Goodbye, MS III

This morning I stopped by Dr. RR's clinic (from family medicine) to say hello and tell him about his patient who I saw in the hospital. He knew enough about her to remember that she had renal insufficiency, so we discussed the possibility of her having CHF, what medication changes Dr. L recommended, and more. It's nice to follow up on what a patient's PCP will do after the patient leaves the hospital, and Dr. RR said he'd look her up and see what her echo says when she comes to his clinic next week. I also said hi to Lupe; she said Tawanna's found a new job in Watauga (which is closer to where she lives anyway) so they need to find a new RN. *sigh* I've barely been gone two months and already people are leaving. Still, at least I know I'm still welcome; when I asked the front desk people if I could go on back and say hello, one lady said, "Girl...you go back there and say hi right now." =)

The morning was spent doing questions to prepare me for the IM shelf (which we'd all heard horror stories about), and when time came for the exam, I was still in question-answering mode and managed to finish the exam with 5 minutes to spare, no rushing. I'm not sure how well I did, but I don't think I failed so that's good. Afterwards, I went with Dina, Heather, Stephanie, Fallon, Cyril, and Erwin to Baker's to eat and chat. We had a lot of stories to exchange about our various rotations, some funny, others infuriating (i.e. classmates skipping out on surgeries by leaving notes for their attendings saying they needed to study and taking off without another word. What BS) We also discussed our experiences at Methodist; Dina had it much worse than I did, while Erwin said he had a good time there. Most of us know what we want to do with our lives now. And to think, this time next year, we'll be DOCTORS. But for now I'm glad just to be a 4th year. =D

IM: Departmental Exam

We had our departmental exam in IM today. To prepare for it, we were given 29 essay questions, 12 of them worth 30 points and 17 of them worth 20 points. From those, we were randomly given two 30-point and two 20-point questions on the exam. I had trouble remembering every single tidbit (these questions had about 6-8 parts to them), but I know I passed, hopefully with an A. That's all I wanted. I also ran into Molly and Erwin outside Everett (Molly looks like a happy mommy-to-be), and Erwin asked if we were meeting for ice cream tomorrow (Heather's idea). The question is where: Marble Slab or Coldstone?

I chatted briefly with Dustin N. before the exam; he'd just finished his rotation at Methodist and had inherited my old team. When I asked about my Vietnamese patient with liver failure, he told me the man had died 2-3 days after he began his rotation =( I was very sad to hear that, even though I'd known that his health had taken a downhill spiral b/c his liver was failing fast. But death in three weeks...that's rough. Dustin didn't have a good experience at Methodist; apparently my team got more strict after Annie and I left (especially once the month changed and Sharif returned to the team), and on top of that, Dustin reported that our team said Annie and I were slackers. How so, when I did everything they told me to do? (though I admit, I didn't go above and beyond like others in our class probably did) What makes me mad is that if they really thought we were lazy, why didn't they tell us so, instead of saying, "Oh, you're doing a great job" and stuff like that? We got zero feedback about our work! Well, that settles it: if that's the way they feel, then I don't want to go back there. I'd originally considered applying to Methodist for residency, but that's gone now.

IM: Last Day!

Two of my patients went home yesterday (well, one went to SNF), so I called Sarah this morning asking who else I should see. While I was there, I overheard a few surgery interns wondering where Ben M was (and saying he'd better not be sleeping), so when I saw Ben later on the floor, I told him to page his intern to let him know where he was. "He has my pager number," he said. Hmm, apparently not. We still had a lot of patients on our service (gained two bouncebacks today), so Dr. L was eager to see how many he could discharge today. Sadly, our "rocks" don't seem to be doing too well. Our man in Tele West was staying on a vent originally in hopes that he'd live long enough for his sisters to come see him from Mexico. The problem: immigration won't let them into the US. Today, from what Sarah told us, he appeared to be tired of living like this and would probably get his trach removed if his grandson wasn't around to stop him. They need a family meeting, pronto. And our prostate CA patient's family isn't "ready to take him home" b/c they need to buy an air mattress and an egg crate mattress for him. Well, that's no excuse b/c we'd told them they needed those things weeks ago. *sigh* As Dr. L said, they're just playing games with the system. The goal is to get him out the door today, whether the family likes it or not, but we'll see.

We finished rounding at 12:30 (one bounceback in ICU took an especially long time b/c he had so many health problems and the son was causing trouble being furious and stuff), after which Dr. L took Angela and me to the hospitalists' office building for a quick lunch (doctors get healthier food from drug reps instead of the crap they serve in the cafeteria) before meeting with us one on one for evaluations. Overall it went about as well as I expected.

Anyways...got to study for the departmental exam tomorrow.

IM: Wrapping things up

This morning as usual, I went to see how my 3 patients were doing. My hospice patient is doing better and awaiting placement in an assisted living facility (I don't want to say "nursing home" b/c he's younger than my parents); he might be placed in SNF for the time being. My HIV patient with pneumonia is doing better; we discharged him later this afternoon. My lady with heart failure doesn't have any complaints, but her lungs really sound like crap. Anyone who's never heard rales or crackles will know what they sound like after hearing her lungs b/c she's crackly everywhere. Right now we're awaiting her echo to see how it looks. Dr. L came to work wearing a "ulnar gutter" cast or something like it after he'd hurt his hand in an accident; as a result, he had to dictate all his notes b/c he couldn't write. On a random note, I ran into my ob-gyn chief, Dr. C, near the cafeteria today. She's as cheerful as ever, especially since she'll be graduating soon; she plans to practice near Lake Worth. Best of luck to her =)

IM: Final Call (Slow Night)

My last call of IM (and 3rd year) began yesterday, and I was warned ahead of time that Sundays were usually very slow, with some teams capping as late as 5 a.m. or not at all. Instead, my team spent the first hour or two sitting in the commons area, watching the Olympic trials for gymnastics and track. Lindsay also told us about her latest encounter with the family of our prostate CA patient (one of our rocks who should have been discharged last week, but his family kept finding excuses to keep him here): apparently, after the patient had an episode of gross hematuria likely secondary to Lovenox, the patient's son got confrontational with her, crossing his arms and saying that he was getting a lawyer to make sure there was "some s*** getting done here." The funny thing was that Terrance had talked to the family shortly before Lindsay did and they had seemed friendly and understanding of the patient's current situation. We'd hoped to discharge him today, but obviously that wasn't going to happen. Dr. L said it was a sticky situation to be in b/c the family is probably going to sue the hospital no matter what action is taken (or not taken). The plan now is to d/c Lovenox (even though it'll increase his chances of a DVT, at least his family can't see the DVT and pitch a fit) and send one of the chaplains to go talk with the family and "defuse" them a bit. Maybe some spiritual guidance will help his family.

My first patient (and Sarah's) did not come rolling in until shortly before 5:00 pm, but I jumped on it the first chance I got. This lady turned out to be one of Dr. RR's patients (I'd never seen her but I recognized Dr. RR's name on her meds as well as the Tessalon pearls he tends to prescribe for pts with cough), presenting with a 2 week hx of SOB, weakness, and hyponatremia. It turned out that she was taking double the dose of Toprol that she was supposed to take (Dr. RR's prescription and a JPS resident's prescription), so that might have something to do with her symptoms. Our second patient was a man on hospice care for end stage liver disease. His chief complaint was SOB, which struck us as a bit odd. What was this man on hospice doing here? He was an interesting case study, though; had scattered spider angiomata along his torso, a huge ventral incisional hernia, and mild ascites. By the time we finished with him, it was almost 9:00 pm, so Sarah and I grabbed some dinner (meatloaf, ugh).

Our final patient was a friendly HIV-positive man who had a 3-day hx of fever, SOB, and cough; his greatest fear was that he had PCP (P. carinii pneumonia). Given his undetectable viral count and adequate CD4 of 850, PCP was not likely, and sputum cultures later revealed the presence of Gram + cocci. It was more likely he had a community-acquired pneumonia. He was also found to have suspicious nodules in his right lung, but so far he's refused to have it biopsied for fear that if he bleeds during the biopsy, the cancer cells will get into his blood and metastasize. At any rate, if he's improving, we'll probably d/c him tomorrow. I finished his H&P at around 1:00 a.m. but went to SSU to check on my earlier patients. There was a Hispanic guy on restraints in one of the beds, continually thrashing around and screaming in Spanish. I later learned he was in alcohol withdrawal, but when I saw him at 1:00 a.m. and later at 6:00 a.m., he was still yelling. I felt really bad for the nurses (and Sarah, who got paged to SSU to write him Ativan on more than one occasion). I ended up falling asleep around 2:00 a.m., only to be awakened by Angela when she came in one hr later. In the morning we learned that the team didn't cap until 4:45 a.m.

During morning report, Dr. L didn't even give me a chance to present my hospice patient b/c in his mind, a patient in hospice should not be at the hospital for something like SOB. I think what happened is that my patient is currently on home hospice but is not doing too well on his own (he's in full code b/c he wants to watch his grandkids grow up, yet he still smokes). And if coming to the hospital was the only way to get into a nursing home, then fine. But I don't think he really needs hospice right now; he looks pretty good and doesn't look like he'll be dying in the next several months. I also messed up by saying that Januvia contained HCTZ when it was really Hyzaar that did (med confusion after 3 hrs of sleep). *sigh* So much for impressing Dr. L. Angela and I are both hoping to get rec letters from him, but that remains to be seen.

On a random note, if there's a fly swatter sitting on the counter of the ER, you have a fairly good idea of what the general population of the patients here are like. =/

IM: Quick day

Amazing how last call, we had 9 patients, and now we're pre-pre call and we only have seven patients (of which three are rocks and another will be discharged later today) Angela and I each saw two patients, but no one told us that we were rounding at 10:00 instead of 9:00 so we fumed a little about how we could have slept later. In the end, we finished rounding in time for morning report, and then stayed for a lecture on epilepsy. Dr. L didn't have time to go over my notes with me, but he did go over Angela's with her, so hopefully I'll get my turn later this week. *sigh* Sooooo glad I have Saturday off.

IM: Discharging like mad

Unbelievable. We had about 25 patients yesterday morning, and this morning we were down to about 14. Then one of my patients, the one who had come for non-specific pain, asked if she could go home before 9:00 a.m. b/c all her symptoms had resolved and she felt great. Sarah paged Dr. L who gave the green light to discharge her. My COPD patient was doing better, except she was concerned about her arthritis and her ability to raise her grandchildren without a steady source of income. I was all up for keeping her here an extra day to recover, but Sarah later called me to say she's been discharged, leaving me with no patients. Yet another lady who had diabetes-induced vertigo (first time I ever heard of such a thing) left AMA b/c her husband was dissatisfied with how slow things were progressing at the hospital and yanked her out. The lady was apparently Muslim b/c she wore a headscarf that she later took off in the hospital when she was alone, which left some of us wondering if she was in a domineering relationship.

After lunch I swung by Dr. P's (my PCP preceptor) office to pick up a rec letter he'd written that needed revising b/c my name got misspelled twice. The office manager corrected one of the mistakes, but not the other, so she had to print another one afterwards. "If you need another one after this, you're SOL," she said as she handed the letter to Dr. P. It took me a while to remember what SOL meant; Dr. L had used that term earlier this week when talking about my stroke patient's chances of discharge on a certain day. SOL = s*** outta luck, though I prefer to think of it as "short on luck."

IM: Donut Stories

Yesterday our ortho intern, Lindsay, came back from vacation, just in time to be on call with us for the first time. RB is doing medicine this month, too, and the two of them joked a little about how they don't remember anything about medicine. We had 9 patients in our service going into call, but Terrence pointed out that 9 wasn't too bad compared to other numbers. On a good note (sort of), Mr. Roboto was no longer "Mr. Roboto;" his movements were a lot more coordinated, the rigidity was gone, and he was able to go back to the prison after getting a bath. Hopefully the doctors there won't try to dope him up with Haldol again. Terrence also told Angela and me that we don't have to stay up past midnight b/c as far as he was concerned, we're almost fourth years and had nothing to prove to him. That's all nice to hear, but we know that Dr. L wants us to see 3 patients a night, and if we have to stay up past midnight to get those 3 in, so be it. I was paired with Sarah, and every time we had two patients to see, she gave me a choice between the two. I tried to choose cases that I hadn't seen before.

My first patient was a 21-year-old girl with a bad case of anemia (H&H 5/20), and while she didn't have a history of heavy periods, she did mention that her flow was lighter these last two months. Her MCV was 68, which seems like a clear-cut case of iron deficiency anemia, and Dr. L said to run some iron studies on her. Sounded simple enough. My 2nd patient came in with HTN and COPD exacerbation secondary to not taking meds for 3 months. Her story was sad; she's unable to work and raising two young grandchildren while their mother (her daughter) is in jail, and she can't afford her meds b/c she doesn't even have enough money to pay rent. She also has two thyroid nodules, but hasn't been able to get them biopsied b/c she can't find anyone to watch her grandkids for her while she gets the procedure done. Her other daughter works full-time and won't take them unless there's a real emergency (like now). *sigh* It's tough.

My third patient had a myriad of problems that I wasn't sure where to begin. She had a cervical epidural block done on her neck last Thursday for cervical radiculitis, and since then she's had HAs, LUQ pain, constipation, etc. On top of that, she claimed she had coughed up blood, so she got put on NPO status awaiting an EGD to see if she got an ulcer. Then she got mad b/c she was hungry and didn't understand why no one was giving her anything to eat. I read through her past records and found she was hospitalized at TSP for a Seroquel OD two years ago; that could explain why she was a hard patient to get history from. Angela and I both finished around 1:00, and I think that was the best sleep I had so far b/c I slept all the way until 5:00 w/o waking up.

As usual, Dr. L brought donuts for the team. In SSR, we offered some to the nurses, and when they declined, one patient said, "I'd like one!" He ended up getting two, and another patient walked over and asked if she could have a donut, too. Since it was hypocritical if she didn't, I went ahead and let her take her pick. Later, I opened the box again to get another donut, and the 2nd patient saw and asked if she could have another donut. "I don't think you can," I said, and she whined, "My nurse is right there. I'm hungry." The nurse looked up and I told him his patient wanted another donut. Beside me, Dr. L shook his head, and the nurse told the patient that the donuts were for nursing and staff. I don't think it got through to her; she's in the hospital for an unknown drug OD. Probably hungry b/c her stomach got pumped. But still...if I were a patient and saw doctors exchanging donuts amongst themselves, I wouldn't ask for one. Lesson learned: from now on, we have to be careful about where we eat our donuts.

Dr. L went over my last batch of H&Ps with me after he saw me wandering around the SSU shortly before I picked up my anemia patient; he said Mr. Roboto's H&P was perfect (yay!) and had only minimal critiques on the other two. Glad I'm doing ok =) I'm also grateful that he won't be going on vacation until after Angela and I leave; when he does, Dr. M (the more long-winded attending) will take over for him, and the interns are not looking forward to it. Dr. M is actually on vacation now so his team is happy to zip through the patients at lightning speed. I'm sure RB isn't complaining about that one =P

IM: Pre-Call Blues

Because we still had 14 patients this morning, I saw 4 instead of 3, but fortunately these cases were pretty straightforward. Mr. Roboto is doing better; when I saw him he was eating a muffin without assistance. Then J, the inmate in the bed next to his, got my attention, saying he was trying to eat the muffin wrapper and needed help using a spoon. "He don't know what he's doing," said J, who was in the same prison unit as Mr. Roboto before their hospitalizations. Sure enough, Mr. Roboto couldn't aim well with his spoon; the eggs and cereal kept spilling on him. His nurse ended up having to feed him. I asked J if he knew what happened to Mr. Roboto prior to his arrival here, but J said no, they'd arrived at different times. "I'm suicidal," he said, "but I'm fine up here (mentally). But him..." He made a twirling motion around his ear (i.e. psycho), and another inmate across the aisle laughed. I'd overheard some of the nurses talking about J, saying that he'd eat anything he could get his hands on (nails, razor blades, etc) just to get a "get-out-of-jail card" and end up in the hospital. Still, he and Mr. Roboto seem to be fairly good buddies (Mr. Roboto is most talkative when he's chatting with J), and with Mr. Roboto doing better, maybe he can go to TSP soon.

My stroke patient got her MRA done yesterday; she was found to have extensive blockage in her right ICA and parts of her right PCA and MCA. It was really obvious in the MRA, with the left side all lit up with vessels and the right side not so much. We had hoped to discharge her today but that wasn't going to happen. Dr. L didn't even go see her, which surprised me and I asked him about it, but he said he had other things to check (and other patients to see since it was close to noon by this point). After we were done, Sarah asked if Angela and I could each do a discharge summary on one patient since we'd known them longer than any of the residents have. Thank goodness we've both dictated before, though I had to do it in front of an attending (who was writing a note in the computer room where I dictated) and was very embarrassed b/c I kept messing up. Either way, I didn't leave the hospital until 1:30 pm, the latest I've ever stayed. I think I'll be working a lot harder these last two weeks on this team.

In other news, there won't be morning report tomorrow, so I won't get a chance to present Mr. Roboto =( Ah well. I also got an email saying that my medicine sub-I for August has been approved, finally. Looks like I'll be going back to Austin this summer!

IM: The New Team

Rounds with the new team started at 8 today. Of the three, we met Terrence, the 2nd year FP resident, and Sarah, the FP intern; the other, an ortho intern, is on vacation and won't be back until next week. Both of them were post-call (yikes), so we were all eager to get started. Terrence said that Jordan had told him good things about Angela and me, and that he would let us do as much as we wanted since we were nearly 4th years. Sounds good to me. From the few hours I spent with this new team, I could tell we were going to get along fine.

Our greatest dismay is that we're on call in two days and still have fourteen patients on service. With today being Sunday, we couldn't discharge anyone. An elderly patient with new onset CHF couldn't go home b/c his BPs were too high even on clonidine. My stroke patient couldn't go come before she gets diabetic education and has an OT see her. One of our "rocks" couldn't go to a nursing home b/c she needed transportation to take her to Oklahoma. Speaking of the rocks...Dr. L's exasperation with their families is really starting to show. Three of them are full-code even though there is no benefit to extending their life (one has metastatic CA, one has a trach and can't leave the hospital without one, and one is severely MR with candidemia) except to ease the consciences of their family members. With any luck, we'll have five patients go home tomorrow, but that still leaves our numbers at nine. >_< And with call in two days, I'd better find my Maxwell guide b/c with my new team for a refresher on writing orders.

Also, I think I'll get to help present at morning report on Tuesday b/c our most interesting case is Mr. Roboto and I'm the only one on the team right now who's been checking on him ever since he was admitted (Jordan's doing inpatient FP and Nanette's doing neuro right now). AWESOME. Actually I'm nervous I might screw up, but let's hope for the best =)