I will admit as many of you have heard - I entered Peds with an open mind and much excitement -burning with desire to take of patients (finally after two years). Unfortunately most of my rotation has been boring as heck. The residents don't let us do histories and physicals. We either shadow them or go in and ask the patient "How were you overnight, any nausea, vomiting, diarrhea, pain, fever, etc." and then do a 2 min exam (which can include ears, throat, chest, lung, abdomen, but usually not even all of these). That's it. I have been demoted to the ranks of a first year medical student who does nothing, knows nothing etc. I did more in physical diagnosis!!!
Changing tunes : maybe it's because I've been so bored, maybe it's the patients, the neurologist or all three -but this past week I have literally been on a high. I have seen the most incredible peds neuro cases. I came home today with so much excitement over a patient I saw that I can't even focus. All I want to do is look up articles about the condition(s) I will describe. I have a shelf in almost one week and know nothing about peds as a whole. All I want to do is study these neuro cases - as I said - I can't even focus on anything else. I have not felt this excited about anything in a while. This does not mean I can do peds neuro as a career (b/c I do not think I would enjoy peds residency) - but I am sad that the rotation is ending when I finally found something interesting.
The neurologist is awesome - despite a strange and harsh sense of humor. I was scared of him at first when he came bolting down the peds floor, busted into patient rooms, and went in and out so fast it was a blur. He asked us some questions - I had no clue about (like 3 types of infantile spasms). He asked who was interested in neuro. I said I was - and he simply laughed and said "you don't have to lie just to impress me." I was somewhat mortified. One time he asked a question and when a student began responding he suddenly interrupted "Stop. Just stop speaking now...nevermind." Geez I thought. However despite other harsh comments and several unsettling encounters I realized - hey - this guy may be a bit harsh - but he actually teaches! He taught me a lot! And turns out.........the patients LOVE him - not just like him - LOVE him - as in they will miss him when they stop having appointments. Pictures of patients with him and thank-you notes adorn the walls of both his office and the peds floor.
TO BE CONTINUED.....................
Tuesday, July 31, 2007
Family Medicine: The Service and the Addicts
This week I'm on the inpatient service at the hospital, and boy is it different from the clinic. I arrived at 7 AM in the hospital cafeteria for morning sign outs... the cafeteria was abuzz with people of all different species; the loud scrubs with a sleepless night etched under their eyes, the manicured hairstyles who got up an hour early just to look pretty, the confused medical students who accidentally turned off the alarm instead of hitting sleep in the morning and therefore have flyaway hair... wait, that's me! Dammit. Amidst the ruckus, I found my group tucked away in a quiet corner going over complicated sheets covered with observations, lab values, and treatment plans. The goal was to cut through the din and simultaneously to make sense of the chaos on the sheet. We got to work with intense focus. I feel that in the hospital environment, that's 3/4 of the battle on a regular basis.
The hospital is a whir of activity, sometimes enough to confuse you to oblivion, at other times enough to literally make me feel nauseated. Five hours in the hospital seeing only 3 patients is significantly more draining than five hours in the clinic seeing 10 patients, and that's just the nature of the beast. Imagine, then, what it's like to be a patient. You come in, by car or ambulance, and you're placed in a stretcher. You're admitted and wheeled through a crowded hallway where dozens of people are walking past you at breakneck speed, into an elevator, and up to a room that you will share with someone's smelly grandfather (unless you are someone's smelly grandfather... then you're the lucky winner of a room shared with the lovely young MS patient with a devastating pulmonary embolism). Your wife, or husband, or daughter, or son, gets to sit on a vinyl-lined seat next to the bed, and place her/his handbag on the table at the foot of your bed... all of which (bed, seat, and table) are generously covered in MRSA. You wait. Sometimes for hours at a time. Your wife/husband/daugther/son grows tired and can't lie down. You freeze in the tiny hospital gown. People in scrubs and white coats come in and out of the room, but you haven't quite gotten the hang of figuring out which ones are doctors, which ones are nurses, which ones are techs... which ones are medical students (we're the ones in the short white coats, by the way... and why the heck am I giving that away??? it must be really late at night). Sometimes they explain something complicated to you, but you're embarassed to asked for clarification. They come and sedate you and then shock your chest so that you squeal in pain and writhe in the bed (by the way, I actually saw this today... it's called cardioversion).
Anyway, the point I'm trying to make is that all that touchy feely stuff is not strictly bullshit. I now know firsthand-- this weekend, I brought a friend into the hospital and witnessed for myself how important patient comfort, communication, and amenities for relatives/friends can be! At 1 AM, after waiting in the ER for 5 hours, I found out exactly how welcome a cot for the companion could be. I reflected on how our children's hospital is so ridiculously proud of its pediatric floors, with their special sections in each room where parents can sleep. It's no wonder that studies have shown: when the loved ones are also cared for, the patient is also healed faster.
After treating a couple more patients in the ER and scarfing dinner, I attended a meeting of what's equivalent to AA for former jail inmates. I listened to these stories with total compassion but a helpless feeling of greenness; there was no way I could ever comprehend what it is like for these people, with this disease of addiction, to walk down the street... to wake up each day and fight the urge to use. I've never been there. A young lady, V, spoke up, saying that the evening group meeting time is difficult for her because walking home, she has to walk the night gauntlet of her addictions, passing every dealer on her street in her neighborhood to make it to the safety of her house. I can't even imagine what it would be like for each day to be a struggle against myself; not a struggle for anything more than just to stay away from heroin, or alcohol, or cocaine... for just one more day...
I drove V home to her grandfather's place on the outskirts of the city and dropped her off at her front stoop, where 4 people were in the process of getting high. I gave her a hug and went back into town, where I contemplated my long day over a draught at the local brewery...
The hospital is a whir of activity, sometimes enough to confuse you to oblivion, at other times enough to literally make me feel nauseated. Five hours in the hospital seeing only 3 patients is significantly more draining than five hours in the clinic seeing 10 patients, and that's just the nature of the beast. Imagine, then, what it's like to be a patient. You come in, by car or ambulance, and you're placed in a stretcher. You're admitted and wheeled through a crowded hallway where dozens of people are walking past you at breakneck speed, into an elevator, and up to a room that you will share with someone's smelly grandfather (unless you are someone's smelly grandfather... then you're the lucky winner of a room shared with the lovely young MS patient with a devastating pulmonary embolism). Your wife, or husband, or daughter, or son, gets to sit on a vinyl-lined seat next to the bed, and place her/his handbag on the table at the foot of your bed... all of which (bed, seat, and table) are generously covered in MRSA. You wait. Sometimes for hours at a time. Your wife/husband/daugther/son grows tired and can't lie down. You freeze in the tiny hospital gown. People in scrubs and white coats come in and out of the room, but you haven't quite gotten the hang of figuring out which ones are doctors, which ones are nurses, which ones are techs... which ones are medical students (we're the ones in the short white coats, by the way... and why the heck am I giving that away??? it must be really late at night). Sometimes they explain something complicated to you, but you're embarassed to asked for clarification. They come and sedate you and then shock your chest so that you squeal in pain and writhe in the bed (by the way, I actually saw this today... it's called cardioversion).
Anyway, the point I'm trying to make is that all that touchy feely stuff is not strictly bullshit. I now know firsthand-- this weekend, I brought a friend into the hospital and witnessed for myself how important patient comfort, communication, and amenities for relatives/friends can be! At 1 AM, after waiting in the ER for 5 hours, I found out exactly how welcome a cot for the companion could be. I reflected on how our children's hospital is so ridiculously proud of its pediatric floors, with their special sections in each room where parents can sleep. It's no wonder that studies have shown: when the loved ones are also cared for, the patient is also healed faster.
After treating a couple more patients in the ER and scarfing dinner, I attended a meeting of what's equivalent to AA for former jail inmates. I listened to these stories with total compassion but a helpless feeling of greenness; there was no way I could ever comprehend what it is like for these people, with this disease of addiction, to walk down the street... to wake up each day and fight the urge to use. I've never been there. A young lady, V, spoke up, saying that the evening group meeting time is difficult for her because walking home, she has to walk the night gauntlet of her addictions, passing every dealer on her street in her neighborhood to make it to the safety of her house. I can't even imagine what it would be like for each day to be a struggle against myself; not a struggle for anything more than just to stay away from heroin, or alcohol, or cocaine... for just one more day...
I drove V home to her grandfather's place on the outskirts of the city and dropped her off at her front stoop, where 4 people were in the process of getting high. I gave her a hug and went back into town, where I contemplated my long day over a draught at the local brewery...
Sunday, July 29, 2007
Surgery: The pimping
This past week I just realized something: There's no such thing as being prepared enough for your attending pimping sessions. Here's my story to back that up.
I've seen many lap cholecystectomy by now, and this past week, there was another one. I scrubbed in, feeling confident I had a pretty good knowledge about the billiary tract and all about gallstones, even though for this specific patient I didn't get a chance to review her charts (had grand rounds that finished after she was prepped in the OR). Well, we started, I grabbed the camera, had my position and everything, and my attending said: "This lady has a gallbladder polyp. What's the most common type of gallbladder polyps?" And of course that question met my blank stare. My brain started working hard, trying to find that piece of information that I've memorized once upon a time that seems so long ago, namely during 2nd year pathology course. Well, it was unsuccessful....couldn't remember. Then it continued to more clinical stuff: "How do you diagnose it?" "How do you differentiate between polyp and stones on ultrasound?" "Is it benign or malignant?" and so on....Ouch!
The other one was during attending rounds. One of the patients have cecal bascule. I read everything about it. I even read about volvulus and incomplete malrotation. We had 3 attendings with us this time, and any of them can ask questions. 1 attending asked several basic questions which I could answer pretty well. Right when I was about to breathe a sigh of relief after he's done with his questions, my attending asked me: "How about complete malrotation? How do you treat it?" Yeah, of course I didn't know. Argh!
Isn't surgery rotation just fun?
I've seen many lap cholecystectomy by now, and this past week, there was another one. I scrubbed in, feeling confident I had a pretty good knowledge about the billiary tract and all about gallstones, even though for this specific patient I didn't get a chance to review her charts (had grand rounds that finished after she was prepped in the OR). Well, we started, I grabbed the camera, had my position and everything, and my attending said: "This lady has a gallbladder polyp. What's the most common type of gallbladder polyps?" And of course that question met my blank stare. My brain started working hard, trying to find that piece of information that I've memorized once upon a time that seems so long ago, namely during 2nd year pathology course. Well, it was unsuccessful....couldn't remember. Then it continued to more clinical stuff: "How do you diagnose it?" "How do you differentiate between polyp and stones on ultrasound?" "Is it benign or malignant?" and so on....Ouch!
The other one was during attending rounds. One of the patients have cecal bascule. I read everything about it. I even read about volvulus and incomplete malrotation. We had 3 attendings with us this time, and any of them can ask questions. 1 attending asked several basic questions which I could answer pretty well. Right when I was about to breathe a sigh of relief after he's done with his questions, my attending asked me: "How about complete malrotation? How do you treat it?" Yeah, of course I didn't know. Argh!
Isn't surgery rotation just fun?
Thursday, July 26, 2007
Family Medicine: Inmates, Indigents, and Ill
Thursday or Friday of each week is the day I get to go to jail. This morning, I got there to discover that I had left my driver's license at home (you need to turn over ID to get past security), which naturally led to many jokes about "did they let you into jail?" I am happy to say that they did, indeed, let me into jail today. And they even let me back out; imagine that.
A classmate and I participate in a program for substance abusers at the county jail. So far, the thing that has struck me most about people in jail is how similar they are to people not in jail. Actually, my most interesting observation so far is that the main difference between people in jail and people not in jail is a peculiar inability to control one's emotions, especially the negative ones. Next time you feel fury, frustration, or despair, remember that self-control goes a long way.
After jail, I headed over to the Catholic charities clinic for an afternoon of women's health. I work with my preceptor and the world's most wonderful PA there; this afternoon I observed 2 colposcopies with endocervical curettage (ECC) and biopsy, and an attempted endometrial biopsy. I didn't do much more than hold the patient's hand, but I somehow managed to get thanked for it. I guess when people are sticking things up your vagina and cutting bits out of your cervix, the person who holds your hand is pretty darn important.
Finally, some quotes of the ill:
M: Do you have a runny nose?
Patient: Who in our state doesn't have a runny nose??
Dr: She used to be psycho... but now she's sweet as a button. A little dab of Zoloft makes all the difference!
A classmate and I participate in a program for substance abusers at the county jail. So far, the thing that has struck me most about people in jail is how similar they are to people not in jail. Actually, my most interesting observation so far is that the main difference between people in jail and people not in jail is a peculiar inability to control one's emotions, especially the negative ones. Next time you feel fury, frustration, or despair, remember that self-control goes a long way.
After jail, I headed over to the Catholic charities clinic for an afternoon of women's health. I work with my preceptor and the world's most wonderful PA there; this afternoon I observed 2 colposcopies with endocervical curettage (ECC) and biopsy, and an attempted endometrial biopsy. I didn't do much more than hold the patient's hand, but I somehow managed to get thanked for it. I guess when people are sticking things up your vagina and cutting bits out of your cervix, the person who holds your hand is pretty darn important.
Finally, some quotes of the ill:
M: Do you have a runny nose?
Patient: Who in our state doesn't have a runny nose??
Dr: She used to be psycho... but now she's sweet as a button. A little dab of Zoloft makes all the difference!
Family Medicine
The nature of my specialty right now is that I don't have glorious stories of pulling tumors out of abdomens or waking up at 4 AM every day (wait, did I say glorious?? I think I meant seriously sadistic). My people-- yes, I feel like I OWN them after a mere 3.5 weeks together-- deal with the seriously mundane business of taking care of what, to the untrained eye, are the most superficial aspects of medical care.
But if you actually agreed with what I just said, you would be horribly, horribly wrong. It is estimated that for every 1000 people in the community in a typical month, 800 feel medical symptoms. Only 327 of those even CONSIDER medical care. 217 of them visit a physician's office (113 visit a primary care office), 65 visit an alternative/complementary medicine provider, 21 visit a hospital outpatient clinic, 13 go to the ER, 8 are hospitalized, and FEWER THAN ONE are hospitalized in an academic medical center.
What does this all mean? For one, it tells us what we can and cannot believe about clinical trials, which are mostly done in the academic medical centers visited by the fewer than 1/800 symptomatic patients in every month: they are not necessarily representative of the total patient population. Secondly, it tells us something about the attitudes towards medicine, and the (in)accessibility of medical care out there in our communities (about 500/1000 don't even consider it). Most importantly, it illustrates the importance of primary care: providers in outpatient settings and family practice clinics are on the front lines of almost every medical battle.
I used to brag that I hate people. I am shocked to find that I actually like them very much. I like how each one comes with a wholly different set of challenges, and how many of them are eager to form an alliance with their medical caregivers (and that now includes me, I'm part of the team, too!) to surmout these challenges. I like the stories I hear, and the stories I get to tell. I even like the patients that don't really get it, or try really hard and are just too weak to do it, whether it's quitting smoking, eating healthier, getting more exercise, getting out of an abusive relationship, or checking blood sugar levels every day-- those are the most challenging ones (and anyone who knows me at all knows I like a challenge).
I got my first taste of continuity last week. I have been seeing patients in one situation or another for longer than many of my classmates, since I worked as an EMT for 2 years before I started medical school. But it was always "Hi, nice to meet you!" and never "It's great to see you again!" Of all the things that have happened to me in the last couple of weeks, I have to say that the first time "It's great to see you again!" happened to me was the most transcendant: continuity of care is really all that it's cracked up to be. I think back to all the stories I've heard about doctors who delivered a baby and remained its care provider for 20 years... what an honor to be a part of an individual's life in that way.
The first 2 minutes of any patient encounter belong entirely to the patient. I have a whole cheat sheet of tips and tricks to make someone talk without the use of torture devices (apart from my presence in the room, that is). My first "It's great to see you again!" patient rewarded me by opening up to the incredibly vague, general question of "So, what's going on your life?" with "well, it's been pretty bad since my wife died five years ago." By the time I left the room ten minutes later I felt like I had died. I thought I was ready to "be there" for people, but that was the arrogance of youth speaking. How could I, without mourning for five years, match the magnitude of sadness this gentle old man felt? In ten minutes, I had drained every ounce of sadness out of my being to share with him in empathy (in school they love to teach us this in abstraction, they call it "humanism"), but it I knew couldn't possibly be enough.
The "don't get burned out" answer is NEVER to let a patient GET to you. I'm still letting them do that. Being in the room with one particular patient, who had a sinus infection and obvious depression, felt like meeting a group of dementors (YES! A Harry Potter reference!) in a dark alleyway-- it was cold, you felt like all the happiness had gone out of the world, despair took over. Why is interviewing her like pulling teeth? Why do I feel so angry at the patient I'm trying to help? There is no hope left. I am helpless... She made me so angry I could barely get my presentation out to my attending afterwards. Her passive agressivism frustrated me: why was she here, in our place of healing, if she didn't want to be healed?
I'm still green, so my frustrations and joys soar and crash with the tide of human drama that is all around me constantly. Eventually, I will become the rock that others depend on for shelter in that stormy sea.
But if you actually agreed with what I just said, you would be horribly, horribly wrong. It is estimated that for every 1000 people in the community in a typical month, 800 feel medical symptoms. Only 327 of those even CONSIDER medical care. 217 of them visit a physician's office (113 visit a primary care office), 65 visit an alternative/complementary medicine provider, 21 visit a hospital outpatient clinic, 13 go to the ER, 8 are hospitalized, and FEWER THAN ONE are hospitalized in an academic medical center.
What does this all mean? For one, it tells us what we can and cannot believe about clinical trials, which are mostly done in the academic medical centers visited by the fewer than 1/800 symptomatic patients in every month: they are not necessarily representative of the total patient population. Secondly, it tells us something about the attitudes towards medicine, and the (in)accessibility of medical care out there in our communities (about 500/1000 don't even consider it). Most importantly, it illustrates the importance of primary care: providers in outpatient settings and family practice clinics are on the front lines of almost every medical battle.
I used to brag that I hate people. I am shocked to find that I actually like them very much. I like how each one comes with a wholly different set of challenges, and how many of them are eager to form an alliance with their medical caregivers (and that now includes me, I'm part of the team, too!) to surmout these challenges. I like the stories I hear, and the stories I get to tell. I even like the patients that don't really get it, or try really hard and are just too weak to do it, whether it's quitting smoking, eating healthier, getting more exercise, getting out of an abusive relationship, or checking blood sugar levels every day-- those are the most challenging ones (and anyone who knows me at all knows I like a challenge).
I got my first taste of continuity last week. I have been seeing patients in one situation or another for longer than many of my classmates, since I worked as an EMT for 2 years before I started medical school. But it was always "Hi, nice to meet you!" and never "It's great to see you again!" Of all the things that have happened to me in the last couple of weeks, I have to say that the first time "It's great to see you again!" happened to me was the most transcendant: continuity of care is really all that it's cracked up to be. I think back to all the stories I've heard about doctors who delivered a baby and remained its care provider for 20 years... what an honor to be a part of an individual's life in that way.
The first 2 minutes of any patient encounter belong entirely to the patient. I have a whole cheat sheet of tips and tricks to make someone talk without the use of torture devices (apart from my presence in the room, that is). My first "It's great to see you again!" patient rewarded me by opening up to the incredibly vague, general question of "So, what's going on your life?" with "well, it's been pretty bad since my wife died five years ago." By the time I left the room ten minutes later I felt like I had died. I thought I was ready to "be there" for people, but that was the arrogance of youth speaking. How could I, without mourning for five years, match the magnitude of sadness this gentle old man felt? In ten minutes, I had drained every ounce of sadness out of my being to share with him in empathy (in school they love to teach us this in abstraction, they call it "humanism"), but it I knew couldn't possibly be enough.
The "don't get burned out" answer is NEVER to let a patient GET to you. I'm still letting them do that. Being in the room with one particular patient, who had a sinus infection and obvious depression, felt like meeting a group of dementors (YES! A Harry Potter reference!) in a dark alleyway-- it was cold, you felt like all the happiness had gone out of the world, despair took over. Why is interviewing her like pulling teeth? Why do I feel so angry at the patient I'm trying to help? There is no hope left. I am helpless... She made me so angry I could barely get my presentation out to my attending afterwards. Her passive agressivism frustrated me: why was she here, in our place of healing, if she didn't want to be healed?
I'm still green, so my frustrations and joys soar and crash with the tide of human drama that is all around me constantly. Eventually, I will become the rock that others depend on for shelter in that stormy sea.
Wednesday, July 25, 2007
OB/GYN: Ma'am, yes ma'am.
"Oh hey! I didn't recognize you in civies!" exclaims Sue.
Civies? What the hell are those? It's got to be a noun: a place, a program, a ... what? Sue explains and I look down. Oh, I get it: civilian clothes - I was wearing a dress shirt, skirt, and my trendy-grandma shoes, as opposed to my "jade" (yes, it actually says that) colored standard-issue scrubs and sneakers.
Armed with my stethoscope and protected by my white coat, I was on a mission. Like a true soldier, I was prepared: my stethoscope had just received its daily alcohol-pad polishing and my coat proudly sported its lapel pins. Only 20 minutes until 13:00 hours. Will I make it?
Ok, so before you all think that I've completely lost it since I've gone MIA for the past three weeks, let me reassure you that I haven't. I just feel like I've been duped into some sort of medical military that is OB/GYN clerkship 1. And seeing how it's now 21:31 and I need to be AAO (alert, awake, and oriented for all you lovely normal people) at 04:45, I'll leave with three little thoughts: 1) Thank your mother for birthing you, no matter how %&#$ing annoying she has been/is/will always be. 2) If you want to decrease teen pregnancy rates, show 6th grade girls an uncensored video of labor and delivery. 3) Coffee is king.
Civies? What the hell are those? It's got to be a noun: a place, a program, a ... what? Sue explains and I look down. Oh, I get it: civilian clothes - I was wearing a dress shirt, skirt, and my trendy-grandma shoes, as opposed to my "jade" (yes, it actually says that) colored standard-issue scrubs and sneakers.
Armed with my stethoscope and protected by my white coat, I was on a mission. Like a true soldier, I was prepared: my stethoscope had just received its daily alcohol-pad polishing and my coat proudly sported its lapel pins. Only 20 minutes until 13:00 hours. Will I make it?
Ok, so before you all think that I've completely lost it since I've gone MIA for the past three weeks, let me reassure you that I haven't. I just feel like I've been duped into some sort of medical military that is OB/GYN clerkship 1. And seeing how it's now 21:31 and I need to be AAO (alert, awake, and oriented for all you lovely normal people) at 04:45, I'll leave with three little thoughts: 1) Thank your mother for birthing you, no matter how %&#$ing annoying she has been/is/will always be. 2) If you want to decrease teen pregnancy rates, show 6th grade girls an uncensored video of labor and delivery. 3) Coffee is king.
Sunday, July 22, 2007
Medicine
I'm thinking that I actually like medicine. I know, I know, scheduling it first was to "get it out of the way" and maybe its just that I actually like third year but either way I'm feeling pretty good. I don't know who else has their med rotation right here but I thought I'd write a little about how the average day goes for your reading pleasure.
We meet in the call room at 7am to get the sign outs from the night float residents. The intern actually gets in around 6:45 because he/she is anal like that (I'm not being vague - first we had a she, now we have a he, and apparently md's their first few weeks are the most stressed out anal people we'll ever meet - and we've been to the ivy & med school). The senior resident PGY3 strolls in about 7:05 looking non-apologetic and the sub-I right behind her even less so. As I gulp down my first diet coke of the morning the res doles out the pts to our team; its the 5th day of my third week and she deems me ready to take 3 pts. Lucky for me they are all on the pseudopsych floor just next to the call room.
I settle into what I'll call PsychBuilding and get my first pts chart. Tina** is a 26 yr old woman who presented with drug overdose of her antidepressant, her son's seizure meds, ambien, and a triptan she takes for migraine solely because she knew it interacted with her antidepressant. I saw her a few times last week when she first came in but my attending thought the case was too boring for me and switched me to some others; since then the mid-month attending switch happened and my res gave me back to Tina. She was pretty cold last week but came around quickly once she saw that I wasn't judging her for her suicide attempt. Having currently 3 suicide pts on our service I've come to the realization that doctors take this shit personally - anyone who harms their bodies with intent like Tina or noncompliance gets this reaction from doctors like they are actually giving their blood pressure meds to the doctor's puppy instead of merely neglecting to refill the prescription.
This morning however was Tina's 9th day in the hospital and she was pissed. The first two days she was here she was intubated and seized a few times - apparently drugs are bad - but since then she's been laying in bed waiting for transfer. I gently prodded her awake at the fresh hour of 7:30 and once she blinked her sleepy eyes she started going off about how her psychiatrist consult is trying to kill her by not getting her into the inpt facility she wants to go to and how we aren't doing a single thing for her. That actually isn't true - not about the consult, I don't really know if Dr. StandsInTheDoorway is trying to kill her or not - but we are doing a single thing for her: her bp was in the 140s so we prescribed a low dose of hctz. Other than that we are waiting for her to get a psych transfer to an inpt facility, and until then we are feeding her three meals a day and keeping a 1:1 watch on her in case she gets her hands on some more migraine medicine. (The 1:1's love when we come to see the pts because they get to go pee! They are really excited about it!!)
I told Tina I'd put her complaints in her chart - which I did - and examined her pupils, heart, lungs, abdomen, and checked for edema. This is what it looks like in her chart:
PE gen: well-appearing young female in NAD, AAOx3
HEENT: PERRL, sclera anicteric, mucus membranes intact
CV: RRR, no murmurs, rubs, gallops or thrills appreciated
Pulm: CTA [clear to auscultation]
Abd: + BS 4 quadrants, soft, ND, NT, no hsm [nondistended, nontender, no hepatosplenomegaly]
Ext: no c/c/e [cyanosis, clubbing or edema]
This is what you get if you are actually 100% physically healthy and waiting a week for transfer. I made my sad sorry-you-aren't-enjoying-your-stay look and waited for her to get out the rest of her morning angst and headed out to write my note.
I got out Ronald's chart next. Ronald is a 30-something black male who p/w epigastric pain and shaking of his hands. He usually drinks a 6-pack of beer/day but stopped around Monday, started shaking on Wednesday and presented to the ED on Thursday. (Ok folks, what's the treatment plan for acute pancreatitis?) When I saw him on Thursday he was not looking well, we had him on a banana bag (saline, thiamine, folate, multivitamin) but it was probably more withdrawal than his pancreas that was hurting him. I went in with Res. This morning he had only a little bit of pain, and was hungry. Res told him that if he felt ok to eat that we would start giving him food.
Ok so last night I decided to read up on pancreatitis because Dr. Attending told us that she would pimp us on it today. Treatment for pancreatitis should be NPO to give the pancreas a break, and generally unless its necrotizing it resolves on its own. Give morphine as needed, and in Ronald's case he gets benzos for his withdrawal - ativan and librium on a standing basis. When we left Ronald's room I asked as politely as I could if it would be ok for us to give him PO, or if we should keep giving his pancreas a break. Res said if his pancreatitis was still bad he wouldn't want to eat, and she put in the order for PO.
Third and my last patient of the morning was Ms. Helen. Ms. Helen is a 49 yo divorced mother of two who presented after injecting herself with 90 units of her son's insulin in a suicide attempt, which resulted in a seizure. Several hours later she was able to call 911 and get herself to the hospital. Today was her 3rd day here and she was looking well. I saved her for last because she is my favorite patient, she is so sweet and pleasant I wonder why anyone would ever want to hurt her, including herself.
I'm worried about Ms. Helen. I've been following her the few days that she's been here and while she brightens up my day and makes me feel good about myself, I'm worried that she's in some denial right now. Here is how the typical exchange goes:
J Ms. Helen? Good morning.
H (waking) Good morning dear! Look at that smiling face!
J How are you doing today?
H Oh I'm doing fine. I'm much better. But how are you doing?
J Well this morning is dragging a bit-- (wait, she is the patient.) Any pain today?
H Not really, my calves feel much better, they aren't as tight. What is your day like today? Long day?
J Well tomorrow we are on call . . .
H On a Saturday? My they work you so hard, don't they?
J It's a lot of work but I am really enjoying it. (Back to the patient, damn it!!) How is your tongue feeling today?
H I think it's healing, but it still hurts.
Ms. Helen's tongue hurts because she bit it pretty hard during her seizure. Her calves are tight because her muscles contracted so hard during her seizure that she had rhabdomyolysis. (What is the number 1 cause of rhabdo in the US?) When she came in, her CPK was elevated in the 3000s so as opposed to Tina, we are medically treating her, bolusing her with fluids to get it down, before she can be transferred to inpt.
Ms. Helen's physical exam was benign, except that I'm pretty sure I heard an S4 at the left sternal border. I don't know why she should have a gallop or how I could be the only one to exam her to actually hear it, but I note it in her chart anyway. I stay in her room talking to her (me desperately trying to keep the conversation on her) until it's time for rounds at 10.
Part II: Rounds, coming soon.
** Names have been changed, and while I usually try to refer to my patients by their last names I'm only using first names for added privacy.
We meet in the call room at 7am to get the sign outs from the night float residents. The intern actually gets in around 6:45 because he/she is anal like that (I'm not being vague - first we had a she, now we have a he, and apparently md's their first few weeks are the most stressed out anal people we'll ever meet - and we've been to the ivy & med school). The senior resident PGY3 strolls in about 7:05 looking non-apologetic and the sub-I right behind her even less so. As I gulp down my first diet coke of the morning the res doles out the pts to our team; its the 5th day of my third week and she deems me ready to take 3 pts. Lucky for me they are all on the pseudopsych floor just next to the call room.
I settle into what I'll call PsychBuilding and get my first pts chart. Tina** is a 26 yr old woman who presented with drug overdose of her antidepressant, her son's seizure meds, ambien, and a triptan she takes for migraine solely because she knew it interacted with her antidepressant. I saw her a few times last week when she first came in but my attending thought the case was too boring for me and switched me to some others; since then the mid-month attending switch happened and my res gave me back to Tina. She was pretty cold last week but came around quickly once she saw that I wasn't judging her for her suicide attempt. Having currently 3 suicide pts on our service I've come to the realization that doctors take this shit personally - anyone who harms their bodies with intent like Tina or noncompliance gets this reaction from doctors like they are actually giving their blood pressure meds to the doctor's puppy instead of merely neglecting to refill the prescription.
This morning however was Tina's 9th day in the hospital and she was pissed. The first two days she was here she was intubated and seized a few times - apparently drugs are bad - but since then she's been laying in bed waiting for transfer. I gently prodded her awake at the fresh hour of 7:30 and once she blinked her sleepy eyes she started going off about how her psychiatrist consult is trying to kill her by not getting her into the inpt facility she wants to go to and how we aren't doing a single thing for her. That actually isn't true - not about the consult, I don't really know if Dr. StandsInTheDoorway is trying to kill her or not - but we are doing a single thing for her: her bp was in the 140s so we prescribed a low dose of hctz. Other than that we are waiting for her to get a psych transfer to an inpt facility, and until then we are feeding her three meals a day and keeping a 1:1 watch on her in case she gets her hands on some more migraine medicine. (The 1:1's love when we come to see the pts because they get to go pee! They are really excited about it!!)
I told Tina I'd put her complaints in her chart - which I did - and examined her pupils, heart, lungs, abdomen, and checked for edema. This is what it looks like in her chart:
PE gen: well-appearing young female in NAD, AAOx3
HEENT: PERRL, sclera anicteric, mucus membranes intact
CV: RRR, no murmurs, rubs, gallops or thrills appreciated
Pulm: CTA [clear to auscultation]
Abd: + BS 4 quadrants, soft, ND, NT, no hsm [nondistended, nontender, no hepatosplenomegaly]
Ext: no c/c/e [cyanosis, clubbing or edema]
This is what you get if you are actually 100% physically healthy and waiting a week for transfer. I made my sad sorry-you-aren't-enjoying-your-stay look and waited for her to get out the rest of her morning angst and headed out to write my note.
I got out Ronald's chart next. Ronald is a 30-something black male who p/w epigastric pain and shaking of his hands. He usually drinks a 6-pack of beer/day but stopped around Monday, started shaking on Wednesday and presented to the ED on Thursday. (Ok folks, what's the treatment plan for acute pancreatitis?) When I saw him on Thursday he was not looking well, we had him on a banana bag (saline, thiamine, folate, multivitamin) but it was probably more withdrawal than his pancreas that was hurting him. I went in with Res. This morning he had only a little bit of pain, and was hungry. Res told him that if he felt ok to eat that we would start giving him food.
Ok so last night I decided to read up on pancreatitis because Dr. Attending told us that she would pimp us on it today. Treatment for pancreatitis should be NPO to give the pancreas a break, and generally unless its necrotizing it resolves on its own. Give morphine as needed, and in Ronald's case he gets benzos for his withdrawal - ativan and librium on a standing basis. When we left Ronald's room I asked as politely as I could if it would be ok for us to give him PO, or if we should keep giving his pancreas a break. Res said if his pancreatitis was still bad he wouldn't want to eat, and she put in the order for PO.
Third and my last patient of the morning was Ms. Helen. Ms. Helen is a 49 yo divorced mother of two who presented after injecting herself with 90 units of her son's insulin in a suicide attempt, which resulted in a seizure. Several hours later she was able to call 911 and get herself to the hospital. Today was her 3rd day here and she was looking well. I saved her for last because she is my favorite patient, she is so sweet and pleasant I wonder why anyone would ever want to hurt her, including herself.
I'm worried about Ms. Helen. I've been following her the few days that she's been here and while she brightens up my day and makes me feel good about myself, I'm worried that she's in some denial right now. Here is how the typical exchange goes:
J Ms. Helen? Good morning.
H (waking) Good morning dear! Look at that smiling face!
J How are you doing today?
H Oh I'm doing fine. I'm much better. But how are you doing?
J Well this morning is dragging a bit-- (wait, she is the patient.) Any pain today?
H Not really, my calves feel much better, they aren't as tight. What is your day like today? Long day?
J Well tomorrow we are on call . . .
H On a Saturday? My they work you so hard, don't they?
J It's a lot of work but I am really enjoying it. (Back to the patient, damn it!!) How is your tongue feeling today?
H I think it's healing, but it still hurts.
Ms. Helen's tongue hurts because she bit it pretty hard during her seizure. Her calves are tight because her muscles contracted so hard during her seizure that she had rhabdomyolysis. (What is the number 1 cause of rhabdo in the US?) When she came in, her CPK was elevated in the 3000s so as opposed to Tina, we are medically treating her, bolusing her with fluids to get it down, before she can be transferred to inpt.
Ms. Helen's physical exam was benign, except that I'm pretty sure I heard an S4 at the left sternal border. I don't know why she should have a gallop or how I could be the only one to exam her to actually hear it, but I note it in her chart anyway. I stay in her room talking to her (me desperately trying to keep the conversation on her) until it's time for rounds at 10.
Part II: Rounds, coming soon.
** Names have been changed, and while I usually try to refer to my patients by their last names I'm only using first names for added privacy.
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