IM Sub-I: The longest post-call

Because we were post-call today, Amy wanted us to start rounding at 8:00 a.m. in order to finish by noon. Considering how we rounded at 6:30 a.m. at JPS when we were post-call (granted, we also spent the night at JPS), this was nothing. Even still between 8:00 a.m. and 9:00 a.m., we only saw two patients in IMC. Amy and Angela take their time going through each patient's individual problems and then discuss a treatment plan amongst themselves that may or may not involve the interns and med students. Most of the time Zack, Yan, An, and I just stood around doing nothing. All of us missed Greg and Dr. C, who went through rounds at lightning speed so that even if we had 18 patients, we could start rounding at 9:30 and be done by noon. An saw Greg earlier this morning and he'd asked, "Do you miss me?" Yes, Greg, we do.

After morning report, it took us until 12:20 to see the rest of our patients. At 11:15 we had three patients left to see and thought we'd do quick rounds on them. No such luck; one lady kept talking nonstop about how she works as a horse trainer (even showed us her "guns") and had been healthy for most of her life until she got "T-boned" in a car accident months ago, etc. Yan had warned us that she was manipulative, going so far as to move during the MRI b/c "they didn't pull me out in 20 minutes." Angela later told An and me to go to pathology to check on biopsy results for our respective patients who had biopsies done yesterday. An's patient's FNA came back inconclusive, and while my liver biopsy patient was revealed to have cholestatic hepatitis, whether she has iron overload or not remains to be seen. I later told Angela the news and she told me to leave a note in the chart, but I forgot and didn't remember until I started writing this entry. Dang it, so much for making a favorable impression, even if I'm only here for a few more days.

I went jogging along Town Lake again and saw two women walking a total of six labs and retrievers. One dog was leashless and another had his leash attached to his owner's belt. Dang...

IM Sub-I: The "New" Blue Team

This week, with Greg moving on to the ICU and Dr. C on vacation, we gained a new attending and resident, both of them female (making Zack the only male on the team). The attending, as I mentioned before, was one of the chief residents last year; she introduced herself as Amy so I guess that's what I'll be calling her. Our resident, Angela, was late, way late; despite numerous pages, she didn't even show up until after we were finished rounding (almost 90 min after we started). Amy said that Angela's lateness was nothing new (apparently she's not punctual at all), but this was ridiculous.

We had two patients who needed biopsies today: a liver biopsy (my patient) and a FNA on a neck mass (An's patient). Before rounds, one of the nurses told Yan and me that our liver lady's biopsy would have to be ultrasound-guided instead of CT-guided because CT-guided biopsies require the presence of a mass (which our lady doesn't have; we think she has hemochromatosis). Yan had to change the orders. Later we went down to the radiology department after it looked like the FNA on the neck mass would be cancelled, and we made sure the order was put in. The radiologist offhandedly mentioned that the CT scanners were empty and that these cases should proceed quickly, and for some reason Angela thought that my liver lady's biopsy would be CT-guided.

"No, it's ultrasound-guided," I corrected, and An said, "No, the FNA is ultrasound-guided. The liver biopsy is CT-guided." I said, "No, it's not!" and Yan looked confused. I knew I was right, and I didn't understand why An and Angela thought the biopsy would be CT-guided. This was my patient. I came very close to losing my temper (something that never happens on rotations), but I kept my cool and muttered, "Fine, I'll keep my mouth shut." Angela said, "No, we have to clear this up. There's too much confusion." So once again, I said, "The nurse on the floor said that her biopsy can't be CT-guided because she doesn't have a mass. It has to be ultrasound-guided." Another nurse walking past us heard me and confirmed that I was right, and I couldn't help but say, "See?" *sigh* Greg was right when he said that we'd miss the way our team used to be. The "old" Blue team really was a dream team. At the very least, there was never any confusion or arguing because Greg was always on top of everything. He always had his facts straight. Yan felt the exact same way; she, An, and I (not sure about Zack) all miss Greg.

We were on call today, and I got my first patient around 4:00 pm. Yan said that we'll have to see him together b/c he was apparently "very sick" and yet ICU rejected him. Speak of the devil, Greg walked into the dining room just as Yan and I were discussing our patient, and Yan asked him why ICU turned the patient away. "It'll be a good learning experience for you," said Greg, and we soon learned what he meant. Our patient had a LONG list of medical problems (i.e. DM, CAD, bilateral AKAs, A-fib, to name a few) and presented with something vague like fever and weakness. His lungs sound like crap, and he definitely has a pleural effusion. An didn't get her first patient until 7:00 pm, so to be fair, Angela decided to let us go after one patient each. This was the earliest I've ever left on a call day, so I was happy =)

IM Sub-I: Untrustworthy patients

Yesterday I spent my morning shopping at the outlets at Round Rock (picked up a suit for interviews), and spent part of the evening browsing through the Domain (an upscale outdoor shopping center on Braker Lane; there's even live music at night) while chatting with Dina on the phone. Then I watched the Olympics in time to see Michael Phelps earn his 8th gold medal; talk about awesome =)

This morning Greg and An had the day off, so it was just me, Zack, and Yan along with Dr. N, our attending of the weekend. Dr. N certainly seemed nice enough; even pimped me on a few topics that were mostly hit or miss. My diabetic noncompliant patient was causing trouble for the nurses again; he kept insisting that he needed to go home because he's supposed to get a motorized wheelchair delivered to his house and he needs to be there to sign for it. "Just give me oral antibiotics," he said, even though Yan tried to explain that pills alone weren't strong enough to treat his osteomyelitis (he needs IV meds). Once we assured him that he could leave AMA with antibiotics, he seemed happy, but then he privately called Yan back to his room and asked for some Norco for his leg pain. Dr. N said that Yan could write him a prescription for 5 Norco, but no more than that. After we left the 4th floor and went to Obs to see 2 patients, Yan got paged twice regarding our noncompliant patient. Apparently he was refusing to sign the AMA form unless he got his Norco prescription. So Yan went in to "negotiate" with him about how much Norco he could get (he kept asking why he couldn't get at least twenty). I stood outside the room eavesdropping on their conversation (I didn't know why I had to be present; I could have gone to other floors to help Zack or something), but I wasn't the only one. Two nurses told me that the patient had never once complained of pain while he was in the hospital, and since he's not taking Norco right now, there's no need to start him on it as an outpatient. "You know what he's going to do with that Norco? He's going to sell it on the streets," said one nurse. "The PICC nurse has seen him on 6th street; he probably wants the Norco so he can make some money, and when he runs out, he'll come right back." Another nurse agreed that he was a tough patient to handle, adding that he's been "stewing" in his urine for almost twelve hours because every time a nurse approached him to change his sheets, he'd get mad and refuse to get cleaned. He's also refusing to get antibiotics (hence, the reason for letting him go AMA), except now he won't leave without Norco. Finally Danielle, one of the nurses, couldn't stand it anymore and asked me to call Yan out, pretending that she had an important phone call. Yan, just like me, had bought into our patient's claim that he was hurting, but its the nurses who spend more hours on the floors near him that know what's going on. Yan didn't know what the policy was for leaving AMA, so we asked another nurse to talk to the patient. He repeated the same story that he needed to be home to accept his wheelchair or else he won't get another one for five years (I've personally never heard of such a thing), but she called his bluff and said that her father was hospitalized once but still got a motorized wheelchair before he left. "Fine, I'll stay here and get the PICC and miss out on the wheelchair," he said angrily, so the nurses left the room thinking that things were settled. Then all hell broke loose as he began screaming and cursing at no one in particular, then throwing things against the wall (someone had to call a Code Gray on him and security came to get him to calm down). Then he started yelling about how no one's cleaned him in hours, and the other nurses were like, "Oh, hell no, he didn't!" (b/c he was the one who had refused to get cleaned and said he'd stay and make everyone's life hell). "Now's he's going to say we neglected him," one nurse grumbled. Earlier in the day, Yan had commented that she doesn't know whether she can trust what patients say anymore. About a week ago, we had a patient who came in with multiple bullae on his left hand that eventually coalesed to form one huge bulla that covered his entire left hand. He claimed he didn't know what happened, that he "woke up" after passing out on his porch and found his hand swollen, then later said he may have scratched himself on the nail. Fearing a bacterial infection (especially since we had no idea what we were dealing with) and compartment syndrome, plastic surgery came to do a fasciotomy on his hand. Then yesterday, his father called the hospital saying that he had seen a copperhead bite our patient's hand. Ummm, what?! Why didn't anyone tell us this earlier? The patient had continually denied that he'd been bitten by a snake b/c he didn't know what had happened, but once Yan showed him an article about snake bites, including an image of a person with multiple bullae on his hand (very similar to his initial presentation), he said, "Yeah, that's exactly what it looked like!" *sigh* Now that we know he doesn't have a bacterial infection, I think we can d/c his antibiotics. After work, I went to the Town Lake Trail and walked/jogged at least 3-4 miles by walking from Lamar Blvd to Mopac, round trip. Needless to say I was exhausted by the time I got back to my car.

IM Sub-I: Changing Attendings

Today was Short Call A, but Greg didn't get any new patients this morning. This turned out to be a good thing for everyone. It was also Dr. C's last day with us (he goes on vacation next week), so he took turns grading both Yan and Zack with their physical examination skills (kind of like an OSCE?) before morning rounds. Rounds proceeded quickly and we saved our "favorite" patient for last: my former noncompliant diabetic patient. Even before we entered his room, we heard some of the nurses murmur, "Oh Lord, that man..." Dr. C asked him why he was refusing treatment, and as expected, the patient got mad and said, "So it's all on ME now?" and added that he couldn't stand the sight of Greg (whose mutual disgust was written clearly on his face). Dr. C asked if he needed a psych consult, and Greg reminded him that psych had said he was competent to make his own decisions. So with nothing resolved, we left the room. Greg commented that tomorrow's attending will be in for a treat when she meets our patient.

After rounds, I accompanied Dr. C to his office for my evaluation. Along the way, he told me that I did a good job (detailed H&Ps and reliable follow-up on patients every morning), that he was glad to have me on the team these last three weeks, and that he'd be happy to write me a letter of recommendation for my residency application. He also told me a little about the program here in Austin and encouraged me to apply, saying he'd put in a good word for me. That's very nice of him; I don't think I could have asked for a better attending this month =) Hopefully our next attending will be cool as well.

We had nothing to do after noon conference, and I was able to talk to Greg and get tomorrow off. That means....TAX FREE SHOPPING!

IM Sub-I: I'm baaaaaack....

This morning I checked our patient list to see that we had eight new admits...among them, my borderline, noncompliant diabetic patient. WHAAAAAT?!? What was he going back at the hospital less than two weeks after we discharged him? He's also on the "no-bounceback" list, so it was by twisted chance that he came to the hospital on the day my team was on call...again. "Third time this month," said Greg, and An joked that it was b/c our patient loves Greg. We all knew that wasn't true though; he flat-out told me two weeks ago that he hated Greg and Dr. C and wanted different doctors. He should have come to the hospital on a different day then. As it turns out, he "lost" his prescription for Levaquin that we'd written for him so he started taking his mother's leftover penicillin instead. As a result, his cellulitis never healed, his sacral decubitus got worse, and now he has chest pain. Things weren't much better when we stopped by his room to see him. The room smelled of cellulitis (not terribly repugnant to the point of making one puke, but not pleasant either). At first he was polite, addressing Dr. C as "Sir," but when we were about to leave, he asked if we were going to put him on the diabetic diet again. When Greg said yes, he got mad and said, "I'm not a diabetic!" Clearly impatient, Greg told him that his HbA1c was between 7 and 8 and that makes him a diabetic. The patient closed his lips and refused to say anymore, so we left. Greg commented that the smell was a lot worse last night in the ER, and Zack agreed he's disgusting. *sigh* I was hoping we'd never have to see him again but oh well. At least I won't have to follow up on him this time around. My compliant diabetic patient who recently had a BKA went home today, too. He's pretty optimistic about his future, and I wished him all the best. As sad as I am to see him go (I've enjoyed talking to him), I hope I don't see him back in Brackenridge while I'm still here. I hope his outpatient EGD and colonoscopy won't show any tumor growths, and that he'll be able to obtain two prostheses so that he can walk on two feet again. =)

IM Sub-I: Wednesday Call

Another day on call. My first patient was an 89-year-old lady with chest pain; this isn't her first visit to the ER with chest pain given her hx of A-fib and CHF so I expected her to get discharged tomorrow. My second patient was a man in his 40s with pneumonia. Greg had run an HIV test on him, and when I examined him I saw some thrush on his tongue. Hmm, definitely suspicious for immunodeficiency. He only spoke a little bit of English so I was very grateful when his sister came in to help translate. Later when I presented him to Greg, Greg asked, "Did you ask him if he was gay?" Well, no, that thought never occurred to me, but Greg said he'd asked and yes, my patient is gay. His CXR and poor oxygen saturation is suspicious for PCP (though I was uncertain since I had an HIV positive patient at JPS who had pneumonia but it had been plain old CAP not PCP), so he's getting an HIV workup. I ended up leaving around 8:30 pm, so I made the drive to Andrew's to watch more Olympics. The US men's gymnastics guys didn't do so well in the all-around.

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.