Home Sweet Home

As the title says, I'm back home now. My memories of Austin are still fresh, and throughout the day I found myself missing it. And in a few days, I'll be in Denver at the same time as the Democratic Convention. Hopefully it won't be too crowded.

Tubing Misadventures =)

Dina and Fallon drove down to Austin today so Dina could look for places to stay during her obgyn rotation. The first house we went to was in a ghetto neighborhood (not too safe), and the second house was in a cute, quiet little neighborhood and home to a 100 lb mastiff that couldn't stop growling at us. This didn't sit well with Fallon. Another dealbreaker was that the woman who owned the house smokes. So Dina thinks she might just stay at an extended living hotel.

After we left the second house, it took almost an hour to get to New Braunfels, but fortunately, Texas Tubes on the Comal River was not terribly hard to find. When we arrived on site, a man came to my window and asked, "Ready to tube?" before directing us to a parking spot. The three of us each spent $14 on a tube with a bottom (we thought that meant our butts wouldn't get soaked; we were wrong), and though Fallon advised against it, Dina and I brought our cameras onto the river. That soon proved to be a mistake; it started to rain, first a light drizzle that eventually progressed to some majorly heavy rain. Fallon and I were close to a shore (Dina got separated from us ages ago), so we managed to pull ourselves (and our tubes) out of the river. Dina continued to float downstream, so I went back in and helped tug her tube to shore. Thanks to all the previous rain, the river was deep and I couldn't touch the bottom sometimes. Once we were all on shore, we wondered whether to stop tubing right then and there (we'd only floated several yards downstream) or continue. The rain was stopping by this point. It was obvious that we wouldn't be able to carry our electronics downstream, so we swam across the river (with our tubes, of course) and I dropped off the cameras and Dina's phone at the front desk. After our things were safe, we continued our tubing adventure.

It was a very relaxing experience at first, just lying back and staring at the sky. Then we ran into the first chute, a sloped tunnel that shot us into another part of the river with lots of rapids. At one point our tubes got trapped in a circular current that pushed us back to where we just came from. Fortunately a man on the sidelines (possibly the guy who welcomed us to the tubing place) was around to push us back into the downstream current. There was another chute up ahead (and a sign that read "Weak swimmers please leave the water"), but instead of going down the chute, we went down a steep vertical drop. I was swept downstream but Fallon and Dina were stuck in the falls (a young kid later pulled them out), so I got out of my tube and stood in the water to wait for them. The current was very strong and almost swept me off my feet several times, but I managed to stay still until they caught up with me. Then it was more floating until we reached another chute. This time we went down the chute, but still wound up drifting in a circular current again.

There, we got separated again as Dina and Fallon got into the current before I did. I'm not sure what happened after that, but just as I got into the current (I think someone ran into me), my tube flipped over and knocked me into the water. The current was strong, but fortunately my feet were able to touch the bottom and I managed to grab on to a nearby ledge to keep from being swept downstream without my tube. I'd lost my water bottle, my shoes, my T-shirt (which had been resting in my lap), and my tube when it tipped over, but luckily nearby strangers recovered my shoes while my upside-down tube floated right in front of me. That was a close call; I'd been worried about the prospect of paying $20 for a lost tube. In the meantime, Fallon and Dina had grabbed on to a tree branch and were waiting for me to rejoin them.

By this time it was almost 3:00 pm, and we'd only covered half of the river. When we saw a sign that said, "Estimated time to the end: 1 hr" we were worried b/c Dina had to catch a flight back home at 6:00 pm. Then we saw a sign up ahead that said, "Public tube exit," meaning that we could leave the river at that point. The problem: we were across the river and the exit was approaching fast, so once again I went back in the river and helped pull the three of us to the exit. It was really tiring, and there were times when I thought we'd float past the exit and lose our chances of getting on land, but we made it. Then Dina lost her tube while climbing ashore and another guy downstream picked it up and brought it back. People on the river are so nice =) The three of us decided that though we had fun, that was enough tubing for the day, so we lugged our tubes up a flight of stairs onto the street and walked a block or two to the pick-up point (the shuttle was waiting, fortunately). I didn't take any pictures at the river, but I have a few bruises, cuts, and scrapes on my legs to remind me of this day.

In the end, we got Dina to the airport in time to make her flight, and Fallon and I had sushi with a friend of ours from college who was very amused when he heard of the numerous fiascos we had on the river (he's been tubing countless times). But now we know better, and the next time we go tubing (maybe we'll try the Guadalupe River instead of the Comal River), we'll be more prepared and have less accidents.

IM Sub-I: Last Day!

Last day of the medicine sub-I! I had four patients to see: my usual three plus the 18-year-old boy with the hand abscess. My liver disease lady had an INR of 7.6 (up from 1.7) this morning, which I think is a faulty lab error, but when I went to see her, she was sitting up in bed staring listlessly out the window. I wondered what she was thinking. Her bilirubin continues to increase, and she's getting more jaundiced, and I don't understand why, seeing how she's discontinued her Tegretol (for real this time, I hope). My trainwreck patient is doing much better, and my gonorrhea patient's joint swelling is finally going down. As long as he can walk, he can go home later today. Too bad I won't be able to stick around for it.

As expected, our cancer patient died last night. We had nine patients on our service, but it still took the team until 12:30 to finish rounding. I don't get it. Dr. C always managed to finish rounding before noon, whether we had 18 or 9 patients. Amy takes time to talk to the patients and listens to them if they have something to say, which is actually a good thing (just not for an impatient team of interns and med students). I can see myself doing the same, actually. I spent two hours of my afternoon filling out discharge summaries and getting drug info for my trainwreck and gonorrhea patients, and then I paged Matt and let him know I was leaving. Before turning in my badge, I got two Odwalla drinks for Beth (something of a goodbye/thank you offering) and went to the 4th floor library to see the pigeons. When I first arrived in Austin, I saw two pigeons taking turns sitting on an egg. Now that egg has grown into a small, fluffy-looking chick. =)

I had time in the afternoon to pack before driving to Andrew's for dinner. Unbenownst to me, Jeff had come over and Andrew had made curry again, so I neglected my salad in favor of curry and spring rolls. The three of us then hung out in front of the TV watching the Olympics, playing WoW (the guys), or just chatting. It's my last night at the house near the hospital; tomorrow Dina and Fallon are coming to Austin and we're going tubing =)

IM Sub-I: Longest Short Stay B

This morning I ran into Angela on the floors when I was seeing my trainwreck and disseminated gonorrhea patient (yes, the blood cultures confirmed the presence of N. gonorrhoeae), and she asked if I'd looked up Light's criteria for my patient's pleural fluid. I hadn't calculated the values yet and she told me to get on it b/c Amy was sure to ask me about it (since I'd failed her questioning yesterday). Sure enough, Amy later asked whether my patient had exudate or transudate, and I was able to say exudate (but not impressively so). On top of that, my gonorrhea patient also had a knee aspiration, so with some previous help from UpToDate I was able to interpret his knee fluid to some extent. Here's the kicker: he also has rhomboid crystals in his knee. Damn...pseudogout on top of gonorrheal arthritis?! This guy really will be an excellent case for morning report. As for my liver disease patient, GI has signed off on her, but we're keeping her in the hospital to see if her enzymes improve more now that she's not taking Tegretol anymore. I hope the gabapentin we gave to replace it does the trick.

One of our patients passed away today. She was a 99-year-old previously alert lady who fell and hit her head, developing a subarachnoid hemorrhage. This morning when we rounded on her, she was having labored breathing (like yesterday) and was less responsive than usual; we felt sure death was coming in the next few days. Certainly not shortly before noon. The progression to death was very fast; maybe she had bled into her brainstem or something.

For short call B, An and I ended up helping Matt (our intern for two days) on the floors with discharge summaries and prescriptions. By the time we got to the ER, Angela had already seen two patients and had two more left for each of us to see. To speed things along, An went with Matt to see one patient, and I went with Angela to see another. One of the two patients she'd already seen was a very sad case: a 64-year-old woman with metastatic endometrial cancer was supposed to have been under hospice care, but she became difficult to deal with b/c she wasn't taking her bipolar meds, and when she developed swelling in her leg, she was brought to the hospital and essentially "dumped" there for us. It turns out she had a huge DVT in her leg (and it was obvious; the bad leg was dusky and cold); on top of that, she had a UTI, the beginnings of pneumonia, and a potassium of 7.5. She was given medicine to drop her potassium and heparin for her DVT until her medical power of attorney came and said to provide comfort care only. When I saw her EKG, it still looked okay (no peaked T waves yet), and she was conscious but very disoriented. She screamed when Angela palpated her abdomen, and she had an ugly distended growth coming out of her left neck. I had to wonder, was that the result of the metastatic cancer? I asked Angela which of her many comorbidities will kill her, and she said the potassium. "She probably won't make it through the night," she said. That made me sad.

The patient we saw together was a 18-year-old guy with right hand cellulitis. Pretty straightforward. Even still, we weren't able to leave until 5:30 pm b/c Angela ran the list with Matt, An, and me before letting us go. Back in the day, Greg let us go as soon as we finished our notes and orders for our patients. I'd never stayed this late for Short Call B before. But today's cases were pretty interesting.

IM Sub-I: Exasperating patients

Yan had the day off today, so it was just me, An, and Zack along with Angela and Amy. Once again we started rounding after morning report, and once again we didn't finish rounding until after 12:00 pm. Our horse trainer lady, once again, kept us in the room longer than usual with her talking, and it didn't help that the neurology team had her chart and took forever discussing her case. Zack, An, and I went down to lunch together, and An told Zack that she envied him b/c it's his last day on the team (he goes to psych/neuro next). "I know, this is awful," Zack agreed. It's probably b/c we're too used to Dr. C rounding at lightning speed, and it doesn't help that Amy doesn't know when to cut a patient off when he/she talks too much. We also blamed the neurology team for taking too long with our talkative patient's chart, and Zack said that Dr. C probably would have said, "Oh, let neurology take care of it" in a perfect imitation of Dr. C's voice. It was pretty funny =) Even still, An and I only have two days left on the team. And then...done =)

After noon conference (I always fall asleep somewhere in the middle), we met up in Obs, where Angela told An and me that she wants to pre-round every morning before morning report b/c today's rounds were chaotic and disorganized (i.e. I said my patient had normal pleural fluid without interpreting it, and I didn't have a good plan for one patient). I'm all for making rounds faster, and if prerounding is the way to go, I'm all for it. Because Yan had a day off and Angela had clinic, it was just Zack, An, and me to do things on the floor. I was in charge of writing orders and stuff for my three patients: a guy with a palmar rash and swollen knees and ankles (we initially thought he might have Rocky Mountain spotted fever but now it looks more like disseminated gonorrhea), my "train-wreck" patient with resolving fever but worsening cellulitis, and my liver biopsy lady who still itches like crazy but her LFTs are improving.

My "train-wreck" was fairly straightforward. For my patient with potential gonorrhea, I was supposed to speak to him alone to tell him we think he has gonorrhea and to ask if he knows who may have given it to him so that she can be treated. The problem: his girlfriend. Almost every time I went into the room, she was lying in bed beside him (hospital beds are wide enough for two thin people to sleep side by side), in a crop top and miniskirt no less. It seemed impossible to get my patient alone without his girlfriend nearby, so after a while I gave up, leaving the task of breaking the news to Zack. Later I asked a Spanish-speaking nurse to come talk to my liver biopsy lady to see if she was taking any herbal supplements that could be contributing to her liver disease. The patient said she was only taking Tegretol for her trigeminal neuralgia, which I said wasn't right since we discontinued it when she came to the hospital. Then came the kicker: she had kept a bottle of Tegretol in her purse beside her bed, and she'd been taking her usual dose of Tegretol without letting the nurses or doctors know. I thought, "Oh crap," since we'd originally thought her Tegretol was the cause of her liver disease (autoimmune vs drug induced). And though her LFTs were falling, her pruritis persisted, and we thought her LFTs were improving b/c she wasn't taking her Tegretol. Not so. The nurse told her that she wasn't supposed to be taking Tegretol without our permission, and the patient replied that she had to take it or else her trigeminal neuralgia would act up. I called Zack to let him know what was going on, and he said he'd ask Angela what to do. In the meantime, I told the patient to stop her Tegretol for now, and she didn't look happy about taht. Later I found Zack, and he told me that Angela gave permission for the patient to continue her Tegretol (since it obviously isn't keeping her LFTs up). Even though she's still jaundiced, there's nothing more we can do for her, so hopefully she got discharged later on. And since it's important to document everything, I wrote an addendum in her chart revealing what happened today. We'll see if any good came of it.

IM Sub-I: The longest post-call

Because we were post-call today, Amy wanted us to start rounding at 8:00 a.m. in order to finish by noon. Considering how we rounded at 6:30 a.m. at JPS when we were post-call (granted, we also spent the night at JPS), this was nothing. Even still between 8:00 a.m. and 9:00 a.m., we only saw two patients in IMC. Amy and Angela take their time going through each patient's individual problems and then discuss a treatment plan amongst themselves that may or may not involve the interns and med students. Most of the time Zack, Yan, An, and I just stood around doing nothing. All of us missed Greg and Dr. C, who went through rounds at lightning speed so that even if we had 18 patients, we could start rounding at 9:30 and be done by noon. An saw Greg earlier this morning and he'd asked, "Do you miss me?" Yes, Greg, we do.

After morning report, it took us until 12:20 to see the rest of our patients. At 11:15 we had three patients left to see and thought we'd do quick rounds on them. No such luck; one lady kept talking nonstop about how she works as a horse trainer (even showed us her "guns") and had been healthy for most of her life until she got "T-boned" in a car accident months ago, etc. Yan had warned us that she was manipulative, going so far as to move during the MRI b/c "they didn't pull me out in 20 minutes." Angela later told An and me to go to pathology to check on biopsy results for our respective patients who had biopsies done yesterday. An's patient's FNA came back inconclusive, and while my liver biopsy patient was revealed to have cholestatic hepatitis, whether she has iron overload or not remains to be seen. I later told Angela the news and she told me to leave a note in the chart, but I forgot and didn't remember until I started writing this entry. Dang it, so much for making a favorable impression, even if I'm only here for a few more days.

I went jogging along Town Lake again and saw two women walking a total of six labs and retrievers. One dog was leashless and another had his leash attached to his owner's belt. Dang...

IM Sub-I: The "New" Blue Team

This week, with Greg moving on to the ICU and Dr. C on vacation, we gained a new attending and resident, both of them female (making Zack the only male on the team). The attending, as I mentioned before, was one of the chief residents last year; she introduced herself as Amy so I guess that's what I'll be calling her. Our resident, Angela, was late, way late; despite numerous pages, she didn't even show up until after we were finished rounding (almost 90 min after we started). Amy said that Angela's lateness was nothing new (apparently she's not punctual at all), but this was ridiculous.

We had two patients who needed biopsies today: a liver biopsy (my patient) and a FNA on a neck mass (An's patient). Before rounds, one of the nurses told Yan and me that our liver lady's biopsy would have to be ultrasound-guided instead of CT-guided because CT-guided biopsies require the presence of a mass (which our lady doesn't have; we think she has hemochromatosis). Yan had to change the orders. Later we went down to the radiology department after it looked like the FNA on the neck mass would be cancelled, and we made sure the order was put in. The radiologist offhandedly mentioned that the CT scanners were empty and that these cases should proceed quickly, and for some reason Angela thought that my liver lady's biopsy would be CT-guided.

"No, it's ultrasound-guided," I corrected, and An said, "No, the FNA is ultrasound-guided. The liver biopsy is CT-guided." I said, "No, it's not!" and Yan looked confused. I knew I was right, and I didn't understand why An and Angela thought the biopsy would be CT-guided. This was my patient. I came very close to losing my temper (something that never happens on rotations), but I kept my cool and muttered, "Fine, I'll keep my mouth shut." Angela said, "No, we have to clear this up. There's too much confusion." So once again, I said, "The nurse on the floor said that her biopsy can't be CT-guided because she doesn't have a mass. It has to be ultrasound-guided." Another nurse walking past us heard me and confirmed that I was right, and I couldn't help but say, "See?" *sigh* Greg was right when he said that we'd miss the way our team used to be. The "old" Blue team really was a dream team. At the very least, there was never any confusion or arguing because Greg was always on top of everything. He always had his facts straight. Yan felt the exact same way; she, An, and I (not sure about Zack) all miss Greg.

We were on call today, and I got my first patient around 4:00 pm. Yan said that we'll have to see him together b/c he was apparently "very sick" and yet ICU rejected him. Speak of the devil, Greg walked into the dining room just as Yan and I were discussing our patient, and Yan asked him why ICU turned the patient away. "It'll be a good learning experience for you," said Greg, and we soon learned what he meant. Our patient had a LONG list of medical problems (i.e. DM, CAD, bilateral AKAs, A-fib, to name a few) and presented with something vague like fever and weakness. His lungs sound like crap, and he definitely has a pleural effusion. An didn't get her first patient until 7:00 pm, so to be fair, Angela decided to let us go after one patient each. This was the earliest I've ever left on a call day, so I was happy =)

IM Sub-I: Untrustworthy patients

Yesterday I spent my morning shopping at the outlets at Round Rock (picked up a suit for interviews), and spent part of the evening browsing through the Domain (an upscale outdoor shopping center on Braker Lane; there's even live music at night) while chatting with Dina on the phone. Then I watched the Olympics in time to see Michael Phelps earn his 8th gold medal; talk about awesome =)

This morning Greg and An had the day off, so it was just me, Zack, and Yan along with Dr. N, our attending of the weekend. Dr. N certainly seemed nice enough; even pimped me on a few topics that were mostly hit or miss. My diabetic noncompliant patient was causing trouble for the nurses again; he kept insisting that he needed to go home because he's supposed to get a motorized wheelchair delivered to his house and he needs to be there to sign for it. "Just give me oral antibiotics," he said, even though Yan tried to explain that pills alone weren't strong enough to treat his osteomyelitis (he needs IV meds). Once we assured him that he could leave AMA with antibiotics, he seemed happy, but then he privately called Yan back to his room and asked for some Norco for his leg pain. Dr. N said that Yan could write him a prescription for 5 Norco, but no more than that. After we left the 4th floor and went to Obs to see 2 patients, Yan got paged twice regarding our noncompliant patient. Apparently he was refusing to sign the AMA form unless he got his Norco prescription. So Yan went in to "negotiate" with him about how much Norco he could get (he kept asking why he couldn't get at least twenty). I stood outside the room eavesdropping on their conversation (I didn't know why I had to be present; I could have gone to other floors to help Zack or something), but I wasn't the only one. Two nurses told me that the patient had never once complained of pain while he was in the hospital, and since he's not taking Norco right now, there's no need to start him on it as an outpatient. "You know what he's going to do with that Norco? He's going to sell it on the streets," said one nurse. "The PICC nurse has seen him on 6th street; he probably wants the Norco so he can make some money, and when he runs out, he'll come right back." Another nurse agreed that he was a tough patient to handle, adding that he's been "stewing" in his urine for almost twelve hours because every time a nurse approached him to change his sheets, he'd get mad and refuse to get cleaned. He's also refusing to get antibiotics (hence, the reason for letting him go AMA), except now he won't leave without Norco. Finally Danielle, one of the nurses, couldn't stand it anymore and asked me to call Yan out, pretending that she had an important phone call. Yan, just like me, had bought into our patient's claim that he was hurting, but its the nurses who spend more hours on the floors near him that know what's going on. Yan didn't know what the policy was for leaving AMA, so we asked another nurse to talk to the patient. He repeated the same story that he needed to be home to accept his wheelchair or else he won't get another one for five years (I've personally never heard of such a thing), but she called his bluff and said that her father was hospitalized once but still got a motorized wheelchair before he left. "Fine, I'll stay here and get the PICC and miss out on the wheelchair," he said angrily, so the nurses left the room thinking that things were settled. Then all hell broke loose as he began screaming and cursing at no one in particular, then throwing things against the wall (someone had to call a Code Gray on him and security came to get him to calm down). Then he started yelling about how no one's cleaned him in hours, and the other nurses were like, "Oh, hell no, he didn't!" (b/c he was the one who had refused to get cleaned and said he'd stay and make everyone's life hell). "Now's he's going to say we neglected him," one nurse grumbled. Earlier in the day, Yan had commented that she doesn't know whether she can trust what patients say anymore. About a week ago, we had a patient who came in with multiple bullae on his left hand that eventually coalesed to form one huge bulla that covered his entire left hand. He claimed he didn't know what happened, that he "woke up" after passing out on his porch and found his hand swollen, then later said he may have scratched himself on the nail. Fearing a bacterial infection (especially since we had no idea what we were dealing with) and compartment syndrome, plastic surgery came to do a fasciotomy on his hand. Then yesterday, his father called the hospital saying that he had seen a copperhead bite our patient's hand. Ummm, what?! Why didn't anyone tell us this earlier? The patient had continually denied that he'd been bitten by a snake b/c he didn't know what had happened, but once Yan showed him an article about snake bites, including an image of a person with multiple bullae on his hand (very similar to his initial presentation), he said, "Yeah, that's exactly what it looked like!" *sigh* Now that we know he doesn't have a bacterial infection, I think we can d/c his antibiotics. After work, I went to the Town Lake Trail and walked/jogged at least 3-4 miles by walking from Lamar Blvd to Mopac, round trip. Needless to say I was exhausted by the time I got back to my car.

IM Sub-I: Changing Attendings

Today was Short Call A, but Greg didn't get any new patients this morning. This turned out to be a good thing for everyone. It was also Dr. C's last day with us (he goes on vacation next week), so he took turns grading both Yan and Zack with their physical examination skills (kind of like an OSCE?) before morning rounds. Rounds proceeded quickly and we saved our "favorite" patient for last: my former noncompliant diabetic patient. Even before we entered his room, we heard some of the nurses murmur, "Oh Lord, that man..." Dr. C asked him why he was refusing treatment, and as expected, the patient got mad and said, "So it's all on ME now?" and added that he couldn't stand the sight of Greg (whose mutual disgust was written clearly on his face). Dr. C asked if he needed a psych consult, and Greg reminded him that psych had said he was competent to make his own decisions. So with nothing resolved, we left the room. Greg commented that tomorrow's attending will be in for a treat when she meets our patient.

After rounds, I accompanied Dr. C to his office for my evaluation. Along the way, he told me that I did a good job (detailed H&Ps and reliable follow-up on patients every morning), that he was glad to have me on the team these last three weeks, and that he'd be happy to write me a letter of recommendation for my residency application. He also told me a little about the program here in Austin and encouraged me to apply, saying he'd put in a good word for me. That's very nice of him; I don't think I could have asked for a better attending this month =) Hopefully our next attending will be cool as well.

We had nothing to do after noon conference, and I was able to talk to Greg and get tomorrow off. That means....TAX FREE SHOPPING!

IM Sub-I: I'm baaaaaack....

This morning I checked our patient list to see that we had eight new admits...among them, my borderline, noncompliant diabetic patient. WHAAAAAT?!? What was he going back at the hospital less than two weeks after we discharged him? He's also on the "no-bounceback" list, so it was by twisted chance that he came to the hospital on the day my team was on call...again. "Third time this month," said Greg, and An joked that it was b/c our patient loves Greg. We all knew that wasn't true though; he flat-out told me two weeks ago that he hated Greg and Dr. C and wanted different doctors. He should have come to the hospital on a different day then. As it turns out, he "lost" his prescription for Levaquin that we'd written for him so he started taking his mother's leftover penicillin instead. As a result, his cellulitis never healed, his sacral decubitus got worse, and now he has chest pain. Things weren't much better when we stopped by his room to see him. The room smelled of cellulitis (not terribly repugnant to the point of making one puke, but not pleasant either). At first he was polite, addressing Dr. C as "Sir," but when we were about to leave, he asked if we were going to put him on the diabetic diet again. When Greg said yes, he got mad and said, "I'm not a diabetic!" Clearly impatient, Greg told him that his HbA1c was between 7 and 8 and that makes him a diabetic. The patient closed his lips and refused to say anymore, so we left. Greg commented that the smell was a lot worse last night in the ER, and Zack agreed he's disgusting. *sigh* I was hoping we'd never have to see him again but oh well. At least I won't have to follow up on him this time around. My compliant diabetic patient who recently had a BKA went home today, too. He's pretty optimistic about his future, and I wished him all the best. As sad as I am to see him go (I've enjoyed talking to him), I hope I don't see him back in Brackenridge while I'm still here. I hope his outpatient EGD and colonoscopy won't show any tumor growths, and that he'll be able to obtain two prostheses so that he can walk on two feet again. =)

IM Sub-I: Wednesday Call

Another day on call. My first patient was an 89-year-old lady with chest pain; this isn't her first visit to the ER with chest pain given her hx of A-fib and CHF so I expected her to get discharged tomorrow. My second patient was a man in his 40s with pneumonia. Greg had run an HIV test on him, and when I examined him I saw some thrush on his tongue. Hmm, definitely suspicious for immunodeficiency. He only spoke a little bit of English so I was very grateful when his sister came in to help translate. Later when I presented him to Greg, Greg asked, "Did you ask him if he was gay?" Well, no, that thought never occurred to me, but Greg said he'd asked and yes, my patient is gay. His CXR and poor oxygen saturation is suspicious for PCP (though I was uncertain since I had an HIV positive patient at JPS who had pneumonia but it had been plain old CAP not PCP), so he's getting an HIV workup. I ended up leaving around 8:30 pm, so I made the drive to Andrew's to watch more Olympics. The US men's gymnastics guys didn't do so well in the all-around.

IM Sub I: Hallelujah!

This morning I saw another familiar face: Melissa. Wonder what rotation she's doing. In morning report today, we got a case about a 76-year-old woman with acute altered mental status. When asked about her past social history, the resident doing the presentation mentioned that the woman had worked as a prostitute from age 15 to her 40s. "What happened in her 40s?" one attending asked. "She became a Christian evangelist," the resident replied. The attending's response? "Hallelujah!"

In other good news, my patients seem to be doing very well. My gallbladder CA patient has been cleared to go home with antibiotics after developing bacteremia from her biliary drain. My colon resection patient is no longer delirious and is scheduled to undergo physical therapy and get his diet advanced so hopefully he can go home in a few days. My patient with osteomyelitis got his leg amputated today, but he remains optimistic that once he recovers, he'll be able to get prosthetic legs and be able to one day walk again. My EtOH withdrawal patient feels pretty good and can probably go home today if ENT clears him to do so (he had 5 days of epistaxis). And today I picked up a new patient: a woman in her 50s with a clear-cut case of unstable angina. Liza and her resident (who are on cardiology service) came to the room near the start of my interview, so we ended up interviewing her together.

Speaking of things to celebrate, anyone watch the men's 400 m relay in swimming yesterday? That was awesome. =)

IM Sub I: The Shortest Day

We only had about eight patients to round on this morning, so we were finished rounding before 10:00 a.m. One of my patients, who recently had a colon resection, was confused and paranoid this morning; he told me he thought his nurse disconnected his phone to keep him from calling his family and that she was out to bury him (he earlier told Zack that he thought the nurse was putting soap in his IV). Because he was afebrile, we deduced that morphine was the cause of his delirium and the nurses turned off his PCA (which made him even more alarmed). My gallbladder CA patient keeps having low potassium levels, and Greg realized that she was getting Ringers instead of NS as her maintenance fluid, and that may have contributed to her hypokalemia. Hmm, I'll have to read up on that. My diabetic patient with ARF is going into surgery tomorrow for debridement of his left foot (he has osteomyelitis), but if no further benefit can be derived from debridement, the surgeons might just perform a left BKA directly. I asked him how he felt about that, but he was accepting of the fact. "It's what I've expected," he said, considering that he'd lost his right leg under similar circumstances.

Because it was Short Call A, Greg had to stick around until noon to admit up to 4 new patients. Zack didn't have much to do so he told me to find Greg and help him out. I ended up filling out orders for Greg while he talked to our newest patient (a guy in EtOH withdrawal and epistaxis x 5 days), and he asked if I'd be interested in following this guy. I said yes, and went into the room to introduce myself. One thing I'd glad about being a student: I have time to chat with the patients whereas the residents and interns usually just poke their head into the rooms for a brief exam before leaving. Dr. C was surprised when I told him my osteomyelitis patient once worked as a nurse and had trained at a nearby hospital; that's something he never asked =)

I left the hospital around 11:00 a.m. (YES!!!) and had time to go grocery shopping before arriving back at the house. I had originally planned to visit the Blanton Museum today with Beth (the roommate) after she asked to come with me, but then she had a lunch date and never came home, so after waiting for hours I ended up not going. Fine. I'll just go another time at my own convenience. In the meantime, I love watching the Olympics in the evenings =)

IM Sub I: Post-Call

We had a total of 8 new patients on our service this morning; yesterday was apparently so slow that the team never capped. Greg blamed it on the Olympic opening ceremony, that people probably said, "Screw the abdominal pain, I'm watching the Olympics!" Some of my neighbors did have a party last night and kept me awake until almost 2 a.m.; needless to say I was very pissed. My patient with two colon masses went through a colon resection with no complications. My gallbladder cancer patient is much better. My diabetic patient with ARF is just "hanging out" for the weekend, but I really like talking to him. He used to be a nurse, so he'd talk about how nurses these days don't do as much (or know as much) as he did back in his day. Not to mention he has a great view of UT from his room.

One of Zack's patients had a "psychotic episode" but we didn't know what he meant until we actually saw the patient himself. He'd been admitted for COPD exacerbation, and when we first spoke to him he was polite and well-mannered. Then Dr. C asked him if he's ever been depressed or anxious, and the patient instantly changed. It was a total Jekyll and Hyde transformation; even though he remained in bed, he immediately began yelling and ranting about why everyone thinks he has a mental problem, that women were manipulative bitches, that foreigners and communists were taking over (it didn't help that our team had two Caucasians, one Bosnian, and three Asians), among other things. He ended each sentence with a weird spitting sound, and Dr. C asked a nurse if we needed to call a Code Gray (aggression in patients). "No, he'll calm down if you leave him alone," she said, so we closed the curtain on him so he wouldn't see us. Even with the curtain drawn, he continued to ramble for another 1 or 2 minutes, at one point making squawking sounds like a chicken. Thank goodness he couldn't see us; we couldn't help but laugh when we heard his squawks. Other than that, the rest of our patients were okay overall. We had several chest pain patients in obs that were discharged later in the day, which is good b/c Greg will admit four more tomorrow morning. An and Yan have the day off tomorrow, so it'll be me and the guys. Joy...

IM Sub I: Another slow call

For my day off yesterday, I went to Town Lake, Mozarts, and Deep Eddy pool (pictures are up on Facebook), and I spent the evening hanging out with friends. It was nice to relax for once =) My team was on call again today; my biggest regret was that I wouldn't be able to watch the opening ceremonies of the 2008 Olympics at Beijing =/ I was able to watch the first hr of the ceremonies in the surgery waiting room (even worse than last call, I didn't see my first patient until almost 8:00 pm. My afternoon wasn't totally wasted; however; I was able to fill out a few things on ERAS and do more research on residency programs. Even still, I hated that it was a slow night. Zack and Yan kept calling Greg in the ER (from the call room, presumably) to make sure there were no patients and that they weren't resting for nothing. An got her first patient in the afternoon, but by 8 pm when I still hadn't seen my first patient, Greg told An she could go home. Like any good med student, she stuck around until I got my first patient: a guy in his forties who had a history of upper GI bleeds and presented with abdominal pain, nausea, and retching. I could barely get him to answer any of my questions b/c he couldn't stop retching into a plastic bag (and understandably, he didn't feel like answring my questions). My physical exam of him wasn't great, but I did notice he had pinpoint pupils even though he denied drug use. Later his urine would show "presumably positive" traces of cannabis and opiates. No illegal drugs my butt. At any rate, there was only one more patient (a chest pain) after I finished seeing my patient, so Greg said I could leave. (An had left about 30 minutes prior). By the time I got home, the Olympic opening ceremony was over, but that didn't matter b/c I don't have TV service here =( Thank goodness I can watch TV at my friend's house.

IM Sub-I: Patients who Nag

The morning proceeded as usual, and of our twelve patients, nine of them were ready for discharge either today or tomorrow. Eager to make our patient list as small as possible, An and I immediately got to work helping Zack print out MOTPs (medicine discharge reconciliation forms; I don't know why they're called MOTPs) and filling out discharge forms for our patients. After lunch, Greg asked me if I had to go to lecture b/c today was Short Call B and we'd be admitting four patients in the afternoon. "I'd rather not," I said, and he told me to ask Ellen (one of the chief residents) to be sure. Fortunately Ellen said fourth years weren't required to attend lecture, so I went to Crash (the triage/urgent part of the ER) and immediately got my first patient: a diabetic man in his 50s with a BKA (below-the-knee amputation) who was sent to the ER by his home health nurse for an elevated creatinine. He felt fine aside from a non-healing ulcer on his left foot (which he will most likely lose before the year is out) and didn't understand why he had to be admitted. Greg gave me a lot of time to think about this case (he saw An's and Zack's patients first), so by the time he got around to me I'd written out my H&P and filled out most of the orders. And this time, I did not dwell on the "non-important" stuff and got straight to the root of the problem, i.e. the patient has acute renal insufficiency and other cormorbidities. While we were down in Crash, we kept getting pages from nurses regarding our floor patients. A 20-year-old who was recently diagnosed with MS kept asking for some Norco for back pain (she'd had a lumbar puncture done), and though Zack said no b/c Norco was too strong for that sort of pain, she was so persistent that he decided to write her a prescription for about 5 to 10 tablets. "Her life's going to be shit from now on," Greg commented, which was another way of saying that in the long run, a stronger pain pill was a small thing to ask for. We also got a page regarding my cirrhosis patient who came to us on Sunday with a fever but now feels well enough to go home; he wanted to know when he could leave. The only thing keeping him in the hospital was an MRCP report (to rule out bile duct obstruction), but the dictation wasn't in the computer or the telephone dictation system. Greg told Zack to check in with radiology and see if they have a dictation or not. "They might get pissed at you for nagging them, but hey, it's part of residency," said Greg. But before Zack could visit radiology, he had to present his patient first. I then remembered how back in Methodist, Dr. M had encouraged Annie and me to check in with pathology any time we wanted b/c the people there love med students and are willing to help us out. Maybe the radiologists here would be more receptive if a medical student (instead of an intern) asks about a report. Deciding to take action, I went to the radiology department, went to the dark room, and introduced myself to one of the radiologists there, explaining the situation and asking if he could help me out. Luckily he was very friendly and pulled up the MRCP right then and there, saying that there was a dictation report in the computer that probably hadn't been uploaded to the system yet. I did notice an accession number beside the dictation, so I copied the number down and thanked the radiologist for his help. I felt like I'd done a good deed when I gave Zack the accession number, but when he punched in the numbers on the phone and put the dictation on speaker phone, we were dismayed to learn that the study had been poor b/c of motion artifact and nothing could be concluded from it. *sigh* The intern on GI immediately called her attending to see if they wanted to repeat the MRCP or just discharge him today; I hope they discharge him, because I was the one who admitted him and I know he's ready to leave. Greg made no mention of my going to radiology, but Zack later thanked me for helping him out. At least I saved him a trip =P This evening I drove to campus and walked to Momoko's for some $4.00 pearl milk tea (but it's worth it). I have the day off tomorrow, and I plan to spend it doing stuff I normally don't do, i.e. going to Zilker Park, going swimming at Deep Eddy, paying a visit to Mozarts, etc.

Pigeon Tales

Austin is home to many pigeons. Back when I was in undergrad at UT, I was often annoyed by the number of pigeons that hung out in the West Mall, constantly underfoot or flapping around looking for abandoned boxes of French fries or other human foods to eat. They're not afraid of humans, either; I've walked so close behind one that I could have stepped on its tail or kicked it like a soccer ball (I've been tempted on a few occasions but never followed through). Likewise, the balconies of Brackenridge are home to many pigeons, and I've had to opportunity to observe them up close.

One family of pigeons lives just beyond the window of the 4th floor IM "quiet" area (where lockers and computers are located). There's a nest in the corner, complete with two little eggs, and the parents take turns sitting on them. I've seen them change shifts before; it's kind of like, "Your turn for egg duty." Other pigeons hang out in the same area but for the most part leave the couple alone; in fact, these days it's not uncommon to see one or two males strutting and cooing their stuff for another female who then flies off while the others give chase. Kind of amusing to watch =P

Today in another patient's room, I looked outside the window and saw a mother pigeon feeding her two chicks (via regurgitation), which was funny b/c her "chicks" were practically as big as she was. They kept hopping around during the feeding process, so it looked almost like the two birds were dancing. Still, at their size (and full feathered plumage) I think it's time they learn to find food for themselves =P

IM Sub I: Cancer cases

The UTMB third years surprised me. After all that fuss about asking whether they had to come to work today, just about all of them showed up for work. I guess they didn't want to look bad in front of their attendings; smart move. I spotted another familiar face in the cafeteria today: Lori. She's doing an ob-gyn rotation here at Brackenridge, so that makes 4 from our class here so far. We don't see the ob-gyn people much except in the elevator or in the cafeteria, but I see Liza more often b/c cardio is part of medicine. She even attended this afternoon's lecture (led by Dr. C) on cancers.

Speaking of cancer...it seems like I get an awful lot of cancer patients. One of my patients, a man we admitted on Friday for LE swelling and a bad case of anemia (H&H was about 7/24), had an EGD/colonoscopy done this morning to see if he had a GI bleed. I saw him not long after he was brought back to his room and went to his chart to see what GI had found. Turns out he has a 1 cm bleeding sessile mass in his sigmoid colon, suspicious for cancer, among other polyps, and surgery has been called to evaluate him. I immediately called Zack to let him know we would not be discharging our patient today, and fortunately he was with Greg at the time and was able to pass the message along. "Better cancel the aspirin, too," said Greg, but surgery had already done that. I accompanied Zack to our patient's room and listened as Zack explained what we'd found (he took good care not to say the dreaded "c-word"), but the patient didn't appear too concerned. He was more interested in eating his lunch (he'd been NPO for over 30 hrs because he was supposed to have been scoped yesterday), which is understandable.

I asked Greg for some feedback on how I'm doing so far, and he said my physical exam skills were great but that when I'm presenting a patient, I need to focus on the important details (i.e. what brought this patient to the hospital) instead of the extra stuff (i.e. the patient is concerned about his erectile dysfunction). Good to know. I'm also hoping to take a day off on Thursday. I try to coordinate it so that I don't take a day off on the same day as one of the interns, and since Yan has tomorrow off, Thursday is a good choice for me. Dr. C says I'm doing well so that I can take any day I want off as long as it's not a call day. Fair enough, except since pre-call is usually the least busy day, I'll stick to taking pre-call days off for now.

On another note, congratulations to Ben and Susan on the birth of their baby girl! =)

IM Sub-I: Sleepy Day

I couldn't believe how sleepy I was this morning, and I wasn't even awake all night like Greg was. After getting to the hospital, I found that my psych patient had checked out of the hospital AMA earlier this morning. According to the nurse, he woke up "suddenly alert," realized where he was, and decided to leave. Hmm, whatever. I'm sure the team won't complain about losing a patient. Later I found out we'd lost another patient; Mrs. X passed away early this morning. "That seems to be the only way you leave this team, you die or you leave AMA," Dr. C said half-jokingly, since most of our patients have major illnesses and keep our census quite full. Hopefully my gallbladder cancer lady and my duodenal mass lady can go home today; there's not much more we can do for them. Zack lamented the fact that two of the patients I've seen have been at the hospital for more than 3 weeks, and dictating their reports will be a long and hectic journey.

In Galveston, UTMB cancelled all its classes tomorrow because of a hurricane threat, and as such, third and fourth year students don't have to go to work. One of the third years brought it up to his attending and asked if the same rule applied to them even though they were in Austin (where it's nice and sunny). I could see where this was going, of course, and obviously so did the attending. He said that he would comply with whatever UTMB said, but personally he didn't think it was necessary to give the Austin third years a day off when they could be learning and helping their teams instead. In the end, I later got a page saying that in accordance to UTMB policy, all third years don't have to come back to work until Wednesday morning. *sigh* Lucky bastards. I still haven't had a single day off since I've been here, and I've been waking up between 5 and 6 every morning to see my patients. I can't remember the last time I got a good night's sleep. Still, I wouldn't be too surprised if An shows up at work tomorrow anyway. She's the perfect med student, after all.

Today Liza and I both spotted Annie in the hospital; I guess that means she's doing a rotation here? Hmm, I'll have to ask the next time I see her.

IM Sub-I: The Longest Wait

We discharged six patients yesterday (including my noncompliant patient), which meant that today, we'd cap after six admissions. Even still, our team had to admit ten patients, then give four of them to the other teams. Yan later told me that my noncompliant patient had to be taken home by ambulance since he wouldn't leave without his wheelchair and the nursing staff was fed up with him and determined to get him out. Dang...

I knew from experience that Sundays tend to be extremely slow days, but today was just ridiculous. An and I spent our entire afternoon in the IM library surfing the net (I was researching residency programs) because there were no new patients coming in. Even Yan and Zack wondered what was going on; all they had were crosscover duties. An was upset b/c the rest of her classmates had some kind of dinner party going on tonight and she couldn't go b/c we were on call. Finally, around 6:30 pm, my beeper went off and I gladly hurried to the ER.

My first patient was a man with a one week history of fever and abdominal pain and a one month history of bilateral leg edema, peripheral neuropathy, and inability to get an erection after he accidentally fell and smashed his groin against a solid surface (yet he had no urinary problems). When I presented him to Greg, I kept focusing on his leg problems, but Greg said the more important issue was his abdominal distention and fever, which is probably SBP (spontaneous bacterial peritonitis). *sigh* Greg must think I'm a dumbass for focusing on so-called non-important things. My next patient was a 27-year-old guy with altered mental status, most likely secondary to marijuana and PCP use. He'd been found running through traffic and was combative when the police tried to restrain him, but by the time I got to see him, he was so doped up he could barely find the words to answer my questions. He knew where he was and what date it was, but he couldn't remember how he got to the hospital or where the scrapes on his palms came from. His pupils were dilated and sluggish. At one point he said his leg hurt and he began touching his leg to show me, but somehow his hand wandered over to his penis and he began masturbating instead. Ohhhhh-kay. Thank goodness Greg assigned this patient to me and not An; I've already had my psych rotation, so masturbation is nothing new or surprising for me. Zack said, "Oh man" when I told him and Greg about our patient, and both guys burst out laughing. An and I both ended up leaving after 10:00 pm (with An grumpy and hungry b/c she'd skipped dinner; I at least had a smoothie). So while this day started out slow as hell, in the end the patients I got were both interesting and made it worthwhile =)

IM Sub-I: Two Interns and an AI (Acting Intern)

Greg and An were both off today, so it was just me, Yan, Zack, and Dr. C today. We were scheduled to round at 8:30 a.m., so I had to wake up at 5:00 a.m. in order to see all five patients on time (about 30 minutes to wake up, get dressed, eat, and drive to the hospital, thirty minutes to write all the lab data down, then 2.5 hrs to see the patients) There's no free hot breakfasts or lunches on the weekends, so since I'm on call tomorrow, I'll have to bring some granola bars from home (or else fork up some cash in the cafeteria) Because we'd capped, we had a full list of patients; none of mine went home. My noncompliant patient finally got his MRI, so if the results look good, he should be going home later today. My transfer patient is set to go home today. My two ladies with cancer will be staying longer. My new admit from yesterday has decreased swelling in his lower extremities so the Lasix is helping with his CHF, but his anemia (H&H of about 7/24) was alarming so we'll be keeping him here for a few days to run more tests and find out why he's losing blood. Dr. C turned this into a teaching case for CHF and spent more time going over this patient's chart with us than any other patient, as he wanted us to learn how to read EKGs and think about what could have caused this man's CHF. I liked that he was willing to teach while rounding; that's something I never got at Methodist.

The saddest case was probably Mrs. X, who was still awake and talking yesterday but is now doing more sleeping than anything else. From the looks of her, she only has a few days left. When we went to her room, her children were keeping an eye on her (and still crying), and everywhere in the room were pictures of happier days with the family. Most prominent was a black-and-white picture of Dr. and Mrs. X on their wedding day; both looked so young and happy. Dr. X was actually quite handsome sixty years ago. "Dad wasn't a Catholic, so they couldn't be married in church; they had a priest marry them at home," said one daughter. I commented that they looked like a lovely couple, and his daughter agreed. After we left the room, Yan started crying a little and said, "She was doing better just a few days ago." Zack, who was not here yesterday, asked what happened. Dr. C told Yan to stay strong. =/

We managed to finish rounding at 11:00 a.m., and Zack lamented that An wasn't around to help him with stuff (usually I help Yan while An helps Zack), so after we ran the list, I offered to write orders for both interns. Dr. C is usually good about saying what tests he wants (i.e. CBC, CMP and heparin infusion for my gallbladder CA pt), so armed with this knowledge, I hurried from floor to floor jotting down orders so that Zack and Yan can sign them later. Sometimes when I was on the floors, the nurses would tell me new developments about certain patients (i.e. one guy had to be put in restraints b/c he got disoriented and tried to climb out of bed, to which Zack groaned, "Again?!" when I told him), but in the end, I got out at noon and both interns thanked me for helping out. This was the most helpful I've ever felt since I've been here, and it was a great feelng.

IM Sub-I: A very Short Call B

This morning I had five patients to round on (Zack went to San Antonio and he never found anyone to cover for him), so I got to the hospital at 6 a.m. At first everything seemed all right with my usual four patients. I told my noncompliant patient that he didn't need an MRI because his blood tests were clean, and he seemed almost disappointed (funny, after he refused to get an MRI three times before). My ICU patient was eating and walking and looked ready to go home. My lady with black stools was getting scoped in both ends this morning. And my cancer lady's family was upset because heme-onc never came to see her yesterday. Then while I was in ICU, I spotted a familiar face: Dr. X, a retired physician whose wife was in our care earlier in the week. He was infamous for using his position (he used to work at this hospital) to get nurses and other doctors to give his wife extra attention and care. We'd been relieved when Mrs. X was discharged two days ago, but now she was back again due to aspiration pneumonia. Some of the younger nurses, not realizing who Dr. X was, asked him to wait in the waiting room, but he refused, saying it was a matter of life or death. As it turned out, Mrs. X has refused any further treatments. She feels that, at 80 years old, she's ready to die. It was very sad when we went into her room b/c her children were crying, but she and her husband both thanked the team for taking care of her up to this point. She was in IMC (the unit for people that are too sick for tele, but not sick enough for ICU), and Dr. C said he'd try to move her to the 9th floor so that she could have a good view of Austin, preferably of the Capitol. =(

I had to present one of Zack's patients and totally messed up b/c I didn't look up how much tube feeds he was getting (don't know where to find that info), but An jumped right in with the correct info. *sigh* Now she's really making me look bad. But later on, when Dr. C pimped us on what drugs to give as prophylaxis to HIV patients, I got them all right. Thank goodness for that IM departmental exam =P Then all hell broke loose. My noncompliant patient has now insisted on getting his MRI (with major sedation), but the problem is Dr. C wants a nurse to accompany him downstairs for the duration of the MRI and the nurses were already understaffed. Heck I don't know why he needs a nurse to follow him, but oh well. Then we got the results of my lady's EGD: she has cancer in her duodenum and will need surgery. O_O Why are all my patients getting cancer?!

Today was Short Call B, which is normally the worst because you have to admit 4 patients in the afternoon. We ended up admitting only two (me and An each got one) b/c we had 16 patients this morning, and after our two admissions we capped at 18. The thing is, Greg didn't tell me we'd capped. He told me to just study and hang out until further notice, so I spent about one hour in the ER computer room surfing UptoDate (or napping). Then I left the room briefly and came back to hear one intern or resident say that "___'s team capped after two admissions." Hmm, that sounded a lot like my team, so I immediately paged Greg. He never called back but showed up in the room where I was waiting a few minutes later (probably recognized the number), and I asked permission to leave. An was nowhere in sight; I bet she was long gone after she admitted her patient. That's just not fair; if I never paged Greg, I probably would have sat around doing nothing until 5 pm (end-time for the students). What am I, expendable? =< Oh well. An and Greg have the day off tomorrow so it'll be just me and the interns. I'll be sure to do well tomorrow =)

There was some good news when I got home from work today:

YES!!! I don't have to go back to Conshohocken! =D