Radiology: PET scans, bone scans, and elections

Today I spent the morning in the PET scan area with Anthony, one of the techs. We had three patients total, and I saw each one of them through the whole process. For those not in the know, PET scans are used to look for tumors, and they're done by injecting radioactive glucose (the isotope is fluoride, pretty harmless and doesn't cause any allergic rxns) into a patient, waiting 45 minutes, and then scanning them for about 18 minutes. The patient is fasting, so any metabolically active structures will quickly uptake the glucose. Brain, kidneys, liver, heart, and bladder aside, any other focal lesion that lights up is suspicious for tumors. Because the dye is made of glucose, patients also require a finger-stick to check glucose levels before the procedure. If the blood glucose is greater than 200, then the patient has to reschedule. Fortunately none of our patients were diabetics. The first lady is actually from Iowa, but flies down to TX once a year to get scanned. She said her original oncologist back home didn't care for her suffering due to chemo, so she was referred to one of the breast cancer oncologists here (the one who reads all the scans). He gave her a fanny pack that administered chemo around the clock so that her side effects were less severe. Another lady had a huge pulmonary nodule, but it didn't light up as much as a tumor is expected to light up, so it may just be a fatty tumor instead of cancer. For the last patient, Anthony let me push all the buttons to move the scanning table and adjust the settings for the machine, which was pretty cool =)

In the afternoon I went to Nuclear Medicine and met Mercedes, the tech, who was doing bone scans. The way it works is that she brings patients in two hours prior to their scan to inject them with technitium, which works the best 2+ hrs after the injection, and in the meantime they either wait in the waiting room or get other procedures done (MRI, CT, etc). There was a period of time where we had nothing to do for an hr, so Mercedes and I just chatted about random things like the election, kids nowadays, cell phones, and bad patients (always a favorite topic). She'll be doing a MUGA scan tomorrow morning which I probably won't get to see (I'll be working in the ultrasound and mammogram areas), but I'll stop by and see the results for sure.

And of course, today was Election Day. I personally did not care for either of the candidates, and it was no surprise that Obama won. Time will tell whether the country made the right decision.

Radiology: CT and MRI

Today I rotated through two departments: CT in the morning and MRI in the afternoon. The two CT techs, Claudia and Tina, were very nice; Tina and I spent a great deal of time talking about our pets (and animals in general) while Claudia talked about her daughter who wants to be a pediatrician. I remember wanting to be a pediatrician as a pre-med, but medical school changed all that =) It was cool getting to see how the CT worked and how patients prepare for their scans (i.e. drinking lemonade-flavored barium to visualize the stomach and later getting an iodine contrast injection after their non-contrast CT is done. Patients who have had allergic reactions to iodine in the past are put on a "13 hr prep protocol" in which they start taking measured doses of Benadryl and methyprednisolone thirteen hours before their scheduled scan. It works pretty well in most people, but some people require as much as a 3-day prep before the doctors decide to go without contrast from then on. Most patients get three scans: one "scout" scan where the entire chest/abdomen/pelvis (whatever you want to visualize) is scanned, one non-contrast scan, and one contrast scan (the latter two with cross sections). Sometimes, if there are suspicious cyst-like lesions in the liver or kidney, there is a "delayed" scan done to see if it takes up the contrast dye (cysts take up dye). Most of the CT scans I saw today were benign, which is good for the patients.

There was only one patient scheduled for MRI in the afternoon (but she needed two separate scans), so I went with Marcy, the MRI tech, to the waiting room to take the patient to the MRI. As it turns out, the MRI machine isn't even in the building; it's housed in one of those one-room temporary structures outside the building. The patient was a woman with stage II breast cancer (recently diagnosed) who'd undergone a bilateral mastectomy with metastasis to two nodes. She also had a history of falling, so in addition to a head/neck MRI she was also getting a lumbar MRI to assess for nerve compression. The MRI was a very loud machine with a tiny tunnel. The patient's head was covered with a cage-live device at one point; if that doesn't make one claustrophobic I don't know what does. Fortunately she was given Ativan before the procedure and handled it nicely. As we waited for the scans, Marcy told me about breast MRIs and how they can be used to detect breast masses that haven't been spotted yet. She said that just because only one breast has noticeable cancer doesn't mean the other one is cancer-free, and showed me several breast MRIs to make her point. That definitely makes me worried, since I don't think breast MRIs are the norm in cancer detection just yet and I'm sure there's many women out there who could benefit from it (but don't get them done).

After the MRI, Marcy took the patient around to all the other departments so she could see how small their tunnels were (CT, DEXA, PET scan) in case she got claustrophobic again. I sat in on the end of a PET scan before going back to CT, where Claudia proceeded to show me some of the more interesting scans they've had like an intussuseption, bone mets in the sternum (looks like a knob sticking out of the chest), and one where the peritoneal organs were totally riddled with mets. =( Cancer is nasty business.

Radiology: Happy Halloween!

Dr. G was out of town today, so I spent the day working with Dr. J instead. I think I learned a lot more today from Dr. J than I have with Dr. G b/c he would ask me questions while examining the images. He'd ask me if I talked about different MRI resolutions, or what the density values of bone, fat, and air were, and if I didn't know, we'd talk about it. It was also Halloween today, so a few people came to work dressed up. One X-ray tech had her birthday today so at lunch there was free food and an ice cream cake (needless to say I overate and gained back all the pounds I've lost since joining a gym). It was also the last day of early voting (sadly I didn't take advantage of early voting when I was doing my geriatrics rotation), so when I went to the nearby recreation center there was a 30 minute line (and I saw my parents about 5 min away from the polls). So yes...I voted. We'll see if it's effective.

Radiology: A Diwali lunch

This afternoon Drs. G and J (the radiologists) ordered Indian food for the department to eat for lunch as a way of bringing Diwali to the workplace. The restaurant they ordered from was Star India in Arlington, and it was pretty good. Not too spicy =) Oncologists were invited too, but only 2-3 showed up. Thank goodness there was enough food for everyone. Dr. G won't be coming to work tomorrow so I'll be with Dr. J. I haven't worked with Dr. J before; hopefully he'll be nice.

Radiology: *zzz*

Another typical day at the radiology department (though it was interrupted by a fire drill). Dr. G and I spoke to Lauri, the med student coordinator; it looks like I'll be doing solely radiology only this week, and then next week I'll start spending about 2-3 days in different departments like CT, MRI, mammography, etc., just so I understand what's going on. Sounded good to me. Since I've been studying CT cross-sections of the thorax (haven't got to the abdomen yet), lots of images make more sense to me now. At one full body scan Dr. G asked me if I noticed anything unusual (i.e. see any "hot spots" that indicate cancer?) There was one solid region in the pelvis that lit up big-time, so I tried to figure out what it was. From the back it looked like he only had one kidney, but from the front...ohhhhhh, it was a horseshoe kidney! It was my first time seeing one of these so I was excited to recognize it for what it was. Dr. G said that since we see mostly cancer here and I'm interested in IM, she'll try to show me some CXRs and CTs of more common medicine disorders like cholelithiasis, pneumonia, and more. That'll be helpful =)

Radiology: Busy Diwali

This morning when I arrived at work I looked into the car next to mine and saw a cocker spaniel (white with brown ears) sitting in the driver's seat looking sad and forlorn. I waved at it, and it just looked at me. I didn't know how long it had been sitting in the car and wondered if its owner was inside getting a mammogram or CT done. The weather was pretty cold this morning (40's), and while I was sure the dog wouldn't freeze to death (with its fur and all), I didn't want to just leave it there either. I told Dr. G about the dog as soon as I walked into her office, and after asking me where my car was parked, she told security to check on the dog to see if we can find its owner. *sigh* Why on earth would you bring your dog with you to a doctor's appointment and leave it in the car? Surely it can stay at home unattended somewhere.

Today was Diwali, the Indian "Festival of Lights," (Happy Diwali!) and with Dr. J out of town to celebrate with his family, Dr. G was the lone radiologist today. We spent the morning going over CTs and MRIs as usual, and every once in a while Nancy, the mammogram tech, would call Dr. G to tell her to check on a mammogram or two and assign BIRADs to them. After lunch I was given some time alone to read a book on interpreting CTs (and have gotten halfway down the thoracic column so far) before sitting in on Dr. G's PET scan readings. Unfortunately we didn't get through all the scans until 5:00 pm because of multiple distractions. There were times when previous PET or CT scan reports were missing and had to be called in to AMH to get faxed over. Other times Dr. D (a well-known breast cancer expert in this area) would pop his head into the darkroom and ask Dr. G to bring up his patients' images so he can see them for himself (he, as well as another breast cancer specialist who recently retired, prided himself on taking the time to see the images and letting Dr. G explain what was going on). Dr. G, however, saw this as a distraction because whenever Dr. D came in (I saw him 3-4 times today), she had to drop whatever she was doing to pull up his patient's files, and then play catch-up on the files she'd been studying prior to his arrival. "This is supposed to be my Diwali!" she lamented (fortunately she gets a three-day weekend this week). And by 5:45 pm, we still weren't able to go through all the CTs on her desk, so she called it quits. "This is private practice, I can set my own schedule," she said. "And whatever I can't finish today, I finish tomorrow." Sounded good to me.

And this is why I can never do radiology. I don't want to sit on my butt all day in a darkroom looking at images and talking only to other doctors, nurses, and techs. I like being around people, talking to patients, walking around. =)

Radiology: Day One

This morning when I arrived at work I looked into the car next to mine and saw a cocker spaniel (white with brown ears) sitting in the driver's seat looking sad and forlorn. I waved at it, and it just looked at me. I didn't know how long it had been sitting in the car and wondered if its owner was inside getting a mammogram or CT done. The weather was pretty cold this morning (40's), and while I was sure the dog wouldn't freeze to death (with its fur and all), I didn't want to just leave it there either. I told Dr. G about the dog as soon as I walked into her office, and after asking me where my car was parked, she told security to check on the dog to see if we can find its owner. *sigh* Why on earth would you bring your dog with you to a doctor's appointment and leave it in the car? Surely it can stay at home unattended somewhere.

Today was my first day of radiology at the local cancer center in town. I first had to wait about 15 minutes for the nurse/program coordinator to meet me and take me to the back room to introduce me to my preceptor, Dr. G. Dr. G seems nice enough, but she soon made me feel like an idiot by asking me if certain CT images looked normal. When I admitted that I didn't really know what "normal" looked like she suggested that I read a book on MRI and CT cross-sections because I "have to know normal anatomy" in order to really do well in radiology. *sigh* Anatomy was one of my worst subjects in 1st year med school; this is not going to be easy.

After one day, I know for sure that despite the cushy hours and high pay, I would never want to do radiology for a living. Dr. G spent the morning reviewing CTs, MRIs, and mammograms and doing dictations after each image study, and in the afternoon it was the exact same thing except we were looking at PET scans for signs of metastasis and tumor. The darkness of the rooms did nothing to help me stay awake, and there were many times when I'd nearly doze off and be confused whenever Dr. G asked me a question. It didn't help that my mind started playing tricks on me, and on the cross-section CT scans I'd see shapes of dogs, ducks, and even faces (don't laugh). Especially on the PET scans; one scan had three dark spots against a white background that made me think I was looking at a ghost (Halloween around the corner, anyone?) The PET scans were pretty cool to look at because they light up at areas of high metabolism. So on every PET scan, the brain, the heart, the liver, the kidneys, and the bladder all light up to some extent; it's more important to find small focal areas in places that should not be lighting up.

There are two radiologists at the center, Dr. G and Dr. J, and when I'm not with one I'll be with the other. There's no set schedule for where I have to be each day; the radiologists want me to spend different days in different departments (i.e. mammography, PET scan, CT scan) while I'm here in order to see how images are obtained, but apparently I get to choose the days. After having each day planned for me for geriatrics, this takes some getting used to. I'll also probably have to make up a day since I plan to take 3 days off for interviews during this rotation, but seeing how I only live 5 minutes from the center (and have December off) I don't expect any problems. Because Diwali is this week, Dr. J has tomorrow off, and he told Dr. G that there will be a lot of "Mary's" tomorrow. At first we thought he said "merry" but he said, "Merry for me, Marys for you" since we have about 6 patients named Mary tomorrow. Good to know =P

Geriatrics: Exam and Exit Interviews

This morning we had our geriatrics exam, which wasn't too bad and hopefully I got at least a B on it. There were several questions from slides I had not reviewed, and afterwards people complained that they spent too much time studying the slides than necessary. I have no regrets; glancing through the slides probably helped me on 3-4 questions, which can make the difference between pass and fail. Afterwards, we went to the GAP clinic for exit interviews. First was a group interview with Dr. JH in which she asked for feedback on the programs and what we should do to make it better. Anita had a lot to say about how much she disliked the EMR system (electronic medical records) b/c her attending made her and Lora scribe for her while she saw the patients. Later, when my turn came to express my thoughts, I said that I was never taught signs of active dying that I could use to see in my hospice patients (though we got a brief lesson on that last year in family medicine). I then came to the defense of EMR by saying that I was able to enter in all my data during the patient visit so that afterwards all Dr. JK had to do was sign off on my note. After hearing all the complaints of doing nothing but scribing and how some of my classmates got bounced around from one attending to the other, I'm extremely grateful that I spent the majority of my rotation working with just one attending (Dr. JK), and that Dr. JK allowed Corey, Justin, and me to see patients alone rather than with her.

Next were individual interviews. Dr. JH saw 5 students and they popped in and out of her office really quickly. By the time the last of those classmates left, there were still 4 of us waiting to see Dr. JK. Finally it was just Justin and me waiting for Sara to finish her exit interview. Sara was in the office for a long time. My interview went well; Dr. JK asked me what grade I thought I should get for my rotation, and I said "Exceeding expectations" (89-94) b/c I felt I worked hard and was able to connect with my patients (and I mastered EMR to some extent). To my relief, Dr. JK told me that all the attendings I worked with gave me an E (in OWL terms, hehe), and she agreed with them. Nice way to end the rotation =) To treat myself afterwards, I stopped by the Cheesecake Factory and took home a slice of pumpkin cheesecake. Who needs EtOH when cheesecake tastes so much better? =)

Geriatrics: Last Day!

This morning was the last day of hospice (and geriatrics). Justin, Corey, and I went to JLWest, where Dr. M got charts for two new patients and said I got to take my pic. Upon hearing one of the nurses saying that one patient was leaking sputum through his trach, I decided to see the non-spitting patient, who turned out to be a man my parents' age with metastatic renal cell carcinoma. He was not in good shape when I saw him; he was unresponsive, tachycardic, and tachypneic. His initial resp rate was recorded as 50 breaths per minute, VERY rapid. When Dr. M went to see him, he was surprised by how much the patient had deteriorated from 4 weeks ago, when he was in the hospital alert and complaining of uncontrollable pain. There were also little notes in his chart saying that his mother was the MPOA (medical power of attorney) and that his son and his girlfriend have been living off his disability checks. Very dysfunctional family, apparently. Justin's cardiac patient whom we saw at Harris on Monday was actively dying; her radial pulses were nonpalpable, her feet were cold and slightly mottled, and the pinna of her ears were relaxed. When the radial pulses are absent, death usually occurs in the next eight hours. We all felt bad for the husband, who had hoped that she'd live to their anniversary, but he was very accepting of what was happening and planned to call his children to come over. Our other patient from Tuesday is still alive, but her family is concerned about whether or not she will die soon b/c they're missing work days to be with her to the end. Dr. M's advice was to play it day by day. My own patient from Tuesday, a man recovering from stroke and a partial craniotomy; seems to be doing very well; I don't think he should be on hospice yet. If anything, he should be in a skilled nursing facility, but Dr. M said you can't be in skilled nursing and hospice at the same time. "Of course, he could always leave hospice to go to skilled nursing," he said, then come back to hospice when he really feels the end is near. After a lecture on pain meds, Dr. M let us go for the rest of the day. AWESOMENESS. Still, instead of studying, I took a nearly 2 hr nap. *sigh* At this rate I just want to pass.

Geriatrics: Presentations and more

We had group presentations today over articles we were assigned to read. Justin and I had to talk about using non-pharmacologic treatments in dementia patients, which was pretty straightforward. Grand Rounds covered pediatric CNS tumors (pretty interesting), and then we drove to Harris. Justin arrived before me and went with two palliative care physicians from Universal Hospice to see some patients while Corey and I went to see the rest with Dr. M. We had one new hospice consult, and then we went to different floors where Corey and I each split up to see a patient before reconvening (usually Dr. M saw Corey's patient first and then went to find me). One patient was a lady with a history of psych issues and an open wound in her left ankle (she requested that we give her more than 10 Dilaudid pills since that's what JPS gave her once and it wasn't even close to enough); she was to be discharged as soon as she found SNF placement so Dr. M didn't go see her. The next patient I saw was the lady I wrote a consult note for on Monday; her pain was slightly better but we decided to put her on a Fentanyl patch in the meantime. Corey and I got out at 3:30 pm; Justin's car was still in the parking lot when I left. Looks like we got lucky.