Radiology: Happy Halloween!

Dr. G was out of town today, so I spent the day working with Dr. J instead. I think I learned a lot more today from Dr. J than I have with Dr. G b/c he would ask me questions while examining the images. He'd ask me if I talked about different MRI resolutions, or what the density values of bone, fat, and air were, and if I didn't know, we'd talk about it. It was also Halloween today, so a few people came to work dressed up. One X-ray tech had her birthday today so at lunch there was free food and an ice cream cake (needless to say I overate and gained back all the pounds I've lost since joining a gym). It was also the last day of early voting (sadly I didn't take advantage of early voting when I was doing my geriatrics rotation), so when I went to the nearby recreation center there was a 30 minute line (and I saw my parents about 5 min away from the polls). So yes...I voted. We'll see if it's effective.

Radiology: A Diwali lunch

This afternoon Drs. G and J (the radiologists) ordered Indian food for the department to eat for lunch as a way of bringing Diwali to the workplace. The restaurant they ordered from was Star India in Arlington, and it was pretty good. Not too spicy =) Oncologists were invited too, but only 2-3 showed up. Thank goodness there was enough food for everyone. Dr. G won't be coming to work tomorrow so I'll be with Dr. J. I haven't worked with Dr. J before; hopefully he'll be nice.

Radiology: *zzz*

Another typical day at the radiology department (though it was interrupted by a fire drill). Dr. G and I spoke to Lauri, the med student coordinator; it looks like I'll be doing solely radiology only this week, and then next week I'll start spending about 2-3 days in different departments like CT, MRI, mammography, etc., just so I understand what's going on. Sounded good to me. Since I've been studying CT cross-sections of the thorax (haven't got to the abdomen yet), lots of images make more sense to me now. At one full body scan Dr. G asked me if I noticed anything unusual (i.e. see any "hot spots" that indicate cancer?) There was one solid region in the pelvis that lit up big-time, so I tried to figure out what it was. From the back it looked like he only had one kidney, but from the front...ohhhhhh, it was a horseshoe kidney! It was my first time seeing one of these so I was excited to recognize it for what it was. Dr. G said that since we see mostly cancer here and I'm interested in IM, she'll try to show me some CXRs and CTs of more common medicine disorders like cholelithiasis, pneumonia, and more. That'll be helpful =)

Radiology: Busy Diwali

This morning when I arrived at work I looked into the car next to mine and saw a cocker spaniel (white with brown ears) sitting in the driver's seat looking sad and forlorn. I waved at it, and it just looked at me. I didn't know how long it had been sitting in the car and wondered if its owner was inside getting a mammogram or CT done. The weather was pretty cold this morning (40's), and while I was sure the dog wouldn't freeze to death (with its fur and all), I didn't want to just leave it there either. I told Dr. G about the dog as soon as I walked into her office, and after asking me where my car was parked, she told security to check on the dog to see if we can find its owner. *sigh* Why on earth would you bring your dog with you to a doctor's appointment and leave it in the car? Surely it can stay at home unattended somewhere.

Today was Diwali, the Indian "Festival of Lights," (Happy Diwali!) and with Dr. J out of town to celebrate with his family, Dr. G was the lone radiologist today. We spent the morning going over CTs and MRIs as usual, and every once in a while Nancy, the mammogram tech, would call Dr. G to tell her to check on a mammogram or two and assign BIRADs to them. After lunch I was given some time alone to read a book on interpreting CTs (and have gotten halfway down the thoracic column so far) before sitting in on Dr. G's PET scan readings. Unfortunately we didn't get through all the scans until 5:00 pm because of multiple distractions. There were times when previous PET or CT scan reports were missing and had to be called in to AMH to get faxed over. Other times Dr. D (a well-known breast cancer expert in this area) would pop his head into the darkroom and ask Dr. G to bring up his patients' images so he can see them for himself (he, as well as another breast cancer specialist who recently retired, prided himself on taking the time to see the images and letting Dr. G explain what was going on). Dr. G, however, saw this as a distraction because whenever Dr. D came in (I saw him 3-4 times today), she had to drop whatever she was doing to pull up his patient's files, and then play catch-up on the files she'd been studying prior to his arrival. "This is supposed to be my Diwali!" she lamented (fortunately she gets a three-day weekend this week). And by 5:45 pm, we still weren't able to go through all the CTs on her desk, so she called it quits. "This is private practice, I can set my own schedule," she said. "And whatever I can't finish today, I finish tomorrow." Sounded good to me.

And this is why I can never do radiology. I don't want to sit on my butt all day in a darkroom looking at images and talking only to other doctors, nurses, and techs. I like being around people, talking to patients, walking around. =)

Radiology: Day One

This morning when I arrived at work I looked into the car next to mine and saw a cocker spaniel (white with brown ears) sitting in the driver's seat looking sad and forlorn. I waved at it, and it just looked at me. I didn't know how long it had been sitting in the car and wondered if its owner was inside getting a mammogram or CT done. The weather was pretty cold this morning (40's), and while I was sure the dog wouldn't freeze to death (with its fur and all), I didn't want to just leave it there either. I told Dr. G about the dog as soon as I walked into her office, and after asking me where my car was parked, she told security to check on the dog to see if we can find its owner. *sigh* Why on earth would you bring your dog with you to a doctor's appointment and leave it in the car? Surely it can stay at home unattended somewhere.

Today was my first day of radiology at the local cancer center in town. I first had to wait about 15 minutes for the nurse/program coordinator to meet me and take me to the back room to introduce me to my preceptor, Dr. G. Dr. G seems nice enough, but she soon made me feel like an idiot by asking me if certain CT images looked normal. When I admitted that I didn't really know what "normal" looked like she suggested that I read a book on MRI and CT cross-sections because I "have to know normal anatomy" in order to really do well in radiology. *sigh* Anatomy was one of my worst subjects in 1st year med school; this is not going to be easy.

After one day, I know for sure that despite the cushy hours and high pay, I would never want to do radiology for a living. Dr. G spent the morning reviewing CTs, MRIs, and mammograms and doing dictations after each image study, and in the afternoon it was the exact same thing except we were looking at PET scans for signs of metastasis and tumor. The darkness of the rooms did nothing to help me stay awake, and there were many times when I'd nearly doze off and be confused whenever Dr. G asked me a question. It didn't help that my mind started playing tricks on me, and on the cross-section CT scans I'd see shapes of dogs, ducks, and even faces (don't laugh). Especially on the PET scans; one scan had three dark spots against a white background that made me think I was looking at a ghost (Halloween around the corner, anyone?) The PET scans were pretty cool to look at because they light up at areas of high metabolism. So on every PET scan, the brain, the heart, the liver, the kidneys, and the bladder all light up to some extent; it's more important to find small focal areas in places that should not be lighting up.

There are two radiologists at the center, Dr. G and Dr. J, and when I'm not with one I'll be with the other. There's no set schedule for where I have to be each day; the radiologists want me to spend different days in different departments (i.e. mammography, PET scan, CT scan) while I'm here in order to see how images are obtained, but apparently I get to choose the days. After having each day planned for me for geriatrics, this takes some getting used to. I'll also probably have to make up a day since I plan to take 3 days off for interviews during this rotation, but seeing how I only live 5 minutes from the center (and have December off) I don't expect any problems. Because Diwali is this week, Dr. J has tomorrow off, and he told Dr. G that there will be a lot of "Mary's" tomorrow. At first we thought he said "merry" but he said, "Merry for me, Marys for you" since we have about 6 patients named Mary tomorrow. Good to know =P

Geriatrics: Exam and Exit Interviews

This morning we had our geriatrics exam, which wasn't too bad and hopefully I got at least a B on it. There were several questions from slides I had not reviewed, and afterwards people complained that they spent too much time studying the slides than necessary. I have no regrets; glancing through the slides probably helped me on 3-4 questions, which can make the difference between pass and fail. Afterwards, we went to the GAP clinic for exit interviews. First was a group interview with Dr. JH in which she asked for feedback on the programs and what we should do to make it better. Anita had a lot to say about how much she disliked the EMR system (electronic medical records) b/c her attending made her and Lora scribe for her while she saw the patients. Later, when my turn came to express my thoughts, I said that I was never taught signs of active dying that I could use to see in my hospice patients (though we got a brief lesson on that last year in family medicine). I then came to the defense of EMR by saying that I was able to enter in all my data during the patient visit so that afterwards all Dr. JK had to do was sign off on my note. After hearing all the complaints of doing nothing but scribing and how some of my classmates got bounced around from one attending to the other, I'm extremely grateful that I spent the majority of my rotation working with just one attending (Dr. JK), and that Dr. JK allowed Corey, Justin, and me to see patients alone rather than with her.

Next were individual interviews. Dr. JH saw 5 students and they popped in and out of her office really quickly. By the time the last of those classmates left, there were still 4 of us waiting to see Dr. JK. Finally it was just Justin and me waiting for Sara to finish her exit interview. Sara was in the office for a long time. My interview went well; Dr. JK asked me what grade I thought I should get for my rotation, and I said "Exceeding expectations" (89-94) b/c I felt I worked hard and was able to connect with my patients (and I mastered EMR to some extent). To my relief, Dr. JK told me that all the attendings I worked with gave me an E (in OWL terms, hehe), and she agreed with them. Nice way to end the rotation =) To treat myself afterwards, I stopped by the Cheesecake Factory and took home a slice of pumpkin cheesecake. Who needs EtOH when cheesecake tastes so much better? =)

Geriatrics: Last Day!

This morning was the last day of hospice (and geriatrics). Justin, Corey, and I went to JLWest, where Dr. M got charts for two new patients and said I got to take my pic. Upon hearing one of the nurses saying that one patient was leaking sputum through his trach, I decided to see the non-spitting patient, who turned out to be a man my parents' age with metastatic renal cell carcinoma. He was not in good shape when I saw him; he was unresponsive, tachycardic, and tachypneic. His initial resp rate was recorded as 50 breaths per minute, VERY rapid. When Dr. M went to see him, he was surprised by how much the patient had deteriorated from 4 weeks ago, when he was in the hospital alert and complaining of uncontrollable pain. There were also little notes in his chart saying that his mother was the MPOA (medical power of attorney) and that his son and his girlfriend have been living off his disability checks. Very dysfunctional family, apparently. Justin's cardiac patient whom we saw at Harris on Monday was actively dying; her radial pulses were nonpalpable, her feet were cold and slightly mottled, and the pinna of her ears were relaxed. When the radial pulses are absent, death usually occurs in the next eight hours. We all felt bad for the husband, who had hoped that she'd live to their anniversary, but he was very accepting of what was happening and planned to call his children to come over. Our other patient from Tuesday is still alive, but her family is concerned about whether or not she will die soon b/c they're missing work days to be with her to the end. Dr. M's advice was to play it day by day. My own patient from Tuesday, a man recovering from stroke and a partial craniotomy; seems to be doing very well; I don't think he should be on hospice yet. If anything, he should be in a skilled nursing facility, but Dr. M said you can't be in skilled nursing and hospice at the same time. "Of course, he could always leave hospice to go to skilled nursing," he said, then come back to hospice when he really feels the end is near. After a lecture on pain meds, Dr. M let us go for the rest of the day. AWESOMENESS. Still, instead of studying, I took a nearly 2 hr nap. *sigh* At this rate I just want to pass.

Geriatrics: Presentations and more

We had group presentations today over articles we were assigned to read. Justin and I had to talk about using non-pharmacologic treatments in dementia patients, which was pretty straightforward. Grand Rounds covered pediatric CNS tumors (pretty interesting), and then we drove to Harris. Justin arrived before me and went with two palliative care physicians from Universal Hospice to see some patients while Corey and I went to see the rest with Dr. M. We had one new hospice consult, and then we went to different floors where Corey and I each split up to see a patient before reconvening (usually Dr. M saw Corey's patient first and then went to find me). One patient was a lady with a history of psych issues and an open wound in her left ankle (she requested that we give her more than 10 Dilaudid pills since that's what JPS gave her once and it wasn't even close to enough); she was to be discharged as soon as she found SNF placement so Dr. M didn't go see her. The next patient I saw was the lady I wrote a consult note for on Monday; her pain was slightly better but we decided to put her on a Fentanyl patch in the meantime. Corey and I got out at 3:30 pm; Justin's car was still in the parking lot when I left. Looks like we got lucky.

Geriatrics: More Hospice

Today Justin and I started our day at the hospice center at JLWest, where we each saw a new admit (Justin saw the woman he did a consult note on yesterday). My patient was a 71-year-old man recovering from both a stroke and a parietal craniotomy (he had glioblastoma), and to me, he didn't look like he should be in a hospice center. He was eating well, could carry on a conversation perfectly, and had plans to eventually be able to get up and walk again. We tried to help him stand when Dr. M came to see him, but his left leg was way too weak to support his weight. Hopefully he'll be able to go home soon. Today was the first time I ever heard of "respite" hospice, where a patient goes to a community hospice center for a few days if the primary caregiver is overwhelmed and needs time for him/her self. There was a 96 year old Chinese patient that Dr. M went to see, and when he learned that Justin and I could both speak Chinese, he lamented not letting us talk to her. One patient I did see was near death; he had Cheyne-Stokes breathing and would sometimes go up to twenty seconds without breathing. The nurses have thought he was going to die every day since Sunday, so with him, it'll probably be a matter of time.

We got out one hour early, so I went to school to check email and ran into Dina. She was meeting Ben and Susan (with baby Anara) at Joe T Garcia's for lunch and invited me to come along. Not about to pass up a chance to meet Anara, I went =). Ben was still working at Harris, so it was just Dina, Susan, and me. Anara is 2.5 months old now and very adorable; she definitely looks more like Ben. It was cute hearing Susan describe Anara's growth progress and how one of their dogs, Minnie, has treated Anara like her baby and has become like a third caretaker to her. I wasn't able to stay until Ben got there, but it was nice catching up. Dina and I found out that we have our interviews in Austin on the same day, so we may share a hotel room the night before.

In the afternoon it was back to Harris where Justin and I ended up sharing a new hospice patient, a lady who came to the hospital with abd pain that was found to be ischemic bowel (yikes), and she hasn't awakened since her surgery. She only has one kidney and her creatinine is starting to go up, but her children don't think dialysis is best for her since it's not what she would have wanted. So hospice is the way to go. Justin did the physical exam while I wrote the note; Justin observed my mannerisms and said I'd make a great ICU doctor. Uh oh. What part of Dr. L or Dr. O rubbed off on me last month? =P

Geriatrics: Hospice Week

This week Justin and I are finishing up our geriatrics rotation doing hospice and palliative care (Corey's in Philadelphia taking his PE so he only gets 2 days of hospice care when he gets back). At Harris, where we were supposed to fill out paperwork and get badges made, we ran into Dr. KC, our Green team 4th year resident from ObGyn. She's working at Harris now and, from the looks of things, couldn't be happier (she was all smiles as always). It was good seeing her again. After we got our badges made, I called Dr. M only to be told that we didn't have to meet him until noon lecture, giving us 2 hours of "freedom" before then. I've been trying to find a pair of Danskos in Cordovan (that reddish hue) in my size and found them at a Scrubs Etc in Hurst, so I was happy =) Noon lecture involved learning about falls and how to prevent then, and then Justin and I returned to Harris with Dr. M. We each got a consult to see; Justin saw a hospice consult, and I saw a pain management consult. This lady was complaining of right leg pain (diabetic neuropathy) that was so painful that she was crying as she spoke to me, and she made several comments about how if she can't walk again she'd be better of dead, and why can't someone just chop off her leg so it'd stop bothering her anymore. I checked her meds and found her on Xanax and almost the full dose of Cymbalta (which can also be used for peripheral neuropathy), and Dr. M ended up upping her dose to the maximum with Cymbalta. He also prescribed some capfaisin (?) cream for her feet so they wouldn't hurt as much. Justin's patient just looked like she was almost at death's door, but her husband is hoping she'll last until their 43rd anniversary in two weeks. *sigh* Doesn't seem likely but it'd be nice.

Geriatrics: Last day of GAP clinic

For our last day of GAP clinic, we saw that there were three annual exams scheduled for today. Annuals take longer b/c you have to do a MMSE, a geriatrics depression scale, and various other questionaires about nutrition and other important things in life. None of us have had much experience with annual exams since Meng usually does them (though Justin and I did one on our first day of GAP clinic), but Justin and I, being future internists, had a pretty good idea of what to do. Corey, future radiologist, was still trying to find things on EMR, and he seemed determined not to see a patient requiring an annual for that reason. I took one of the physicals and met a very nice woman in her 80s along with her son. She seemed very alert with very little cognitive decline; she only had trouble naming animals and got the hands of a clock confused during the clock test. I probably spent an hour with her, and but it was well worth it, and afterwards her son thanked me and told me I would make a great internist someday =) When I left the room I found that Justin and Corey were gone; because there were so many no-shows, Dr. JK sent my "partners-in-crime" to Westover Hills to start seeing patients (we had 11 for the afternoon). That was fine with me; I just saw one other patient who needed and ER F/U for abdominal pain that Dr. JK and I think is attributed to anxiety more than anything else (but we're giving her Ensure with fiber and Benefiber to keep her bowels healthy, anyway).

I left the PCC at 12:30 and drove to Chick Fil-A for lunch. I left just as Corey came toward the restaurant; he said there were only three patients left to see. Back at Westover Hills, I meant to see two patients (I was taking too long pre-writing notes so Corey offered to see another pt to speed things along), but one of them was away at work and the other was perfectly fine (just needed labs). We went to some interesting rooms today; one lady had a room full of antique vases and other things from her grandmother and great-grandmother's time. We also saw my bipolar patient who'd taken St. John's wort; she was still having some abd pain so to be safe, we removed the bottle of St John's wort. With all the notes that needed signing and orders that needed writing (I spent about 5-10 minutes just trying to find a chart with patients' weights in it), even when starting rounds at 2:30, we didn't get out until after 5:00 pm. Imagine if the guys hadn't prerounded on the patients starting at 10:00...I'd hate to think how long we'd be there.

Geriatrics: Small is not harmless

This morning my classmates and I were supposed to present the papers we'd written about our experiences with grief, but Dr. RM never showed up at the appointed time (apparently he forgot). I was a little disappointed b/c I'd looked forward to hearing what others had to say, but instead we passed the time by chatting about our various rotation experiences (Eric and David had lots to share about their surgery experiences). Dr. JK gave Justin and me our patient cards for the afternoon (Corey was randomly chosen to spend his afternoon with another attending at the PCC) with the understanding that we'd see be ready to present at 2:00 pm. So we saw two patients in the morning, then two patients after lunch, and managed to start rounding a bit early.

One of my Alzheimers patients was all nice and sweet when I saw her (she kept humming Christmas carols), but later, for no reason at all, she came up to me with a somewhat menacing stare (even though she was smaller and thinner than me, I still felt scared) and asked me what I said. "I didn't say anything," I said, and a nearby nurse got the patient's attention and made her sit down. Dr. JK later told Justin and me that my patient used to fly into rages when she didn't get her way and has beaten both her grown son (gave him bruises all along his arm) and her incapacitated husband (who had a stroke and couldn't defend himself), and while she's calmed down considerably, her behavior can still be unpredictable. Another of my patients was a former firefighter captain, and he has a habit of spitting as he walks. It made me watch my step to make sure I didn't step on spit. We also met a lady who's been at JLWest for 13 years; there was a meeting held to discuss her care, but her son has been to so many of these meetings (52 to be exact) that he knew the drill and the meeting resolved in 5 minutes. Dr. JK also dug up some EKGs for Justin and me to read; I think we've gotten better at it =P

Geriatrics: The Flat Tire

This morning Corey, Justin, and I went to the Arlington Heights Health and Rehab center to see some more longterm care patients. From the start, we could tell that AHHR was nothing like Lakewood, Westover Hills, or any of the other assisted living facilities we have seen. The interior had a more hospital-like setting, and the halls smelled of urine and medications (the reason for this was that AHHR was for Medicaid patients who can't afford other luxuries that the other places offered). And of the 4-5 patients assigned to us, all of them had either dementia, a psych disorder, or both. One lady with bipolar and dementia was convinced that she had pneumonia and even went to Sherry to inform her that she had a doctor's appointment later that day (and her roommate looked at me and gestured that the woman was "cuckoo"). Another guy with schizophrenia went down the hall mumbling to himself, and when I called his name, he turned to talk to me but had extremely pressured speech and some mild lip smacking tardive dyskinesia. My last patient had multiple sores on his body b/c he'd been paraplegic (paralyzed below the nipple) for almost thirty years after a C5-C7 injury. Sometime later, when we were all in the conference room discussing patients, a nurse poked their head into the room and asked, "Does anyone here drive a Honda Accord?" I said I did, and after describing my car perfectly, she said that it had a flat tire. Whaaaaaaat?! I went outside to check, and sure enough, my car's left rear tire was completely flat. I had no problems driving to AHHR this morning so I had no idea what went wrong, but even still, I was grateful that my tire didn't burst while I was driving. After talking it over with Corey and Justin, we decided to leave my car at AHHR until after our afternoon shift at Westover Hills.

The three of us did lunch at Chick Fil'A (Corey's favorite fast food restaurant; he joked that the chicken had crack) before going to Westover Hills. We had time to kill before Barb (the NP) arrived, so Corey and I played a round of checkers (and I got soundly defeated). When Barb arrived, she assigned us two patients each and gave us a little information about each one (which none of our attendings have ever done, so this was nice), warning us if any patients were particularly cranky. One of my patients was rumored to be quite argumentative, so I made a note to be on my best behavior. She was a 95 year old lady who used to be an opera singer in FW, so her room was filled with pictures from her glory days in the 1950's. She was nice enough and told me she developed RUQ pain after taking St Johns wort, but fortunately she knew to stop taking it by herself. Barb said that there are many residents here that she'd love to take home and care for as a surrogate grandmother, and others where she can understand why their family doesn't visit b/c they're so cranky. Pretty interesting overall.

I called Triple A after work and they send someone to my car within 10-15 minutes. Justin drove me back to my car, and the repairman showed me that not only was there a nail deeply embedded in my flat tire, there was also a thin slash across part of it (on top of that, the tread was wearing thin so I would have had to change the tire anyway). A part of me wonders if someone purposely cut my tire. At any rate, the spare tire was put in place and I was cautioned not to drive more than 50 mph. Luckily for me, Lancaster St goes all the way to Arlington so I was able to return home without ever driving on the highway. I'll get the car fixed at a later date.

Geriatrics: More Long-term care

Today Corey, Justin, and I went back to Lakewood Village. As we sat surrounded by charts and jotted down medications and problem lists, a woman nearby kept humming and singing non-stop (though I couldn't recognize a particular tune). Then another woman set off the alarm by opening one of the doors leading outside. I had to wonder how much order there was in the dining room (where we were charting) or if we med students were the only non-residents there. One of the patients I saw was 99 years old and practically completely deaf; I either had to scream in his ear or write on a sheet of paper. I asked Sherry (the NP) if he could benefit from hearing aids, and she told me that most families won't do it b/c it costs about $3000, which is almost as much as it costs to stay at Lakewood for a month. Fortunately we were able to finish before noon, but the three of us were late to the geriatrics board review at noon (led by Dr. JH). At least there was free food =)

On a random note, looks like I was right to make December my vacation month. It's not easy scheduling interviews during a rotation.

Geriatrics: Another Day

This morning Corey, Justin, and I found ourselves back at Lakewood, but this time we were working in the long-term nursing unit where patients undergo physical therapy and more after they are discharged from hospitals. Today we followed Sherry, a nurse practitioner who gave us a stack of 10 charts and told us to see the patients while she does some new admits. I saw three patients: a lady recovering from spinal surgery, an Alzheimer patient who's very deaf (he couldn't understand most of what I said), and a lady who's learning how to use a walker after being independent previously. Sherry saw our patients independently; we all met at 11:30 to discuss our findings with her and see if they match up with her findings. We were allowed to go at noon and I called Dr. JH to see if she needed us to come to school to pick up her charts. She said since we were at Lakewood and already closer to Arlington than school, we should just have a nice long lunch. Sounded fine with me. Corey wanted to know where the closest Chick Fil'A was in Arlington so I was able to tell him that one.

Pecan Park, the assisted living facility in Arlington, was very much like its sister complex in Fort Worth and had a homey feel to it. We had seven patients total, of which Dr. JH saw two and we split the other five amongst ourselves. My first patient was a very nice man (used to be a professor at UTA) who had early Alzheimers; his biggest problem is word recall, as he knows he has an illness that makes him forget but can't remember the word 'Alzheimer' until I brought it up. He had a dog named Mr. Happy that barked and growled menacingly when I knocked on the door, but when the door opened out ran a Lhasa Aspo/dachshund mix, hardly threatening at all =P My second patient was a pleasant 97-year-old woman (who can still walk without any assistance) who kept saying she was fine. Going through her file, though, I read that three years ago, her son scheduled her for a geriatric exam b/c he was concerned about her memory loss. During that exam, she was uncooperative and kept lashing out at her son for doing this to her, saying she hated him and threatening to cut him from her will. How is it that I get the patients who are normally mean but are nice when I examine them? Justin had one patient who was very talkative, and when I looked at the pictures of her grandchildren I thought I recognized a guy who was in orchestra with me during high school. At any rate, today was our last day with Dr. JH. I've enjoyed working with her, and she seemed to like us, too.

Geriatrics: Well-Behaved patients

I wore my "interview shoes" to work today in order to break them in, and Anita teased me about not wearing my usual Danskos. This morning we had lectures at JLWest about behavioral changes in the elderly and the cost of living in nursing homes and assisted living centers. Not surprisingly, prices started at about $150-$200 per day, give or take another hundred or more for incontinence care, medication dispensing, trips to the YMCA, etc. Bottom line: the cost of health care for the elderly is very expensive, and will probably require a lifetime of saving in order to live comfortably.

Grand Rounds covered yellow fever and was actually pretty interesting. The afternoon found me back at the JW Clinic, where Justin, Corey, and I were each given 4 patients to see. My first patient was well known for refusing her meds and fighting with staff (and med students), so I was determined to be at my nicest when I saw her. As it turns out, she was very pleasant towards me and had no objections to having me examine her. A "Happy Birthday" balloon hung from her wheelchair, but since she has dementia she said, "I haven't had a birthday in a while." Then she saw her balloon and remembered. My second patient was severely impaired and though she smiled at me, I couldn't understand her speech when she did speak. My third patient was a Parkinsons patient who's been having awful hallucinations ever since his Seroquel got discontinued; he told me his legs had been shot off and he needed prostheses (yet both legs were intact). I had to see my fourth patient in under 2 minutes (it was dangerously close to 3:00 pm, our meeting time), but fortunately she just sat still and let me examine her. As I later found out, she was one of those patients who was notorious for spitting at med students, yet she was well behaved for me. Dr. K later said that the stars must have been smiling at me for two normally troublesome patients to be so nice this afternoon. =)

Rounds proceeded as usual, with one of Justin's patients being flirtatious towards all things male and even called Corey to her side to say that she was waiting for a handsome man to carry her home (we all got a good laugh out of that one). My Parkinsons patient has a son who's a radiologist in FW, so when he was told that Corey wanted to be a radiologist he seemed pleased. Unfortunately the radiologists in FW don't allow med students to shadow them, which is odd and Dr. K suggested that Corey tell our associate dean Dr. D about it. Another patient proudly showed off his past as a Marine with pictures around the room, though it took him a while to explain the USMC on his polo shirt (US Marine Corps). On the Azalea wing, we met Miracle the cat again, and on the opposite wing we saw two cages, each with a rabbit in them. Two resident rabbits, how cute! One of them was black (Blackie) and rather defensive, and the other (Thumper) looked like he had a bum leg. The two of them are caged most of the time until the evening, when they are put in a pen so they can play together. Dr. K likes to quiz us all on EKGs, which we're not all very proficient at, but Corey gets the worst of it since Justin and I are future internists and Corey won't have to read any EKGs after his intern year. We all agreed that we'll have to find Dubin's EKG book and read it before next week.

Tomorrow it's back to Lakewood

Geriatrics: The Last Founding Father

This morning GAP clinic proceeded as usual: slow. Dr. K passed out paper progress notes so that we could take notes first, then transfer those notes into the computer whenever we had spare time (which we did, whenever we weren't seeing patients or waiting for Dr. K to come out of an exam room so we could present to her), but it wasn't a total success. One of my patients had brought along his own problem list, and I found it easier to get on the HPI template on the computer and type down everything he told me. The last patient wasn't seen until about 12:40, but Justin and I finished earlier so we were able to grab some lunch at the conference room. Corey got some lunch after his patient was seen, and then we made the drive downtown to Trinity Terrace, an upscale retirement community that probably costs lots of $$$ to stay at. We had seven patients to see, among them 3 annual exams. One of those annual exams just happened to belong to Dr. E, the last surviving founder of our medical school, and we debated over who would see him. In the end, Corey got to see him while I took the extra patient.

All our patients were on the 2nd floor and required more nursing care than other residents who lived more independently on the higher floors. My patients were fairly straightforward. One was a 89-year-old lady who was hospitalized after a fall and is getting physical therapy here; she seemed to be doing very well and even hit on Corey when we came to the room (she said we were all good-looking young people, hehe). My second patient was a man with Parkinsons and a very prominent right hand tremor; he was once a prominent citizen of Tulsa, OK, though I'm not too clear what his occupation was that made him so important. My third patient was s/p ischemic bowel and had a colostomy bag; he was also weaned off his trach but failed his swallow study so he should only be on a thickened liquid diet. However, when I saw him he was munching on Doritos and saying he didn't need a liquid diet. Dr. JH laughed when I told her that.

While we presented our patients to Dr. JH, some of the staff brought out a Nintendo Wii for the residents to play Wii Sports. At first it was just the staff playing (to demonstrate?) and one family member said within earshot, "I thought it was for the residents to play." Eventually the residents did get to try their hand at baseball and golf. Still, the Wii is definitely something good to have to keep the residents swinging their arms and stuff =)

Of our patients, we were all most interested in meeting Dr. E, now 94 years old and having some forgetfulness (among other numerous health problems). He remembers that he used to be a primary care doctor, but can't remember practicing at the O (even though he has a tile from the OMCT on his desk). He asked Dr. JH if he could stop taking any of his medications b/c his monthly bill was high, but the only thing that they could do was make Mucinex prn. When Dr. JH recommended not stopping his gout medicine, he asked just how much a gout attack would hurt, saying that he could probably take it. "No, it really does hurt," said Dr. JH. It was a little sad seeing Dr. JH explain what each medication does to him; he knew all this once upon a time. And later Dr. JH said that it's because of his stubbornness regarding his medicines that he had to move to the 2nd floor (from independent living) b/c the nurses had to make sure he takes everything as directed. DNR was discussed as well, and fortunately his mind is still clear enough that he can make a decision for himself. That's always good.

Geriatrics: The Family Conference

This morning Corey, Justin, and I attended a family conference with Dr. K, Dr. Hall (the psychologist), a social worker, and the patient (an 82-year-old lady) and her nephew. Dr. K and Dr. Hall each presented their findings which showed that the patient's cognitive function was slowly declining, typical of early Alzheimer's. Now we were told that many patients become angry when they heard the "A" word, but this lady was very accepting of the diagnosis. "I knew something was wrong," she said, and the fact that she had the insight to tell that she was losing her memory was a positive sign that we had caught this early. So the family conference proceeded as perfectly as one can imagine. The patient has a supportive extended family, so I feel confident she'll be in good hands.

Because we finished at 10:45 a.m., there was time to call Dr. JH (one of the other geriatrics attendings) and ask her which patients she wanted us to see at our assigned assisted living center for the afternoon. She gave us six names and we headed for the center in hopes of completing rounds by 1:30 (our original meeting time). In that, we succeeded (my two patients were in their 90s and slightly demented but very friendly). Dr. JH listened as we presented our patients and then we went to round on them, but there we hit some roadblocks whenever we had talkative patients. One man kept us in his room for nearly 30 minutes talking about how he cured his own Crohns' disease by "flushing out the bacteria" with supplements. *sigh* We did get out before 5:00 though =)

Geriatrics: On Death and Grief

This morning we met with Dr. M (ethics professor) to discuss how we as doctors should help patients and their families deal with death and the grieving process. We have an essay due in two weeks in which we write about our own experiences with death and grief, and to start things off, Dr. M went around the room and asked us to describe experiences we've had throughout 3rd and 4th year in which a patient died. The stories we heard were all very interesting. Marcus described seeing a father shake his six-year-old son's body, still trying to wake the boy up after time of death had been called. Janet talked about seeing a SIDS baby that was brought to the ER too late. Corey told of how a friend of his was beaten to death. The stories went on and on. I was the last to get called on, and as I listened to each story, I tried to decide which case to talk about. I saw plenty of deaths in ICU, but none of them really stood out. In the end, the case for which I remembered almost every detail was the death of little AJ back in Corpus, and that was the story I talked about. I sounded very clinical when I was talking, but I told how AJ developed Pseudomonas sepsis after his first round of chemo for ALL, how his parents clung to each other and cried during the chest compressions, how his mother held his body and rocked him after he died, and how his many relatives waiting in the hallway mourned his death with the staff and chaplains comforting them. Dr. M commented that my summary was a very good one as I described everything that had happened in precise order, then asked me which hospital this took place in. "Driscoll," I said, and he agreed that Driscoll would have services like that for its patients and their families. I have to wonder, did the students who rotated through Cooks spend any time at the PICU? Maybe that's why Dr. M asked me where I did my rotation.

It seemed strange that throughout this discussion of death and dying, the most memorable cases we talked about revolved around the deaths of children and not the elderly. Dr. M said that he and Dr. K were trying to publish an article about learning about death and grief should be required in every geriatrics curriculum, and Janet wondered aloud why there wasn't such a requirement for any pediatric curriculums since children die, too, and the level of grief with the loss of a child is different from the loss of a parent. Dr. M asked if she would email him with her suggestion later, and she said she would. After Dr. M left, we all hung around and chatted until our next lecturer arrived. I told Corey and Danny about taking psych patients to the State Fair last year and described all the different fried foods they have (this year's special is fried Jelly Bellies), and then Anita interrupted to say the State Fair sucked. XP It's definitely too expensive; with the money spent there I could go to Six Flags.

Geriatrics: Assisted Living

This morning we had GAP clinic again, but Corey, Justin, Meng, and I spent the first thirty minutes or so getting acquainted with EMR so that we can input data more quickly when we see our patients. I have to keep reminding myself that not every elderly patient who comes to the clinic is demented; some are in wheelchairs but have very sharp minds. My first patient had early onset dementia but was still in very good health at 78 (walks unassisted), and her husband has them both on multiple supplements designed to improve memory. My second patient was an Alzheimer patient who denied having any problems or taking medications, even though she's on a lot of meds and supplements. Her daughter was very short with me at first until I realized that there should be a note in the patient's chart saying we're not supposed to discuss medications in front of her mother. Oops. Then, shortly after I left the 2nd room, I was ushered into another room to see another elderly lady. Dr. K sees lots of patients, but today was more hectic b/c we had two walk-ins, one of which was so sick that an ambulance had to be called to the PCC to take her to a hospital (probably Plaza). Once again we didn't finish until nearly 1:00 pm, but this time Dr. K told us where the conference room was so we could grab some free food before heading over to the assisted living facility where we'd be spending the afternoon. It would be just Corey and me for the afternoon; Justin left early for an interview tomorrow.

This assisted living facility was very nice; the interior reminded me of a hotel and patients are allowed to bring their own furniture and decorate their suites as they see fit. We had seven patients to see, so Corey took 3 (two of which were new patients and required a more thorough exam) while I took 4. My one new patient was a man with Parkinson's. The first thing I noticed when I entered his room was that it reeked of urine; for a while I was reminded of being in a pet store (didn't see any dogs in his suite though). He did fine on his MMSE and was clearly not depressed, but he did have some executive function delays (i.e. the way he drew a clock) that Dr. K is concerned about. Most Parkinson patients aren't prone to falls until end-stage and he's only had it for 2 years, so now she's thinking Lewy body dementia. Another lady in her 90s was very charming and sweet; she does have some major knots in her neck so Dr. K wanted to refer her to our OMT clinic. One man graduated from TCU with a degree in chemistry in 1950; he told me about how he took comparative anatomy and had to dissect a cat back in the day. Inevitably, the three of us fell behind schedule so that we still had one more patient to see when dinnertime rolled around (5:00 pm). Everyone eats in the dining room except for my Parkinson patient, who seems to prefer the smell of urine in his suite to meeting others in the dining hall =/

Thank goodness we only have lecture tomorrow.

Geriatrics: The Alzheimer Center

Today my ten classmates and I met at the JL West Alzheimer Center for morning didactics and a tour of the facilities. Justin, Corey, and I were assigned to spend the afternoon here with Dr. K, and we received little green cards with our patients' names and locations on them. The patients are housed on three different floors, with the 3rd floor housing those with earlier onset of Alzheimers' and the 4th floor housing those with end-stage Alzheimers'. The elevators require a code in order to move, and you can't leave the units without a badge (which the nurse uses to swipe you out). I overheard people saying that they hoped they wouldn't have to come to this center to see patients, but that won't be true for me since Dr. K sees many patients here.

I had three patients to see: two on the 4th floor, one on the 2nd floor. My lady on the 2nd floor was watching TV in the common room when I went to see her; she smiled politely when I said hello and commented that there were many people in the room. She's been at the center since 2005. Next I went to see my two patients on the 4th floor. One was a 93-year-old man in a wheelchair who used to be an American Airlines pilot; he introduced himself by name when he saw me and smiled a lot, but he was very hard of hearing. Dr. K later told me that he still thinks he needs to report for work once in a while and will try to get out of the wing, but his wife (a flight attendant) managed to get an official letter from AA saying that all flights were grounded, and once he sees that letter, he calms down and goes back to his room. My third patient seems to be more clear of mind than the other two, but she was still agitated about being in the center. She said several times that she wanted to go home, but "the man" wouldn't let her, and that he had no right to keep her here b/c the United States is a free country. I felt bad for her; she knows that she's sick, but she still wants to go home.

Since I was the only one with patients on the 4th floor, I got some one-on-one time with Dr. K and we chatted a bit about internal medicine and Philadelphia, after I told her I'd gotten an interview there (she graduated from PCOM). We then rounded on my patients before meeting Corey and Justin on the 3rd floor. The 3rd floor has a resident feline named Miracle, a gray male cat with white "socks" on both hind feet who was found abandoned in front of the center as a kitten. Because he's essentially been raised by humans and has never seen another cat, he thinks he's one of the people and at one point followed us around hoping for a scratch on the neck. He even joined us in a patient's room, and the patient goodnaturedly shooed him out, saying she didn't want fur in her room. Miracle seemed to get along well with everyone from residents to nurses to med students alike, hehe; it's nice to have a pet.

Dr. K does a lot of teaching when we go over our patients, and the three of us disappointed her when we didn't know how to grade heart murmurs. Corey was put on the spot when he was asked to interpret an EKG, and I got tricked into thinking a patient had an S4 when he didn't. "If a patient has A-fib, his atrium can't contract, so he can't have an S4," she said. Some of the residents were watching Singin' in the Rain on TV, so when Corey commented that he loved that movie, Dr. K and I were quick to chime in that we did, too. We were all given assignments for tomorrow; I'm supposed to look up aortic insufficiency and its signs and symptoms. That shouldn't be too bad...I hope.