IM Sub I: Hallelujah!

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

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

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

IM Sub I: The Shortest Day

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

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

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

IM Sub I: Post-Call

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

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

IM Sub I: Another slow call

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

IM Sub-I: Patients who Nag

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

Pigeon Tales

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

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

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

IM Sub I: Cancer cases

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

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

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

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

IM Sub-I: Sleepy Day

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

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

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

IM Sub-I: The Longest Wait

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

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

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

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

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

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

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