Like yesterday, Jenn and the painstakingly thorough attending are still rounding, they sent Tony and me into the weekend though. It's 5:15pm now. Last week, with the other attending, rounding started at 1pm and took around two hours, was laced with teaching and I was home sometimes before four. Today, we started rounding at 11:30am and they're still at it right now.
I'm rather sure that this is why people hate internal medicine.
Right now, I'm sitting in the residents' workroom waiting for Borat to call me back when he knows how long his rounds are still going to take. If he will be done within a reasonable amount of time, we would try and find the chief residents to interview for our mentoring project. But he said I should go if he didn't call me back within 10 minutes. I'll give him 20 I guess.
If there's no call back within that time I guess I'll call it a day and go grocery shopping and maybe even to the gym.
Blog to you later.
Friday, April 13, 2007
Thursday, April 12, 2007
Slammed.
That's the term Jenn used after a rather relaxing morning for me. Checking up on my old patients wasn't so much work since many of the first ones had been discharged by now and I'm getting better at quickly extracting the important information about the new ones.
With Jenn and the attending at the clinic all morning and therefore completely off the radar, I was cautious though and went up to A700 early, at around 9am, to get breakfast. Because once I had that in me, they wouldn't be able to take it from me again easily. But I got to eat in peace and even had time afterwards to write a little more on the mentoring project page before the pager went off close to 10am, right before morning report.
Jenn asked me whether I felt comfortable seeing a "complicated" patient. Of course I would see that patient. It's what I was there for. Out of curiosity, I asked what would happen if I said "no". She replied that then she would see the patient after clinic and before rounds. Well, she could do that anyway in case I mess it up. So I went to see this patient in medical ICU. She was indeed not a clear-cut case, mixed connective tissue disease with idiopathic pulmonary fibrosis status post bilateral lung transplant with history of gastro-esophageal reflux disease status post multiple dilations, Botox injections and finally Nissen's fundoplication surgery that was revised a little more than a week ago. She grew partially insufficient with her gas exchange, so she was intubated, later tracheotomized. She coded for half a minute these past days. Her sputum grew pseudomonas, so they placed her on ciprofloxacin. It took me a while to gather this information from the charts and the computer. Now she was in acute renal failure, trouble was that my job was to figure out why.
Hypotension/hypoperfusion with acute tubular necrosis? Dehydration? Cipro or cyclosporin toxicity? Contrast nephropathy? The time course of her renal failure would have fit most of these causes. I talked to her, which wasn't so easy since she was tracheotomized and on a vent and examined her, she seemed pretty dry. I took a few ccs of the urine she was still making and went to dip it and spin it down. When I was just done looking at it, it was about 12:15pm, would have been just the right time to go up to A700 again to grab lunch and listen to the M&M meeting. But that's just when my pager went off, Jenn told me that we were getting "slammed" today and asked whether I could see another patient right now. "Sure", I said, not yet knowing what I was going to get myself into.
This was actually going to be a 24 year old female - I was relieved, that couldn't be too hard. So I actually went up to A700 and took about 15 minutes to munch down some very good food and listened to the middle of the M&M meeting (attendance was astoundingly excellent, by the way - 100 people easily) before going back down to see this second patient. Problem was that she was brought over from another hospital because they couldn't figure out what they should do. So they sent her over, along with records of what they had done so far in the past two weeks. She had been admitted on March 30th, so exactly two weeks ago. The records lying on the table outside her room were in three thick envelopes full of copied pages. The stack was as thick as both volumes of Harrison's together.
Splendid.
Right around that time, Jenn text-paged me informing me that we were to round at 2pm in the nephrology conference room. So I had little more than an hour to sift through this litany of photocopied partially hand-written reports, consults, flowsheets and whatnot, talk to the patient, examine her, take her urine and analyze it. Not surprisingly, that didn't work. About ten minutes to two, I had still just about covered 700 pages or so, not even seen the patient yet, I text-paged Jenn back that I was sorry and that I'd be at least fashionably late. At one point, I just gave up trying to look for everything that I'd want to know and quickly got the rest of it done, then showed up 25 minutes late for rounds with fresh urine in a cup in my pocket.
The attending didn't comment on my late arrival at all. I assume she was displeased. The new resident on the service, Tony, had also seen two new patients and Jenn managed to also squeeze one in between clinic and rounds so we had five new ones so far, with another one that Jenn was called to see but didn't have time for yet. We got done presenting the new ones to our new, very thorough attending at about 3:15pm - that's when we finally got started going to see them. Of course that meant, looking at their urines first.
Mercifully, they began rounding on a route that would lead us to my two new patients rather early. At close to 5pm we were on my second new patient's ward and went into the visitor's lounge with her three envelopes of paper. The trio of Jenn, Tony and the attending started sifting through the stuff for a while too before they declared that it looked like those people didn't know what they were doing. So they decided to re-do all the tests they did and to biopsy this young girl's kidney tomorrow to see what's going on. Which is what they have also planned for the patient I saw yesterday.
While we were rounding, Jenn got two more calls for more consults that we'd have to do tomorrow. That plus two biopsies. And normally, we start a day without any debts from the day before. That's why tomorrow is shaping up to be "another day in hell" as Jenn put it.
And she's going to be on call tonight.
Oh, and she has her parents visiting her these days.
I guess the medical profession has the same effect on your cortisol levels and social life anywhere in the world.
With Jenn and the attending at the clinic all morning and therefore completely off the radar, I was cautious though and went up to A700 early, at around 9am, to get breakfast. Because once I had that in me, they wouldn't be able to take it from me again easily. But I got to eat in peace and even had time afterwards to write a little more on the mentoring project page before the pager went off close to 10am, right before morning report.
Jenn asked me whether I felt comfortable seeing a "complicated" patient. Of course I would see that patient. It's what I was there for. Out of curiosity, I asked what would happen if I said "no". She replied that then she would see the patient after clinic and before rounds. Well, she could do that anyway in case I mess it up. So I went to see this patient in medical ICU. She was indeed not a clear-cut case, mixed connective tissue disease with idiopathic pulmonary fibrosis status post bilateral lung transplant with history of gastro-esophageal reflux disease status post multiple dilations, Botox injections and finally Nissen's fundoplication surgery that was revised a little more than a week ago. She grew partially insufficient with her gas exchange, so she was intubated, later tracheotomized. She coded for half a minute these past days. Her sputum grew pseudomonas, so they placed her on ciprofloxacin. It took me a while to gather this information from the charts and the computer. Now she was in acute renal failure, trouble was that my job was to figure out why.
Hypotension/hypoperfusion with acute tubular necrosis? Dehydration? Cipro or cyclosporin toxicity? Contrast nephropathy? The time course of her renal failure would have fit most of these causes. I talked to her, which wasn't so easy since she was tracheotomized and on a vent and examined her, she seemed pretty dry. I took a few ccs of the urine she was still making and went to dip it and spin it down. When I was just done looking at it, it was about 12:15pm, would have been just the right time to go up to A700 again to grab lunch and listen to the M&M meeting. But that's just when my pager went off, Jenn told me that we were getting "slammed" today and asked whether I could see another patient right now. "Sure", I said, not yet knowing what I was going to get myself into.
This was actually going to be a 24 year old female - I was relieved, that couldn't be too hard. So I actually went up to A700 and took about 15 minutes to munch down some very good food and listened to the middle of the M&M meeting (attendance was astoundingly excellent, by the way - 100 people easily) before going back down to see this second patient. Problem was that she was brought over from another hospital because they couldn't figure out what they should do. So they sent her over, along with records of what they had done so far in the past two weeks. She had been admitted on March 30th, so exactly two weeks ago. The records lying on the table outside her room were in three thick envelopes full of copied pages. The stack was as thick as both volumes of Harrison's together.
Splendid.
Right around that time, Jenn text-paged me informing me that we were to round at 2pm in the nephrology conference room. So I had little more than an hour to sift through this litany of photocopied partially hand-written reports, consults, flowsheets and whatnot, talk to the patient, examine her, take her urine and analyze it. Not surprisingly, that didn't work. About ten minutes to two, I had still just about covered 700 pages or so, not even seen the patient yet, I text-paged Jenn back that I was sorry and that I'd be at least fashionably late. At one point, I just gave up trying to look for everything that I'd want to know and quickly got the rest of it done, then showed up 25 minutes late for rounds with fresh urine in a cup in my pocket.
The attending didn't comment on my late arrival at all. I assume she was displeased. The new resident on the service, Tony, had also seen two new patients and Jenn managed to also squeeze one in between clinic and rounds so we had five new ones so far, with another one that Jenn was called to see but didn't have time for yet. We got done presenting the new ones to our new, very thorough attending at about 3:15pm - that's when we finally got started going to see them. Of course that meant, looking at their urines first.
Mercifully, they began rounding on a route that would lead us to my two new patients rather early. At close to 5pm we were on my second new patient's ward and went into the visitor's lounge with her three envelopes of paper. The trio of Jenn, Tony and the attending started sifting through the stuff for a while too before they declared that it looked like those people didn't know what they were doing. So they decided to re-do all the tests they did and to biopsy this young girl's kidney tomorrow to see what's going on. Which is what they have also planned for the patient I saw yesterday.
While we were rounding, Jenn got two more calls for more consults that we'd have to do tomorrow. That plus two biopsies. And normally, we start a day without any debts from the day before. That's why tomorrow is shaping up to be "another day in hell" as Jenn put it.
And she's going to be on call tonight.
Oh, and she has her parents visiting her these days.
I guess the medical profession has the same effect on your cortisol levels and social life anywhere in the world.
Wednesday, April 11, 2007
"Thank you for keeping patient confidentiality!"
Walking into the hospital today, I got this greeting followed by a lollipop ceremoniously handed to me. Americans can be so funny.
But it was good remuneration for actually coming to work today, the weather was and still is miserably hideous, snow/rain and a lot of wind turning over my umbrella.
I got another new patient when I came in this morning and Jenn supposedly had another one for herself as well. Turns out she tricked me, her consult was cancelled later on because the patient was apparently improving on his own. So the new attending and Jenn were already rounding when I paged Jenn at around 10:30 informing her that I was done with my patient. So I caught up with them and we went to see my patient and her urine shortly thereafter. Rounding with the new attending was pleasant, more quiet and much more thorough. She actually even examined the patient herself.
When we were done half an hour ago, she said "see you in the afternoon". Actually I'm clueless as to what she meant but I'll page Jenn in a few minutes. She may know.
Blog you later.
But it was good remuneration for actually coming to work today, the weather was and still is miserably hideous, snow/rain and a lot of wind turning over my umbrella.
I got another new patient when I came in this morning and Jenn supposedly had another one for herself as well. Turns out she tricked me, her consult was cancelled later on because the patient was apparently improving on his own. So the new attending and Jenn were already rounding when I paged Jenn at around 10:30 informing her that I was done with my patient. So I caught up with them and we went to see my patient and her urine shortly thereafter. Rounding with the new attending was pleasant, more quiet and much more thorough. She actually even examined the patient herself.
When we were done half an hour ago, she said "see you in the afternoon". Actually I'm clueless as to what she meant but I'll page Jenn in a few minutes. She may know.
Blog you later.
Tuesday, April 10, 2007
Volleyball
Hey reader,
the kidney biopsy was pretty cool. Well-organized and radiologist, pathologist and internist working together smoothly in the same cramped room. It was astounding to see.
Afterwards, surprise-surprise, now that the attending was gone, there was another consult. It was the cardiac ICU calling who had received a new patient. Yesterday, his glucose was 136, his potassium 4.0, his bicarbonate 24 and his creatinine 1.1. Today, he was rushed to the ICU unresponsive with a glucose of 11, a potassium of 6.1, a bicarbonate of 5 and a creatinine of 2.6; pH 7.1, base excess of -25 and lactate at 19.5. This is going to be one heck of a case for the electrolyte conference next monday.
After spending about an hour from 2:30 till 3:30 getting informed about him, Jenn got him started on CVVH, after which we went to a nephrology conference, taking a look at his urine on the way. Somehow I got the rotation upside down - these days I have someone with me most of the time - this would have been a better way to start off the rotation. But it'll change again tomorrow. Justin is coming off the service and the new guy has clinic tomorrow morning. So it'll just be Jenn and me - plus a new attending who is apparently more thorough.
Anyway, what I wanted to tell you about: Jenn dragged another attending to see this patient with the whacky labs. When we actually went in to see him a family member was there. After they had discussed a bit, the attending asked her whether she had any more questions. She denied and left. And then the attending did something strange - he turned to me and asked "do YOU have any more questions?". Does that ever happen in Germany?
After finishing up with that guy it was 5:30pm, not quite the short day it had set out to be. In spite of that I did go to the gym again today, adding some more to the blisters on my feet - this time there were actually people playing volleyball. There were only five of them, so again, I asked whether they'd let me play while they were warming up. They said they're actually just a few members of the team that are going to compete in some national thing over the weekend, the other ones didn't show today, they'd just be "goofing off". Ah yes. But they let me goof off with them and it was a fun game, even though I missed my kneepads dearly.
For the daring ones among you, here's a picture of my foot afterwards. Be warned .. GRAPHIC CONTENT. NOT INTENDED FOR CHILDREN, QUEASY GIRLS OR PEOPLE WITH ANY KIND OF HEART CONDITION. Click AT YOUR OWN RISK.
the kidney biopsy was pretty cool. Well-organized and radiologist, pathologist and internist working together smoothly in the same cramped room. It was astounding to see.
Afterwards, surprise-surprise, now that the attending was gone, there was another consult. It was the cardiac ICU calling who had received a new patient. Yesterday, his glucose was 136, his potassium 4.0, his bicarbonate 24 and his creatinine 1.1. Today, he was rushed to the ICU unresponsive with a glucose of 11, a potassium of 6.1, a bicarbonate of 5 and a creatinine of 2.6; pH 7.1, base excess of -25 and lactate at 19.5. This is going to be one heck of a case for the electrolyte conference next monday.
After spending about an hour from 2:30 till 3:30 getting informed about him, Jenn got him started on CVVH, after which we went to a nephrology conference, taking a look at his urine on the way. Somehow I got the rotation upside down - these days I have someone with me most of the time - this would have been a better way to start off the rotation. But it'll change again tomorrow. Justin is coming off the service and the new guy has clinic tomorrow morning. So it'll just be Jenn and me - plus a new attending who is apparently more thorough.
Anyway, what I wanted to tell you about: Jenn dragged another attending to see this patient with the whacky labs. When we actually went in to see him a family member was there. After they had discussed a bit, the attending asked her whether she had any more questions. She denied and left. And then the attending did something strange - he turned to me and asked "do YOU have any more questions?". Does that ever happen in Germany?
After finishing up with that guy it was 5:30pm, not quite the short day it had set out to be. In spite of that I did go to the gym again today, adding some more to the blisters on my feet - this time there were actually people playing volleyball. There were only five of them, so again, I asked whether they'd let me play while they were warming up. They said they're actually just a few members of the team that are going to compete in some national thing over the weekend, the other ones didn't show today, they'd just be "goofing off". Ah yes. But they let me goof off with them and it was a fun game, even though I missed my kneepads dearly.
For the daring ones among you, here's a picture of my foot afterwards. Be warned .. GRAPHIC CONTENT. NOT INTENDED FOR CHILDREN, QUEASY GIRLS OR PEOPLE WITH ANY KIND OF HEART CONDITION. Click AT YOUR OWN RISK.
"Grand rounds"
I know, the name is misleading. No one rounds or goes round or turns or spins or anything on "grand rounds". It's a lecture.
But a good one - at least today. The way Americans give talks is something I dearly missed over in the motherland. The added comfort of a voluptuous catered meal is an added bonus, but this would almost have been worth listening to without food! I can see that screening for colorectal cancer is not everybody's first choice to listen to over lunch but all I can say is it was informative, interesting and even halfway pertinent to my doctoral thesis on gastrointestinal tumors.
And the reason I had time to go there today was that things are extremely quiet. As blogged before, the attending left very early for Florida today and we actually had no consults before rounds. We got hit with one shortly after rounds, but when the dream-team dynamic duo of Jenn and Justin went to work that one up they were done inside of 20 minutes and caught the attending before he could leave for the airport and even though we were called with the consult at around 11:15 I was able to make it to grand rounds at noon.
Jenn is about to do a kidney biopsy at 1:30pm, I'll meet her in the patient's room. And this time around I was smart enough not to assume I'd do the biopsy myself nor did I even ask her about it ;D .
Blog to you later.
But a good one - at least today. The way Americans give talks is something I dearly missed over in the motherland. The added comfort of a voluptuous catered meal is an added bonus, but this would almost have been worth listening to without food! I can see that screening for colorectal cancer is not everybody's first choice to listen to over lunch but all I can say is it was informative, interesting and even halfway pertinent to my doctoral thesis on gastrointestinal tumors.
And the reason I had time to go there today was that things are extremely quiet. As blogged before, the attending left very early for Florida today and we actually had no consults before rounds. We got hit with one shortly after rounds, but when the dream-team dynamic duo of Jenn and Justin went to work that one up they were done inside of 20 minutes and caught the attending before he could leave for the airport and even though we were called with the consult at around 11:15 I was able to make it to grand rounds at noon.
Jenn is about to do a kidney biopsy at 1:30pm, I'll meet her in the patient's room. And this time around I was smart enough not to assume I'd do the biopsy myself nor did I even ask her about it ;D .
Blog to you later.
Wind of change
Hope you guys back in the mainland had a happy easter!
Seems that things are about to change around here - tomorrow half my team will change, we'll get a new resident and a new attending. I'm a little worried - according to Jenn, rounds will be significantly longer under the new reign. We'll see.
Right now I'm up in the residents' lounge waiting for my beeper to tell me to quickly go see a patient before rounds at ten today. Our attending is flying to Florida to give some speeches for the National Kidney Foundation at 1:30pm. So he wants to be out the door at noon sharp. That means we'll round with him at 10am instead of the normal 1pm. Unfortunately, calls for consults usually trickle in at around 9-9:30am, which will not leave us a lot of time to see the new patients before rounds. Actually around half an hour instead of three and a half. I'm afraid that won't work unless we're really lucky and get no more than one patient each.
Speaking of which, I should finish checking up on my old patients before I get a new one. Blog to you later!
Seems that things are about to change around here - tomorrow half my team will change, we'll get a new resident and a new attending. I'm a little worried - according to Jenn, rounds will be significantly longer under the new reign. We'll see.
Right now I'm up in the residents' lounge waiting for my beeper to tell me to quickly go see a patient before rounds at ten today. Our attending is flying to Florida to give some speeches for the National Kidney Foundation at 1:30pm. So he wants to be out the door at noon sharp. That means we'll round with him at 10am instead of the normal 1pm. Unfortunately, calls for consults usually trickle in at around 9-9:30am, which will not leave us a lot of time to see the new patients before rounds. Actually around half an hour instead of three and a half. I'm afraid that won't work unless we're really lucky and get no more than one patient each.
Speaking of which, I should finish checking up on my old patients before I get a new one. Blog to you later!
Sunday, April 8, 2007
Oh no! There goes my offspring!
I'm sorry. I really was going to leave you alone for today but I had another "may contain peanuts"-revelation while getting ready to iron my shirts that I have to share with you guys.
What can I say. Californians are smart. Thanks guys.
Don't even get me started on the State of Fear issue (thanks Michael Moore). I mean all I want to do is iron my stuff and they have to threaten me and my kids with cancer and birth defects?
And LOL! I was going to leave it at that but then it came to me - did they warn me that the iron may become hot? I didn't recall such a thing so I went back to it and turned it over.
Before they educate me on the fact that the iron is hot though, they have more for me to read.
And only then
I love this country!
What can I say. Californians are smart. Thanks guys.
Don't even get me started on the State of Fear issue (thanks Michael Moore). I mean all I want to do is iron my stuff and they have to threaten me and my kids with cancer and birth defects?
And LOL! I was going to leave it at that but then it came to me - did they warn me that the iron may become hot? I didn't recall such a thing so I went back to it and turned it over.
Before they educate me on the fact that the iron is hot though, they have more for me to read.
Do not immerse in any liquid(whatever they think I'd be doing otherwise ..)
Household use only
And only then
CAUTION: hot surfaces
I love this country!
I've got blisters
Hey gang,
so as expected, this weekend was rather dull. Even the Hyde Park Food Produce was closed when I went there this morning. Closed! Something about easter sunday and what have you. Just when I was getting accustomed to this buying groceries on sunday thing. Oh well, so I got some water, bread and milk from the pharmacy next door. Heheh.
After that I went to the gym. Now the plan was to shoot some hoops - or at least try to - first to warm up, then do my weight routine, shower, sauna, shower, done. So I borrowed a basketball and went to the little "auxiliary" gym. In there were three guys playing on one hoop. I did walk past them and started shooting on my own but it felt impolite not even to offer to play two on two. How could they know that I haven't played this game in almost seven years.
So when I offered two on two, they surprised me by saying "sure, but let us finish the game first". See, I didn't even know you could mount a "game" with three people. So I went back to shoot at another hoop by myself and while their game was still going on, two more people went through and said that they wanted to play on the main court. Soon afterwards, when the initial three were done playing, they said they'd go to the main court and that I should come.
Uhm, well, OK.
So the new arrivals were actually four people - just like the four of us that had been in the little gym. So teams were pretty much decided on right off the bat.
I did get a warning in during warm-up shots that they should beware of me. Trouble was that during those warm-up shots I miraculously got a few three pointers in so the people on my team probably thought I was full of it. Oh well.
Those four that had arrived together obviously didn't team up for the first time. They had their act down and destroyed us in the first game. Obviously, we wanted to rematch and this time it was a closer game that we actually won in the end. So of course, we needed a tie breaker. This was the point that I knew I had to stop - I was wearing the wrong shoes for this and that tiny little bottle of water I brought was drier than moon sand by now.
Unfortunately, that would have left the teams uneven at three to four, again, not really a polite time to go. So we played that third game and I finally have my blisters - same place on both feet, dang those shoes.
So I'll give my best impression of House, MD limping across the wards these coming days.
so as expected, this weekend was rather dull. Even the Hyde Park Food Produce was closed when I went there this morning. Closed! Something about easter sunday and what have you. Just when I was getting accustomed to this buying groceries on sunday thing. Oh well, so I got some water, bread and milk from the pharmacy next door. Heheh.
After that I went to the gym. Now the plan was to shoot some hoops - or at least try to - first to warm up, then do my weight routine, shower, sauna, shower, done. So I borrowed a basketball and went to the little "auxiliary" gym. In there were three guys playing on one hoop. I did walk past them and started shooting on my own but it felt impolite not even to offer to play two on two. How could they know that I haven't played this game in almost seven years.
So when I offered two on two, they surprised me by saying "sure, but let us finish the game first". See, I didn't even know you could mount a "game" with three people. So I went back to shoot at another hoop by myself and while their game was still going on, two more people went through and said that they wanted to play on the main court. Soon afterwards, when the initial three were done playing, they said they'd go to the main court and that I should come.
Uhm, well, OK.
So the new arrivals were actually four people - just like the four of us that had been in the little gym. So teams were pretty much decided on right off the bat.
I did get a warning in during warm-up shots that they should beware of me. Trouble was that during those warm-up shots I miraculously got a few three pointers in so the people on my team probably thought I was full of it. Oh well.
Those four that had arrived together obviously didn't team up for the first time. They had their act down and destroyed us in the first game. Obviously, we wanted to rematch and this time it was a closer game that we actually won in the end. So of course, we needed a tie breaker. This was the point that I knew I had to stop - I was wearing the wrong shoes for this and that tiny little bottle of water I brought was drier than moon sand by now.
Unfortunately, that would have left the teams uneven at three to four, again, not really a polite time to go. So we played that third game and I finally have my blisters - same place on both feet, dang those shoes.
So I'll give my best impression of House, MD limping across the wards these coming days.
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