IM: Last Day with the Current Team

As usual I rounded on my patients in the morning. I talked to the IDA nurse about Mr. Roboto; he's still catatonic but can now sit up, respond to commands, and say, "I don't want to talk to you" in Spanish. We did hear him say "Andale!" a few times to no one in particular, but we think he could be talking to his schizophrenic voices. When time came to see our "mean" trauma patient, the first thing Jordan asked was, "Is he still naked?" Ryan said yes, and Jordan groaned. Even worse when Ryan said the guy's parents were in the room and apparently the mother is as messed up as she son, trying to draw attention to herself by stating what medical problems she had. Fortunately with his parents there, the guy's groin was covered with a large blanket.

Sarah, our new FP intern, was on call for peds today (catching babies), but when there was downtime she rounded with us. We soon saw she'd be an important asset to the team based on her fluency in Spanish alone; she'd spent a year in Venezuela doing mission work so from what I could tell, she spoke Spanish without an American accent. At the end of the day, I was a bit sad to see my old team go, but look forward to meeting the new team tomorrow.

IM: Crazy Call Night

Yesterday afternoon we had a GI lecture in which our professor gave us a scenario of a Vietnamese man with fatigue and asked us to work him up. Since I recently had a Vietnamese patient with Hep B induced liver failure at Methodist, I knew a good portion of which questions we want to ask (i.e. how long he's been in the US). When our prof asked us what specialty I wanted to go into, I was the only one who said IM (the others either played the I-don't-know card or said something else).

When Angela and I arrived at 1:00, we saw Jordan and his wife (an FP intern) playing with their sixteen-month-old daughter, who had a VCUG earlier that day and needed lots of comfort. Then our first patient came in around 2:00 so Angela went to see him/her, and I hung out in the lounge until about 3:30. My first case was certainly very interesting; a 19-year-old guy that Jordan dubbed "Mr. Roboto" was brought in with catatonia, a rigid body, and a CPK level of about 18,000 (VERY high). He was a schizophrenic prisoner on high amounts of haldol, and so we strongly suspected that despite the absence of fever (this wasn't the first time he had theses symptoms) he had neuroleptic malignant syndrome (NMS) and rhabdymyolysis. When I went to see him, he just kept staring at the ceiling with his arms and legs oddly flexed; I don't think he ever blinked. Dr. L just happened to be on site and he suggested we start Mr. Roboto on Benadryl and if that doesn't work, give dantrolene.

My second patient was a Hispanic lady surrounded by 3-4 adult children and some grandchildren in one tiny exam area, and they didn't speak English. Great. She presented with a headache and left-sided weakness; indeed, her presentation was classic for a right-sided stroke, just like my stroke patient from the last call. When I was testing her position sense, she got several answers right, but we saw her opening her eyes (cheating) or else rubbing her fingers together so she could tell if they were "up" or "down." When Nanette put a quarter in her left hand, she couldn't feel it and tell us what it was. She also lost her balance and fell toward the left after going to the bathroom. Initiate stroke protocol.

After seeing my 2nd patient I got a JPS sandwich for dinner. Big mistake; it make me sick. =( Then I saw my last patient: a middle-aged man with a bad case of altered mental status. According to the nurse's report, he was agitated, kept trying to climb over the bedrails, broke free of his restraints and drank water from the sink when he was thirsty, and "peed on the ER resident" (Jordan's words, not the nurse's). Jordan gave the case to me thinking it'd be something really exciting (mad cow's, maybe? hehe), but in the end, it was EtOH intoxication, pure and simple. The guy had a BAL of 332, which he claims came from drinking 4 shots of vodka but Dr. L and Jordan both think it was more like the entire bottle (the guy's a self-proclaimed alcoholic). When I saw him, he was a lot calmer, but had tremors, nausea, and dry heaves. Then one nurse told Nanette that she saw my patient sticking a finger down his throat to induce vomiting on several occasions, and Nanette said, "Great, a male borderline." I asked if that should go in the DiffDx, and she said no =P We were done before midnight, but I didn't get to sleep until almost 2:00 a.m. This was due to several factors, namely Angela not finishing until that time (I finally went to the ER to see what was up and she said her patient had 2L of "pea soup" fluid sucked from his gut during a paracentesis) and the fire alarm going off at 1 a.m. and scaring the crap out of me. Ben M was the student on surgery call, so we chatted briefly in the lounge. RB saw me at the computer and asked what I was doing up so late, I said I couldn't sleep. Hard to sleep in these call rooms, dang it.

In the morning, we found out we only had 14 new admits; one left AMA and the other was a chemo patient who never showed. Mr. Roboto improved slightly; he was still in and out of it most of the time, but his rigidity was more "waxy." Then we had a young guy who broke his hip in a MVC after getting high on meth; ho was reputed to be a "total ass" by nurses and doctors alike. He was in the same room as another patient, and when we turned away from the other patient to look at him, he was lying on his back, snoring, and totally naked except for his restraints and a Foley catheter. O.O "Whoa..." Angela, Nanette, and I said as we looked away, and Ryan joked, "What, never seen one of those before?" Jordan thought the sight was disturbing and threw a gown over the guy's groin, but it didn't help b/c as soon as the guy shifted his legs, everything became visible again. Fortunately, the patient wasn't too mean when we talked to him; when we asked him if he hurt anywhere, he replied, "I've had plenty to drink." Ummm, okay. Afterwards, Jordan complained, "That guy needs some clothes. I don't get these patients who like to lie around naked; he's the 2nd one I've seen. The first one I saw weighed 400 lbs and was always sweating." Lovely mental image there. When I was in high school, I never understood why patients had to be naked under their gowns, thinking it was an invasion of privacy and basic rights. And even though I know now, it doesn't mean we need to see blatant nudity in hospitals.

With the new shift change coming up, Angela and I are expected to work this weekend and educate our new team on our patients and how they're doing. "It's a big responsibility," said Jordan. I sure hope so, seeing how on post-call days, it's the med student's job to carry the donuts and make sure they don't get left on some random floor. I think I got Dr. L's attention today by knowing the conversion of Celsius to Kelvin (the things I remember from general chem...), but as far as medical treatments and plans go, I'm still in need of improvement.

IM: Getting feedback

This morning Nanette had the day off, so I went to see her three patients for her. We were hoping that one of our patients, a guy who had confusion and DTs after a vodka-drinking binge, would be able to go home today, but after talking to the night nurse and finding that he needed 2 and 4 mgs of Ativan to calm him down (he tried to climb over the railings of his bed), it was out of the question. On top of that, he can only eat if nurses feed him and his urine output really sucked; his banana bag was nowhere in sight. My stroke patient got his CT and MRI done yesterday; the CT showed no new bleeding, but the infarct has taken up a good 1/3 of his right hemisphere. It's amazing that the only symptoms he has are left hand weakness and left sided numbness. He's also a Vietnam vet, so with his VA connections he should be able to go to a good rehab center once he's discharged. I was supposed to see one other patient, an OB patient with HTN, but Jordan caught up with me and said he'd go see her instead. Funnily enough, he forgot which patients he was supposed to see, so he ended up seeing about 6-7 while Ryan only saw 3.

Rounds progressed as usual (though Jordan lamented that we were picking up more and more "rocks"), and afterwards Dr. L sat down with Angela and me to go over our H&Ps. Angela went first b/c Dr. L never went over her first round of H&Ps (but I told her what went on during my session), so there was a noticeable difference between her H&Ps from last Monday and her H&Ps from Saturday. "This is what I want to see," he said about one of her later H&Ps. When my turn came, he said that for my Wellbutrin overdose lady, I should have mentioned the adverse side effects of too much Wellbutrin and what I should look out for. For my stroke patient, I did a good neuro exam but needed a better plan. My H&P on my liver patient got the best assessment (all thanks to Jordan listing all the things we had to do to work him up), but I failed to mention the prognosis of Budd Chiari (bad). Overall, Dr. L said that we were progressing well, as he expected. We're on call again on Thursday, so my next notes should be even better...I hope.

IM: Leaving AMA

This morning in the middle of rounds, I learned that our Budd Chiari patient left AMA yesterday afternoon. My first thought: "Oh crap, Jordan's going to be pissed." Nanette echoed the same thoughts when I told her about it later, and when I told Jordan (who'd been hoping that the "ID" by our patient's name was a mistake), his reaction was pretty much what I expected: "F***!!!" There was another FP resident in the room, and he and Jordan began discussing other patients they'd seen who were really sick but still left AMA ("the idiots"). Jordan's concern was that our patient's liver was really shot, and that he was going to die faster without more workup to see how we could treat him. He then talked about how he stayed behind an hour after everyone left to work up "that buttmunch" and how it was all worthless now. *sigh* Even still, he told me to expect our patient to come back as a bounceback, b/c once the liver starts failing worse, the patients become more frantic and in need of medical attention. Of course, seeing how he's been going to Mexico for all his treatments, maybe he won't come back after all. "Is JPS really worse than Mexico?" someone joked. Maybe; from what I saw in Ojinaga, if you have the money, you can get excellent care in Mexico.

Nanette got more details from the day nurse; it turns out the patient left b/c his family wasn't satisfied with his diagnosis and his sister wanted a second opinion. She said that she went to Harris once and was well taken care of there, so she wanted to take him to Harris for that second opinion. Apparently, however, Harris doesn't do well with patients without insurance or already have JPS connections, so if he doesn't get cared for there, hopefully he'll come back to JPS b/c with all his conditions he's a walking time bomb

IM: First Zebra Case

Yesterday call didn't start until 2:00 pm, but we didn't have any patients to see until after 3:30 (slow day), so Angela and I lay down/napped for a good hour or so. My first patient was a woman in her mid-30s who was found lying on the floor with an empty bottle of Wellbutrin nearby; when I went to talk to her (s/p charcoal lavage), she was completely alert and oriented. A little too alert, actually; her eyes were wide and she had tremors in her hands, a common side effect of too much Wellbutrin. She couldn't remember what she took or how much and denied being on any medications, and she took offense to some of my questions. There was a young Benbrook cop sitting beside her, looking very bored; he kept asking when we were going to admit her b/c he couldn't leave until we did (and he had nothing to occupy his attention like a book to read). After Nanette talked to her (she's a psych intern so she knew how to get through to my patient), she told the cop to take the detainment warrant up to the 10th floor and that we'd be writing orders for her soon. Minutes later, we called 10th floor and found that the cop had disappeared after dropping off the warrant. This was a problem; since she was a risk to herself, the patient was supposed to be supervised. Well...if anything happens to her, it'll be on Benbrook PD. I couldn't blame the guy for leaving, though; it's tough being a babysitter, and since it was around 5 pm, he was probably hoping to get home to his family.

My second patient was a 55 yo AA male who recently suffered a right MCA stroke. He had left-sided mouth droop and decreased sensation on the entire left side of his body. He couldn't tell sharp from dull, up from down (proprioception), or that I was even touching his skin in his arm and leg. He, too, had a history of depression/psychosis after serving two tours in Vietnam, but he was pretty lucid when we spoke. By the time I finished seeing him it was 8:00 pm so we went to get dinner. The cafeteria was serving leftover tacos from lunch (*gag*) so I spent money on McDonalds instead. Jordan had the same idea, and in the call room, he went over my next patient with Nanette: a guy with new onset painless jaundice, a total bilirubin of 32 (yikes), AST of 1300 and ALT of 650 (double yikes), and an enlarged gallbladder on CT (among other things). "This guy's screwed," said Jordan. He was also an illegal who'd been in the US for about a month, and all his previous treatments for metastatic prostate cancer (diagnosed earlier this year) were done in Mexico. We had to get a translator to ask him questions for the H&P (and he claimed to have lived here for 35 years), and later on the computer, we learned that due to lack of blood flow in two veins in the liver, he had a possible case of Budd Chiari syndrome (occlusion of the hepatic vein), which is often read about but not seen. Jordan got really excited when he read that. "I've been searching for a case of Budd Chiari for years!" he said. At first I thought he was joking, but it turns out he was dead serious. "This'll be a great case for morning report!" he said. Budd Chiari or no, we had to do a huge writeup on him and list how to proceed to find out what caused his liver failure. The possibilities were endless. I didn't get done until after midnight, and ended up chatting with Jordan and Ryan about our college days at UT. Jordan had a lot of funny stories to share.

Angela, Asuka, and I had the call room to ourselves, but I did not sleep well b/c Ryan was staying next door and whenever he got paged, I woke up and could hear every word clearly as though he was in the same room (paper thin walls can do that). I never slept more than 2 hrs at a time, probably. Needless to say I felt like a zombie in the morning, but Nanette got no sleep at all b/c of crosscover pages. We started rounds at around 6:30 (Dr. L brought donuts again) and saw all our patients before 10:30. When I got to the call room I found Fallon asleep at the table =P Yes, studying for surgery can be sleep-inducing. I was glad to get home; I slept for about 3-4 hrs after lunch until dinnertime.

IM: Lessons Learned

Both Angela and Jordan got the day off today, so it was just me, the two interns, and Dr. L on rounds. My cellulitis patient asked me where I was yesterday, and I told her I'd be seeing her for as long as she was here. I spoke too soon; Dr. L said she'll be transferred to SNF and after that we won't have to see her anymore. I think I may swing by her room on a regular basis anyway, just to see how she's doing and whether or not her cellulitis is healing. The hospital's a lonely place and I haven't seen her parents visit her yet, so maybe she could use a hello now and then.

The biggest issue of the day was our 82-year-old psych patient who was admitted to the hospital screaming, spitting, and biting but now lies curled up in her bed moaning everyday w/o eating or drinking. She's been widowed for 9 years and her only family is a niece who lives in Oklahoma who said the patient had previous signed a DNI/DNR/no feeding tube order. Now, with her not eating, it seems as though she's lost the will to live. Dr. L called the niece today to discuss their options, but thinks that the patient should be placed in hospice care because this is prolonging her suffering. She did open her mouth today to take some oatmeal, so I'm hoping she'll be able to eat a little more to sustain herself until she can transfer to a nursing home or hospice in OK.

We only had five patients on our service (not bad since we're on call tomorrow), and in the 30 minutes before morning report, Dr. L sat down with me to go over my H&Ps. Overall, he said I did a good job with history taking, but wants me to go more in depth into my assessment and plans. For my angina patient from last call, he made me go through a long differential for chest pain and said I should be thinking about all these things when considering chest pain. Dr. L went through every H&P and every progress note with detail and a dark pen, and I was very grateful for his input. This sort of feedback is something I never got at Methodist, and it was a nice change.

IM: Learning More

Normally I set aside 20-30 minutes per patient to write my notes, but for patients with complicated illnesses (i.e. my morbidly obese patient who has a ton of health problems like diabetes, yeast infection, cellulitis, and drainage s/p open appendectomy, to name a few), it can take much longer. I was supposed to see 3 patients by 8:30 and only saw two by 8:10. Fortunately for me, my third patient was taken to the cath lab in the morning so we didn't see her. This patient presented with SOB and chest pain, and we all thought she had something cardiac going on. As it turned out, her cath and echo were completely normal, but her lungs looked really bad. Ryan, one of the interns, wrote the diagnosis as "UIP." Dr. L asked us what we thought UIP was, and I said, "Something interstitial pneumonitis?" Correct, with U = usual. ("As opposed to unusual," said Dr. L). Later I had to put a physical therapy order form in the chart, and the nurse was confused. "You're sending her to PT after a cath?" she asked. I explained that her heart was fine, and that it was her lungs that were bad, and the nurse said, "Oh, we were trying to figure out what this meant" and showed me "UIP." When I told her what it stood for, she laughed and said, "That's not a real diagnosis!" I couldn't agree more =P

Imagine my dismay when I went to the SSU to find the same drunk patient who'd cussed me and my intern out sitting in the same bed having breakfast, but this time he was also wearing an old jacket. One of the nurses went over to him and scolded him for showing up drunk (again) and cussing at other people until the alcohol wore off. He didn't care; he gets a free meal out of it. *sigh* Jordan (the 3rd year resident) said, "That's what it's like to hit rock bottom," referring to that man. Something tells me I'll be seeing a lot of him this month. Another thing I noticed is that the senior residents here don't think very highly of how our school schedules lectures in the mornings when we could be at the hospital learning things. Like JB (my surgery chief), Jordan thought having lectures in the morning was stupid and said, "I don't know what your school is thinking." He was similarly annoyed when he got a long neuro report from the PCC regarding a patient with MS, and Dr. L chided him on his lack of courtesy/respect since students and residents at JPS both come from our school. The neurologist came from our very own Dr. McI, so Angela was told to give him a call. She hesitated after what happened to me yesterday, but Ryan said he didn't see a problem with it. As it turned out, the patient was discharged before the phone call was made, so Angela didn't have to do that consult. Even still, I would hope that since Dr. McI is a professor, he'd be more open to having a student call him for a consult.

Jordan explained how days off work: I'm with Nanette, and Angela is with Ryan. If Ryan's taking the day off, then Angela stays to see his patients, and I take the day off. If Nanette is off, I see her patients, and Angela gets the day off. Ryan's taking tomorrow off, so I get tomorrow off, too. Not that it matters since I still have lecture at school...oh well. I'll take whatever I can get.

IM: First Call Faux Pas

So yesterday afternoon before call, I met with Dr. D and we talked a little about my future aspirations (still IM at this point), what electives I'm taking, and where I want to apply for residency. Overall he said I'm a strong candidate and that my grades/scores make me competitive for both allopathic and osteopathic residencies. He did disagree about my taking an ICU elective at JPS in September because he thinks I should be out doing audition rotations. That all sounds good except right now, I don't have a program in mind that I would want to "show off" for. What should I do, apply to do a sub-I at a program that I have no interest in applying to, just for the sake of "getting out there?" A friend of mine got her top pick residency without doing any away rotations, so I don't think it's as crucial for IM as it is for other specialties like surgery. Besides, ICU is a great elective for doing procedures and really caring for the sick patients, so I don't think I'm wasting anything. Others will disagree, I'm sure, but to each their own opinion.

This call was probably one of the easiest/best calls ever. My first patient, a lady with chest pain, arrived around 4:30 pm, and we worked her up for angina. After I wrote her up, it took a while to get in touch with my intern b/c I paged her just after she went to see another patient, so I had to wait for her to finish with that one (had time to eat dinner while I waited) before I could present to her (even though I already presented to Dr. L). Honestly, I think I learned more tonight with Dr. L than I did from any of the attendings at Methodist; they occasionally pimped but never actually sat down to go over things with me. My second patient was this morbidly obese lady with a lot of things going wrong for her: she had an appendectomy in late March that had to be left open to drain b/c a fistula formed (they found traces of digested CORN in her incision site), and now she has cellulitis in both legs (but way worse on the left leg, which was swollen to 2 times the size of my thigh). Bad, bad case. Students have to see three patients before going to bed, and my third patient was a drunkard who was on his 120-something visit to the hospital this year alone (he's infamous in the ER). Apparently he presented to the ER two days ago for chest pain, left AMA yesterday morning, and came back several hours later drunk as a skunk. When I went to see him, the nursing staff asked if I could tell the intern to see him quickly b/c they couldn't find a blood vessel on him to draw blood from (he had tons of medical problems like diabetes, COPD, and cirrhosis, to name a few), so he had no new labs and we had no clue what his alcohol level was. He was snoring loudly and had flies flying around his head (yikes), and when I asked him where he was, he said, "Camp Bowie." Not quite. When I palpated his stomach, he grimaced, so when I asked him if it hurt, he snapped, "Yes. Go away, you f***ing p***y." O.O All right then. Obviously I couldn't get much from him, so I found my intern and told him all I knew. She got cussed out, too, and Angela asked me, "That your patient?" Yup. We capped by 11:20 pm (SCORE!), so Angela and I were asleep within the next hr or so.

Of course, this morning we had to wake up around 5:00-5:15 a.m. to eat (me) and start printing out patient lists. Rounds started promptly at 6 and we were done by 9:00. After that, I went with my intern to help remove a guy's central line (he didn't even feel me take out his staple, hehe, because he was so busy talking). Then...the faux pas. My intern told me to do an ID consult, saying it was good experience for students to learn how to talk to doctors. So I paged the ID doc and spoke to him by phone, and he seemed surprised to hear a student on the other line. "How'd you end up with this job?" he asked. At any rate, he agreed to see my 2nd patient and I thought nothing of it until my resident stopped me in the hall later to ask me if I spoke to the ID doctor. I said yes, and he said not to do that anymore. At this hospital, apparently, staff physicians will only speak to another resident or intern, doctor to doctor, b/c med students have less credibility (makes sense to me). Apparently the cardiologist here will only speak to residents and not interns, so there's some sort of hierarchy thing going on. I explained that my intern told me to make the call, and he said that's fine, but that she shouldn't have done it. *sigh* Just great. This is probably going to get back to Dr. L, who knows what he'll say to that. What a way to end my first call.

IM: Call on the First Day

Welcome back to JPS. This is my third time here, and I saw lots of familiar faces at orientation this morning. Angela and I are paired together on Team A, with Dr. L as attending. All I've heard about him is that he's nice but has his students write really long H&Ps and progress notes, but hopefully the hours are decent. Venessa is back from Corpus to do her last month of IM here in town; part of the reason is that the 2nd years' boot party is coming up and she wanted to be with her bf. In fact, she told us she demanded that Dr. B let her do her rotation in town b/c one of the hospitals in Corpus closed or something and they weren't learning anything. Wow. Still, I'm pretty sure the main reason for her coming here is her bf.

When we got our schedules, I was dismayed to find that I'm on call tonight. How on earth did I get so "lucky" as to be on call on my first day at both Methodist and JPS? *sigh* Fortunately call doesn't officially start until 2:30, so my 3rd year resident said we could go home until then. Except I also have a meeting with Dr. D to go over the Dean's Letter at 3:00, so I'll be one hr late. I'll update more then.

IM: Rheumatology Clinic

This morning I met several classmates at the PCC for the required Rheumatology Clinic, where we met with four older ladies who told us about living with arthritis, from the first signs and symptoms to how they're doing now. Then we split into different groups with just one of the women so we could learn more about her condition in general. Kim, Jedd, and I had a woman who was initially diagnosed with seronegative RA but feels that she is now seropositive after having had it for 15-20 years. She barely had any telltale signs of RA; she had some ulnar deviation and one finger with a swan-neck deformitiy, plus some decreased range of motion in her right shoulder and hip, but that was it. Sadly I forgot her name, but she was an excellent teacher and showed us several gadgets that she keeps on hand to help make life easier (i.e. long handle for car keys, a picker-upper, etc) This workshop, we all agreed, was more educational than any lecture on rheumatology we could have received. =)