ICU: Out in a Blaze of Glory

Last day of ICU! Sarah had seven admits yesterday (three in the morning, three in the evening, and one who died of a hemorrhagic stroke), so rounds were expected to take a while. Other attendings chose to look at CXRs before rounds, but Dr. P liked to look at them in the patient's room. By this time we knew what he expected of us. Within thirty seconds after he entered a room, the lights in the room were on, the charts and rounds reports were in front of him, the CXR was on the computer screen, and someone was ready to write orders. It's interesting the way he said, "Someone needs to be in charge of turning on the lights" as though that was all we're good for. *sigh*

The girl with the bad heart, we learned, had developed the clots in her leg b/c she stopped taking her Coumadin after her mother died about a week ago (too upset to take care of herself, understandably). When Dr. P questioned her on that, she got mad b/c thought he was accusing her of bringing this on herself, and the nurse had to calm her down afterwards. Dr. P, after a disclaimer, said that this girl was "one of God's mistakes." Why, he asked, was she given life when she had heart failure so severe (isolated noncompacted left ventricle is a rare condition) that she will probably die within the year if she doesn't get a heart transplant? No one had an answer for that (or wisely stayed silent), but I think we all agreed that it was horrible for a twenty-year-old girl who should be enjoying life to instead be living on borrowed time.

On a good note, both of my patients have been weaned off the vent and fitted with trach collars, and they were given the green light to transfer out of ICU to the Tele units. The nurses kept pushing at us to discharge our patients to the medicine team b/c at the moment the ICU is packed (and more beds are needed). They will be going to my old medicine team (with Dr. L) and I have a feeling Dr. L is going to hate us for sending him my comatose patient. He made it perfectly clear last year how he felt about rocks, and she's been in the ICU for a whole month with no real improvement. My mediastinal abscess lady, however, is on the road to recovery, and I went to her room specifically to tell her goodbye and wish her well. She has a child waiting for her at home, so hopefully she'll get better and leave the hospital in the next few weeks.

No noon conference for students, so Garrett, Loan, and I had lunch downstairs with a visiting student from A&M, Andrea, who went to college with Garrett's wife. Family medicine programs send invites out early, so Andrea already has several interviews lined up. I just hope to get more invites in the next few weeks now that my chairman's letter has arrived at the Student Affairs office. After lunch Garrett left after saying goodbye to Loan, Heather, and Tony, but I stayed around b/c I had two transfer notes to write on my two patients.

Two of our patients needed thoracenteses. Loan did one, and she suggested that since it's my last day, I should do the other with Tony (who turned 29 today). I never really got to work much with Tony before, but he's an awesome teacher. The patient, a guy from the UTMB federal prison who had tongue cancer, asked (on paper) if I would be doing the procedure b/c he didn't want a collapsed lung. (Gee, thanks). Tony assured him that he would be guiding me the entire time, and in the end the patient gave the ok for us to proceed. The thoracentesis needle is freaking long, but with Tony directing where to push I tapped the fluid collection on the first time. "Now, pull the needle back slightly," he said, but I accidentally pulled back too far and couldn't advance the catheter, so Tony took over briefly. Then, once he was deep in the fluid collection, he let me suction out the fluid (straw-colored) and then hook the catheter to a line that led to one of those huge 1 L collection bottles. Then we waited for the fluid to drain in the bottle (nearly 800 mL in all!) before removing the catheter and putting a Band-Aid on the patient's back (random comment, the patient's back was entirely covered with tattoos, some of the images resembling demonic faces). The patient fared well and wrote "Thank you both" on his notepad to us, and Tony and I thanked him for letting me participate in my first thoracentesis.

As we were writing orders, the nurses nearby asked us where Heather and Loan (the ones on call) were b/c they needed to send our transfer patients out to make way for the new ones (we had four transfers total). They then asked Tony if he could do the transfers instead, and Tony joked, "Why? Those two hos are the ones on call." The nurse said, "What?" and without thinking I repeated what Tony had said. "Ohhhhhh! I'm telling!" the nurse laughed, and Tony said, "Hoser. I called them hosers. Are you trying to get me in trouble?" That last line was for me, of course, but it was all in good humor. Later Tony paged the girls and they said they were coming upstairs, and in the meantime we chatted about my future residency plans. Tony was very supportive of my applying to the two IM programs in Colorado (where he went to med school), saying that both UCHSC and St. Joseph had excellent training (based on the opinions of friends who went there). That all sounds great, if I can get an interview =)

One important event happening in the unit today was that Dr. Hess, an ICU attending who lives out of state but spends several weeks at JPS a year (b/c he used to be here full-time), was back for one week. It was his first time in the new ICU, so the nurses practically gave him a welcome back party (complete with a pair of mesh undies that some patients, wear, hehe). When he heard it was my last day of ICU, he said, "Congratulations, you survived." Heather and Loan both wished me luck for the rest of my year, and we all wished Tony a Happy Birthday and told him to have fun tonight (there's a party in his favor).

Doing an ICU rotation was definitely a great experience. Not only have I become accustomed to seeing patients die (which will undoubtedly prepare me for the hospice portion of my geriatrics rotation), I've learned how to interpret ventilators and have several procedures under my belt so that I won't be a total novice as an intern. Three subclavian lines, one thoracentesis, one attempted paracentesis, and two attempted arterial lines...not too shabby. Garrett one-upped me by getting to do a chest tube insertion, but maybe I'll get to do one of those in ER, who knows? =) I'm just glad to get a weekend off.

ICU: Almost done

Because rounds started at 8:30, there was time to run over to "Christmas" to pick up a burrito and other goodies. Kate and Tony had a busy night; four admits, and Tony had to check on each of our patients at least once throughout the night. Craziness. Once again Dr. P hurried to get through the patient, but at one point there was only Garrett and me because Kindrick had to make a phone call, Sarah had to do a new admit, Loan had the day off, Chris and Kate were post-call, and Heather was seeing Loan's patient (more on that below). "Where's my team?" he demanded. Uh oh. To make things faster we went to see my two patients, and finally we made some progress in my comatose lady: she got a trach collar. Hopefully in a few days my other patient will be able to use a trach collar, too.

About halfway through rounds we realized that no one had seen Loan's patient (she took the day off b/c she had an OB appointment in the afternoon), so Heather went to write a quick note on her. When Kindrick found out that Loan had taken the day off without telling someone to see her patient he was not pleased. "You're not supposed to take a day off on Thursdays!" he exclaimed. "If you're on call during the weekend, you take Friday off. Otherwise, you take Saturday or Sunday off!" I tried to defend her, saying that she had an OB appointment (she had contemplated not taking the day off if Dr. P was on lightning rounds, but decided in the end to go ahead and take the day off). To this, Kindrick said that being pregnant is not an excuse b/c pregnancy is something that women choose and bring on themselves, to which Dr. P agreed. Geez, and this is coming from two fathers? Well hopefully Loan won't get in trouble, though Kindrick has resolved to give her a talking-to. I then told Kindrick that I had taken last Thursday off (to finish my personal statement, which I succeeded in doing), but Kindrick waved that off, saying that was fine b/c I'm just a student. Since he's on call on Saturday (which he's not happy about b/c he won't have any med students around to teach/scut around, though I mean that in a nice way), he's taking tomorrow off, so he divided his patients among Garrett and me so that we each get 3 tomorrow. I wondered why we get 3 each and Loan only gets 1, but Garrett said not to bother Loan with more patients. Okay...

We were 30 min late to noon conference, but today's topic touched on spirituality and medicine. The speaker asked how we would deal with a teenage girl who was brought up to believe masturbating was a sin, but then masturbates out of curiosity and ends up feeling guilty for her so-called sin. Her guilt threw her into full-blown depression (not eating or sleeping well, feeling sad, etc.), and the speaker said that he addressed her concerns by telling her that she is not alone, among other things, and that masturbation was normal in teenagers. The discussion went on and on (with Jordan being the most vocal resident), but in the end the speaker said the girl grew up to be a happy and healthy adult, so something good came out of that one. I didn't stay terribly long after noon conference; Sarah was on call with Dr. O and there was an imminent central line to be done. So when Garrett suggested that I go home, I didn't even question it; I knew he wanted that line =P As with all future anesthesiologists, he likes keeping his hands busy.

Last day of ICU tomorrow! I'll be glad to adapt a schedule with no call.

ICU: Good news

I keep forgetting that with Dr. P as the attending, rounds start at 8:30 and not 8:00 this week. Still, that allowed me to take my time writing my notes and not have to rush through them (as I tend to do sometimes). The 20-year-old girl I saw yesterday is doing better; we didn't round on her this morning b/c she was in the angio lab (again). Both of my regular patients are doing okay, but today is my mediastinal abscess lady's 30th birthday. Who wants to spend their 30th birthday lying in a hospital bed, trached and sedated? It was a bit sad, and Tony didn't make things better by saying that he turned 29 on Friday and no one said a word. Dr. P said he heard a joke about women turning 30, but as usual I missed the punchline. *sigh* I'll say one thing for Dr. P, he's very organized. When we enter a patient's room, he expects to have the round reports in one hand, our progress note in the other, and the CXR up on the computer screen within a minute. Thank goodness I know Kindrick's user name and password for MagicWeb; it helps me bring up the images faster and helps us run more efficiently. At one point Dr. P said, "Come on, you don't want this to be like rounding with Dr. ML!" To this, we all agreed he had a point.

Noon conference was the most boring talk ever (I don't even remember what it's about); Garrett read articles online (on my PDA, blc I let him borrow it) while I doodled notes to a "Gavotte" from La Corda d'Oro on my styrofoam cup. Afterwards, Dr. C told me I'd written a good admission H&P on our heart-failure patient and suggested I look up her condition, "isolated noncompaction of the left ventricle." I found an image on UpToDate, and basically the LV chamber looked like it was full of trabeculae instead of being a nice smooth chamber. "That's what makes her prone to thrombi," said Dr. C. "The muscles there can't compact against the heart wall." Yikes. After that lesson, Kate let Garrett and me go home at around 1:15 pm, so we left.

I got a nice surprise in my email when I got home: two residency interview invites! Amazing, considering that our school still hasn't uploaded 1-2 of my letters to ERAS. At any rate I'm not complaining =)

ICU: When the young are ill

We changed upper level residents today: Aaron and Eddy left, and we gained third-year Kindrick and second years Tony and Sarah (whom I worked with during my IM rotation). When Kindrick saw me and Garrett, he asked if any of us were on call today. "I wasn't planning on it," I said, and he said, "Why, because you knew I'd be on call tonight?" Nope. So now our team is a ridiculously large size of eight (one chief, three second years, two interns, and two med students), and we only have nine patients. And guess who's seeing two patients? Me. I haven't had much interaction with Tony so far, but Sarah's been great as usual. This afternoon she let Garrett do an LP on a septic lady with enlarged ventricles. It took several sticks and pokes (at least 4-5), but then Sarah said, "I'm going to try one of these old holes." (the lady had a previous LP attempt yesterday that had failed to turn up any CSF). There was silence, then Garrett said, "Oh, oh! There it is!" Finally, we struck gold, and when we measured her CSF (it was clear), the opening pressure was 25 (normal <18). Damn. But we're testing her for everything from herpes zoster to West Nile virus, so hopefully we'll get a diagnosis.

We got a new attending today, Dr. P, a pulmonologist. Kindrick introduced himself as "one of the Indians," which fortunately Anita explained to me back in obgyn as meaning, "one of the chiefs." Dr. P didn't even listen to my entire presentation (unlike Dr. C, who lets us run down the entire list); he'd interrupt to ask why my comatose patient was on four different seizure medications, or why my Ludwig angina lady wasn't on vancomycin, among other things. *sigh* This one is hard to please. We finished rounding with about an hour to spare, so Garrett and I passed the time by talking about our musical backgrounds and where to get decent Chinese food in the DFW area. There was no lunch b/c there was a residents' meeting, so Garrett and I went out to Paul's Donuts, a restaurant that sells pretty good gyros (of all things; the name is pretty misleading).

Loan and Sarah asked Garrett and me if we were taking call this week and seemed disappointed in us when we said no. I know Garrett never wants to take call again b/c nothing ever happens when he's on call, so instead, I offered to do a short call today (no overnight). Sarah said that sounded fair enough. Garrett left after doing the LP, and when Kindrick said I could leave too, asked if anything was going on. "Not right now, and I don't want anything to happen right now," he said, and said something about the ICU "ju-ju" (whatever the hell that means) when one of the nurses ran into the hall and yelled, "Kindrick, NOW!" Kindrick muttered, "Oh shit" and we ran to another patient's room where he'd suddenly gone into asystole. When the nurse shook him, he immediately woke up and his heart started beating again. "What?" he asked, and we all breathed a sigh of relief. The nurse later told Dr. C that she'd made Kindrick wet his pants, and Kindrick said, "It was her fault!" and pointed to me. "You jinxed it by asking if anything was going on!" Haha.

We got one new admit in the afternoon. From the past progress notes and reports online, I read "dilated cardiomyopathy" and thought my patient was a middle-aged woman. Never did I expect that our patient was in fact a twenty-year-old girl. She'd been born with a bad heart and had a tendency to form blood clots (she'd had DVTs in the past and was on coumadin), and her chief complaint was a 3-day history of abd pain and nausea & vomiting. She also complained of numbness and swelling in her right leg, and her angiogram showed two clots, one in each femoral artery. Surgery fixed her up by dissolving her clots (go TPA) and putting a catheter of some sort in her femoral arteries to prevent future ones, and she was sent to the ICU. When we saw her, she was in very bad shape. She had a fever of about 100, she was diaphoretic, and despite an O2 sat of 100% her lips looked purple. On top of that she had no pedal pulses. Her EKG looked horrible. There were suggestions of infarcts and at one point her heart rate shot up to the 220s, while her BP kept dropping. Her prognosis looked so ominous that a crash cart was parked right outside her room, and family was brought back to see her. Then we learned that her mother had died five days ago from complications after surgery, and they had just buried her today. To make things worse, Dr. C was at his son's soccer game and nowhere nearby, and the cardiologist never once showed his face, and that pissed everyone off. "She's only 20!" said one nurse. As though we could forget. And to make matters worse, her BP dropped to 53/30.

I felt bad for Kindrick, getting swamped like this on his first night on call in the ICU as a chief. Later he got a page from some drug reps who'd brought dinner for the family residents, and he told me to grab some dinner. I let the drug reps into the lounge (they'd brought Jason's Deli) and joined interns Jared and Di for dinner before packing a plate with fruit and sandwiches for Kindrick. By the time I got back to the ICU, things were much better. Quadruple strength Levophed had boosted her BP to 100/70, she never needed to get intubated, and she was awake and smiling at her family. Thank goodness she had youth in her favor. By this time it was nearly 8:00 pm, and Kindrick told me to go home. He was grateful for my bringing him dinner and said, "I owe you one." Me: "No, you don't."

I hope that when I come back to work tomorrow morning, that girl will still be alive.

ICU: When patients deteriorate

For the last week or so since my first patient (pancreatitis and respiratory failure) went to an LTACH, I've been seeing the same two patients: a comatose woman in her 50s who suffered an anoxic brain injury (she's been here as long as I have), and a 29-year-old woman with a neck abscess that spread to her mediastinum. The 29-year-old also has MR, but to what extent we're not sure; she understands us perfectly and usually responds to commands when given. She's also usually very calm when I see her, but today was not the case. CT showed that her mediastinal abscesses were dangerously close to her heart (despite a thoracotomy to debride the abscess), so when she began having vagal episodes two days ago (her HR would plummet to the 30s if she didn't breathe), we suspected that the infection had touched her vagus nerve. This morning, she was clearly agitated: trying to sit up in bed, pulling at her trach, and trying to pull her gown off (which was a first). I asked her if she was hot, and she said yes, but she also said yes when I asked where she was hurting (everywhere). And when she's agitated, she holds her breath, and her HR drops down to the 30s for a few seconds until she breathes again. The nurse gave her Haldol with no improvement. When my team went to her room to round on her, she immediately started tugging at her trach and as expected, her HR dropped down. Dr. C held one arm down while Kate and Loan held the other down; Dr. C told us to order wrist restraints for her. I checked back on her later to find that she had successfully pulled out her trach (but the nurses were able to get it in), and her gown was pooled around her stomach revealing her breasts. I asked the nurse if we should cover her up, but the nurse said that even with wrist restraints, she managed to pull the gown down. We even turned the fan on, but she still felt hot so...

My other patient seems to truly be in a vegetative state. The first two weeks she had no improvement at all, but lately she's been blinking and opening her eyes spontaneously, though she still won't respond to voices. Not even Dr. C's voice from hell, and Heather joked that she should do a research project to see which of Dr. C's voices patients usually respond to. There was a group of respiratory therapy students in the room when I went to see her, and the professor asked me to remove the sutures from her trach so they could put a foam pad in there to prevent skin breakdown. I wasn't sure why they needed me to do it (I was just a student after all), but after getting permission from Heather I went ahead and removed the sutures for them.

Today was a short day. Aaron and Garrett were post-call, Eddy had the day off, and Kate had to take three fourth years who were interviewing for the FP program (Mike included; Loan and I saw him near the elevators and we waved to each other) out to lunch at Blue Mesa. After noon conference I couldn't find Heather or Loan anywhere, so I just left. I did call Andy (student affairs) to get his opinion on which letters I should submit in my ERAS, and I plan to submit my application tonight =) Finally!

ICU: Short Sunday

We only had 11 patients to see today; Kate didn't have any admissions last night, much to our surprise. On top of that, Dr. C rounded with us today so we were done before 11 a.m. Garrett was on call today, and he suggested that since we've each done four calls and haven't been getting very much out of them, we should probably forgo them this week (call is optional for us but one a week is highly recommended). I agree, but seeing how we get new upper levels this week they might want us on call with them, so we're just going to take things as they go. Especially with Kindrick on the team; I can see him making us take call with him just to learn.

My dad and I went to Bistro for lunch and stopped by the HK Supermarket, where I saw new flavors of Hi-Chew straight from Japan: Aloe Yogurt, Kiwi, and Mixed Fruit! =D YES!!! (loves aloe yogurt)

ICU: Overdoses and Codes

I took the day off on Thursday and finally finished the first draft of my personal statement, which I promptly sent off for review. I was on call on Friday. We finished rounding before noon again and were able to attend noon conference for lunch. Thank goodness for that; I'm running low on cafeteria dollars.

I was on call with Eddy again, and our first case of the afternoon was an apparent methadone overdose. We went to Kindrick to get the story, and Kindrick shared his suspicions that the woman had aspirated corn. This led to a few jokes exchanged about corn stalks growing out of her nose in a week. We went to examine her, and sure enough, there were dried bits of corn around her pillow where she'd vomited and her lungs sounded horrible. There were coarse crackles and rhonchi all over the place and we couldn't even hear her heart. Then we got another overdose (this one on Wellbutrin, and she ODed on her birthday, no less) so Eddy and I went to the ER wondering if today was overdose day. When Kindrick saw me, he motioned me to the front of the bed and said he was going to let me intubate. I was all gloved and ready until he took a look and saw that the larynx was too anterior so he ended up doing the intubation himself. "It was a hard one enough for me to do," he said, and I understood. He's actually going to be working in ICU next week when the upper levels switch out, so maybe I'll find a day to be on call with him. Either way, since he knows me already, I know he'll let me do more stuff. =) In the end, this OD patient never made it to the ICU; she woke up and was so responsive that she got extubated and went to the medicine team instead. When our first OD patient came upstairs, Garrett did the central line, and Dr. O was impressed b/c it went so smoothly (this is Garrett's 3rd line ever).

After that there was nothing to do for a while when suddenly we heard "Code Blue, Special Procedures, Radiology Dept." Dr. C, Eddy, and I went to Radiology to see what was going on and found the code team in the cath lab doing compressions on an extremely frail elderly woman. There was a horrific looking bruise along her femoral area that was oozing blood; it looked almost like a cath gone wrong. Dr. A, the vascular surgeon, was doing one-handed chest compressions, and when Eddy offered to let me take over the compressions, Dr. A said he had it taken care of. "I already broke three ribs doing compressions," he said, which sounded very painful to me. Another third-year resident intubated the patient while others checked for pulses (unsuccessful, b/c as I later found out, this lady was a huge vasculopath). Eventually they got her heart beating again and plans were made to take her up to ICU. Her daughter was waiting outside, and Dr. C talked to her, asking if her mother was DNR or full code. The daughter wasn't sure; her mother had said moments before to the medicine attending that she wanted "everything done" but also did not want to be a vegetable. Dr. C gave his honest opinion that it would be in the patient's best interests not to run another full code, as her body probably couldn't handle it (esp with three broken ribs). Still, until her daughter made her decision, the patient remained in full code. Eddy clearly disagreed, as did I, that the patient should be full code. She looked awful, all thin and pale the way she was, and we knew that she probably would not survive the night.

The patient was brought up to the ICU, where Dr. C said that the daughter has signed a DNR. Not twenty minutes later, the patient's heart began slowing again, but this time no one intervened, and before long she was in asystole (flat line). The daughter was summoned from the ICU and immediately started crying when she saw her mother; the chaplain had left to do other things and she had no one with her. Dr. C said he'd call for another chaplain and we all filed out of the room. Time of death: 5:50 pm (though official TOD was written as 6:10 pm b/c someone saw the reflection of the clock in the window and erroneously thought it was 6:10)

I got dinner and went to the commons and overheard two surgery interns running their list. Then the ortho intern said, "VS (the patient who had just died) is probably going to lose her leg." Hearing her name, I said, "VS just passed away." The interns were shocked; no one had told them the news. They'd assumed that she was still recovering in the cath lab. I explained to them all that happened, and they said that she'd gone to the cath lab b/c one of her legs was during pale from no circulation. It turned out her femoral artery had been completely occluded. "I was thinking we'd have to do an AKA (above-the-knee amputation) on her," said the ortho intern. "I guess she lost a lot more than that." The interns lamented over how nice VS had been, and the family intern said, "Well, I guess we can take her off our list." Later on Scott, one of the interns who had been taking care of VS on medicine, came over to the ICU to find out what happened. He was noticeably upset by her passing and brought up the fact that she had wanted "everything done." Dr. C explained the situation and said that having "everything done" was not in her best interests given her age and state of health, and after a while Scott thanked him and left.

At 9:00 pm Eddy went to get dinner so I went to the Commons to work on my ERAs and nap. At 11:00 pm I returned to the unit and found Eddy leaving one patient's room with a huge adrenaline surge. That patient (one of Kate's) was a psych patient who'd been weaned off the ventilator days before, but suddenly he became tachypnic and had to be reintubated, not an easy task since he gets agitated easily and put up a very good fight before getting sedated. "I won't be able to sleep for the rest of the night," said Eddy. We had another interesting patient, a lady with lupus who was losing her vision, so we called an ophthalmology resident from UTSW to get his input. He ended up driving all the way to the hospital b/c he had another consult here, and he examined our patient too. He even let me wear his fancy headset with a light and huge magnifying glass so I could see into her eyes, and from what I saw (and what he saw) she didn't have papilledema. So we don't know why she's going blind, but Dr. O suspects a posterior brain infarct. After midnight, Eddy and I did a central line on one of Garrett's patients; Eddy got the needle in while I put the wire and catheter in. Then Eddy sewed all the sutures except the last one (he was running low on thread), which I tied in. "Curse my huge man-fingers," he joked. Once again, I had to thank Dr. M, the OB fellow last year who taught Anita and me how to do one-handed ties. It's come in very handy.

I was allowed to go to bed at 1:30 a.m. and woke up at 6 to see my patients. The medicine team that took care of VS came to us and thanked Dr. O and our team for everything. Dr. O hadn't known about the code (he was off duty in the evening), so I filled the others in on what happened. The medicine attending said that VS had bled out from her femoral artery (which supports the cath-gone-wrong theory) and questioned the validity of sending a sickly 74-year-old vasculopath doomed to lose her leg to a cath lab in the first place. "Of course, this won't be blamed on the cath," she commented, and Dr. O agreed that they'll probably keep that quiet. Dr. O brought on a few laughs today when he complained about our patients being on bowel management protocol (basically hooked to a rectal tube that flushes feces out) b/c he doesn't know if they're having diarrhea or not. I can see why nurses like the "butt-management" tubes b/c they make cleanups a lot easier, but Dr. O hates them. "So if I come to the hospital with normal bowel movements, I'm just going to have a big ass tube placed in my rectum?" Guess so. After Eddy presented his patients, everyone assumed I was not post-call and began seeing other patients instead. Fortunately there were only two patients to see before mine, so I still got home before noon. *sigh* One more week before ICU ends...

ICU: The Shortest Day

This morning I came to work expecting to see two patients (my third patient, a gastric bleed, was supposed to have gone to the floors after getting transfused), but instead found my gastric bleed patient still in his room. He hadn't gotten his transfusion until last night b/c he had some sort of antibody in his blood that made it hard to narrow down his blood type, and by then there was no point in transferring him to the floor. Dr. O's orders: Get him out of here by this afternoon. I'd already written my transfer note so it was up to Eddy to call the medicine resident on call.

We finished rounding by 11:00 because Dr. O had to attend a meeting (thank goodness, otherwise rounds would have lasted forever), and I accompanied Loan to L&D so she could get an ultrasound to see how her baby was doing. The FP resident working the day shift, Tuere, brought the ultrasound machine to the lounge area, had Loan sit in the chief's chair, and proceeded to ultrasound Loan's abdomen. At first we thought we were looking at a boy b/c there was something between the legs, but looked too big to be a penis, so we got Melissa, who was my OB intern last year, and Dr. R (attending who loves to pimp) to take another look. Dr. R couldn't see any "boy parts" (the baby was 16 weeks old) and told Loan she was expecting a girl. =)

Garrett was on call today, and after noon conference he said I could probably go home since there was nothing going on at the moment, so I did. Hopefully he'll be able to do some procedures tonight.

ICU: Busy Call

Today (Monday) our team met Beth, a 4th year from UTSW who's doing a one-week rotation in ICU as part of her FP elective. She seems to have clicked with our team quite well so far. Dr. C rounded with us today, and we finished in time to attend noon conference. It's funny when we round on heavily sedated/comatose patients and Dr. C uses a deep booming voice (which some of us have dubbed "the voice from hell") to try to startle his patients into waking. "I wouldn't want to wake up to a voice like that," Eddy joked. In the afternoon there really wasn't too much going on. We had another patient who needed a cardioversion, and this time Garrett and Beth got to watch. I commented that someone should find Aaron and get him here b/c he'd been wanting to see a cardioversion, and Dr. C said, "Well, looks like he'll miss this one." As it turned out, the guy had to get shocked twice because the first one didn't take. I felt sorry for him b/c it really did look like it hurt; the first time he let out a yell and muttered, "WTF was that?!" For the second one, he asked that we give him lots of stuff to knock him out, and he was given Ativan and fentanyl. The second time he got shocked, he yelled again, but this time it worked and hopefully he was so doped up he won't remember anything. Aaron came in just as the second shock was administered, and he exclaimed, "I missed it again?!" He lamented that there were two cardioversions in two days and he missed them both, but the cardiology nurses assured him that he'll get to do some cardioversions when he does his cards rotation.

We learned that our favorite drunk patient had passed away, and Heather said that she and several people had held a moment of silence in the ER, "where we knew him best." Sometime later I was sent down to the ER to see a new admit: a 53-year-old woman possibly in DKA but with complete heart block and bradycardia (BP 65/40, HR 35-40). She was MR so it was hard to get anything out of her, as she kept saying her side hurt and that she was thirsty. The cardio attending (with Brown in tow) poked his head in briefly and then went on his way, apparently unconcerned. Eddy passed by the cardio team when he came to the ER and asked how the patient was, and the attending said she was fine. When Eddy saw the BP and HR readings he muttered, "That is not fine," and ran after the attending to see what he was thinking. As it turned out, Kindrick was working the day shift at ER, and with him, Brown, and me within feet of each other, I felt like I was back in obgyn. The cardio attending said that since we don't know anything about the woman's history (meds, pmh, etc) he didn't want to jump the gun and put in a pacemaker if it isn't necessary. The patient kept saying she wanted water, so I made a faux pas and gave her a few sips of water, which she threw up several minutes later. When the nurse asked why the patient was throwing up after being given Zofran, I fessed up, and she lightheartedly scolded me for doing so. Fortunately the mother soon came to talk to Eddy and me, and it turned out our patient was on clonidine, propanolol, and verapamil for chronic HTN. That's a lot of BP meds. We then decided that her symptoms were a combination of DKA and too many BP meds, put her on an unsulin drip, gave her some calcium gluconate and sent her to the ICU. When I saw her several hours later, she was calmer, more alert, and smiling. Looks like we fixed her up =)

I then drove to school to meet with the chairman. The meeting was brief; he just asked me a few questions about what I'm looking for in a residency, where I see myself in five years (primary care vs fellowship), and other things. I honestly don't know what he thought about me, but by mannerisms he was fairly reserved. Oh well, at least he said he'll write me a letter. When I drove back to work, I got some dinner and returned to the unit, where I found Aaron on the phone with Kindrick regarding a gastric bleed patient down in the ER. He then told me to go see the patient and told Kindrick, "I'm sending down my student." Aaron wasn't on call tonight; he was covering for Eddy until 7:30 pm b/c Eddy had to attend his son's soccer game.

When I went down to the ER around 7:00 pm, I found another dad (Kindrick) eager to get home and see his kids. "Hey kiddo," he said when he saw me, and when he asked where I was this month I said, "ICU." "No, not for long," he said, and it took me a few seconds to realize he had turned "ICU" into "I see you," which was, obviously, a joke. He told me a bit about my gastric bleed patient and said to look out for tachycardia or hypotension, and he said the patient badly needed a central line. He asked some nearby interns if they wanted to do a central line, but they hadn't done one before. "Why doesn't the third year stick around to teach us how to do one?" asked one intern, and he replied, "The third year wants to see his kids before they go to bed!" He seemed a bit hesitant about leaving things not taken care of, but the nurses and I told him to go home. My patient had just returned from an EGD (that revealed actively bleeding gastric varices secondary to alcoholism) and was sleeping soundly (there was a basin full of bloody emesis nearby that was pretty gross though), so at the moment he was stable. I couldn't get too much out of him, but as I watched his BP drop from 90/60 to 81/55 (yet his HR never went above 90), I wondered if I should worry. Dr. ML said no, that we would get a central line in him once he got to the unit and take care of him from there.

Back on the unit, Eddy went off to do a few lines on his own while I stuck close to Dr. ML. He let me attempt a paracentesis on a lady with a possible SBP (also a Jehovah's witness so she can't get blood products; her lab draws had to be done in pedi tubes), but we couldn't get any fluid. I then asked if I could do a central line on the gastric bleed patient, and Dr. ML asked which route I wanted to take. I said subclavian since that was most common (I thought), and Dr. ML said okay, but commented that he prefers the IJ route. The procedure went pretty well; after hitting the clavicle with the needle a few times, I got the vein in one stick. Dr. ML watched me almost the entire time; when all that was left were the sutures he said, "Nice work" and left. Umm, what? How could he just leave me there? What if I didn't know how to suture? At any rate, I don't know how good my sutures were and hope that my patient won't get an infection. It was hard to stick the Tegraderm on there b/c his wound kept bleeding, but fortunately the nurse, who could tell I was a newbie, helped me out. I also found out where to print procedure notes so that whenever Eddy does a procedure, I can modify it and print it out so all he needs to do is sign. That'll save a little bit of time. We didn't get a chance to rest until well after midnight (about 12:45 a.m), and Eddy said I could go to sleep if I wanted to. So I did, but was awakened at 2:30 by someone talking next door. Gee, thanks.

Our attending in the morning was Dr. O, and once again we had to adjust to a new attending and his ways. Dr. O, like Dr. ML, does teaching rounds, but he also wants a lot more detail about our patients than what we're used to. He asked us to calculate ideal body weights for all our patients, which means we need to know their heights (which we don't), so that we can write our own TPN orders (something I never remembered from surgery). Dang. With my patients, it wasn't enough that one was in a coma; he asked me the GCS score and asked how she responded to painful stimuli (which I hadn't been checking). And all this while I was post-call and brain-dead! If that wasn't enough, I couldn't finish seeing my patients until close to 12:30 pm b/c Heather had clinic in the afternoon and had to present her patients before mine. I suppose I could have been a real prat and insisted on seeing my patients before hers so I could go home early, but she's a resident so her needs come before a med student's. At least I was able to grab some lunch at noon conference before going home.

ICU: Thank goodness I'm not post-call...

Last night Aaron had seven new admits, and only got one hour of sleep. If I'd been on call with him, I undoubtedly would have suffered the same fate (though I didn't sleep much better; I only got about 4-5 hrs of sleep b/c I had trouble falling asleep). Needless to say we were all relieved when we found that we'd be rounding with Dr. C (who rounds at lightning speed) instead of Dr. ML. Even still, because we had 15 patients to see, we didn't get done until shortly before noon. My longterm patient finally went to an L-tach yesterday, so I no longer have any established patients (saw two patients for Garrett and Aaron today). I'll have to ask Aaron to for some of his patients tomorrow.

We had two problem patients today: one was a man from IPA with a bad case of A-fib, and another was a septic patient we've had for over a week (coincidentally, he was also in IPA before he coded and had to be brought up to ICU) who, according to Dr. ML, was finally succeeding in dying after trying for many days (more on that later). Aaron was all excited about seeing a possible cardioversion on our A-fib guy ("Mr. Red"), but was so busy making phone calls and other things that he missed it. Mr. Red was sedated, the pads placed on his chest, everyone clear, then BZZT! His eyes flew open and he gasped, but the shocks did the trick; his heart resumed a normal sinus rhythm. We thought that was the worst of it, but suddenly he developed very bad SOB, and even with the oxygen turned on full blast he was still only sating at 80% or worse b/c he kept coughing and gasping. At one point he coughed up some frothy red stuff, and the nurse, afraid that he would need to be intubated, called Dr. C over the intercom. Dr. C hurried over to see what was going on and suggested giving Mr. Red some Ativan to calm him down, then put in a Foley (which he'd originally refused) and some Lasix to treat what was most likely flash pulmonary edema secondary to pneumonia (he had infiltrates on CXR). The Ativan helped a lot, and with the Lasix and Foley he ended up making a lot of urine. Let's hope that'll help with his flash pulmonary edema; of all our patients, we got paged the most regarding his care.

Our other IPA patient was "actively dying," but I still have no idea what that means. His blood pressure held steady in the 70s-80s/50s, and he was completely dependent on the ventilator (his sats were about 70%), but I'd expected "active dying" to be a quick, noticeable decline, the way little AJ's heart rate dropped to zero in a matter of minutes back at Driscoll. I took a closer look at him and saw that there were tears in his eyes. That made me sad. =(

Loan and Heather were on call today, and I ended up hanging out with Loan. She told me that I should take call with her sometime, since she and Heather operate independently of each other. Sounds tempting, but I think I'll stick to working with Eddy for a while. Unless another fourth year comes along, then I may give up my spot (and Garrett will think I'm being too nice again). Speaking of fourth years, apparently Mafruha didn't make a favorable impression on some of the residents last week. Of course, it's hard to live up to Mike and Jay's standards (those two were on top of everything and Jay chatted with Dr. C when he was in the ICU during his medicine rotation). In addition to being on call tomorrow, I'm also meeting with the chairman of IM at our school to get a rec letter. Hopefully I'll make a favorable impression on him.