Hey, reader.
I think it is time to stop giving you exact reports of what I've been doing on an hourly basis. It's way too much for me to write and I'm sure it has been way too much for you to read for a while now.
Instead, and as I have been prompted to do so by one of the people sending us here, I will try and summarize my impressions of this past week.
Was it as expected? Yes and no.
Consult service is like what I imagined it'd be. Checking on patients that present a problem with your "area of expertise", hardly getting your hands dirty while giving them a minimal physical (sometimes from the door, if you're really pressed for time or uninterested) and getting an overview of what's going on with the patient. Then discussing what you found with your attending, interspersed with a lot of "ooohhh no"'s and "they did WHAT?" and "what service is this patient on? Surgical? Ouch! This patient needs a real doctor." thrown in by him. The attending does a good amount of teaching during rounds, as I had reported. It does feel like Jenn, the fellow, would like to do the same in principle, but I hardly see her during the day except for rounds. That is because usually so far neither of us has had time for that.
And that's the part I had not expected - seeing the first patients by myself starting on the morning of my arrival. Actually, thinking back now, it had been the same way in New York. I remember having had no idea what it should include when they said "see the patient in bed 16". At the time, I could easily attribute that to the fact that this ER was busy and there simply wasn't time to hold every medstudent's hand and show him where the bednumbers, IV lines or urine containers or even admission forms would be. Likewise, I got lost initially looking for my first patient here, it took quite a while finding everything I needed in the charts and the computer and up until rounds that day I still had no idea how thorough I should be with the history and physical and I didn't know the way to the room where I could spin down the urine sediment.
I guess I hadn't expected my start here to be equally confused and uninformed as back then because of all the preparation that went into it beforehand and because of the fact that contrary to New York this was part of a "program" and I felt taken care of well because people were organizing and worrying about things for me. And I'm not complaining about that - they did a wonderful job at it. I guess what I'm saying is this lulled me into a feeling that things would continue as well-organized and as manageably as before.
But enough about that - some cold water never really hurt anyone and I do get the feeling that just like in NYC the curve may be steep but things will be fine very soon. Actually, they're not really bad as it is at least judging from what Jenn and the attending have been telling me. But how much can you rely on that, we're in the States after all - most everything you do will likely be "a superb job".
And it's not like it hasn't been fun so far. Granted, during the majority of the day, I do feel like I have to do three things at once and time is the one thing I wished I had a lot more of. But so far, things have worked out most of the time, sometimes even with a few minutes to spare to eat or read up on something. And that will likely improve as well when I finally start getting things organized and prioritized in my head and I become more efficient in planning my way around the wards in the morning when checking up on old patients and seeing the new ones. And hopefully I will also start to foresee all the questions about a patient that the attending may be going to ask me - this will likely happen just around the time I start being able to actually focus on the medicine - because I will finally have the things surrounding it down.
About the hospital - if you count the buildings adjacent to the main wards, it is quite huge and a poor unsuspecting student that forgot to bring a map may well spend a week or two wandering the convoluted hallways of the adjacent buildings for a week without finding his way back. Note to the three waiting to get here: a pdf version of the map is on the intranet here - I suggest you print it out and have it in your lab coat, I'll send you a copy if I remember when I'm there.
In terms of quality of care, teaching and research I am positively impressed by this hospital. They certainly don't seem to be lacking financially and the atmosphere is very good throughout all activities of daily life of a medstudent. The attendings I have spoken to and talks I have heard so far lead me to believe that this is no small provincial hospital and their motto "at the forefront of medicine" isn't to be taken all that lightly either. Still, even the higher-ups here seem accessible and they are not afraid to joke around with you, pat you on the back or use some time at rounds to privately teach you something.
All in all, things are good.
The thing I'm lacking so far is some social integration - Nema and Borat are way ahead of me with that. With Trillian gone though I suppose it'll only be a matter of time until I will actively pursue this when the ceiling will finally appear to fall on my head. So far it's OK though, I needed the time to do other stuff today anyway, laundry and dishes as well as tv-show episodes were stacking up to be done and seen, I still need some groceries (although not many since I'm getting a lot of nutrition at the hospital) and I'll still be going to Ratner's today for some more basketball and other exercise.
Of the past days, only three things come to mind that I should tell you (and myself, when I read this in five years) about.
Dinner with CS and BT at their place was fun and very good. BT made greek salad and home-made lasagna for us and they had ice cream for desert. We had initially planned to go into a blues bar afterwards that our hosts actually had wanted to go to for a while - but postprandial weakness overcame us and we just moved to the couches where the conversation rapidly deteriorated though, since we ended up discussing the project we are supposed to do that would introduce some form of mentoring into our medschool at home.
In other news, my very first patient turned out to be very interesting - so interesting actually, that my attending keeps asking for a case report to be written on her. After the lab values for vitamin D finally came back it was clear that this was a case of vitamin D toxicity. This lady had been ingesting 50.000 IU of vitamin D every day for a year. That dose should only be given weekly under supervision of a physician. Normal dietary supplements contain 200-400IU max in their daily dose. The half-life of vitamin D is 20-29 days, so this lady's calcium will probably be an issue for a while.
And the third thing I have to report is that I was in this hospital's ED for the first time on Thursday. It looks and feels very similar to the Bronx and brought about many good memories.
Now, dear readers, I retire from blogging to go about my errands. Shouts out to Europe and Bremen today in particular.
Saturday, April 7, 2007
Wednesday, April 4, 2007
Day three
Today was better. Finally less of a haze.
Also, since I didn't have a meeting at 10:30 this morning I finally could go to the so-called "morning report" from 10am-11am.
But first, when I came in this morning, Jenn had another patient for me. After a little begging and convincing she gave in and allowed me to see this patient together with Justin instead of alone so I'd finally see how they actually do these consults.
So after checking in on my patient from yesterday I paged Justin, he said it was fine that we'd see that new patient together and we went to morning report.
This was one of the places where there was free food.
I had a bagel with cream cheese and two glasses of orange juice while listening to someone reiterate the different forms of machine ventilation and their advantages and drawbacks. They do seem to have quite different preferences here from those in Germany but that's not really surprising.
After that, Justin and I went to see that hypertensive patient in one of the ICUs and it seemed that he didn't do too many things differently. When we were just about done with what we could get out of the computer and from the charts the patient just started getting physical therapy, so we went back up to "A700", the residents' area, to read up on the causes of secondary hypertension and wait for lunch and .. uhm .. this noon conference of course.
This one was actually on chronic renal insufficiency. I would have liked to listen to it all but I still had to see both my hypercalcemic and my new hypertensive patient before rounds at 1pm, so I just grabbed a can of soda and one of the hundreds of Potbelly sandwiches lying around (yes! Those delicious ones I told you about weeks ago!), gulped it down and went to see the patients at 12:15.
Contrary to the past two days, I felt better prepared for rounds today even though it were three patients that I would report on. Of course, I still would have liked to have more time to think it all through but at least I wasn't missing anything obvious today that I could have thought of myself. That was a start.
Rounds were good, I had some more answers today and had more instances where it must have at least seemed like I halfway knew what I was talking about.
We actually went to see a renal biopsy Jenn had taken yesterday with a pathologist today. This took place in a room where about a dozen binoculars were connected to a single microscope. I wished our university had that kind of money.
I have to go through this rather quickly since we got done rounding at 4:15pm today and as I said, CS invited us to dinner. It's 4:50pm now and CS is going to pick me up at my place around 5:15pm. Since I'm in the residents' workroom now I'm going to have to get home and changed by then.
So please excuse my brevity but I know that I probably wouldn't get to blog today anymore otherwise.
And Jenn has clinic duty tomorrow and asked that we do show up early tomorrow .. early as in 8-8:30am .. heheh. Bad news is though that Justin is on call tonight, so he will be post-call tomorrow. That means I may get stuck with more than one patient tomorrow morning. So maybe I shouldn't have too much at the bar tonight.
Anyway, have a good night for now.
Also, since I didn't have a meeting at 10:30 this morning I finally could go to the so-called "morning report" from 10am-11am.
But first, when I came in this morning, Jenn had another patient for me. After a little begging and convincing she gave in and allowed me to see this patient together with Justin instead of alone so I'd finally see how they actually do these consults.
So after checking in on my patient from yesterday I paged Justin, he said it was fine that we'd see that new patient together and we went to morning report.
This was one of the places where there was free food.
I had a bagel with cream cheese and two glasses of orange juice while listening to someone reiterate the different forms of machine ventilation and their advantages and drawbacks. They do seem to have quite different preferences here from those in Germany but that's not really surprising.
After that, Justin and I went to see that hypertensive patient in one of the ICUs and it seemed that he didn't do too many things differently. When we were just about done with what we could get out of the computer and from the charts the patient just started getting physical therapy, so we went back up to "A700", the residents' area, to read up on the causes of secondary hypertension and wait for lunch and .. uhm .. this noon conference of course.
This one was actually on chronic renal insufficiency. I would have liked to listen to it all but I still had to see both my hypercalcemic and my new hypertensive patient before rounds at 1pm, so I just grabbed a can of soda and one of the hundreds of Potbelly sandwiches lying around (yes! Those delicious ones I told you about weeks ago!), gulped it down and went to see the patients at 12:15.
Contrary to the past two days, I felt better prepared for rounds today even though it were three patients that I would report on. Of course, I still would have liked to have more time to think it all through but at least I wasn't missing anything obvious today that I could have thought of myself. That was a start.
Rounds were good, I had some more answers today and had more instances where it must have at least seemed like I halfway knew what I was talking about.
We actually went to see a renal biopsy Jenn had taken yesterday with a pathologist today. This took place in a room where about a dozen binoculars were connected to a single microscope. I wished our university had that kind of money.
I have to go through this rather quickly since we got done rounding at 4:15pm today and as I said, CS invited us to dinner. It's 4:50pm now and CS is going to pick me up at my place around 5:15pm. Since I'm in the residents' workroom now I'm going to have to get home and changed by then.
So please excuse my brevity but I know that I probably wouldn't get to blog today anymore otherwise.
And Jenn has clinic duty tomorrow and asked that we do show up early tomorrow .. early as in 8-8:30am .. heheh. Bad news is though that Justin is on call tonight, so he will be post-call tomorrow. That means I may get stuck with more than one patient tomorrow morning. So maybe I shouldn't have too much at the bar tonight.
Anyway, have a good night for now.
Tuesday, April 3, 2007
Day two
Allright, I'll try to do this. The last entry was written in the residents' workroom on the fifth floor - internet is fast there and I needed some uptodate.com information. But let's start at the beginning.
After saying goodbye to Trillian who is on the plane back to Munich for about another hour now, I walked to the hospital today since it was raining. I arrived around 8:45am. Beautiful. I went up to the residents' workroom on the fifth floor and started reading yesterday's patient's labs while paging Jenn to "touch base", as she likes to say. Also I needed to tell her that CS had arranged for me to present one of my old patients to the director of the cath lab at the hospital, as I remembered this morning. That was scheduled for 10:30am-11am. Jenn said that wasn't a problem, she would need me to see another patient before rounds at 1pm though. And she had decided to give "my" patient 20mg of Lasix this morning. So far so good. While I started jotting down the new lab values of my hypercalcemic patient (they draw blood every 8 hours here it seems .. internists ..), I paged the resident, Justin, that I couldn't make it to the conference at 10am for donuts and coffee.
I used the time between 9 and 10am to try and get up to date on the hypercalcemic patient. When I went up to her to give her another physical exam, the girls from physical therapy were just about to start working with her. And I was pleased to see that my theory about physical therapists also seems to hold true in this country.
After a bit of fun with the girls from PT and the obviously improved patient I went back to the workroom to page Carolin and print out my old admission note of the patient I was going to present to the attending from the cath lab. Carolin said on the phone that she'd come to the workroom at 10:20 so I used the time to review the old note - I had seen that patient in November of last year, so almost six months ago. Carolin came and led me to his office, where we waited for him to finish his conference call.
When he was done, Carolin introduced me to the not so tall but in-shape and intimidatingly serious attending. Despite his stern exterior we started out with a friendly but very business-like discussion about how studying and graduating works in Germany, what my own plans were and what I'll be doing here in Chicago. He probably wasn't so pleased to hear that internal medicine was actually a required part of the final year and that in that respect I hadn't chosen to be in his specialty. But he didn't let it show. Anyway, he then asked me whether we should focus on my written note or on my oral presentation. I chose the oral presentation, since I wouldn't really be doing pure admission notes here on the consult service anyway.
So I started to present that patient as I normally would and the attending took notes. When we were briefly interrupted by a phone call, I had a chance to look around his office and see the same kind of intimidating plaques and certificates on the wall, firmly linking this director of the cath lab to a certain medschool in Boston and one of the many awards was indeed for teaching. I finished my presentation and he, being a true American, started by saying that I did "a perfect job" before starting to criticize what I did. But I think it went pretty well nonetheless.
After a pleasant goodbye with him at 11:15 I went back to the workroom once more. I had another hour and 45 minutes for my second patient. She was going to be a bit more complicated than the last one, having a sudden rise in serum creatinine after a cycle of multiple chemotherapy drugs last week for her Hodgkin's lymphoma. As I started reading about her on the computer in the workroom, something weird happened.
Green-grayish goo was sprayed in thick drops over my notes, my computer and me from the left. This was accompanied by a rather big commotion in the room, there were about ten people in the tiny room rushing towards the resident next to me who apparently had lost her cup of broccoli soup out of her grip, causing it to fall down and land with a splash. She sprayed a good portion of it on herself, but considerable amounts also landed on my head, my keyboard and the note I was writing the new patient on. Luckily, almost miraculously, only minimal amounts had found my pants and coat. The people in the room were busy cleaning the resident that dropped the soup, jokingly asking her whether she seized. No one really paid attention to me as I got Kleenexes out of my pocket and started crisis management. After clearing the worst parts of the soup off of myself and the computer I tried to save the note but it was beyond presentable unfortunately.
So I got up and set out to find Jenn's office by myself for the first time. After several pit stops on maps posted at the elevators and discussing the map with one secretary I did find the place eventually. In there, I got a new inpatient consult sheet. With that, I went back to the workroom. It was noon by the time I had the labs and similar info on that sheet and was up on the sixth floor to see the patient. Before even going to her I paged Jenn again and expressed my doubts that I could come up with a very thorough or even intelligent workup, assessment and plan in the remaining hour by myself. Jenn regretted to inform me that she had two new consults in the meantime and really couldn't come to my rescue. So I said I'd do the best I could.
And not surprisingly I wasn't feeling very good about my second patient on the way to rounds, since even on the way there I could think of at least three things that I had forgotten to look up on this patient. And they were obvious things because even I could think of them. Things like how long she had been on her present medication of antibiotics, antifungals and antivirals. Or her exact liquid intake and output over the past few days. Kidneys, dude. Think! Yet again, after the rest of my presentation, these things did, of course, come up. The attending smiled and said that "we will have to get more info on this patient" - I'm not sure if he was disappointed, if he was he was rightfully so, but he didn't show it.
Somehow I still feel in this haze at the hospital - I can't really think straight, especially not about medicine. I constantly feel under time pressure and a plethora of everyday things is still totally unfamiliar. I lose my bearings walking around the place, something I don't usually do. I feel like I can just about stem the tasks I am given in the time I have but nothing gets done thoroughly. And if something unexpected happens, like broccoli soup, it can seriously mess with my timetable.
I think there is two things that I'm lacking and if I had at least one of them, I wouldn't miss the other one so much. One is time, the other one is a working familiarity with all things renal. After four months of surgery and four months of anaesthesia, now several years after the semester I learned medicine in, I feel about as far away from nephrology as from Munich.
Anyway. Since Justin, the resident, had seen another two patients too we actually had to present five new patients total to the attending, including discussing what happened to the old ones. After discussing what to do with them intermixed with a lot of teaching from the attending as usual, it was 2:30 when we got up from the office to actually start rounding them. First, we looked at their urine samples in the lab, though, as always. Then we visited all of them individually. On the way there the attending kept quizzing us, that was becoming a habit. Oh and he did remember to ask me about the assignments he had given me yesterday, the effects of different diuretics on serum calcium and the effects of calcium on the ECG.
And I do have to confirm yet again the old prejudice against American medical professionals. Physiology is not their forté. The right answer to the question "how does digoxin work?" is not "it inhibits the sodium-potassium ATPase" but "it increases contractility and decreases AV conduction".
So you can actually replace the question "how does xy work" with "what are the effects of xy on the system". This is valid even if the question is rephrased to a "why does xy do yz?". For example - if asked "why do thiazide diuretics lead to hypercalcemia" the right answer is actually "because they lead to increased calcium reuptake". People start looking at you funny if you start with the answer any German teacher would expect by talking about basal or luminal transport systems in the distal tubule and ionic potentials driving the calcium out.
Results count here, apparently. And they do have a point, that is what does count in the end and that is what you should really try not to get wrong by trying to explain it from the bottom up and getting confused. The attending does seem to have a weakness for pathophysiology though and is thoroughly pleased if I sometimes do know why something is the way it is.
Seeing all those patients and finishing up my note on the Hodgkin patient that was lacking lots of important stuff as well as looking at some more urine took until 5. After that, I did run down to "au bon pain" in the lobby and got myself a cookie before I went back up to the resident workroom and read a bit about Fanconi syndrome, my assignment for tomorrow, taking a break to write the first blog entry today that is right below here.
By now, Trillian has informed me that she has safely landed in Munich and is on her way back to town. In all likelihood, CS and BT will have all three of us over tomorrow for a barbecue (if the weather permits) and hitting a bar afterwards.
Chicago kicks butt! (Insert picture of me complacently waving to the east coast here).
Thank you Amsterdam and good night
After saying goodbye to Trillian who is on the plane back to Munich for about another hour now, I walked to the hospital today since it was raining. I arrived around 8:45am. Beautiful. I went up to the residents' workroom on the fifth floor and started reading yesterday's patient's labs while paging Jenn to "touch base", as she likes to say. Also I needed to tell her that CS had arranged for me to present one of my old patients to the director of the cath lab at the hospital, as I remembered this morning. That was scheduled for 10:30am-11am. Jenn said that wasn't a problem, she would need me to see another patient before rounds at 1pm though. And she had decided to give "my" patient 20mg of Lasix this morning. So far so good. While I started jotting down the new lab values of my hypercalcemic patient (they draw blood every 8 hours here it seems .. internists ..), I paged the resident, Justin, that I couldn't make it to the conference at 10am for donuts and coffee.
I used the time between 9 and 10am to try and get up to date on the hypercalcemic patient. When I went up to her to give her another physical exam, the girls from physical therapy were just about to start working with her. And I was pleased to see that my theory about physical therapists also seems to hold true in this country.
After a bit of fun with the girls from PT and the obviously improved patient I went back to the workroom to page Carolin and print out my old admission note of the patient I was going to present to the attending from the cath lab. Carolin said on the phone that she'd come to the workroom at 10:20 so I used the time to review the old note - I had seen that patient in November of last year, so almost six months ago. Carolin came and led me to his office, where we waited for him to finish his conference call.
When he was done, Carolin introduced me to the not so tall but in-shape and intimidatingly serious attending. Despite his stern exterior we started out with a friendly but very business-like discussion about how studying and graduating works in Germany, what my own plans were and what I'll be doing here in Chicago. He probably wasn't so pleased to hear that internal medicine was actually a required part of the final year and that in that respect I hadn't chosen to be in his specialty. But he didn't let it show. Anyway, he then asked me whether we should focus on my written note or on my oral presentation. I chose the oral presentation, since I wouldn't really be doing pure admission notes here on the consult service anyway.
So I started to present that patient as I normally would and the attending took notes. When we were briefly interrupted by a phone call, I had a chance to look around his office and see the same kind of intimidating plaques and certificates on the wall, firmly linking this director of the cath lab to a certain medschool in Boston and one of the many awards was indeed for teaching. I finished my presentation and he, being a true American, started by saying that I did "a perfect job" before starting to criticize what I did. But I think it went pretty well nonetheless.
After a pleasant goodbye with him at 11:15 I went back to the workroom once more. I had another hour and 45 minutes for my second patient. She was going to be a bit more complicated than the last one, having a sudden rise in serum creatinine after a cycle of multiple chemotherapy drugs last week for her Hodgkin's lymphoma. As I started reading about her on the computer in the workroom, something weird happened.
Green-grayish goo was sprayed in thick drops over my notes, my computer and me from the left. This was accompanied by a rather big commotion in the room, there were about ten people in the tiny room rushing towards the resident next to me who apparently had lost her cup of broccoli soup out of her grip, causing it to fall down and land with a splash. She sprayed a good portion of it on herself, but considerable amounts also landed on my head, my keyboard and the note I was writing the new patient on. Luckily, almost miraculously, only minimal amounts had found my pants and coat. The people in the room were busy cleaning the resident that dropped the soup, jokingly asking her whether she seized. No one really paid attention to me as I got Kleenexes out of my pocket and started crisis management. After clearing the worst parts of the soup off of myself and the computer I tried to save the note but it was beyond presentable unfortunately.
So I got up and set out to find Jenn's office by myself for the first time. After several pit stops on maps posted at the elevators and discussing the map with one secretary I did find the place eventually. In there, I got a new inpatient consult sheet. With that, I went back to the workroom. It was noon by the time I had the labs and similar info on that sheet and was up on the sixth floor to see the patient. Before even going to her I paged Jenn again and expressed my doubts that I could come up with a very thorough or even intelligent workup, assessment and plan in the remaining hour by myself. Jenn regretted to inform me that she had two new consults in the meantime and really couldn't come to my rescue. So I said I'd do the best I could.
And not surprisingly I wasn't feeling very good about my second patient on the way to rounds, since even on the way there I could think of at least three things that I had forgotten to look up on this patient. And they were obvious things because even I could think of them. Things like how long she had been on her present medication of antibiotics, antifungals and antivirals. Or her exact liquid intake and output over the past few days. Kidneys, dude. Think! Yet again, after the rest of my presentation, these things did, of course, come up. The attending smiled and said that "we will have to get more info on this patient" - I'm not sure if he was disappointed, if he was he was rightfully so, but he didn't show it.
Somehow I still feel in this haze at the hospital - I can't really think straight, especially not about medicine. I constantly feel under time pressure and a plethora of everyday things is still totally unfamiliar. I lose my bearings walking around the place, something I don't usually do. I feel like I can just about stem the tasks I am given in the time I have but nothing gets done thoroughly. And if something unexpected happens, like broccoli soup, it can seriously mess with my timetable.
I think there is two things that I'm lacking and if I had at least one of them, I wouldn't miss the other one so much. One is time, the other one is a working familiarity with all things renal. After four months of surgery and four months of anaesthesia, now several years after the semester I learned medicine in, I feel about as far away from nephrology as from Munich.
Anyway. Since Justin, the resident, had seen another two patients too we actually had to present five new patients total to the attending, including discussing what happened to the old ones. After discussing what to do with them intermixed with a lot of teaching from the attending as usual, it was 2:30 when we got up from the office to actually start rounding them. First, we looked at their urine samples in the lab, though, as always. Then we visited all of them individually. On the way there the attending kept quizzing us, that was becoming a habit. Oh and he did remember to ask me about the assignments he had given me yesterday, the effects of different diuretics on serum calcium and the effects of calcium on the ECG.
And I do have to confirm yet again the old prejudice against American medical professionals. Physiology is not their forté. The right answer to the question "how does digoxin work?" is not "it inhibits the sodium-potassium ATPase" but "it increases contractility and decreases AV conduction".
So you can actually replace the question "how does xy work" with "what are the effects of xy on the system". This is valid even if the question is rephrased to a "why does xy do yz?". For example - if asked "why do thiazide diuretics lead to hypercalcemia" the right answer is actually "because they lead to increased calcium reuptake". People start looking at you funny if you start with the answer any German teacher would expect by talking about basal or luminal transport systems in the distal tubule and ionic potentials driving the calcium out.
Results count here, apparently. And they do have a point, that is what does count in the end and that is what you should really try not to get wrong by trying to explain it from the bottom up and getting confused. The attending does seem to have a weakness for pathophysiology though and is thoroughly pleased if I sometimes do know why something is the way it is.
Seeing all those patients and finishing up my note on the Hodgkin patient that was lacking lots of important stuff as well as looking at some more urine took until 5. After that, I did run down to "au bon pain" in the lobby and got myself a cookie before I went back up to the resident workroom and read a bit about Fanconi syndrome, my assignment for tomorrow, taking a break to write the first blog entry today that is right below here.
By now, Trillian has informed me that she has safely landed in Munich and is on her way back to town. In all likelihood, CS and BT will have all three of us over tomorrow for a barbecue (if the weather permits) and hitting a bar afterwards.
Chicago kicks butt! (Insert picture of me complacently waving to the east coast here).
Thank you Amsterdam and good night
Day one
Hello dear reader, the rotation has started.
I am - of course - pressed for time, still I want to try and write down the details of the past two days before I forget everything.
So, yesterday started at aroud 7:50am, when I met Nema and Borat in full medstudent gear
outside the building where we were supposed to hand our checks in. $26 per month each for something called a "health service fee", $200 as collateral for the pager we'd receive as well as $10 air service fee. Luckily, CS had been so kind as to provide these checks for me in exchange for cash (since I get cash without any fees here as opposed to money orders).
Anyway, we waited outside the offices for as long as seemed appropriate and entered them at 8am sharp with two other visiting medstudents - one other actually from Stuttgart, studying in Berlin. Must have felt like a German invasion to the one guy from the U of Michigan. Rightfully so.
We received paperwork entitling us to pick up our IDs and pagers
and all of us together went a few blocks south to pick them up.
Note the back of the ID in the meantime.
After that, we entered the main hospital building and called what we assumed was a secretary in the internal medicine department from the main lobby. I only got voicemail, but when Borat tried a while later he actually got said secretary. She was very nice and gave us pager numbers of members of the teams we'd be with.
We paged them in turn - I was actually given the numbers of my resident and fellow, somehow the secretary seemed to know that the resident wouldn't really be the one I'd need. I spoke to the resident first, also a nice guy, who explained to me though that he had clinic duty this morning and that I should page the fellow. After I had done that, Nema paged her own team and picked up on the first return call. After my fellow, Jenn and Nema had taken about a minute to find out they were talking to each other in error, Nema handed me the phone and Jenn explained that she was swamped with consults and that I should come up to her onto the ward.
Right there I was glad CS had given us a rudimentary tour of the medical wards, because I almost didn't get lost on the way there. Anyway, when I was on the ward and asked for Jenn, she was indeed there.
Pretty much right off the bat Jenn reminded me of "the cute resident" in New York. She talks faster than I can think, only interrupted by her almost continuously beeping pager. After a quick hello and an even quicker introduction to the computer system she apologized and explained that she had just started on the service today. That meant she was just handed a stock of 18 patients that she needed to get semi-acquainted with plus three new requests for consults this morning. She apologized again but asked me to see one of the three patients right away, she wouldn't have time to explain things right now.
Ummmm, kay.
She gave me a "nephrology initial inpatient consultation" sheet, wrote name, medical record number and room number in the top right corner and gave me directions towards where she'd be. It was quarter past ten by now and she said I had until quarter to noon to get this patient's history and see why she was hypercalcemic and in acute renal failure. She gave me a quick rundown on the patient's story, including the fact that she was deaf and mute. Great.
So I headed down to her floor and took about an hour to work through the stuff I could find in her chart and on the computer. After I had her chief complaint, history of present illness, past history, family history, social history, allergies, medication, review of symptoms (since I wasn't going to be able to talk to her), vital signs, lab values and radiology reports all assembled from somewhere and copied onto my sheet, I actually went in to examine her. Of course, she immediately started talking to me. Or trying to. She mumbled incomprehensibly and pointed to both her feet alternatingly. My gesturing in response didn't help much. It wasn't going to work this way.
I went back out and found the nurses that had worked with her, asking them whether they understood what she said or had found another way of communication. They hadn't. So this actually wasn't going to work.
Oh well.
Using gestures, I could kind of make her do just about what I needed her to in order to give her a quick physical. I jotted down what I had found and then paged Jenn again, it was now about a quarter to noon. She asked me whether I knew how to get urine from her foley for "us" to look at. Well, uhm, I didn't really. So she came up and took the urine, then we rushed down incredibly convoluted corridors to her office, dropping the urine in a room on the way and making another quick pit stop at the dialysis unit where she apparently also had to do something. She took a stack of paper from her office and led me to a conference room, where a lot of people in white coats were already sitting.
I didn't take in much of the scene anymore since there was pizza on the table. Mmmmmh. Jenn told the group who I was and the attending at the head of the table invited me to grab some pizza and a soda, have a seat and enjoy the show. I complied most willingly.
The "show" was actually Jenn handing out pieces of paper that showed nothing but the age, gender and lab values over time of two patients. The residents and fellows at the table took turns to look at some of these values and give their opinions on it. I munched pizza happily. They tried to find a diagnosis and guessed at what was happening to the patient in terms of course of the illness and treatment outcome based only on the lab values, primarily electrolytes.
These guys knew what they were talking about.
I was for the most part barely able to keep up with them, actually still thrown off by the mere fact that they call Na "sodium" and K "potassium", which I should really have gotten used to by now. They were using lots of other abbreviations, presumably kidney stuff, only part of which I could figure out on my own. Naturally, I was never called upon by the attending to contribute anything to the discussion and I didn't. Maybe I should have, because the group spent a considerable amount of time discussing some "outlying" values at one time point of the second patient. They were apparently so wrapped up in their theories on the electrolytes and why this was going up here and dropping there that they didn't notice that at this time point that they found so particularly strange, everything was lower than before except for sodium and chloride, which were higher.
As I'm sure is evident to you now, this blood draw had been watered down by mere saline solution. I didn't dare to chime in on such a high-class meeting on my very first day so I listened to their discussions on these strange, aberrant values until someone else slapped themselves on the forehead and found the technical, yet simple answer. See, mom? I can shut up! ;)
That conference was over at around 1:15pm. Jenn told me on the way out that "rounds" would be at 1:30pm. Not knowing anything about how things would work here, I asked who is actually rouding with whom. She said "the attending with us". Ah great so I'd get to present my patient right away .. thanks for the warning.
When we sat in the attending's office a short time later we were joined by the resident who had thereby finished his clinic duties for the week. As it turned out, the attending was also new on the service so he would have to hear about all the patients. He wanted to start with the new ones though. Ah great.
At least, Jenn also had a patient to present so I happily left it to her to start off. And she did. It was pretty quick, but the attending - while seemingly a very friendly but also extremely competent guy - kept asking her difficult "teaching" questions. I was trying to listen and follow for most of the time, but I was distracted by my own case that I was thinking about and growing ever wearier of presenting later. At the point where I additionally glanced up to one of the frames hanging in the attending's office that showed he was one of "America's top physicians", he shot a question at me. "What else could it be, Philip?"
No clue. This is not my league. At that point I wasn't even sure whether I could roughly point at a person's kidneys.
When I admitted that I had no idea, it luckily didn't seem a big deal.
After Jenn's presentation, they were both looking at me expectingly. Thankfully, the attending said after a short pause, "don't worry, I won't be as hard on you as I was on her".
And he wasn't. It went quite OK. And as he asked me a few more questions - some of which I was even able to get partially right he seemed overjoyed.
After we had discussed the patients for today, we actually went to see most of them on the floors. This gave me a chance to get more acquainted with the resident. A rather quiet but very friendly guy - future cardiologist - who later on gave me a run down on what conferences to be at at which times in order to get through the week with the maximum amount of free food. My kind of guy!
After rounding, the day was over. At about 4pm. When I asked when and where I'd have to be the next morning, Jenn said I could come "whenever I wanted", I'd just have to check in on my patient again and it'd be nice if I touched base with her some time around 8:30 or 9. Hooray :D
So I went home happy.
This was going to be the last day that Trillian was in the US, so I called around and we arranged for a little impromptu party at Nema's place.
We bought some drinks and had a lot of fun together until Trillian and I felt that we couldn't keep Nema up anymore at 12:30, since her day would apparently start at 7:30 the next morning.
I am - of course - pressed for time, still I want to try and write down the details of the past two days before I forget everything.
So, yesterday started at aroud 7:50am, when I met Nema and Borat in full medstudent gear
outside the building where we were supposed to hand our checks in. $26 per month each for something called a "health service fee", $200 as collateral for the pager we'd receive as well as $10 air service fee. Luckily, CS had been so kind as to provide these checks for me in exchange for cash (since I get cash without any fees here as opposed to money orders).Anyway, we waited outside the offices for as long as seemed appropriate and entered them at 8am sharp with two other visiting medstudents - one other actually from Stuttgart, studying in Berlin. Must have felt like a German invasion to the one guy from the U of Michigan. Rightfully so.
We received paperwork entitling us to pick up our IDs and pagers
and all of us together went a few blocks south to pick them up.
Note the back of the ID in the meantime.
After that, we entered the main hospital building and called what we assumed was a secretary in the internal medicine department from the main lobby. I only got voicemail, but when Borat tried a while later he actually got said secretary. She was very nice and gave us pager numbers of members of the teams we'd be with.
We paged them in turn - I was actually given the numbers of my resident and fellow, somehow the secretary seemed to know that the resident wouldn't really be the one I'd need. I spoke to the resident first, also a nice guy, who explained to me though that he had clinic duty this morning and that I should page the fellow. After I had done that, Nema paged her own team and picked up on the first return call. After my fellow, Jenn and Nema had taken about a minute to find out they were talking to each other in error, Nema handed me the phone and Jenn explained that she was swamped with consults and that I should come up to her onto the ward.
Right there I was glad CS had given us a rudimentary tour of the medical wards, because I almost didn't get lost on the way there. Anyway, when I was on the ward and asked for Jenn, she was indeed there.
Pretty much right off the bat Jenn reminded me of "the cute resident" in New York. She talks faster than I can think, only interrupted by her almost continuously beeping pager. After a quick hello and an even quicker introduction to the computer system she apologized and explained that she had just started on the service today. That meant she was just handed a stock of 18 patients that she needed to get semi-acquainted with plus three new requests for consults this morning. She apologized again but asked me to see one of the three patients right away, she wouldn't have time to explain things right now.
Ummmm, kay.
She gave me a "nephrology initial inpatient consultation" sheet, wrote name, medical record number and room number in the top right corner and gave me directions towards where she'd be. It was quarter past ten by now and she said I had until quarter to noon to get this patient's history and see why she was hypercalcemic and in acute renal failure. She gave me a quick rundown on the patient's story, including the fact that she was deaf and mute. Great.
So I headed down to her floor and took about an hour to work through the stuff I could find in her chart and on the computer. After I had her chief complaint, history of present illness, past history, family history, social history, allergies, medication, review of symptoms (since I wasn't going to be able to talk to her), vital signs, lab values and radiology reports all assembled from somewhere and copied onto my sheet, I actually went in to examine her. Of course, she immediately started talking to me. Or trying to. She mumbled incomprehensibly and pointed to both her feet alternatingly. My gesturing in response didn't help much. It wasn't going to work this way.
I went back out and found the nurses that had worked with her, asking them whether they understood what she said or had found another way of communication. They hadn't. So this actually wasn't going to work.
Oh well.
Using gestures, I could kind of make her do just about what I needed her to in order to give her a quick physical. I jotted down what I had found and then paged Jenn again, it was now about a quarter to noon. She asked me whether I knew how to get urine from her foley for "us" to look at. Well, uhm, I didn't really. So she came up and took the urine, then we rushed down incredibly convoluted corridors to her office, dropping the urine in a room on the way and making another quick pit stop at the dialysis unit where she apparently also had to do something. She took a stack of paper from her office and led me to a conference room, where a lot of people in white coats were already sitting.
I didn't take in much of the scene anymore since there was pizza on the table. Mmmmmh. Jenn told the group who I was and the attending at the head of the table invited me to grab some pizza and a soda, have a seat and enjoy the show. I complied most willingly.
The "show" was actually Jenn handing out pieces of paper that showed nothing but the age, gender and lab values over time of two patients. The residents and fellows at the table took turns to look at some of these values and give their opinions on it. I munched pizza happily. They tried to find a diagnosis and guessed at what was happening to the patient in terms of course of the illness and treatment outcome based only on the lab values, primarily electrolytes.
These guys knew what they were talking about.
I was for the most part barely able to keep up with them, actually still thrown off by the mere fact that they call Na "sodium" and K "potassium", which I should really have gotten used to by now. They were using lots of other abbreviations, presumably kidney stuff, only part of which I could figure out on my own. Naturally, I was never called upon by the attending to contribute anything to the discussion and I didn't. Maybe I should have, because the group spent a considerable amount of time discussing some "outlying" values at one time point of the second patient. They were apparently so wrapped up in their theories on the electrolytes and why this was going up here and dropping there that they didn't notice that at this time point that they found so particularly strange, everything was lower than before except for sodium and chloride, which were higher.
As I'm sure is evident to you now, this blood draw had been watered down by mere saline solution. I didn't dare to chime in on such a high-class meeting on my very first day so I listened to their discussions on these strange, aberrant values until someone else slapped themselves on the forehead and found the technical, yet simple answer. See, mom? I can shut up! ;)
That conference was over at around 1:15pm. Jenn told me on the way out that "rounds" would be at 1:30pm. Not knowing anything about how things would work here, I asked who is actually rouding with whom. She said "the attending with us". Ah great so I'd get to present my patient right away .. thanks for the warning.
When we sat in the attending's office a short time later we were joined by the resident who had thereby finished his clinic duties for the week. As it turned out, the attending was also new on the service so he would have to hear about all the patients. He wanted to start with the new ones though. Ah great.
At least, Jenn also had a patient to present so I happily left it to her to start off. And she did. It was pretty quick, but the attending - while seemingly a very friendly but also extremely competent guy - kept asking her difficult "teaching" questions. I was trying to listen and follow for most of the time, but I was distracted by my own case that I was thinking about and growing ever wearier of presenting later. At the point where I additionally glanced up to one of the frames hanging in the attending's office that showed he was one of "America's top physicians", he shot a question at me. "What else could it be, Philip?"
No clue. This is not my league. At that point I wasn't even sure whether I could roughly point at a person's kidneys.
When I admitted that I had no idea, it luckily didn't seem a big deal.
After Jenn's presentation, they were both looking at me expectingly. Thankfully, the attending said after a short pause, "don't worry, I won't be as hard on you as I was on her".
And he wasn't. It went quite OK. And as he asked me a few more questions - some of which I was even able to get partially right he seemed overjoyed.
After we had discussed the patients for today, we actually went to see most of them on the floors. This gave me a chance to get more acquainted with the resident. A rather quiet but very friendly guy - future cardiologist - who later on gave me a run down on what conferences to be at at which times in order to get through the week with the maximum amount of free food. My kind of guy!
After rounding, the day was over. At about 4pm. When I asked when and where I'd have to be the next morning, Jenn said I could come "whenever I wanted", I'd just have to check in on my patient again and it'd be nice if I touched base with her some time around 8:30 or 9. Hooray :D
So I went home happy.
This was going to be the last day that Trillian was in the US, so I called around and we arranged for a little impromptu party at Nema's place.
We bought some drinks and had a lot of fun together until Trillian and I felt that we couldn't keep Nema up anymore at 12:30, since her day would apparently start at 7:30 the next morning.
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