After having a relaxing day off yesterday, it was back to work this morning. I saw my two patients (pancreatitis man and dissecting aneurysm man), who are the same as usual. Another 4th year interested in the FP program here joined us today; she's from DMU and wants to go to residency in FW b/c her parents have moved here. I originally offered to let her be on call tomorrow with Aaron, but Garrett told me to take it back. "She's just an FP student," he said. "We're here for the whole month. We're already second to three interns (I corrected him saying that Loan was a second year and not an intern, but technically she's still learning and not at Aaron's level), and the only time to learn anything is on call." So later I told the girl that I'll be taking call tomorrow after all, and she said it was fine. I told Garrett that I have a tendency to be too nice (which people have taken advantage of, I'm sure), and he reminded me that I'm learning, too, so I shouldn't have to give up good learning opportunities to others.
We had barely begun to see our first patient when we heard a Code Blue from Tower 6 over the walkie talkies. Kate (who's on call) and Garrett immediately headed over there to see what was going on while Aaron called Tower 6 to see what happened. All we got was that a woman with metastatic breast cancer had coded and that she was being intubated as we speak. When Kate and Garrett returned, I asked Garrett if the woman was alive. He said yes, and she was soon brought to our unit. All thoughts of rounding forgotten, Dr. ML immediately went to her room and said he needed someone to do a femoral line, another to do an IJ (intrajugular line). Heather started on the femoral line while Kate did the IJ. A nurse put a Foley in the woman and I saw some blood come out of the Foley; it made me wonder if it was possible to puncture the bladder if the Foley is pushed in too hard. Not too long afterwards, the woman coded again, and everyone immediately began feeling for a pulse. One nurse started compressions and then asked for someone to take over, so Garrett jumped in. I told Garrett to switch with me if he got tired, but I had the feeling he wouldn't get tired anytime soon.
A few thready pulses were felt once in a while, but in the end, it was decided that there was nothing that could be done and Dr. ML told Aaron to bring the husband into the room. As the chest compressions continued, the patient's remarkably calm husband entered the room and Dr. ML explained what was going on and asked the husband if he wanted them to stop the code. His reason for bringing the husband into the room was so that the husband could actually see what we were doing to keep his wife alive (pounding her chest, bagging her, etc.); many families have some false idea that we keep patients live by injecting them with drugs, nothing physically demanding like CPR. The husband told us to stop the code, and time of death was listed as 9:35 a.m. And yet when I looked at the monitor, she was still breathing on her own and her heart was still beating, albeit erratically. Why were they calling time of death so soon?
All tubes were removed, and the husband went to his wife's side and held her hand. Her eyes were open, and even though he tried to close them, they stayed open for a while. I kept an eye on the monitor and watched her HR drop from 80 to 70, then 65, then 40, then 35, then 0, then back to 30, then 0 again. Her breathing eventually flatlined, and soon, so did her HR, not to beat again. The husband never once lost his composure; maybe he prepared for this a long time ago. Dr. ML murmured some words of condolence as he left the room, and one by one we left too, leaving only the husband, the patient, and the chaplain. I did look back in the room once, and I noticed that the patient's eyes had finally closed.
Needless to say this reminded me of the death of little AJ back in Corpus Christi over a year ago. Back then, they didn't call time of death until his heart had stopped beating, and we had to listen to the screams of his brokenhearted mother throughout the code. But in the end she, like this patient's husband, knew not to prolong their loved one's suffering, and was willing to let them go peacefully.
After our patient passed away (Garrett left the room early and didn't realize she'd passed until later), rounds resumed as though nothing had happened. Then we had another emergency; our patient from IPA had somehow extubated himself (even though he was in restraints; maybe he coughed up the tube?) and needed an emergency trach. Kate got to do the intubation, and she struggled a bit, too, but she got it in. That's part of the learning experience. I also saw another familiar name on our patient list: the name of a homeless man familiar to the ER whom I met on my first day at JPS in medicine. Back then he came to the ER almost every night after getting drunk as a skunk for a place to sleep off the alcohol, and I specifically remember him calling me a "f***ing p***y." Aaron, too, asked if he'd been admitted to the hospital for being drunk or if he developed sepsis (his reason for being in the ICU) later. "Looks like he finally got sick for real this time," I commented, and Dr. O agreed. Someone made a semi-joke about how maybe he liked our new ER and ICU so much that he decided to figure out a way to stay here long term. It's not worth his while though; he's suspected of having TB and had to get a trach. My pancreatitis patient got a trach, too; hopefully he'll be more comfortable now.
There were lots of procedures going on this afternoon (3-4 trachs, 1 bronchoscopy, one core biopsy of the breast), but because I had to write a transfer note, I missed out on the trachs (though I did get to see part of one). Hopefully I'll be able to do more on call. Heather commented that when she was a 4th year, taking call was optional. It still is, but if you think about it, the only time I really learn anything is when I'm on call, and q4 isn't too bad as long as there are no codes during the night. Garrett said he got 6 hrs of sleep last night (lucky him). We'll see how things go for me.
Monday, September 8, 2008
Saturday, September 6, 2008
ICU: First Call
I was on call yesterday, and it was one of the longest days ever. Today we rounded with one of the ICU attendings, Dr. ML, who is very smart, very nice, and loves to teach. He does bedside teaching, which means we can spend anywhere from 10 to 30 minutes (or more) with each patient, depending on their pathology. We had a lot of patients this morning and didn't start rounding until almost 9:00 a.m. (we usually start by going over everyone's imaging studies before seeing the patients), and since I only had one patient to present, there was a lot of time just standing around doing nothing. Mike and Jay, as usual, were on top of things and wrote orders whenever they could, and on rare occasions Garrett and I would beat them to the punch and grab the orders folder before they did. Finally, with three patients left to go at 1:30 pm, Dr. ML told us to grab some lunch before the cafeteria closes. As usual, the cafeteria sold the most unhealthy stuff (chicken enchiladas, sausage and rice), but had pretty good desserts. Since Garrett and I were sitting at one end of the table, we began chatting about how we felt about the rotation so far. Garrett liked to do procedures (future anesthesiologist), and he signed up for ICU b/c he was told (as was I) that you get to do a lot of procedures in ICU. Standing around wasting time was not his idea of fun. That's why we've decided to take call on days when it's just the upper level resident on call, so we can do more procedures.
After we saw our last patient, I thought that was the end of the day, but we went to a smaller room to run the list. I chatted with Heather and Eddy about the residency application process and asked how much influence the residents had on whether an applicant is accepted or not. The answer: a lot. At JPS, the applicants are grouped into thirds, and most residents who get accepted made it into the upper third (obviously). Residents are asked for feedback on interviewees (i.e. interviews, dinner or happy hr meetings, etc), so I'll be sure to attend most pre-interview socials if I can just to get my face known. Mike, who has already submitted his ERAS, says he's going to have an interview here at the end of the month (since he won't be back to TX for a while). Jay, like me, hasn't submitted his ERAS yet so he'll have to come back, but he and Mike have already become good friends and act as though they'll definitely be at JPS next year. I hope for their sakes that it works out.
Early in the evening I had nothing going on at first, so I chatted with the ICU attending on call, Dr. O (but Dr. ML was still doing stuff around the unit). Dr. O is extremely nice. He asked me what I was interested in, whether I wanted to specialize, and where I wanted to go. And because there was some downtime, he sat down with me and began teaching me about various ICU topics like acid/base disorders, fluid replacement, and more. Aaron saw us and joked, "What lies are you feeding her?" Then we got a call from the ENT team about a woman coming in with necrotizing fasciitis to the neck. Her CT showed air pockets in her throat (definitely not a good sign) and when we saw her, she was leaning forward to breathe and had what looked like a huge goiter under her chin. Yikes. While that was being drained in the OR, we got another consult in the ER, so we went down two flights of stairs to see what was going on.
Previously, when JPS had proposed having an ER residency, I wasn't impressed with the idea of residents spending 3-4 years in the old JPS ER, which was too small, nasty-looking, and disorganized. But the ER in the new pavilion is large, clean, and much more organized; I easily got lost in there at first. There are some parts of the ER that are starting to smell bad b/c of the patients that come in, but it's still a great improvement from the old ER. A potential ICU patient came to us b/c he had a seizure while driving and crashed into a tree, and despite Aaron's calls to the ER telling the team not to intubate the patient, by the time we got down there he was paralyzed and in the process of getting intubated. Dr. O said that it's not a good idea to intubate seizure patients right off the bat but said that's what they tend to do in the ER. I did notice that the attending was an ER physician that no one seems to respect very much; I've heard surgical residents say negative things about him before, mostly along the lines that he has no clue what he's doing.
When we returned to the floors, I had time to run across the skywalk to the old building to get some food from the cafeteria (namely, a chocolate cheesecake and an apple as snacks) before Dr. O took me to do my first central line. It was on our lady with the neck abscess (I don't want to call it a neck fasc; they also say it might be Ludwig's angina). Dr. O showed me where to place the needle, but he ended up pushing it in b/c I couldn't (kept hitting the clavicle). I did an okay job of feeding the wire in, but it was harder than I thought. I don't think I'll be able to do any of these alone anytime soon, but it was good to at least get the experience. And I found that I still remember how to do one-handed ties, which is great =) Aaron was going to let me do an arterial line on another patient after showing me how to do one (unlike Loan, he barely made a mess), but even while under sedation, the other patient kept tensing and it was hard to stabilize his hand. Aaron came back from writing a note or two thinking I'd set everything up, but when he found out that I did nothing he was visibly annoyed. "I showed you how to do it, you should at least set it up," he said. Great, now he thinks I have no initiative. But later he saw for himself that this patient was not an idea candidate for an art line, so he let me off the hook...for now.
By this time it was past midnight, and with nothing else to do, I was happy to retire to the call room (I managed to get an empty resident room instead of having to share the third year med student room with 2 others) and sleep. I got up at 5:20 to eat and see my patients. On top of my pancreatitis guy (whose condition has been the same for days now), I saw two others, including a guy who was here earlier in the week for a TIA, went to the floors, then came back b/c he was found to have a dissecting aortic aneurysm that originated in the ascending aortic arch. It seems to be beyond any surgeon's ability here to fix, so we're trying to get him to THI in Houston, where there's a surgeon that specializes in aorta repairs.
The rule in ICU is that half of the team takes the day off on Saturday while the other half takes the day off on Sunday. Garrett, Kate, and Eddy were absent, so it was Aaron, Loan, Heather, me, and another 4th year who only did one day of ICU (today). I was able to leave around 11:15. Heather said that if I wanted to stay later to do an arterial line I could. If I weren't post call, I would have stayed, but more importantly, I needed to sleep. But at least I get tomorrow off =D
After we saw our last patient, I thought that was the end of the day, but we went to a smaller room to run the list. I chatted with Heather and Eddy about the residency application process and asked how much influence the residents had on whether an applicant is accepted or not. The answer: a lot. At JPS, the applicants are grouped into thirds, and most residents who get accepted made it into the upper third (obviously). Residents are asked for feedback on interviewees (i.e. interviews, dinner or happy hr meetings, etc), so I'll be sure to attend most pre-interview socials if I can just to get my face known. Mike, who has already submitted his ERAS, says he's going to have an interview here at the end of the month (since he won't be back to TX for a while). Jay, like me, hasn't submitted his ERAS yet so he'll have to come back, but he and Mike have already become good friends and act as though they'll definitely be at JPS next year. I hope for their sakes that it works out.
Early in the evening I had nothing going on at first, so I chatted with the ICU attending on call, Dr. O (but Dr. ML was still doing stuff around the unit). Dr. O is extremely nice. He asked me what I was interested in, whether I wanted to specialize, and where I wanted to go. And because there was some downtime, he sat down with me and began teaching me about various ICU topics like acid/base disorders, fluid replacement, and more. Aaron saw us and joked, "What lies are you feeding her?" Then we got a call from the ENT team about a woman coming in with necrotizing fasciitis to the neck. Her CT showed air pockets in her throat (definitely not a good sign) and when we saw her, she was leaning forward to breathe and had what looked like a huge goiter under her chin. Yikes. While that was being drained in the OR, we got another consult in the ER, so we went down two flights of stairs to see what was going on.
Previously, when JPS had proposed having an ER residency, I wasn't impressed with the idea of residents spending 3-4 years in the old JPS ER, which was too small, nasty-looking, and disorganized. But the ER in the new pavilion is large, clean, and much more organized; I easily got lost in there at first. There are some parts of the ER that are starting to smell bad b/c of the patients that come in, but it's still a great improvement from the old ER. A potential ICU patient came to us b/c he had a seizure while driving and crashed into a tree, and despite Aaron's calls to the ER telling the team not to intubate the patient, by the time we got down there he was paralyzed and in the process of getting intubated. Dr. O said that it's not a good idea to intubate seizure patients right off the bat but said that's what they tend to do in the ER. I did notice that the attending was an ER physician that no one seems to respect very much; I've heard surgical residents say negative things about him before, mostly along the lines that he has no clue what he's doing.
When we returned to the floors, I had time to run across the skywalk to the old building to get some food from the cafeteria (namely, a chocolate cheesecake and an apple as snacks) before Dr. O took me to do my first central line. It was on our lady with the neck abscess (I don't want to call it a neck fasc; they also say it might be Ludwig's angina). Dr. O showed me where to place the needle, but he ended up pushing it in b/c I couldn't (kept hitting the clavicle). I did an okay job of feeding the wire in, but it was harder than I thought. I don't think I'll be able to do any of these alone anytime soon, but it was good to at least get the experience. And I found that I still remember how to do one-handed ties, which is great =) Aaron was going to let me do an arterial line on another patient after showing me how to do one (unlike Loan, he barely made a mess), but even while under sedation, the other patient kept tensing and it was hard to stabilize his hand. Aaron came back from writing a note or two thinking I'd set everything up, but when he found out that I did nothing he was visibly annoyed. "I showed you how to do it, you should at least set it up," he said. Great, now he thinks I have no initiative. But later he saw for himself that this patient was not an idea candidate for an art line, so he let me off the hook...for now.
By this time it was past midnight, and with nothing else to do, I was happy to retire to the call room (I managed to get an empty resident room instead of having to share the third year med student room with 2 others) and sleep. I got up at 5:20 to eat and see my patients. On top of my pancreatitis guy (whose condition has been the same for days now), I saw two others, including a guy who was here earlier in the week for a TIA, went to the floors, then came back b/c he was found to have a dissecting aortic aneurysm that originated in the ascending aortic arch. It seems to be beyond any surgeon's ability here to fix, so we're trying to get him to THI in Houston, where there's a surgeon that specializes in aorta repairs.
The rule in ICU is that half of the team takes the day off on Saturday while the other half takes the day off on Sunday. Garrett, Kate, and Eddy were absent, so it was Aaron, Loan, Heather, me, and another 4th year who only did one day of ICU (today). I was able to leave around 11:15. Heather said that if I wanted to stay later to do an arterial line I could. If I weren't post call, I would have stayed, but more importantly, I needed to sleep. But at least I get tomorrow off =D
Thursday, September 4, 2008
ICU: A long non-call day
This morning I saw my one patient, an elderly man who initially came with pancreatitis and then developed respiratory failure. When I talked to him and examined him this morning, there were times where he'd try to speak and then become agitated because he can't, and his hands are in restraints to keep him from yanking out the tube. He's also been NPO for several days now, so we got a nutritionist to see him today for TPN purposes. Dr. C spent a lot of time on a sepsis patient, discussing different types of sepsis and what pressors are good to use in certain situations. I'll say one thing for the ICU attendings, they all love to teach. The four med students took turns writing orders; I got to write 2 and there were times when I wasn't paying attention and Heather (intern) would nudge me to get my attention. *sigh* Mike and Jay, of course, are usually on top of everything (to impress Dr. C); Mike even stayed past 11 am even though he was post call b/c there was stuff going on.
After rounds I went with Loan, Garrett, and Mike to SNF to see a 48-year-old patient (new ICU admit) with systemic fungemia. Her story was a sad case; about a year ago, her son died unexpectedly and she was so immersed in grief that she did nothing but lie in bed all day. Eventually she developed bed sores that turned into osteomyelitis (which still haven't healed properly), and somehow this turned into fungemia. Her tongue was completely covered with creamy Candida, her extremities were swollen with peeling skin, and she was barely conscious. One thing everyone noticed was her appearance; even though her records say she was 48, she looked ten to fifteen years older. Her face looked very wrinkled, and when Dr. C left the room, he shook his head and said, "Forty-eight?!" One of the residents had a theory that she could be here illegally and using a false ID, but even if that were true, it was ridiculous.
Because Loan, Garrett, and I had nothing to do before noon conference, we went to morning report. I nearly fell asleep, and Garrett said, "Okay, don't lie, how many hours of sleep did you get last night?" I answered, "Between 5 and 6," which is because I don't get to bed until after 11 and I have to get up earlier than usual to drive to JPS. I know I need more sleep; heck, Dr. R at TSH called me on my sleepiness during one of her first lectures. And since I'll be on call tomorrow, I'm determined to go to bed at least one hour earlier tonight. The internet is usually the reason why I sleep so late, what with researching residency programs, chatting online with friends, or watching videos on YT. *sigh* I need to get my priorities straight.
Sadly there was a lot of downtime in the afternoon. We did get to see one man get a burr hole drilled into his skull b/c he had a chronic head bleed that was shifting his brain past the midline. Jay got to hold the bulb, and the neurosurgeon told him, "So you'll be here for another month? You'll get to do another of these." Hmm, that all sounds nice, but what about me and Garrett, who are actually the ones doing an ICU rotation? Later our fungemia patient was transferred to the ICU from SNF, and we all prepared to do an arterial line and central line on her. Sadly, there were a lot of delays so that it took about 2-3 hrs to get everything done. First, Loan was unable to get a good reading on her first attempt at the arterial line. The second time, her sutures were "off" so Dr. L (the other ICU doc, NOT the same Dr. L as my medicine attending) made her redo the entire line (yikes). Fortunately the third one worked. Garrett and I had the job of holding the patient's arm and leg still b/c she sometimes struggled against us (despite getting fentanyl). Spilled blood was everywhere and Dr. L (when he first came in) scolded Loan for not putting chux on the floor and bed to minimize the mess. When a Code Blue was called in IPA, Garrett seemed all too glad to accompany Dr. C to IPA while I stayed and waited for the central line to be put in. It took forever for them to find the equipment, and in the meantime the patient's breathing was getting worse so we had to intubate her. Loan and Dr. L decided that I should do the intubation, and even though I had no trouble intubating dead patients in our anatomy lab, I did struggle with this woman. Her mouth was full of yeast (eww) and I couldn't find her vocal cords. On top of that I selected a laryngoscope with a straight blade instead of a curved blade (didn't know which one was easier), which Dr. L said made things more difficult (note to self: choose a curved blade next time). Finally Dr. L took over and, once he isolated the vocal cords, gave me the honors of pushing the breathing tube into position. So that was my first real intubation, and hopefully my next one will go more smoothly.
That wasn't the end. The central line kit finally arrived, but Loan accidentally put the line in the artery instead of the vein, so once again that had to be reinserted. The nurses also needed to put in a Foley (this lady was obese), and they asked me to wipe her down before they inserted the catheter. So yeah, since I had nothing else to do, I cleaned her up. With all the fungemia, blood, and what not, one of the nurses said she was going to take a shower as soon as she got home. Good idea. It was about 5:45 pm when I left, and the central line still needed to be sutured to the neck. *sigh* For someone who's not even on call, I sure did stay a long time.
After rounds I went with Loan, Garrett, and Mike to SNF to see a 48-year-old patient (new ICU admit) with systemic fungemia. Her story was a sad case; about a year ago, her son died unexpectedly and she was so immersed in grief that she did nothing but lie in bed all day. Eventually she developed bed sores that turned into osteomyelitis (which still haven't healed properly), and somehow this turned into fungemia. Her tongue was completely covered with creamy Candida, her extremities were swollen with peeling skin, and she was barely conscious. One thing everyone noticed was her appearance; even though her records say she was 48, she looked ten to fifteen years older. Her face looked very wrinkled, and when Dr. C left the room, he shook his head and said, "Forty-eight?!" One of the residents had a theory that she could be here illegally and using a false ID, but even if that were true, it was ridiculous.
Because Loan, Garrett, and I had nothing to do before noon conference, we went to morning report. I nearly fell asleep, and Garrett said, "Okay, don't lie, how many hours of sleep did you get last night?" I answered, "Between 5 and 6," which is because I don't get to bed until after 11 and I have to get up earlier than usual to drive to JPS. I know I need more sleep; heck, Dr. R at TSH called me on my sleepiness during one of her first lectures. And since I'll be on call tomorrow, I'm determined to go to bed at least one hour earlier tonight. The internet is usually the reason why I sleep so late, what with researching residency programs, chatting online with friends, or watching videos on YT. *sigh* I need to get my priorities straight.
Sadly there was a lot of downtime in the afternoon. We did get to see one man get a burr hole drilled into his skull b/c he had a chronic head bleed that was shifting his brain past the midline. Jay got to hold the bulb, and the neurosurgeon told him, "So you'll be here for another month? You'll get to do another of these." Hmm, that all sounds nice, but what about me and Garrett, who are actually the ones doing an ICU rotation? Later our fungemia patient was transferred to the ICU from SNF, and we all prepared to do an arterial line and central line on her. Sadly, there were a lot of delays so that it took about 2-3 hrs to get everything done. First, Loan was unable to get a good reading on her first attempt at the arterial line. The second time, her sutures were "off" so Dr. L (the other ICU doc, NOT the same Dr. L as my medicine attending) made her redo the entire line (yikes). Fortunately the third one worked. Garrett and I had the job of holding the patient's arm and leg still b/c she sometimes struggled against us (despite getting fentanyl). Spilled blood was everywhere and Dr. L (when he first came in) scolded Loan for not putting chux on the floor and bed to minimize the mess. When a Code Blue was called in IPA, Garrett seemed all too glad to accompany Dr. C to IPA while I stayed and waited for the central line to be put in. It took forever for them to find the equipment, and in the meantime the patient's breathing was getting worse so we had to intubate her. Loan and Dr. L decided that I should do the intubation, and even though I had no trouble intubating dead patients in our anatomy lab, I did struggle with this woman. Her mouth was full of yeast (eww) and I couldn't find her vocal cords. On top of that I selected a laryngoscope with a straight blade instead of a curved blade (didn't know which one was easier), which Dr. L said made things more difficult (note to self: choose a curved blade next time). Finally Dr. L took over and, once he isolated the vocal cords, gave me the honors of pushing the breathing tube into position. So that was my first real intubation, and hopefully my next one will go more smoothly.
That wasn't the end. The central line kit finally arrived, but Loan accidentally put the line in the artery instead of the vein, so once again that had to be reinserted. The nurses also needed to put in a Foley (this lady was obese), and they asked me to wipe her down before they inserted the catheter. So yeah, since I had nothing else to do, I cleaned her up. With all the fungemia, blood, and what not, one of the nurses said she was going to take a shower as soon as she got home. Good idea. It was about 5:45 pm when I left, and the central line still needed to be sutured to the neck. *sigh* For someone who's not even on call, I sure did stay a long time.
Wednesday, September 3, 2008
ICU: Too Many Med Students
Our current ICU team is huge. Aside from three upper level residents and two interns, there are four 4th year medical students. And while the residents are happy about it (less patients for them to see), I am not, and neither is Garrett. Jay, Garrett, and I were joined by Mike, the 4th year from KCUMB, whom we met yesterday while waiting in line for IDs to be made. Mike and Jay are both interested in the family practice residency program at JPS, and it just so happens that the program director is Dr. C, our current ICU attending. As a result, Jay and Mike have been doing their best to make themselves well-known to Dr. C (writing orders, hanging out with the residents, etc) and leave Garrett and me with absolutely nothing to do even though we're the ones doing ICU for an entire month. 4th years rotating through family medicine do everything in one-week blocks, so next week Mike and Jay will be somewhere else, but that also means other 4th years doing a month of family medicine (I know of at least two others) may also do an ICU week, leaving us hanging again. Even still, I have nothing against Mike and Jay; they're both nice guys and I like working with them. And who can blame them for wanting to do their best in a program they're interested in? At least only one student is on call at a time; if an emergency LP or central line needs to be done after hours, we'll get first dibs when we're on call. Mike got "suckered" into being on call with Eddy today (b/c Eddy has no interns to help him tonight), and I think Garrett is on call tomorrow, so I'll take call on Friday. That's another thing with ICU: too much freedom among the students regarding call and days off. We have to work with each other to make sure not everyone takes call or vacation the same day.
I think I did a pretty good job presenting my cardiac arrest patient today; later I wrote an ICU transfer note for her to go to Medicine B (Manov's team), so I had to pick up another patient at the end of the day. Another patient with miliary TB got an LP, and Mike immediately went in to observe. That left me, Jay, and Garrett hanging around outside, so Garrett (who had done an anesthesiology rotation at UTSW) gave me a few pointers on doing an LP so that when I get to do my first one, I'll be more prepared. Inevitably our conversation went to ERAS; Mike and Garrett submitted their apps yesterday. And here I'm still working on my PS and deciding what programs to apply to. *sigh* Oh well. My rec letter from Dr. C in Austin should be arriving later in the week, and when that happens hopefully I'll have almost everything finished.
I think I did a pretty good job presenting my cardiac arrest patient today; later I wrote an ICU transfer note for her to go to Medicine B (Manov's team), so I had to pick up another patient at the end of the day. Another patient with miliary TB got an LP, and Mike immediately went in to observe. That left me, Jay, and Garrett hanging around outside, so Garrett (who had done an anesthesiology rotation at UTSW) gave me a few pointers on doing an LP so that when I get to do my first one, I'll be more prepared. Inevitably our conversation went to ERAS; Mike and Garrett submitted their apps yesterday. And here I'm still working on my PS and deciding what programs to apply to. *sigh* Oh well. My rec letter from Dr. C in Austin should be arriving later in the week, and when that happens hopefully I'll have almost everything finished.
Tuesday, September 2, 2008
ICU: First Day
Today was my first day of ICU at JPS. I ran into Garrett on the bus and found out that he'd be doing ICU with me. There were even MORE familiar faces (Andrew, Asuka, Jon, Rachel, Lydia, Mani) once we got to orientation with Margie, and a few unfamiliar ones, too. There were a few fourth years visiting from OU, KCUMB, UT-HSC, and UTHSCSA, to name a few; they were doing rotations in ortho, ob-gyn, and FP. Garrett and I soon found out that the ICU has been relocated across the street to the "Pavilion" along with the Tele units, ER, and surgery, and after calling Eddy, our 2nd year resident, we headed across the walkway to the Pavilion. (Oh yeah, the cafeteria is STILL not open) 
Compared to the old ICU (smelly waiting rooms, old rooms), the new ICU (and the Pavilion in general) was amazing. The rooms were larger, with hardwood floors; most patients had their own room. We soon found the rest of the team: Dr. C, 2nd years Eddy and Loan, and interns Kate and Heather. There's also another fourth year, Jay, from MUSC (South Carolina) who actually started working yesterday, so he knows a little bit more than Garrett and I do about how the ICU works. Since there's so many of us, each person has about 1-2 patients to see; Garrett and I each took one of Heather's patients b/c she's on call tonight along with Loan. Eddy said that we could take call only if we wanted to, which to me didn't make much sense. You either take call or don't. I think I'll try and do one call a week, because hey, at least it's not q3. But I also want to know when I can take a day off. Maybe I'll ask Eddy later.
Rounds went by quickly, but there was still a lot of downtime where Garrett and I stood around talking about ERAS. Dr. C told us to follow Loan and Heather to admit a patient from SNF, so we did. This lady suddenly became unresponsive (previous hx of TIA, if I remember correctly), and when we examined her, she had fluid in her right lung and her pupils were dilated and not really responsive to light. We then talked to another ICU doctor, Dr. L, who LOVES to teach. He spent a great deal of time going over distinguishing shunts from dead space, characteristics of SIRS, and more. The only downside: we spent so much time talking that we weren't able to get lunch until 3:30 pm. Dr. C saw me reading through my patient's chart in the ICU and commented that I must have had a lot of reading to do. Yup.
Compared to the old ICU (smelly waiting rooms, old rooms), the new ICU (and the Pavilion in general) was amazing. The rooms were larger, with hardwood floors; most patients had their own room. We soon found the rest of the team: Dr. C, 2nd years Eddy and Loan, and interns Kate and Heather. There's also another fourth year, Jay, from MUSC (South Carolina) who actually started working yesterday, so he knows a little bit more than Garrett and I do about how the ICU works. Since there's so many of us, each person has about 1-2 patients to see; Garrett and I each took one of Heather's patients b/c she's on call tonight along with Loan. Eddy said that we could take call only if we wanted to, which to me didn't make much sense. You either take call or don't. I think I'll try and do one call a week, because hey, at least it's not q3. But I also want to know when I can take a day off. Maybe I'll ask Eddy later.
Rounds went by quickly, but there was still a lot of downtime where Garrett and I stood around talking about ERAS. Dr. C told us to follow Loan and Heather to admit a patient from SNF, so we did. This lady suddenly became unresponsive (previous hx of TIA, if I remember correctly), and when we examined her, she had fluid in her right lung and her pupils were dilated and not really responsive to light. We then talked to another ICU doctor, Dr. L, who LOVES to teach. He spent a great deal of time going over distinguishing shunts from dead space, characteristics of SIRS, and more. The only downside: we spent so much time talking that we weren't able to get lunch until 3:30 pm. Dr. C saw me reading through my patient's chart in the ICU and commented that I must have had a lot of reading to do. Yup.
Monday, August 25, 2008
Home Sweet Home
As the title says, I'm back home now. My memories of Austin are still fresh, and throughout the day I found myself missing it. And in a few days, I'll be in Denver at the same time as the Democratic Convention. Hopefully it won't be too crowded.
Saturday, August 23, 2008
Tubing Misadventures =)
Dina and Fallon drove down to Austin today so Dina could look for places to stay during her obgyn rotation. The first house we went to was in a ghetto neighborhood (not too safe), and the second house was in a cute, quiet little neighborhood and home to a 100 lb mastiff that couldn't stop growling at us. This didn't sit well with Fallon. Another dealbreaker was that the woman who owned the house smokes. So Dina thinks she might just stay at an extended living hotel.
After we left the second house, it took almost an hour to get to New Braunfels, but fortunately, Texas Tubes on the Comal River was not terribly hard to find. When we arrived on site, a man came to my window and asked, "Ready to tube?" before directing us to a parking spot. The three of us each spent $14 on a tube with a bottom (we thought that meant our butts wouldn't get soaked; we were wrong), and though Fallon advised against it, Dina and I brought our cameras onto the river. That soon proved to be a mistake; it started to rain, first a light drizzle that eventually progressed to some majorly heavy rain. Fallon and I were close to a shore (Dina got separated from us ages ago), so we managed to pull ourselves (and our tubes) out of the river. Dina continued to float downstream, so I went back in and helped tug her tube to shore. Thanks to all the previous rain, the river was deep and I couldn't touch the bottom sometimes. Once we were all on shore, we wondered whether to stop tubing right then and there (we'd only floated several yards downstream) or continue. The rain was stopping by this point. It was obvious that we wouldn't be able to carry our electronics downstream, so we swam across the river (with our tubes, of course) and I dropped off the cameras and Dina's phone at the front desk. After our things were safe, we continued our tubing adventure.
It was a very relaxing experience at first, just lying back and staring at the sky. Then we ran into the first chute, a sloped tunnel that shot us into another part of the river with lots of rapids. At one point our tubes got trapped in a circular current that pushed us back to where we just came from. Fortunately a man on the sidelines (possibly the guy who welcomed us to the tubing place) was around to push us back into the downstream current. There was another chute up ahead (and a sign that read "Weak swimmers please leave the water"), but instead of going down the chute, we went down a steep vertical drop. I was swept downstream but Fallon and Dina were stuck in the falls (a young kid later pulled them out), so I got out of my tube and stood in the water to wait for them. The current was very strong and almost swept me off my feet several times, but I managed to stay still until they caught up with me. Then it was more floating until we reached another chute. This time we went down the chute, but still wound up drifting in a circular current again.
There, we got separated again as Dina and Fallon got into the current before I did. I'm not sure what happened after that, but just as I got into the current (I think someone ran into me), my tube flipped over and knocked me into the water. The current was strong, but fortunately my feet were able to touch the bottom and I managed to grab on to a nearby ledge to keep from being swept downstream without my tube. I'd lost my water bottle, my shoes, my T-shirt (which had been resting in my lap), and my tube when it tipped over, but luckily nearby strangers recovered my shoes while my upside-down tube floated right in front of me. That was a close call; I'd been worried about the prospect of paying $20 for a lost tube. In the meantime, Fallon and Dina had grabbed on to a tree branch and were waiting for me to rejoin them.
By this time it was almost 3:00 pm, and we'd only covered half of the river. When we saw a sign that said, "Estimated time to the end: 1 hr" we were worried b/c Dina had to catch a flight back home at 6:00 pm. Then we saw a sign up ahead that said, "Public tube exit," meaning that we could leave the river at that point. The problem: we were across the river and the exit was approaching fast, so once again I went back in the river and helped pull the three of us to the exit. It was really tiring, and there were times when I thought we'd float past the exit and lose our chances of getting on land, but we made it. Then Dina lost her tube while climbing ashore and another guy downstream picked it up and brought it back. People on the river are so nice =) The three of us decided that though we had fun, that was enough tubing for the day, so we lugged our tubes up a flight of stairs onto the street and walked a block or two to the pick-up point (the shuttle was waiting, fortunately). I didn't take any pictures at the river, but I have a few bruises, cuts, and scrapes on my legs to remind me of this day.
In the end, we got Dina to the airport in time to make her flight, and Fallon and I had sushi with a friend of ours from college who was very amused when he heard of the numerous fiascos we had on the river (he's been tubing countless times). But now we know better, and the next time we go tubing (maybe we'll try the Guadalupe River instead of the Comal River), we'll be more prepared and have less accidents.
After we left the second house, it took almost an hour to get to New Braunfels, but fortunately, Texas Tubes on the Comal River was not terribly hard to find. When we arrived on site, a man came to my window and asked, "Ready to tube?" before directing us to a parking spot. The three of us each spent $14 on a tube with a bottom (we thought that meant our butts wouldn't get soaked; we were wrong), and though Fallon advised against it, Dina and I brought our cameras onto the river. That soon proved to be a mistake; it started to rain, first a light drizzle that eventually progressed to some majorly heavy rain. Fallon and I were close to a shore (Dina got separated from us ages ago), so we managed to pull ourselves (and our tubes) out of the river. Dina continued to float downstream, so I went back in and helped tug her tube to shore. Thanks to all the previous rain, the river was deep and I couldn't touch the bottom sometimes. Once we were all on shore, we wondered whether to stop tubing right then and there (we'd only floated several yards downstream) or continue. The rain was stopping by this point. It was obvious that we wouldn't be able to carry our electronics downstream, so we swam across the river (with our tubes, of course) and I dropped off the cameras and Dina's phone at the front desk. After our things were safe, we continued our tubing adventure.
It was a very relaxing experience at first, just lying back and staring at the sky. Then we ran into the first chute, a sloped tunnel that shot us into another part of the river with lots of rapids. At one point our tubes got trapped in a circular current that pushed us back to where we just came from. Fortunately a man on the sidelines (possibly the guy who welcomed us to the tubing place) was around to push us back into the downstream current. There was another chute up ahead (and a sign that read "Weak swimmers please leave the water"), but instead of going down the chute, we went down a steep vertical drop. I was swept downstream but Fallon and Dina were stuck in the falls (a young kid later pulled them out), so I got out of my tube and stood in the water to wait for them. The current was very strong and almost swept me off my feet several times, but I managed to stay still until they caught up with me. Then it was more floating until we reached another chute. This time we went down the chute, but still wound up drifting in a circular current again.
There, we got separated again as Dina and Fallon got into the current before I did. I'm not sure what happened after that, but just as I got into the current (I think someone ran into me), my tube flipped over and knocked me into the water. The current was strong, but fortunately my feet were able to touch the bottom and I managed to grab on to a nearby ledge to keep from being swept downstream without my tube. I'd lost my water bottle, my shoes, my T-shirt (which had been resting in my lap), and my tube when it tipped over, but luckily nearby strangers recovered my shoes while my upside-down tube floated right in front of me. That was a close call; I'd been worried about the prospect of paying $20 for a lost tube. In the meantime, Fallon and Dina had grabbed on to a tree branch and were waiting for me to rejoin them.
By this time it was almost 3:00 pm, and we'd only covered half of the river. When we saw a sign that said, "Estimated time to the end: 1 hr" we were worried b/c Dina had to catch a flight back home at 6:00 pm. Then we saw a sign up ahead that said, "Public tube exit," meaning that we could leave the river at that point. The problem: we were across the river and the exit was approaching fast, so once again I went back in the river and helped pull the three of us to the exit. It was really tiring, and there were times when I thought we'd float past the exit and lose our chances of getting on land, but we made it. Then Dina lost her tube while climbing ashore and another guy downstream picked it up and brought it back. People on the river are so nice =) The three of us decided that though we had fun, that was enough tubing for the day, so we lugged our tubes up a flight of stairs onto the street and walked a block or two to the pick-up point (the shuttle was waiting, fortunately). I didn't take any pictures at the river, but I have a few bruises, cuts, and scrapes on my legs to remind me of this day.
In the end, we got Dina to the airport in time to make her flight, and Fallon and I had sushi with a friend of ours from college who was very amused when he heard of the numerous fiascos we had on the river (he's been tubing countless times). But now we know better, and the next time we go tubing (maybe we'll try the Guadalupe River instead of the Comal River), we'll be more prepared and have less accidents.
Friday, August 22, 2008
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 =)
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 =)
Thursday, August 21, 2008
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.
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.
Wednesday, August 20, 2008
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.
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.
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