IM Sub-I: Last Day!

Last day of the medicine sub-I! I had four patients to see: my usual three plus the 18-year-old boy with the hand abscess. My liver disease lady had an INR of 7.6 (up from 1.7) this morning, which I think is a faulty lab error, but when I went to see her, she was sitting up in bed staring listlessly out the window. I wondered what she was thinking. Her bilirubin continues to increase, and she's getting more jaundiced, and I don't understand why, seeing how she's discontinued her Tegretol (for real this time, I hope). My trainwreck patient is doing much better, and my gonorrhea patient's joint swelling is finally going down. As long as he can walk, he can go home later today. Too bad I won't be able to stick around for it.

As expected, our cancer patient died last night. We had nine patients on our service, but it still took the team until 12:30 to finish rounding. I don't get it. Dr. C always managed to finish rounding before noon, whether we had 18 or 9 patients. Amy takes time to talk to the patients and listens to them if they have something to say, which is actually a good thing (just not for an impatient team of interns and med students). I can see myself doing the same, actually. I spent two hours of my afternoon filling out discharge summaries and getting drug info for my trainwreck and gonorrhea patients, and then I paged Matt and let him know I was leaving. Before turning in my badge, I got two Odwalla drinks for Beth (something of a goodbye/thank you offering) and went to the 4th floor library to see the pigeons. When I first arrived in Austin, I saw two pigeons taking turns sitting on an egg. Now that egg has grown into a small, fluffy-looking chick. =)

I had time in the afternoon to pack before driving to Andrew's for dinner. Unbenownst to me, Jeff had come over and Andrew had made curry again, so I neglected my salad in favor of curry and spring rolls. The three of us then hung out in front of the TV watching the Olympics, playing WoW (the guys), or just chatting. It's my last night at the house near the hospital; tomorrow Dina and Fallon are coming to Austin and we're going tubing =)

IM Sub-I: Longest Short Stay B

This morning I ran into Angela on the floors when I was seeing my trainwreck and disseminated gonorrhea patient (yes, the blood cultures confirmed the presence of N. gonorrhoeae), and she asked if I'd looked up Light's criteria for my patient's pleural fluid. I hadn't calculated the values yet and she told me to get on it b/c Amy was sure to ask me about it (since I'd failed her questioning yesterday). Sure enough, Amy later asked whether my patient had exudate or transudate, and I was able to say exudate (but not impressively so). On top of that, my gonorrhea patient also had a knee aspiration, so with some previous help from UpToDate I was able to interpret his knee fluid to some extent. Here's the kicker: he also has rhomboid crystals in his knee. Damn...pseudogout on top of gonorrheal arthritis?! This guy really will be an excellent case for morning report. As for my liver disease patient, GI has signed off on her, but we're keeping her in the hospital to see if her enzymes improve more now that she's not taking Tegretol anymore. I hope the gabapentin we gave to replace it does the trick.

One of our patients passed away today. She was a 99-year-old previously alert lady who fell and hit her head, developing a subarachnoid hemorrhage. This morning when we rounded on her, she was having labored breathing (like yesterday) and was less responsive than usual; we felt sure death was coming in the next few days. Certainly not shortly before noon. The progression to death was very fast; maybe she had bled into her brainstem or something.

For short call B, An and I ended up helping Matt (our intern for two days) on the floors with discharge summaries and prescriptions. By the time we got to the ER, Angela had already seen two patients and had two more left for each of us to see. To speed things along, An went with Matt to see one patient, and I went with Angela to see another. One of the two patients she'd already seen was a very sad case: a 64-year-old woman with metastatic endometrial cancer was supposed to have been under hospice care, but she became difficult to deal with b/c she wasn't taking her bipolar meds, and when she developed swelling in her leg, she was brought to the hospital and essentially "dumped" there for us. It turns out she had a huge DVT in her leg (and it was obvious; the bad leg was dusky and cold); on top of that, she had a UTI, the beginnings of pneumonia, and a potassium of 7.5. She was given medicine to drop her potassium and heparin for her DVT until her medical power of attorney came and said to provide comfort care only. When I saw her EKG, it still looked okay (no peaked T waves yet), and she was conscious but very disoriented. She screamed when Angela palpated her abdomen, and she had an ugly distended growth coming out of her left neck. I had to wonder, was that the result of the metastatic cancer? I asked Angela which of her many comorbidities will kill her, and she said the potassium. "She probably won't make it through the night," she said. That made me sad.

The patient we saw together was a 18-year-old guy with right hand cellulitis. Pretty straightforward. Even still, we weren't able to leave until 5:30 pm b/c Angela ran the list with Matt, An, and me before letting us go. Back in the day, Greg let us go as soon as we finished our notes and orders for our patients. I'd never stayed this late for Short Call B before. But today's cases were pretty interesting.

IM Sub-I: Exasperating patients

Yan had the day off today, so it was just me, An, and Zack along with Angela and Amy. Once again we started rounding after morning report, and once again we didn't finish rounding until after 12:00 pm. Our horse trainer lady, once again, kept us in the room longer than usual with her talking, and it didn't help that the neurology team had her chart and took forever discussing her case. Zack, An, and I went down to lunch together, and An told Zack that she envied him b/c it's his last day on the team (he goes to psych/neuro next). "I know, this is awful," Zack agreed. It's probably b/c we're too used to Dr. C rounding at lightning speed, and it doesn't help that Amy doesn't know when to cut a patient off when he/she talks too much. We also blamed the neurology team for taking too long with our talkative patient's chart, and Zack said that Dr. C probably would have said, "Oh, let neurology take care of it" in a perfect imitation of Dr. C's voice. It was pretty funny =) Even still, An and I only have two days left on the team. And then...done =)

After noon conference (I always fall asleep somewhere in the middle), we met up in Obs, where Angela told An and me that she wants to pre-round every morning before morning report b/c today's rounds were chaotic and disorganized (i.e. I said my patient had normal pleural fluid without interpreting it, and I didn't have a good plan for one patient). I'm all for making rounds faster, and if prerounding is the way to go, I'm all for it. Because Yan had a day off and Angela had clinic, it was just Zack, An, and me to do things on the floor. I was in charge of writing orders and stuff for my three patients: a guy with a palmar rash and swollen knees and ankles (we initially thought he might have Rocky Mountain spotted fever but now it looks more like disseminated gonorrhea), my "train-wreck" patient with resolving fever but worsening cellulitis, and my liver biopsy lady who still itches like crazy but her LFTs are improving.

My "train-wreck" was fairly straightforward. For my patient with potential gonorrhea, I was supposed to speak to him alone to tell him we think he has gonorrhea and to ask if he knows who may have given it to him so that she can be treated. The problem: his girlfriend. Almost every time I went into the room, she was lying in bed beside him (hospital beds are wide enough for two thin people to sleep side by side), in a crop top and miniskirt no less. It seemed impossible to get my patient alone without his girlfriend nearby, so after a while I gave up, leaving the task of breaking the news to Zack. Later I asked a Spanish-speaking nurse to come talk to my liver biopsy lady to see if she was taking any herbal supplements that could be contributing to her liver disease. The patient said she was only taking Tegretol for her trigeminal neuralgia, which I said wasn't right since we discontinued it when she came to the hospital. Then came the kicker: she had kept a bottle of Tegretol in her purse beside her bed, and she'd been taking her usual dose of Tegretol without letting the nurses or doctors know. I thought, "Oh crap," since we'd originally thought her Tegretol was the cause of her liver disease (autoimmune vs drug induced). And though her LFTs were falling, her pruritis persisted, and we thought her LFTs were improving b/c she wasn't taking her Tegretol. Not so. The nurse told her that she wasn't supposed to be taking Tegretol without our permission, and the patient replied that she had to take it or else her trigeminal neuralgia would act up. I called Zack to let him know what was going on, and he said he'd ask Angela what to do. In the meantime, I told the patient to stop her Tegretol for now, and she didn't look happy about taht. Later I found Zack, and he told me that Angela gave permission for the patient to continue her Tegretol (since it obviously isn't keeping her LFTs up). Even though she's still jaundiced, there's nothing more we can do for her, so hopefully she got discharged later on. And since it's important to document everything, I wrote an addendum in her chart revealing what happened today. We'll see if any good came of it.

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. =)