Over time.

I had a very good one and a half days.

They'd probably not be very good by everyone's standards as I've been in the hospital for 26 of the past 33 hours.

So here's how that happened. Yesterday started at 7:30 with critical care rounds again, I was pretty tired after around four hours of sleep - it had gotten rather hot and humid in Chicago that night and I needed to wait for Monday's episode of Heroes to download and be watched, obviously. But it went on to be a pretty normal day on the heart failure team. I was still enjoying having a load of time to go to all the conferences, with ample time to check on the three patients on our service. Jess was in clinic, but that didn't matter too much. It only meant that we'd be rounding a tiny bit later than we were used to, started maybe at around 3pm. A patient from the critical care unit was in surgery at that time and on our way to a lecture by a German liver surgeon we met his family. News from the OR had thus far been good, except for the fact that he was oozing blood just about everywhere, since he was on argatroban being heparin-intolerant which is non-reversible. So Brainy answered their questions and told them that they'd just have to wait for the bleeding to stop and that things would be fine. Even at that point in time, she was a little too definite with that last statement for my tastes when talking about a very sick patient from the unit undergoing open heart surgery.

Brainy and I went to the lecture, we were sitting rather isolatedly amidst all the surgeons. As it seemed, Brainy really didn't have any barriers when it comes to hierarchy and the likes. It was awesome. From the way we talked, joked around and exchanged candy in there she might as well have been a medstudent or I may have been an attending or we could basically just have been friends. I mean I really appreciate it and I'd love to see it the same way when or if it ever will be the other way around, with me not on the bottom end of the hierarchy I mean. Unfortunately, Brainy was paged during the lecture that the patient had died on the table, so she left and brought the bad news to the family.

Now, CS had told us two days before that she had changed to the cardiology inpatient service and was going to be on call yesterday. There were no U of C medstudents with her that night so she had invited any two of us to join her and admit cardiology patients that may come in. She was also planning on continuing the little EKG tutorial she had once started with us at six and had asked us to decide upon the two of us that would be on call with her yesterday. I figured, we might as well do that together during the tutorial since I expected all of us to be there. Unfortunately, I learned through a page during the lecture by the German guy that EKGs were cancelled. During the day, some of us had talked about who wanted to go on call and it seemed that not all were interested to do it and people from the second wave of the German invasion were kind enough to say that they'd probably have more opportunities to get a taste of on call inpatient admissions. Nevertheless, when I paged CS after the lecture at 6pm, I fully expected the jury still to be out on who'd be doing it.

"Philip, yes. Come down to the ER, Nema's already here and I have a patient for you."

So that was that then, it seemed.

Apparently though, my questionably bad luck with on call nights has turned since our service got slammed last night. CS was actively and actually sweating with the number of patients pouring in and that was the main reason why I was actually in the hospital until almost midnight - so six hours later. CS would not let me see more than one patient, but she wanted to hear my entire presentation on her and go through assessment and plan before she'd let me present to the attending the next morning. That was not an easy thing to get done while new patients required a cardiology bed left and right and CS was wheathering the storm. Still, she took a remarkable amount of time to listen to our presentations and give us hints and corrections for when we'd present to the attending the next day. So apparently the deal was that I should just see one patient and then go home - which is what I did. From what I heard from CS, their attending was going to arrive around 9 the next day and I was to present the patient I saw during their rounds which would be around then.

So I went home and slept. Critical care rounds this morning had unfortunately been pushed up to 7am, so I guess I wasn't really all that fresh again when I came to the hospital this morning. This time though, I arrived before Brainy (so far they had always been rounding for at least five minutes before I came stumbling through the door). So I paged my new fellow on the general cardiology consult team (because I was actually switching teams today, from heart failure to general cardiology). I had never seen her or heard of her in the hospital - I guess she must have been away, maybe on vacation before. I should ask her about that. When Brainy came, we rounded for just half an hour until we went up to cardiology case report conference at 7:30. The cases were pretty interesting. At 8:30, the conference was done. Walking out of the conference room, Brainy saw the intern that was going to be on cards consults with me and introduced us. While we were still walking down the halls, I got a page from CS at 8:36 reading "Phil, rounds in 5th fl WR now. Thx, CS".

Uhm, ok. So I went to the workroom where last night's team was assembled - CS, the two interns, Nema and myself. CS asked me whether I had checked up on my patient and was displeased to hear that I hadn't - I thought I still had time. One of the interns had grabbed the morning vitals and labs on the patient though and kindly brought me up to speed before the attending came. When he did, we went to a little windowless conference room (apparently nicknamed the "Bat Cave" by some as I had learned the night before), sat down and got introduced. The attending asked for our names and pager numbers. At first, I said he wasn't going to need my pager since I wasn't going to be on his service. Turns out I was wrong, though, since he would also be the attending for the general cardiology consult service.

Speaking of which, I hadn't heard back yet from the fellow of that service that I had paged at 7am. But hey, I tried to touch base .. what more could I do. So after that short introduction, the on call team started rounding with the attending and I just followed along, since I didn't have anything else to do anyway. While they were seeing the first patient, which was not mine, I paged my new fellow again and this time she did respond. I talked to her on the phone while the team was rounding, it was around 9:20. The new fellow, let's call her Missy, said she was just on her way in and that I didn't have to come in this early. I told her that I had just come for CCU rounds and the conference. She said "oh, OK" and then asked me to just hang out until she'd get there. I told her what I was doing, that I was rounding with the on-call team from last night because I had a patient to present. At that point she got confused and asked who I was again. I reiterated and explained the whole thing, emphasizing the fact that me staying at night was an exceptional thing but already then I feared she would expect me to know much more about what I was doing than I actually did. We saw another patient first, then Nema's and only then did we come up to mine, it was around 10:30 then. Now here's where the main part about the goodness started - I think the presentation went very well. It didn't seem like I had forgotten anything major and sometimes must even have sounded like I knew what I was saying. Having just come off the heart failure team, I was even able to back up some of what I said in the discussion of the plan for the patient with actual trial data. Of course the attending knew much more about the subject and taught us some new stuff but I still think it went exceptionally well. Unfortunately, now I seemed to have two people to convince not to expect too much from me since I seemed to have made rather favorable first impressions on both the fellow and the attending. They're going to be so much more disappointed when they find out the truth about me after initially having this distorted picture of me being highly competent. I would have been much more comfortable if they took me for the rookie I am.

Unfortunately, when I met my current team, fellow and intern a little bit later, Missy handed me an EKG strip to interpret. Despite the fact that I strongly emphasized how little I knew (which as feared, Missy didn't believe) I interpreted the strip correctly as being sinus with incomplete left bundle branch block that turned into overdrive-suppression by a ventricular automaticity focus that paced the heart only slightly above the sinus rate. At that point, Missy completely stopped listening to me when I pleaded that I didn't know what I was doing. So now I was screwed.

She gave me one of the new patients she got today to see and while I was presenting this patient to the attending, I got a glimpse of what was to come when they finally realize the extent of my knowledge. Missy asked me what I thought of the use of "Cardizem" in this case. I truthfully replied that I didn't even know what that drug was. At that moment, I caught a short glimpse of astonished jaw-dropping on Missy's side. I asked her whether that was a brand name and she apologized with a hint of relief that it was diltiazem. After that, I could answer her question somewhat satisfyingly but I'm not sure I want to see what happens when they find out how vague my understanding of things like the anatomy of coronary arteries or cardiology in general actually is.

Still, today was a good day and I can now comfortably watch the new episodes of 24, House and Gilmore Girls, since I don't have to be back in that place until 9am.

Yay!

Blog to you later.