overdose lady, I should have mentioned the adverse side effects of too much Wellbutrin and what I should look out for. For my stroke patient, I did a good neuro exam but needed a better plan. My H&P on my liver patient got the best assessment (all thanks to Jordan listing all the things we had to do to work him up), but I failed to mention the prognosis of Budd Chiari (bad). Overall, Dr. L said that we were progressing well, as he expected. We're on call again on Thursday, so my next notes should be even better...I hope.

IM: Leaving AMA

This morning in the middle of rounds, I learned that our Budd Chiari patient left AMA yesterday afternoon. My first thought: "Oh crap, Jordan's going to be pissed." Nanette echoed the same thoughts when I told her about it later, and when I told Jordan (who'd been hoping that the "ID" by our patient's name was a mistake), his reaction was pretty much what I expected: "F***!!!" There was another FP resident in the room, and he and Jordan began discussing other patients they'd seen who were really sick but still left AMA ("the idiots"). Jordan's concern was that our patient's liver was really shot, and that he was going to die faster without more workup to see how we could treat him. He then talked about how he stayed behind an hour after everyone left to work up "that buttmunch" and how it was all worthless now. *sigh* Even still, he told me to expect our patient to come back as a bounceback, b/c once the liver starts failing worse, the patients become more frantic and in need of medical attention. Of course, seeing how he's been going to Mexico for all his treatments, maybe he won't come back after all. "Is JPS really worse than Mexico?" someone joked. Maybe; from what I saw in Ojinaga, if you have the money, you can get excellent care in Mexico.

Nanette got more details from the day nurse; it turns out the patient left b/c his family wasn't satisfied with his diagnosis and his sister wanted a second opinion. She said that she went to Harris once and was well taken care of there, so she wanted to take him to Harris for that second opinion. Apparently, however, Harris doesn't do well with patients without insurance or already have JPS connections, so if he doesn't get cared for there, hopefully he'll come back to JPS b/c with all his conditions he's a walking time bomb

IM: First Zebra Case

Yesterday call didn't start until 2:00 pm, but we didn't have any patients to see until after 3:30 (slow day), so Angela and I lay down/napped for a good hour or so. My first patient was a woman in her mid-30s who was found lying on the floor with an empty bottle of Wellbutrin nearby; when I went to talk to her (s/p charcoal lavage), she was completely alert and oriented. A little too alert, actually; her eyes were wide and she had tremors in her hands, a common side effect of too much Wellbutrin. She couldn't remember what she took or how much and denied being on any medications, and she took offense to some of my questions. There was a young Benbrook cop sitting beside her, looking very bored; he kept asking when we were going to admit her b/c he couldn't leave until we did (and he had nothing to occupy his attention like a book to read). After Nanette talked to her (she's a psych intern so she knew how to get through to my patient), she told the cop to take the detainment warrant up to the 10th floor and that we'd be writing orders for her soon. Minutes later, we called 10th floor and found that the cop had disappeared after dropping off the warrant. This was a problem; since she was a risk to herself, the patient was supposed to be supervised. Well...if anything happens to her, it'll be on Benbrook PD. I couldn't blame the guy for leaving, though; it's tough being a babysitter, and since it was around 5 pm, he was probably hoping to get home to his family.

My second patient was a 55 yo AA male who recently suffered a right MCA stroke. He had left-sided mouth droop and decreased sensation on the entire left side of his body. He couldn't tell sharp from dull, up from down (proprioception), or that I was even touching his skin in his arm and leg. He, too, had a history of depression/psychosis after serving two tours in Vietnam, but he was pretty lucid when we spoke. By the time I finished seeing him it was 8:00 pm so we went to get dinner. The cafeteria was serving leftover tacos from lunch (*gag*) so I spent money on McDonalds instead. Jordan had the same idea, and in the call room, he went over my next patient with Nanette: a guy with new onset painless jaundice, a total bilirubin of 32 (yikes), AST of 1300 and ALT of 650 (double yikes), and an enlarged gallbladder on CT (among other things). "This guy's screwed," said Jordan. He was also an illegal who'd been in the US for about a month, and all his previous treatments for metastatic prostate cancer (diagnosed earlier this year) were done in Mexico. We had to get a translator to ask him questions for the H&P (and he claimed to have lived here for 35 years), and later on the computer, we learned that due to lack of blood flow in two veins in the liver, he had a possible case of Budd Chiari syndrome (occlusion of the hepatic vein), which is often read about but not seen. Jordan got really excited when he read that. "I've been searching for a case of Budd Chiari for years!" he said. At first I thought he was joking, but it turns out he was dead serious. "This'll be a great case for morning report!" he said. Budd Chiari or no, we had to do a huge writeup on him and list how to proceed to find out what caused his liver failure. The possibilities were endless. I didn't get done until after midnight, and ended up chatting with Jordan and Ryan about our college days at UT. Jordan had a lot of funny stories to share.

Angela, Asuka, and I had the call room to ourselves, but I did not sleep well b/c Ryan was staying next door and whenever he got paged, I woke up and could hear every word clearly as though he was in the same room (paper thin walls can do that). I never slept more than 2 hrs at a time, probably. Needless to say I felt like a zombie in the morning, but Nanette got no sleep at all b/c of crosscover pages. We started rounds at around 6:30 (Dr. L brought donuts again) and saw all our patients before 10:30. When I got to the call room I found Fallon asleep at the table =P Yes, studying for surgery can be sleep-inducing. I was glad to get home; I slept for about 3-4 hrs after lunch until dinnertime.

IM: Lessons Learned

Both Angela and Jordan got the day off today, so it was just me, the two interns, and Dr. L on rounds. My cellulitis patient asked me where I was yesterday, and I told her I'd be seeing her for as long as she was here. I spoke too soon; Dr. L said she'll be transferred to SNF and after that we won't have to see her anymore. I think I may swing by her room on a regular basis anyway, just to see how she's doing and whether or not her cellulitis is healing. The hospital's a lonely place and I haven't seen her parents visit her yet, so maybe she could use a hello now and then.

The biggest issue of the day was our 82-year-old psych patient who was admitted to the hospital screaming, spitting, and biting but now lies curled up in her bed moaning everyday w/o eating or drinking. She's been widowed for 9 years and her only family is a niece who lives in Oklahoma who said the patient had previous signed a DNI/DNR/no feeding tube order. Now, with her not eating, it seems as though she's lost the will to live. Dr. L called the niece today to discuss their options, but thinks that the patient should be placed in hospice care because this is prolonging her suffering. She did open her mouth today to take some oatmeal, so I'm hoping she'll be able to eat a little more to sustain herself until she can transfer to a nursing home or hospice in OK.

We only had five patients on our service (not bad since we're on call tomorrow), and in the 30 minutes before morning report, Dr. L sat down with me to go over my H&Ps. Overall, he said I did a good job with history taking, but wants me to go more in depth into my assessment and plans. For my angina patient from last call, he made me go through a long differential for chest pain and said I should be thinking about all these things when considering chest pain. Dr. L went through every H&P and every progress note with detail and a dark pen, and I was very grateful for his input. This sort of feedback is something I never got at Methodist, and it was a nice change.

IM: Learning More

Normally I set aside 20-30 minutes per patient to write my notes, but for patients with complicated illnesses (i.e. my morbidly obese patient who has a ton of health problems like diabetes, yeast infection, cellulitis, and drainage s/p open appendectomy, to name a few), it can take much longer. I was supposed to see 3 patients by 8:30 and only saw two by 8:10. Fortunately for me, my third patient was taken to the cath lab in the morning so we didn't see her. This patient presented with SOB and chest pain, and we all thought she had something cardiac going on. As it turned out, her cath and echo were completely normal, but her lungs looked really bad. Ryan, one of the interns, wrote the diagnosis as "UIP." Dr. L asked us what we thought UIP was, and I said, "Something interstitial pneumonitis?" Correct, with U = usual. ("As opposed to unusual," said Dr. L). Later I had to put a physical therapy order form in the chart, and the nurse was confused. "You're sending her to PT after a cath?" she asked. I explained that her heart was fine, and that it was her lungs that were bad, and the nurse said, "Oh, we were trying to figure out what this meant" and showed me "UIP." When I told her what it stood for, she laughed and said, "That's not a real diagnosis!" I couldn't agree more =P

Imagine my dismay when I went to the SSU to find the same drunk patient who'd cussed me and my intern out sitting in the same bed having breakfast, but this time he was also wearing an old jacket. One of the nurses went over to him and scolded him for showing up drunk (again) and cussing at other people until the alcohol wore off. He didn't care; he gets a free meal out of it. *sigh* Jordan (the 3rd year resident) said, "That's what it's like to hit rock bottom," referring to that man. Something tells me I'll be seeing a lot of him this month. Another thing I noticed is that the senior residents here don't think very highly of how our school schedules lectures in the mornings when we could be at the hospital learning things. Like JB (my surgery chief), Jordan thought having lectures in the morning was stupid and said, "I don't know what your school is thinking." He was similarly annoyed when he got a long neuro report from the PCC regarding a patient with MS, and Dr. L chided him on his lack of courtesy/respect since students and residents at JPS both come from our school. The neurologist came from our very own Dr. McI, so Angela was told to give him a call. She hesitated after what happened to me yesterday, but Ryan said he didn't see a problem with it. As it turned out, the patient was discharged before the phone call was made, so Angela didn't have to do that consult. Even still, I would hope that since Dr. McI is a professor, he'd be more open to having a student call him for a consult.

Jordan explained how days off work: I'm with Nanette, and Angela is with Ryan. If Ryan's taking the day off, then Angela stays to see his patients, and I take the day off. If Nanette is off, I see her patients, and Angela gets the day off. Ryan's taking tomorrow off, so I get tomorrow off, too. Not that it matters since I still have lecture at school...oh well. I'll take whatever I can get.

IM: First Call Faux Pas

So yesterday afternoon before call, I met with Dr. D and we talked a little about my future aspirations (still IM at this point), what electives I'm taking, and where I want to apply for residency. Overall he said I'm a strong candidate and that my grades/scores make me competitive for both allopathic and osteopathic residencies. He did disagree about my taking an ICU elective at JPS in September because he thinks I should be out doing audition rotations. That all sounds good except right now, I don't have a program in mind that I would want to "show off" for. What should I do, apply to do a sub-I at a program that I have no interest in applying to, just for the sake of "getting out there?" A friend of mine got her top pick residency without doing any away rotations, so I don't think it's as crucial for IM as it is for other specialties like surgery. Besides, ICU is a great elective for doing procedures and really caring for the sick patients, so I don't think I'm wasting anything. Others will disagree, I'm sure, but to each their own opinion.

This call was probably one of the easiest/best calls ever. My first patient, a lady with chest pain, arrived around 4:30 pm, and we worked her up for angina. After I wrote her up, it took a while to get in touch with my intern b/c I paged her just after she went to see another patient, so I had to wait for her to finish with that one (had time to eat dinner while I waited) before I could present to her (even though I already presented to Dr. L). Honestly, I think I learned more tonight with Dr. L than I did from any of the attendings at Methodist; they occasionally pimped but never actually sat down to go over things with me. My second patient was this morbidly obese lady with a lot of things going wrong for her: she had an appendectomy in late March that had to be left open to drain b/c a fistula formed (they found traces of digested CORN in her incision site), and now she has cellulitis in both legs (but way worse on the left leg, which was swollen to 2 times the size of my thigh). Bad, bad case. Students have to see three patients before going to bed, and my third patient was a drunkard who was on his 120-something visit to the hospital this year alone (he's infamous in the ER). Apparently he presented to the ER two days ago for chest pain, left AMA yesterday morning, and came back several hours later drunk as a skunk. When I went to see him, the nursing staff asked if I could tell the intern to see him quickly b/c they couldn't find a blood vessel on him to draw blood from (he had tons of medical problems like diabetes, COPD, and cirrhosis, to name a few), so he had no new labs and we had no clue what his alcohol level was. He was snoring loudly and had flies flying around his head (yikes), and when I asked him where he was, he said, "Camp Bowie." Not quite. When I palpated his stomach, he grimaced, so when I asked him if it hurt, he snapped, "Yes. Go away, you f***ing p***y." O.O All right then. Obviously I couldn't get much from him, so I found my intern and told him all I knew. She got cussed out, too, and Angela asked me, "That your patient?" Yup. We capped by 11:20 pm (SCORE!), so Angela and I were asleep within the next hr or so.

Of course, this morning we had to wake up around 5:00-5:15 a.m. to eat (me) and start printing out patient lists. Rounds started promptly at 6 and we were done by 9:00. After that, I went with my intern to help remove a guy's central line (he didn't even feel me take out his staple, hehe, because he was so busy talking). Then...the faux pas. My intern told me to do an ID consult, saying it was good experience for students to learn how to talk to doctors. So I paged the ID doc and spoke to him by phone, and he seemed surprised to hear a student on the other line. "How'd you end up with this job?" he asked. At any rate, he agreed to see my 2nd patient and I thought nothing of it until my resident stopped me in the hall later to ask me if I spoke to the ID doctor. I said yes, and he said not to do that anymore. At this hospital, apparently, staff physicians will only speak to another resident or intern, doctor to doctor, b/c med students have less credibility (makes sense to me). Apparently the cardiologist here will only speak to residents and not interns, so there's some sort of hierarchy thing going on. I explained that my intern told me to make the call, and he said that's fine, but that she shouldn't have done it. *sigh* Just great. This is probably going to get back to Dr. L, who knows what he'll say to that. What a way to end my first call.

IM: Call on the First Day

Welcome back to JPS. This is my third time here, and I saw lots of familiar faces at orientation this morning. Angela and I are paired together on Team A, with Dr. L as attending. All I've heard about him is that he's nice but has his students write really long H&Ps and progress notes, but hopefully the hours are decent. Venessa is back from Corpus to do her last month of IM here in town; part of the reason is that the 2nd years' boot party is coming up and she wanted to be with her bf. In fact, she told us she demanded that Dr. B let her do her rotation in town b/c one of the hospitals in Corpus closed or something and they weren't learning anything. Wow. Still, I'm pretty sure the main reason for her coming here is her bf.

When we got our schedules, I was dismayed to find that I'm on call tonight. How on earth did I get so "lucky" as to be on call on my first day at both Methodist and JPS? *sigh* Fortunately call doesn't officially start until 2:30, so my 3rd year resident said we could go home until then. Except I also have a meeting with Dr. D to go over the Dean's Letter at 3:00, so I'll be one hr late. I'll update more then.

IM: Rheumatology Clinic

This morning I met several classmates at the PCC for the required Rheumatology Clinic, where we met with four older ladies who told us about living with arthritis, from the first signs and symptoms to how they're doing now. Then we split into different groups with just one of the women so we could learn more about her condition in general. Kim, Jedd, and I had a woman who was initially diagnosed with seronegative RA but feels that she is now seropositive after having had it for 15-20 years. She barely had any telltale signs of RA; she had some ulnar deviation and one finger with a swan-neck deformitiy, plus some decreased range of motion in her right shoulder and hip, but that was it. Sadly I forgot her name, but she was an excellent teacher and showed us several gadgets that she keeps on hand to help make life easier (i.e. long handle for car keys, a picker-upper, etc) This workshop, we all agreed, was more educational than any lecture on rheumatology we could have received. =)

IM: Last Day at Methodist

Today was a typical Friday; I went to Grand Rounds, then finished writing my note on 4Tower (where the rest of my team was conveniently located with the exception of Malini). Chris asked me if I learned a lot this month, and I said yes, though I know I learned a lot more with Dr. M (who liked to pimp) than with Dr. B, who was more relaxed and easygoing. My liver patient still doesn't look well; he now c/o generalized pain but can't receive pain meds because his liver's in lousy shape. =/ I'm a bit sad that I won't be able to follow him throughout the rest of his hospital stay, and find out whether he'll get that liver transplant he needs. Still, I'm all too familiar that organs are not easy to come by. After we finished rounding, Patel and Chris told me I could go home. And so concluded my one-month rotation at Methodist.

All in all, I think I had a pretty good experience here. I know I can juggle 3-4 patients with ease, my presentation skills have improved, and I still like internal medicine. =) Just one more month at JPS and then...3rd year's over! Wow...time flew by so fast.

IM: Almost Done

Since I only had one patient I went to see another patient who just had his toe amputated (he's a Type II DM who neglected a wound on his foot until it was too late). He had a low grade fever but was otherwise okay; we're just worried he might become septic if his infection wasn't isolated to his toe (he also has osteomyelitis). My liver failure patient isn't doing too well; he's become pretty thin and I think some of his ascites is coming back. He also pulled out his feeding tube sometime during the night. >_< It's almost like he wants to let himself go. At any rate, he's going to have that feeding tube put back in. Though I got to wonder...that tube went all the way to the duodenum, so pulling it out must have been a pain in the you-know-what. It must have hurt, too. I asked why he couldn't have a PEG put in, and Dr. B said that you don't put PEGs in patients with ascites. I hope that wasn't a stupid question, because I really didn't know.

IM: Setbacks

As it turns out, my liver failure patient did have syphilis (FTA-Ab reactive and RPR reactive). It's hard to say when he got it, since he's asymptomatic. Normally one would do an LP on him to check his CSF for syphilis (distinguish between secondary and neurosyphilis), but given his crappy coagulopathy (elevated PT, PTT, and INR) Dr. H, the ID specialist (and program director for the IM residency program here), decided to treat him empirically for neurosyphilis with large amounts of Penicillin G right off the bat. Probably a good move, except that until he won't be a good candidate for liver transplant until he's syphilis free. Neurosyphilis requires 2 weeks of treatment, so he'll probably be in the hospital for a long time. When I voiced my dismay about this, Patel said that I'll be gone by the time he leaves the hospital. I know...but I'll still wonder.

Jacob's team had an interesting case to present at morning report today; a 31 year old Hispanic male presented at the ER after a 12+ hr history of ascending paralysis with total weakness and loss of sensation in the LEs. Many people immediately thought it was Guillain-Barre, except that he had no recent illnesses and this weakness had happened previously at least six times, just not this bad. Further workup revealed a potassium of 1.6 (what is it with these patients who show up with hypokalemia?) and an undetectable TSH. This patient's problem was hyperthyroidism, and it was interesting b/c he didn't have an enlarged thyroid. Then the attendings began talking about radioablation vs PTU treatment, and as a result they spent 50 min on the same case. Wow. My team never saw anything that interesting.

IM: Mass Patient Discharge

Yesterday we had a full list of 24 patients; this morning we had 14 b/c Chris and Malini managed to discharge 10 yesterday (9 of those were from 4 South so the social worker on that floor was ecstatic). Everyone congratulated the interns on a job well done. Chris was especially relieved to have discharged a few "rocks" including the lady who came in for a COPD exacerbation but ended up staying over a week for chronic constipation, knee pain, and chest pain that might have been psychosomatic. Even at the end, said Chris, she said that she had problems swallowing in an effort to stay at the hospital longer, but he assured her she'd be fine. My mastoiditis patient who had a drug reaction to vancomycin was doing well; he's ready to go home. My liver failure patient, sadly, was not in good shape. The ascites and the LE edema had disappeared over the weekend, but now I could appreciate just how thin and weak he appeared. His daughter was concerned that he wasn't eating well, so we may put him on a feeding tube. He's currently being evaluated for a liver transplant, yet I have to wonder: compared with younger patients, who's going to give a liver to a 67-year-old man? Maybe his children will be a match if they are willing to be living donors. Our TIPS lady was doing better, but was still confused and complained of diarrhea secondary to lactulose, which she'll have to take for the rest of her life in order to keep her ammonia levels down. I questioned if maybe she would have been better off without the TIPS (she was asymptomatic before the TIPS aside from some hematemesis secondary to varices), and Malina said no. Eventually, the patient would have had ascites that required regular paracentesis, and TIPS prevented her from having that. But at the cost of diarrhea for the rest of her life? Maybe she can take something to harden the stool a bit.

Before rounds I met with Chris and Patel in the library. Annie called Chris' cell to see where they were meeting and Chris said, "That was Med Student 2." Pointing to me, he said, "That's Med Student 1." What were we, Thing 1 and Thing 2 from The Cat in the Hat? I also asked for advice on Step 2; Chris recommended USMLEWorld and USMLE2 Secrets. I have an old edition of Crush the Boards that I'll probably use in lieu of Secrets (same author), and I may refer to First Aid and USMLEWorld later on. We'll see. Boards in two months....AAAAAAAAH!!!

IM: Bouncebacks

Annie and I got the weekend off, so we arrived at the hospital at 6:30 a.m. to learn that our team had capped yesterday for call. O.O Among our patients were two bouncebacks I'd seen in previous weeks. One was a lady who got a TIPS procedure done last week was back for altered mental status secondary to ammonia buildup (apparently very common after TIPS since blood bypasses the liver and ammonia isn't filtered anymore). Last week she'd been smiling and happy (she works as a translator at the hospital), but today she was huddled under the covers, barely rousable. Her husband said that there were several times during the night where she tried to climb out of bed and had to be put in restraints =/ The other bounceback was my DM II patient who had a resistant form of mastoiditis that he was getting vancomycin for, but a day or two ago he developed a 102 degree fever and, after some googling on vancomycin, deduced that he had "red man syndrome." Don't you just love it when patients try to diagnose themselves? =P Another culture was run and he was found to be sensitive to clindamycin, so he'll be put on that once he leaves the hospital. He was, however, annoyed when he was put under contact isolation (protocol for patients who were recently hospitalized), and it took a while for Dr. B to explain to him that he was under isolation for the protection of other patients, not because he himself was "diseased" (which offended him the most). He was also mad when he was asked to take an HIV test (I saw his partner last week), but it was negative. At any rate, I'll be checking on him and my Vietnamese patient with liver failure tomorrow. Patel tried to assign patients with "educational value" to Annie and me, but as it happened, there weren't many of those. Most of our patients came for chest pain, SOB, and seizures, which we've seen previously.

One of our patients was a "trauma" patient who was found passed out on the street with a blood alcohol concentration of about 55%. It fell down to 29% by the time we saw him, and though Malina said that he was the most alert he's ever been when we rounded on him, he was still pretty out of it. "Are we going to discharge him?" someone asked. Dr. B said no; we'll wait until he's sober, then him some librium. Another patient asked us when he could smoke, and Patel said, "When you go home, you can smoke as many as you want." We couldn't believe said that, but Patel said that there's no point in telling patients they can't do something they're going to do anyway, so it's okay to encourage it. Hmm, if you say so.

IM: Realities of Medicine

Today was a fairly short day; we saw our patients, attended Grand Rounds, and then rounded on them with Dr. B. When we had time to spare in the library, I chatted a bit with Patel about how he came to be a doctor. He said in India, there were only 1200 residency openings available throughout the whole country (all residencies, including IM, obgyn, etc), with placement based on scoring well on a national exam. Wow. Also today, Dr. B told Annie and me that our notes were excellent and that we were doing well. =) Positive reinforcement is a good thing. We never got that with Dr. M; as long as he didn't say anything negative about us, we assumed we were doing what he expected of us.

Today he and Chris had to do a rectal exam on a morbidly obese woman b/c a 3 cm mass was found in the wall of her rectum. Neither of them were able to palpate it; the mass was way too high. "This is internal medicine," said Patel. I hope not.

IM: ZZZ

Annie and I saw my patient who was was in her 5th or 6th day of constipation, and while we were chatting with her, she suddenly became depressed and started crying. She felt like she was nothing but a burden, that she spent her life taking care of her children, and of those four children only her daughters come to see her and she hasn't seen one son in about 3 years. Annie pointed out her book of prayers that she keeps on her nightstand, and my patient said that without her book and the care of the doctors, she didn't know how she could go on, and she thanked God for our care. She still hadn't had a BM b/c she didn't drink 2 gallons of Golytely in 6 hrs as instructed (more like 3/4 gallon the entire day), so we're going to try again today.

IM: Post-Call Scutwork

Got to the hospital around 5:30 a.m to round on patients, only to not see them because not long after we started rounding, we heard, "Code Blue, Tower 6." We were on the 4th floor, so Alex immediately made a run for the stairs with Malini and Chris behind him. Annie and I weren't sure whether to go or stay since Chris told us to tell Dr. B where they were going, but Patel volunteered to stay behind so Annie and I ran after the other residents. The patient who coded had apparently collapsed in his room (someone heard him fall, thank goodness), and chest compressions and epi injections were already underway. I wanted to get closer but overheard one nurse say there was too many people in the room so Annie, Andrew (who was on the floor), and I ended up watching from the doorway. Chris, being an anesthesiology resident, got to intubate (his only job), while Malini put in a femoral line. She never took off her white coat, but didn't get a single drop of blood on her, which Alex found amazing. I know I would not want to get blood on my coat (came close in that one trauma case during surgery call where I had to help a nurse clean a bloody backboard). In the end, the patient lived, but was transfered to the "Unit" (CCU). After that, we rounded on our patients and got done in time for morning report. After that, I had nothing to do, so I spent about an hr in the library and then went to find the interns to see if I could be useful somehow. Just in time, Malini said that the Health Department wanted her to fax one of our patient's records (about 40 pgs worth) to them, and she didn't have time to stand in front of a fax machine feeding it papers. "Hey, sounds like a job for the medical student!" said Chris (who didn't have to sound that cheerful about it). Later he said he was joking but I figured, I wasn't doing anything else so why not. It was a bit tedious (the fax machine was not my friend at first), but in between feeding the fax machine papers I read the patient's records. She'd been hospitalized at TSH (psych hospital) eleven times, so I recognized the names of the psychiatrists who'd dictated her psych notes. Talk about a trip down the memory lane; didn't think I'd have to deal with stuff from TSH anytime soon. Even still, I was glad to have done something somewhat useful for Malini. I just wish she'd learn my name and Annie's instead of calling us, "the med students." =P

Oh, and I didn't have to disimpact my patient with chronic constipation b/c one of the nurses gave her a rectal during the night and found nothing to disimpact in her rectum. So we're going to give her a lot of Golytely and see if it does the trick.

IM: Tuesday Day Call

My last day call was on a Saturday (hospital was half empty), so there was a lot more to do this time around. My mastoiditis patient was doing well, but he couldn't go home this afternoon b/c his culture came back positive for Staph epi that was resistant to everything but vancomycin, chloramphenicol, and gentamycin. He'd been on vanc since his arrival and was doing well on that, but vancomycin has to be administered IV, so we have to keep him here at least one more day. My end stage COPD patient has not had a bowel movement in 4-5 days, despite getting Fleet enemas, mag citrate, and other stool softeners, and Dr. B said, "If she doesn't have a BM by tomorrow, someone needs to disimpact her." Chris said, "That sounds like an MS3 job!" Gee, thanks a lot, Chris. As it turned out, she still hadn't had a BM by the time my shift ended, and both Chris and Alex (the chief resident) were gleeful at the prospect of me having to disimpact her. *sigh* It'd probably be too much to hope for her to have a BM during the night.

I saw two patients today with Chris: an elderly lady with COPD exacerbation (along with multiple other health problems like CAD, CHF, A-fib). Her daughters were with her and one of them has power of attorney; she said her mom was DNR/DNI in case something happens (which I hope not). The second patient was a Vietnamese man with cirrhosis who had new-onset ascites and LE swelling. Because most Asians tend to look yellow, I didn't even realize how jaundiced he was until I looked at his eyes (I'm really not trying to be funny here). Both he and his daughter spoke predominately Vietnamese, so Chris had to get an interpreter on the phone and attach another receiver so that he and the daughter could speak with the interpreter at the same time. After seeing that patient, I followed Chris around to write discharge summaries (only to realize later that the patients couldn't go home for some reason or another; one lady couldn't go home b/c her daughter "wasn't ready to take her in"). We also heard a "Code Verte" (at least that's what it sounded like), which is like a Code Blue for outpatients, in another pavilion, but by the time we got there the pt was stabilized and getting ready for transfer to the ER. Apparently he'd passed out in the middle of an ophthalmology exam, possibly secondary to hypoglycemia.

Patel got an unconscious patient while Chris and I were away, but later her condition got worse and she required intubation. We saw her head CT and it showed something in her brain along with hydrocephalus, weren't sure if it was a mass or a bleed. Annie and I switched off at 7:00 pm, but since I had four coupons to use I got dinner at the cafeteria with Annie and Alex before taking everything up to the lounge. Patel thought I was nuts for staying at the hospital longer than I had to (even if it was for free food), but Alex, Annie, Chris, and I just sat around chatting while watching a basketball game. It was nice to just hang out outside of the ER.

Tomorrow...got to wake up at 4 something again. *sigh*

IM: New Attending

Today we met our "new" attending of the month, Dr. B, who really wasn't all that new; she was our attending last Sunday when we were post-call. She just got back from a weekend trip to Vegas, where she got to see O and Ka. I wanted to see O when I last went to Vegas but got roped into watching Zumanity instead. Not saying Zumanity wasn't good (b/c it was), but O was my first pick. Many people asked Dr. B how much money she made, and she said she didn't gamble, choosing instead to put her money where she knew she'd enjoy it (in shows). I picked up two patients today and presented one to Dr. B, and Dr. B called me on not giving the pmh before telling what was wrong with the patient. This man had a ruptured TM and mastoiditis and was put on vanc and zosyn, and she asked what else he had. "Type II DM," I said. She said, "And why is that important to know? What should you be worried about in diabetics?" Um, infections? Malignant otitis, which never popped into my mind. But now I know.

In morning report, Dr. H (the doctor who always leads morning reports; she always wears mini skirts too short for her white coat) told of a "very exciting case" where a man presented with extreme weakness and was found to have a potassium of 1.6 (us: holy #$&!), and right now it's debatable whether he has an RTA or some other thing. Patel wasn't here today so Annie and I got to work on the list again (with help from Chris). I have to say, though, I miss the old team with Sherif, Keira, and Dr. M. Sherif's so much more organized, Keira likes to talk (Malini, our new intern, is more quiet and serious), and Dr. M, despite his pimp sessions, seems more interested in teaching. Still, I'll wait and see what everyone's like tomorrow, when I'm on call. Day call this time, thank goodness.

IM: Second Night Call

Expecting another late night, I drank a tall latte before reporting for work at 8 pm, where I immediately got my first patient, a lady with COPD exacerbation. Her case was pretty straightforward; I presented to Chris, and we were done by 10:00 pm. Chris suggested I get some sleep until the next case, but since I had that latte, well, I wasn't sleepy. I tried, though; I lay in bed until almost 2 a.m. wondering when I would ever sleep or see my 2nd patient, whichever came first. Chris's room was next door to mine (and the walls are thin) so when I heard his beeper go off, I immediately got up and was ready to go by the time he came to knock on my door. Turns out he didn't get any sleep, either.

The second patient was a 20-year-old guy with seizure disorder, except he didn't fit the profile of someone who had seizures b/c he had no post-ictal symptoms (he was perfectly lucid). He'd been hospitalized a year ago for his first seizure, but the hospital he went to had chalked it up to hypoglycemia (me: doubtful). That was another quick case, and the night resident let me go by 3:00 a.m. But once again, I couldn't sleep. Not sure if it was the latte or the fact that I don't sleep well in unfamiliar beds (I eventually adapted to the JPS call room beds b/c I was q4, not q10 for night call), but I could not fall asleep. I think I dozed off somewhere between 3:30 and 4:00, but the next time I checked my cellphone it was 5:15. *sigh* Didn't sleep again after that. Apparently most of the patients rolled in after I went to bed, because when I went downstairs at 6:30, Chris and Afua (the 3rd year) were fuming about a patient who arrived at 6:00 a.m. because she didn't have insurance to see her PCP. Needless to say I was a zombie in the morning, sustained only by free breakfast from Grand Rounds. My team was very busy yesterday; the day team capped and we had a total of 23-24 patients to see this morning.

Today was my first day working with my new team of Patel and Malini (new intern), and the change is already noticeable. When Sherif was the resident, he made sure that Annie and I paid attention during patient presentations b/c we were in charge of making the patient list. Because Patel insists on doing everything himself, he didn't care whether Annie and I listened in or not, and as a result, we didn't know what was wrong with half the patients on the list. The new team members seem to be in their own world during presentations and act as though the med students don't exist, which is a bit disappointing. Still, there was one good thing about Patel making the list today: he let me go to the call room and catch up on Z's. I probably slept from 10:45 to noon, and it was enough to keep me awake when I drove home.

Oh yes...after working many days straight since last Monday, I get the weekend OFF! *celebrates*