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.