IM: Changing Residents in Midstream

This morning I got to the hospital by 6 a.m. to see all my patients before the EKG class at 7:30 a.m. The other two teams aside from Jacob and Phuong were there, and later Annie showed up b/c Andrew told her about the class. "Was this required?" she said, and I said I didn't know; I just followed Sherif's instructions to attend. I hope Annie doesn't think I tried to screw her over, because I'd asked her yesterday if she planned to come early to round on patients and she said no. Heck, if Sherif hadn't told me about the lecture, I wouldn't have gone, either. Still, I was pleased that I was able to see all 3 patients in 90 minutes, and everyone on the team was happy that our psych patient, who'd been "chilling" at the hospital for the last week or so b/c no other psych hospital in town would take him, finally got discharged yesterday.

It's the end of the month, and Keira, Sherif, and Dr. M are leaving the team. Keira's going to another team, so I'll probably see her around, but not sure about Sherif and Dr. M. I did meet our new 2nd year resident though (I forget his first name so I'll just call him Patel), and he is nothing like Sherif. First off, when he saw Annie and me making the patient list, he told us not to do it anymore, that he could do it himself, faster. No real complaints there, since making the list keeps us at the hospital later than other people, but then he said he didn't want us seeing more than 2 patients at one time. Considering how Sherif wanted us to see six by the end of our rotation (I was curious to see just how many I could handle), this is a bit of a letdown. *sigh* Now I can see why some people loved this hospital while others hated it; it's all about the team.

IM: The things we don't want to be

As usual, we rounded on patients before 9:00 a.m., and on the 6th floor I ran into Chris and we went to see our 29-year-old CHF patient together. He's in pretty bad shape; has an ejection fraction of 15-20% and nothing in his history except HTN and a recent viral illness that could point to a cause of his CHF. Chris showed me how to read his EKG, which showed right atrial enlargement (look for P waves that look like a "sine" wave) "See, you're learning something," said Chris, and I'd glad; cardio was never one of my strong points and I can't read abnormal EKGs to save my life. Andrew stopped by to say hello; he wondered why we arrived at 7:00 a.m. each morning while the rest of them arrive at 6:00 to round. It really depends on the attending; Dr. M likes to round at 9:00 while others round at 8:00.

One of the last patients we saw today was a man with metastatic liver cancer who came to the ER with chest pain, SOB, and a UTI. He was a "bounceback" who had originally been sent to hospice, yet somehow ended up back here. He was on a morphine drip when we went to see him, and we learned that he "shot up" on heroin 2 days ago. Dr. M proceeded to check the patient's back to check for costovertebral tenderness, except he didn't tap, he pounded. The strength he used to hit the patient's back was audibly harder than the strength we'd use for tapotement, and the patient almost screamed from the pain. "Stop...stop!" he gasped, and quickly explained that he had a spinal cord injury. "Oh, sorry," Dr. M said shortly, and left it at that. Annie looked as horrified as I felt, and I thought, That's it? You hit someone's back and cause them excruciating pain, then say, "Oh, sorry" and leave? That patient's back pain was probably secondary to liver mets and why he went out to "shoot up" on morphine in the first place! That was bad. Annie was furious by the way our patient was treated, and I didn't blame her. I mean, I know our residents told us that Dr. M has lousy bedside manner, but this was ridiculous. I know which program in Chicago he trained at, and I don't know what kind of training they have there, but I know one thing: I want to go to a residency program that'll teach me to be compassionate to my patients, not brush them off like dirt, even if they are druggies. I do not want to be like Dr. M, ever.

After lunch conference I asked Sherif what time we should see our patients by tomorrow. He said, "I'd like you to get done earlier, by 7:30, so you can go to lecture with the interns and learn how to read EKGs." I asked Annie if she was planning to go, and she said no. But after working for one call day with Sherif, I know that if he tells me to do something, I'd better do it. So...looks like I'll be rounding on my patients earlier tomorrow so I can go to lecture.

IM: First Patient Lost

This morning I got to the hospital as usual to round on patients, and when I looked up my 82-year-old A-fib patient, his records said that he was discharged yesterday. I knew that couldn't be right; he was in no condition to go anywhere. So I looked through the patient's notes, with the latest one reading, "Patient cleaned and taken to the morgue." Oh. That was how I found out my patient had passed away =( Going backwards in the notes, I read that around 2:40 pm yesterday, his HR shot up to 160-170 and wouldn't stabilize (I doubt his dyspnea and tachypnea helped), and his son, after being briefed on the seriousness of his father's condition, decided to sign a DNR. My patient was pronounced dead at 15:09. Did I know when I rounded on him that morning that he had only nine hours to live? I didn't, but I'd like to think that the small things I did for him (adjusting his oxygen mask, giving him some water even though he was NPO, wiping his face after he finished drinking) helped him in the end, even just a little. I remember he thanked me before I left the room. =(

This is the my first real patient to pass away. The trauma patients from the ER and the little boy, AJ, back at Driscoll didn't count because they were already near death and my role in their care had been minimal if anything. But this man, I saw him in the ER, and I saw him the following morning and had hoped he'd eventually get better. I think I have to start realizing that not every patient who comes to the hospital will be able to leave by their own accord. Jacob has already seen 3 codes and I've yet to see one. Annie had one code happen on Saturday/Sunday night but didn't know about it until afterwards. I think I'd like to participate in at least one code if it comes my way.

So with two of my three ER patients gone, I had to pick up two random patients, and when time came to present to Dr. M, I was less than stellar in my presentation. I told him I'd just gotten the patients this morning b/c I lost two, and he asked me if I was choosing my patients. I said, "No, one of them passed away yesterday" and he joked, "You didn't take good care of him?" No, but everyone had a good laugh over it. At lunchtime Jacob started talking in Chinese (he's learning), so when I answered back, Dr. M asked the difference between, "Ni hao" and "Ni hao ma." I said that with the latter, it's a question form that expects a response, and Chris (who's from Taiwan) said, "That makes sense." Our lecturer today was a neurologist who stressed that we should never tell a patient's family that a patient will not wake up if there is even a small part of the brain that is still alive. It made me think of the elderly lady I saw at JPS who had a midline brain herniation and had lost most of her reflexes. To me, she had no hope of a full recovery, and JB had told her son that she would not wake up, yet later she opened her eyes. Did that constitute waking up? I would say no, but a family member would most likely say otherwise.

IM: Sunday Post-Call

The hospital was a very lonely place at 5:00 a.m. It took me a while to even find an unlocked door (had to press the HELP button in the parking lot for advice) to get into the hospital, but I was able to see my patients before rounds. My N&V lady felt better, my rectal bleeding lady was still afraid to have a bowel movement for fear of "bleeding out" (even though her H&H was stable), and my A-fib guy was more lucid than yesterday. "I need some water," he said, and seeing a cup of water on the counter, I gave some to him. Then I left his room and saw a big "NPO" sign on the door that I apparently didn't notice when I went into his room. O.O Oh crap. I later reported my faux pas to Keira and she asked me if he'd choked on the water. I said no, and she said it's fine; apparently he's NPO to avoid potential aspiration. Our attending this morning was a lady who brought pigs-in-a-blanket and donuts for our breakfast, which we were all grateful for. Later Sherif asked me if I looked up the A-fib article yet. I said no, and he handed me a copy that he'd taken the liberty of printing. "You gave her a reading assignment? How mean!" said Annie, but Sherif said it was pertinent to my A-fib patient and that Dr. M loves that sort of thing. "And someone has to channel him when he's not here," he said. How true.

Annie and I each had three patients to present and I thought I did pretty well in my presentation (with occasional input from Keira; we all got a laugh over my rectal bleed patient b/c she kept saying her stomach was "griping" her); Chris later said I did a good job. *feels pleased* Chris had some back pain and Sherif said he could do some OMM on him, but never got around to it; Annie and I offered it again at the end of rounds and Chris asked if we were being serious (then turned us down). We did an orthostatic test on one lady (take her BP supine and then sitting), but it was nothing significant. I think I like weekend rounds b/c you don't have to stick around for lunch conference. But...I need to stop blogging and go read that article =P

IM: First Day Call

Ahh...how nice to sleep until almost 7:00 a.m. =) All my patients got discharged yesterday, so I rounded on Annie's patients before meeting the rest of the team at around 10:00 a.m. Keira let me present one patient to our attending (who was here for the weekend), but when I started rambling (since I'd just picked up the chart this morning) and not knowing what I was talking about, Keira quickly took over. *sigh* The attending didn't even see the patients, just took notes on them and left. "That's it?" I wondered. After rounds, I was free to myself from about 11:00 a.m. to 1:00 p.m., where I stayed in the library so that Sherif could reach me if a patient came (I forgot the cell phone again). I grabbed lunch at the cafeteria downstairs; amazing how much a $7.50 ticket can buy =)

The first patient I saw was a 79 yo lady with a two-day history of nausea and vomiting that's most likely GERD-related; we're keeping her for 24 hrs to see if it resolves. Keira let me write the admit order, which took a lot of thinking and confusion on my part, but I'm glad I got to do it b/c it got me thinking more about what to do for the patient. Sherif, too, asked me the differentials of nausea and vomiting associated with stomach pain, and I named several that we were able to rule out with the Chem-14 alone. My next patient was an 82-year-old man with altered mental status and a-fib. When I went to ask him what brought him to the hospital, he yelled, "I have no strength!" and either couldn't hear me or refused to answer my questions. Keira and I managed to get more answers from his son, but not much, since this man lives alone (son lives in SC) and had fared pretty well until recently, so no one knew what meds he was taking or what medical problems he had. We didn't know if his a-fib was new or old, what allergies he had, or what medications (if any) he took for HTN. *sigh* So he was a challenge for everyone. My last patient was a 74-year-0ld lady who has had bleeding from her rectum for 4 days; she knew this b/c there was blood on the toilet paper and in her underwear, but she never once looked in the toilet bowl to see how much blood there was. Then she'd say that she had diarrhea and increased frequency in bowl movements but when Keira asked her how many BMs she had, she replied, "One." Apparently she tries to "hold it in" b/c having to see bloody toilet paper freaked her out. She also had a long history of abdominal cramps in the morning after drinking coffee and eating sweet things for breakfast, cramps relieved by defecation, yet morning after morning she eats the same stuff despite the pain. Heck, even I get sick having coffee on an empty stomach (my Corpus roommates can attest to that), so yeah, she was kind of nuts too. Later, when Sherif was talking to her, her son came in to tell her that her grandson and his girlfriend/wife crashed into a telephone pole and weren't wearing seatbelts, and EMS had brought them to this exact same hospital. Needless to say she got upset and sent Sherif out of the room. Man...talk about awful. She was the last patient of the day and I got to go home at 7:30 pm, but...have to be back at the hospital at 5:00 pm to round on my pts. Argh...

IM: Not Proactive Enough

Yesterday Dr. M had told Annie to go to the pathology lab to "put a rush" on finding out the FNA results of one patient's neck mass. Annie had not gone b/c she thought it wasn't the place of a medical student to tell the pathologists which slides to look at, and this morning the FNA results came back positive for "colloid growth" that was most likely benign. When Dr. M asked Annie if she went to the lab to find out those results, and Annie said no, he asked why not. "I guess I'm not that ambitious," said Annie. That did not sound like a good response (certainly not something Dr. M wanted to hear), and after rounds Chris sat us down and told us that when Dr. M tells us to do something, we should do it. Annie responded that doing something that Dr. M told her to do for the sake of doing it felt fake, and that the pathologists would see right through her, whereas Chris was a real doctor and the pathologists would have listened to him. Chris argued that the pathologists like it when med students stop by and that they wouldn't have minded Annie asking about the FNA results. Annie said if it was a matter of life or death, she might have done things differently, but the neck mass had been present for ages so it was probably not a life-or-death thing.

Chris said that the key was to say something like, "Hi, I'm following up on a patient who got a FNA done today, and I want to see what the results are" without mentioning that you were there on the attending's orders. Knowing me, had I been in Annie's shoes, I probably would have blown my cover by saying something like, "Hi, I'm one of Dr. M's students, and I'm here to follow up with Mrs. C's FNA for him." Yup, I'm too honest for my own good. Annie and I discussed our fears about the residency application process with Chris and Keira (i.e. not matching), and our interns said we should be fine. Easy for them to say; we have no idea how competitive their scores were, so maybe the match was a piece of cake for them.

The rude general surgery intern struck again by leaving a progress note that offended Dr. M. The final comment: "Medicine consult appreciated." Dr. M got mad and said, "Is he being sarcastic?" before slamming the binder shut. Chris and Keira thought he was reading too much into it, but since Annie and I have seen that intern (whom I'm tempted to nickname "that a**hole") at work we kept our opinions to ourselves. *sigh* At any rate, I'm on day call tomorrow, but no complaints there. I did plenty of 12-hr day shifts in ob-gyn so I'm used to it. But night shift...that's something I can't get used to b/c I value my sleep. Andrew positively looked like a zombie this morning b/c he got no sleep at all (his team "capped" last night), but it turns out that was his doing and not b/c his residents worked him all night. Elizabeth said that his residents had joked about deducting points from Andrew b/c he didn't go to sleep when they told him to. Heck, if residents tell me to go to bed, I'll gladly go to bed.

IM: Doing OMM?

This morning I found that we only had seven patients left on our service, so instead of our usual three, Annie and I only saw two patients each today. Dr. M wondered why we didn't see all seven and asked Sherif how many patients we were supposed to see. Sherif's response: "Start with 3 or 4, have 5 to 6 by the end of the month." Good to know. Sometime before rounding, Annie and I were in the library when she said she felt like her sacrum was out of whack. The conference room was empty, so I treated her shear with a leg tug and fixed an anteriorly-rotated innominate before it was time to start rounds. When we left the room, an anesthesiology intern asked us what we were doing, "Massages?" Annie said, "She was fixing my sacrum" and I said it was manipulative medicine, which we learn at osteopathic medical schools. I don't think he really knew what to think of it, but one of the other anesthesiology interns here went to our school so I figure if he really wanted to know what OMM was, he could ask his classmate. Annie and I tried explaining what we were doing to Chris but he said that sort of anatomy was beyond him.

We got lunch at the cafeteria today b/c there was no lunch conference, and while their food selection is nothing like Plaza, it still beats JPS. Then Elizabeth, Annie, and I had lunch in the library, where Elizabeth and Annie talked about specialties. Annie's still undecided, so Elizabeth was telling her about pathology and what it had to offer. My team got to go to the pathology lab today to see a patient's blood smear after seeing "1+ schistocytes" on his lab report (in reality he only had one or two negligible schistocytes, hardly 1+), and that got Annie thinking about pathology. Sherif had told us that he wanted to be a pathologist until he did a rotation at UTSW and learned that you spend 3 months doing nothing but autopsies during the training. "I couldn't even handle it for a few days," he said, giving gory details about men who blew a hole in their heads or cutting into bloated, decomposing bodies found 3 weeks postmortem to find a swarm of maggots in the body. "The smell was so bad it went all the way up to the sixth floor," he said. As much as I love CSI, maggots and rotting flesh are enough to keep me away from pathology. Elizabeth has a lot of passion about pathology, so I know she'll be great at it, but it makes me wonder when I will find something that I can be passionate about, too, in the same way.

Later Sherif sat down with Annie and me and asked if we were having any problems with Dr. M, the interns, or anything about the rotation in general. "Dr. M's nicer to you than he was to the guys (preceding us), and he hasn't said anything bad," he said. Sherif also said that Dr. M loves gunners (which Annie and I are not) and wants us to be interested, engaging students, so I'll have to up my "engage-o-meter" somewhat =P Speaking of things that bother us, there's this one general surgery intern I keep running into that some of us don't like too much. He thinks he's all that even though he's only an intern and talks to us like we're lowlifes, not even letting me use the phone to page my intern b/c his call was more important. *sigh* Someone made an excuse for him saying he was trained at UTSW and has that sort of ego, but Chris trained there too and he's pretty down to earth. Whatever...

IM: A Typical Day?

This morning we were told to finish seeing our patients by 9:00 a.m., so Annie and I arrived shortly before 7:00 a.m. to see our 3 patients. It took me way longer than I thought and I just barely finished seeing my last patient (whom, as it turned out, I didn't have to see b/c she was transferred to the care of ob-gyn) at 9:00 a.m. It was an interesting case; a 16-year-old came to the hospital with an acute abdomen for no clear-cut reason (CT just showed diffuse thickening of the bowels, which point to IBS), so surgeons did an exp lap on her and found out she had an infection in/on her uterus that had spread to her bowels and appendix. Possibly a bad case of PID? At any rate, ob-gyn was taking care of her now, and I had to remove my progress note from her file since we wouldn't be seeing her again.

Based on what kind of patients we saw, Dr. M gave us assignments to look up tonight (i.e. parotid gland masses, Kussmaul breathing in constrictive pericarditis, etc) and asked me to tell him about jaundice. I started out good but grew rather disorganized, so I have to work on my presentation skills b/c I think the knowledge is there (I read the same jaundice article at least three times). Jacob and Phuong were on call yesterday and were kept pretty busy, but Jacob said it was still much better than surgery call. I agree completely; q5 beats q4 anyday. And I got my CD back =)

IM: First Night Call

After meeting up with friends (you know who you are) for dinner at Panera Bread, I drove back to the hospital for my first night call. There I met up with the night resident, Amie, and she told me that since it's my first call, she doesn't plan on working me too hard. "You have all of residency to do that," she said, and told me to go study until a new patient comes in. Sounded good to me, so I gave Keira (intern) my phone number and went upstairs to lie down/do questions. About 90 min later Amie knocked on my door (apparently the phone call didn't go through) to tell me I had a patient. This lady came to the ER b/c she'd had myoclonic seizures all day, then had a grand mal seizure as soon as she came to the ED. Oddly enough (or maybe not), she had a similar seizure last week in which several of her teeth got knocked out when she fell to the ground. This time she bit her tongue so hard it looked bruised and swollen on one side, and she complained of post-ictal dizziness. I wrote a detailed H&P on her and thought I did a pretty good job (Amie thought I did well, too), but it turned out my team would not be admitting her. She was a "bounceback" patient, meaning that she'd been seen in the ER in this same month for the same reason, and because of that, the team who took care of her last week will care for her now. Fortunately there was another patient available for me to see.

This second patient came in for a HA and knee pain secondary to a fall but when she got to the ED she was found to have a BP of 240/140. Yikes! Further questioning revealed that she'd been out of her HTN medications for 3 weeks, and that she had a history of being noncompliant with meds. She was given nifedipine in the ER and it began dropping her BP down to 170/90, at which point I retired to get some sleep before rounds at 6:30 a.m. The time: 1:40 a.m. Despite how "comfy" the room appeared, it was still too cold for my taste and I had trouble sleeping. Total hours of sleep, I'd estimate I got about 2-3 hrs. Then there was no time to get breakfast before rounds at 6:30, so I ate some cake from home and hurried down to the ER.

The attending, Dr. M, was nice, but had a somewhat brusque bedside manner. There were many times where he just left the patient's room without saying goodbye and it was up to Sherif (the third year) to say, "Let us know if you need anything" before leaving the room. He also likes to pimp, and the interns already warned us that if we don't know the answers, then he asks the interns, so it's best if we know the answers beforehand =P Today he asked us causes of pulsus paradoxus, and tomorrow I'm to tell him everything possible about jaundice. Oh boy...that's going to be a broad topic. We had a total of 13 patients today. It took about 2.5 hrs to round on all of them. One patient had attempted suicide and mentioned that he once stayed at TSH. "Where's Terrell?" Dr. M asked, and I was able to tell him where it was (sort of). On another floor, the chief medicine resident saw me, Annie, and Chris standing together and joked, "Man, what's with all the Asians here? It's like we're breeding like crazy" (he's Asian himself) He also offered Annie a free lunch coupon but not me or Chris; I had to wonder if it's b/c she's the only one on our team who was dressed up and not in scrubs (and therefore more presentable).

When we got back to the library, Annie and I were given the task of typing out our checkout list to give to Jacob's team (they're on call today). Using a sample list that Sherif left us and our own notes, we were able to compile a pretty good list with pertinent information; Sherif gave us an A for effort and commented that our predecessors (who'll remain nameless) had gotten an F on their first list because they'd had no clue what to do. I was pretty exhausted when I left the hospital at 12:30 but halfway home I realized I'd left a brand new CD that I got last weekend in the call room =( Fortunately Jacob found it and I'm hoping he'll store it in the cabinet for safekeeping until I can pick it up tomorrow.

Later I checked my email and was saddened to learn that Dr. Bailey from OB had passed away. He was the attending on call for at least two or three day shifts during my OB rotation, and he was infamous for not allowing the residents to use the Bovie during C-sections (though Dr. C has been known to bring out the Bovie once his back was turned). I was just telling the others about him yesterday at dinner, and now this happens =( Still, he'll be missed by many for sure.

Goodbye Family Medicine, Hello Internal Medicine

The shelf exam on Friday wasn't too bad; some of Dr. RR's mini pimp-sessions really came in handy (otherwise I wouldn't have looked up stuff like cauda equina syndrome, which appeared on the exam). I had a pretty good weekend, too; my sister and brother-in-law came to visit and they brought their Wii, so we had fun playing Super Smash Bros, Mario Party, and Bleach: Shattered Blade (me). My arms are still sore from waving the Wii around like a sword, but it was worth it.

My first month of IM was at Dallas, so seven other classmates and I drove over there this morning. I'm paired with Annie on the Blue Team. The residents there are Chris (anesthesiology intern), Keira (IM intern), and Sharif (IM 3rd year), and I've yet to meet the attending. As luck would have it, my team is on call today, but I worked it out with Annie so that she takes day call today while I take night call this evening. *sigh* Fortunately MDMC is only 15-20 min drive from my house, no farther than the other hospitals, so I can drive home easily and don't have to find someone in Dallas to stay with until the next time I work. As nice as the call rooms might appear, I have no desire to spend more time in them than necessary. More on my call night tomorrow.