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

IM Sub-I: Short Call A

This morning I saw three patients (a fourth one was supposed to leave, but she ended up staying because she had "grossly bloody stools" and we wanted to have GI look her over) and had plenty of time to kill before rounds. It turned out morning report was at 8 a.m. instead of the usual 9 a.m., but I missed the memo b/c I wasn't in the computer system (the drawback of being a visiting med student). Erin, one of the chief residents, added me to the list at my request, so next time I won't miss morning report (hopefully). My noncompliant patient was supposed to get an MRI yesterday, but he turned it down for the third time b/c he was claustrophobic and insisted on getting complete sedation before submitting to the MRI. Since his blood cultures were clean and his white count was falling, we decided to forgo the MRI; chances are he doesn't have osteomyelitis. Today was Short Call A, so Greg had to admit 4 patients to our service before noon (and he got all four in before morning report b/c they were "hand-offs.") Tomorrow is Zack's birthday so he asked to take the day off, but then we hit a rut: tomorrow is Short Stay B, when we admit 4 patients in the afternoon, and Yan has clinic in the afternoon, leaving our team without an intern to help admit patients. Zack looked really upset and said he'd cancel his birthday plans, but Greg said no and suggested that Zack find someone to cover for him. That definitely would have sucked if Zack had to come to work tomorrow after making all these plans (family was driving to Texas to see him, apparently), so I hope it worked out. For the rest of the afternoon (until about 3:00 pm) I helped Yan with writing prescriptions and transfer orders, getting to know more about her in the process. We managed to finish early while An and Zack were still working on their patients. One of An's patients, a bipolar guy with DKA, was supposed to go home today, but he didn't want to b/c he didn't feel as though his "psych" issues were treated. We had gotten a psych consult and they'd cleared him for discharge (the only adjustment they made was increasing his Lamictal) and he didn't think that was enough. "How can you discharge me without knowing if the medicine works?" he asked. "I don't like this. I really don't like this. This hospital is gonna get sued." Later on he threatened to commit suicide if he was discharged, and his death would be on his hands, so we had no choice but to let him stay. *sigh* He'd better not pull the same stunt tomorrow; every team caps at 19 patients and we currently have 16. We need to get some of these patients out of the hospital, soon. When I got home, I met Beth, the girl who's renting the room next to mine. She seems pretty nice so far, and I've already said I'd bring back some Odwalla drinks that I can get for free in the physician's dining room for the two of us to enjoy =) Nothing like bonding over drinks =P

IM Sub-I: Still learning

I got to the hospital at 6 a.m. to preround on all my patients. I saved my noncompliant patient for last (after what happened yesterday I was dreading seeing him), but when I went to his room he was in a much better mood. For starters, he's eating the ADA diet like he's supposed to, and his white count went down so the antibiotics are working well for his cellulitis. He was more agreeable to letting me check his wound this morning than yesterday, when he flat-out refused to let me examine him. He said that the reason he was being so stubborn about not getting Accuchecks was because he was afraid of needles (namely, the pain that needles cause) and that no one listened to him when he tried to tell them. We were in the middle of discussing which fruits were good or bad for diabetics to eat when Greg came in. He told the patient that he was doing very well, but that they still had to check his sugars regularly. Well, the patient didn't take that too well and said, "I'm getting angry again." Greg pretended that he had a page and said, "I'll let the two of you to talk." After he left, my patient growled, "He always does that when I try to talk to him. Can I get another doctor?" I said no, explaining that he was assigned to our team and that the doctors meant well and just wanted to help him get better. At any rate, I probably spent 20-30 minutes just talking to him, but I think he needed someone to talk to. He got a psych consult later in the day and was diagnosed with mixed narcissistic and borderline personality disorder. It's easy to see the borderline in him; the way he's nice to me and mean to Greg and Dr. C is a classic example of splitting.

I messed up in my presentation of my cancer patient today; I was going through all the details of how she got diagnosed with gallbladder cancer when Dr. C interrupted and said, "Ok, so she's already been diagnosed? Then just get to the point and say so." Damn. *sigh* Even though I'm a fourth year, I feel somewhat inferior to An b/c she's already been here a month and knows how everything in the hospital works. Not to mention she's on good terms with everyone on the team (especially the guys) and even has their cell phone numbers so that she can call them directly instead of paging them. On top of that, she's the perfect third-year medical student. It's almost like she wants me to look stupid. Of course, maybe I'm just paranoid. >_< Hopefully things will get better; it's only day 3 after all.

IM Sub I: First Call

Today was my first day on call, and despite going to bed at 11:30 pm with the intent to wake up at 6:20 am, I woke up at 5:00 a.m. instead. *sigh* Still not used to this place, I guess. I was assigned two patients to round on this morning: one was a sweet, compliant lady with a lumbar abscess, and another was a disgruntled, non-compliant diabetic with cellulitis. He has refused to eat his diabetic diet and says he just won't eat until he gets a regular diet (even though it's against the law to grant his request), and he flat-out refused to let me examine him. *sigh* He had the exact same cellulitis problem the last time he was here last week (and he'd left AMA); I think everyone on the team is hoping he'll leave AMA again b/c he's flat-out rude to everybody. Heck, I'm dreading having to see him tomorrow. He said he didn't want to see any doctors for the rest of the day, and since I'm not a doctor yet, Greg says it's my job to bargain with him to be compliant (even though he'd refused to sign Greg's contract to "stop being an asshole" earlier). *sigh* Yan said that she never had difficult patients in China, but that's because in Asia, doctors are well respected. My first patient got me out of a lecture on chest xrays; I had to write an acceptance note for an ICU patient coming to our service. A nearby intern was shocked that Greg would give a med student such a complicated case (this guy's been in the hospital for 5 weeks secondary to complications of a perfed bowel), but when she found out I was an AI and not a third year she said that was okay. Then I had a 3 hr break during which I surfed the net, slept, or ate dinner before I got my second admit of the night. This lady had a cholecystectomy for abdominal pain that never resolved and began draining dark bilious fluid, so another hospital did a CT scan and found tumors in her lung. Biopsy revealed metastatic giant cell tumor of the gallbladder, which is VERY rare. I felt so horrible for this woman after I learned her diagnosis; when I was talking to her, she said she'd heard that she had tumors in her liver but didn't know how bad it was. I don't think she was under the impression that this would kill her, and gallbladder cancer is highly fatal =( I was done by 9:00 pm and allowed to leave, but I stuck around until An finished presenting her patient b/c it'd look bad if the AI went home before the med student. I'm supposed to be acting like an intern here, after all.