Hey reader,
as promised - another round of sky-high blogging to complete the circle.
I'm on the plane back from the Windy City after a long morning of finishing up packing, sweeping carpet floor with my broom (a vacuum was not among the things I had bought from Target) and giving heaps of stuff away to one of the Germans and the sociologist. Over the course of just one hour this morning, pretty much everything except one can of olives found a new home and I had to throw away very little.
I was just about done tidying up and getting ready to go around 12pm, Nema, whose flight departed around 3pm was long gone by then. The bad thing about that was that she was getting a ride with one of her roommates to the airport which was just so much more convenient than the one and a half hours of one bus and two train rides with my suitcase and two bags in the summer Chicago heat I was looking forward to. But I had missed that ride, so there I was, dropping off my keys and my laundry card at the graduate student housing office mailbox. Back across the street, there was actually a bus coming.
So far so good - but the driver warned us not to come in because her bus had been breaking down all morning and she couldn't guarantee to take us anywhere. That veered off me plus another young guy with a big bag who asked whether I was going to the airport.
Yeah, I was.
- Me too, been waiting for a bus for 15 minutes and now this, I'll have to take my car. Want a ride?
AWESOME!
- Can you watch my bag while I get the car?
You betcha, dude! Were things shaping up to repeat my incredible traveling luck from the way here?
Not quite!
We found out rather quickly that we had two different airports in mind. Rats. He wasn't going to O'Hare. BUT, he saved me the bus ride by dropping me off at the green line, which did bring me a short distance but otherwise long bus ride towards O'Hare.
The rest went rather smoothly except for me having to find out the hard way after lugging my baggage across the terminal to the Lufthansa check-in that this flight was going to be handled by United again after all.
And this time the bastards actually did make me sit with the cheap crowd. I miss the attention.
But they do have individual TV screens even here now so who am I to complain.
I still don't quite feel like writing the overall evaluation of the trip here so you'll have to wait a little longer for that while I pop in an episode of Battlestar Galactica now. I'm never able to sleep on these flights anyway.
Blog to you later.
Sunday, June 3, 2007
Thursday, May 31, 2007
Good bye.
So strange.
After parting with my team today, only saying a proper goodbye to the attending because I'll see the fellow again tomorrow to pick up a letter she's writing for me I went to get the signed confirmation that I'll need for my medschool and turn in my pager. After that, I went up to Brainy's office to say goodbye to her, arriving at the same time as the heart failure team that wanted to round. But Brainy was on the phone anyway and they let me trade goodbyes with her before they started.
It was only after I left her office that I started feeling sad. Like they always say .. you never know what you have until you lose it. Working here was fun. I've pretty much decided not to come to the United States permanently - but that certainly wasn't for the work environment.
Walking down those halls in my terribly ugly short white coat towards the exit for the very last time even choked a heartless person like me up a little. And as if in agreement, a hot summer rain had started just around this time.
After parting with my team today, only saying a proper goodbye to the attending because I'll see the fellow again tomorrow to pick up a letter she's writing for me I went to get the signed confirmation that I'll need for my medschool and turn in my pager. After that, I went up to Brainy's office to say goodbye to her, arriving at the same time as the heart failure team that wanted to round. But Brainy was on the phone anyway and they let me trade goodbyes with her before they started.
It was only after I left her office that I started feeling sad. Like they always say .. you never know what you have until you lose it. Working here was fun. I've pretty much decided not to come to the United States permanently - but that certainly wasn't for the work environment.
Walking down those halls in my terribly ugly short white coat towards the exit for the very last time even choked a heartless person like me up a little. And as if in agreement, a hot summer rain had started just around this time.
Wednesday, May 30, 2007
Excitement
The day started out as usual, went up to A700 to get breakfast after getting up to speed with my patients from the past days. I hung out with some Germans and listened to morning report, which was about an interesting case of a 28-year-old pregnant patient that presented to two different ERs with a cough, one of those ERs being ours, both of those ERs making a chest x-ray (yes, on a pregnant patient!) and sending the patient home, both ERs calling the patient back into the ER after having taken a second look at the x-ray. After they did a CT at the U of Chicago (yes, patient still pregnant .. at least pre-CT ..) they found her to have sarcoidosis.
But that was not the exciting part. Neither was my stroll afterwards, at around 11am to the cardiology fellows' room to check in with Missy. She said that she hadn't gotten a consult yet and with a smile on her face offered that if there wasn't a consult by noon, I should go home (the weather today is what other people would call gorgeous .. I actually liked the mostly air-conditioned interior of the hospital at that point). Even when she said that though, I knew that wasn't going to help her karma. It's those days where the morning seems like nothing's going to happen that come back to bite you in the ass. Which was good. I wanted to do consults. That's what I'm here for.
So I left the fellows' room thoroughly expecting the page that came half an hour later about a patient in one of the surgical ICUs. She had received a left lung transplant yesterday. Somehow I still have a high level of respect for lung transplants. But the way they have simply extubated the patient this morning, just about 12 hours after surgery and the way Missy would just send a foreign med student that's still coughing once in a while to see this highly immunosuppressed patient breathing with someone else's lung for a few hours now started wearing down this respect.
Anyway, I went up to that ICU and spent the rest of the time until noon getting started with the consult, jotting down her history and deciphering some of the surgical (i.e. minimal and cryptic) notes of the past days. The reason we were called was that the anesthesiologist who did the intraoperative transesophageal echo found severe mitral regurgitation. I looked at the pre-transplant workup and found a right heart catheter from just a few months ago numbering her pulmonary capillary wedge pressure at 1 mmHg which all but rules out any mitral regurgitation back then. That means if she had MR now, it would have to be rather acute. So I did check in on the patient - who was doing remarkably well, obviously having pain in her chest on day one post surgery but was very lucid and pleasant to talk to - before going back to A700 for lunch and an interesting infectious disease conference on endocarditis.
I had meant to go back to finish the consult about half an hour into the conference, after having enjoyed the excellent free Potbelly lunch. But the presenter from ID did such a great job presenting that I stayed until the end at about 1pm. So that's when I went back to the ICU.
After settling down again with the patient's charts (because they have two on ICU) I happily scribbled away at my consult sheet when the surgical resident from the primary team asked me whether I was from cardiology.
Sure.
- Oh good. Cardiac enzymes just came back positive. Did you see the EKGs?
There were EKGs? You drew enzymes? What's going on?
- Oh the EKGs are not in the charts, huh. Let me see if I can track down the nurse to find them.
And off she went after the nurse to get the EKGs. While she did that, I brought up the patient's labs on oacis and sure enough, she had had cardiac enzymes drawn this morning at 2am and again around noon. The latter ones had just come back positive with a troponin of 0.26 - with the 2am ones already at 0.16. CK-MB ratio was also mildly positive on both.
Just about after I had found this out, the nurse came around with two EKG's from the patient. They had almost identical time stamps to the two sets of cardiac enzymes, 2am and noon. The 2am EKG looked normal enough. The noon one had pretty impressive ST elevations in the inferior and lateral leads, yet not in the anterior ones. With scaredly-widened eyes I looked up to the nurse (the surgical resident had apparently taken off again) and asked her if the patient had chest pain with this.
Of course the patient had chest pain.
Duh. She had had her left lung replaced yesterday.
So this patient had chest pain, positive cardiac enzymes, a new onset of localized ST-elevations on a day after major surgery and I seemed the only one freaking out about this. That couldn't stay that way, so I paged Missy with a text page saying just that - something along the lines of "pt has cp (confounded by surgery), + enzymes and ST-elev. I think you". Apparently, as I later learned, I must have sent the page before I was done writing it because it ended in the middle of a sentence and before I gave a call-back number or my own pager number to identify who sent the page. This may have happened because I was showing Jen, who happened to be there, the EKGs and running to the patient's cubicle to look at the vitals on the monitor while writing parts of the page. Which was why Missy never called back.
Jen was seeing another patient and had come over to chat so I showed her those EKGs. Being a nephrologist, she said she hadn't been reading EKGs in a while but agreed this together with positive enzymes was likely to be either pericarditis or an acute myocardial infarction.
I knew this had to happen on a day that Missy wants to send me home at noon. With Missy not answering her page (which she couldn't as I only found out later) I went to the most extreme measures, came into the patient's cubicle and talked to her. And when asked about it specifically, she'd say that she had no pain in her chest - unless she moved.
Phew.
Her vitals were stable, on two pressors admittedly. But stable, and the patient had no chest pain at rest. Then again, she had a high epidural. I still didn't quite understand why I was the only one worrying there. I was about to send another page to Missy, when she came into the ICU around 2pm. She showed me the botched-up page that I apparently had sent and said that she had checked up on the other patients on the service that were a little more likely to be having acute MIs than mine not knowing where or who the page came from.
Oops.
So I gave her a quick run down on the patient's story and came to the enzyme and EKG part rather quickly. She was similarly relieved by the fact that the patient had no chest pain and a decent blood pressure of 100/60 and also pointed out the PQ depression hinted at in some leads that would make pericarditis more likely. But she asked for another EKG nonetheless, since the one we had was already two and a half hours old by then.
That's when the attending called to go start rounding in ten minutes. Missy had gotten another consult in the meantime (karma's a bitch), so we went down to that other ICU to at least grab that person's EKGs before meeting the attending in the workroom.
We relayed the most pertinent information about our patients to him upfront but he'd of course as always want to look at a maximum amount of "pictures" (read: imaging studies) on all the patients we were going to see. So that took a while and afterwards, when deciding which patient to see first, we went to see Missy's patient. She wasn't as critical as the patient in ICU but geographically closer. Guess that's what you get for being on a regular floor.
Afterwards, we finally went to see the freshly transplanted lady at around 3:45pm but we were apparently just in time, the tech was in the process of writing my patient's third EKG for the day. While we were kind of aimlessly standing around waiting for her to get done, I saw the first Dr. Cart being initiated in front of my eyes.
No, it wasn't on my patient.
I was leaning on the ICU's coordinating clerk's desk which was just a few steps outside of another patient's cubicle. Anyone who's ever been on an ICU knows they are noisy places with ubiquitous and incessant beeping coming from somewhere or other around the clock. There's so much of it you get used to it and you don't even consciously perceive it anymore.
Except for a few kinds of beeping - those ones where the monitor actually means business.
And this was one of them.
When I looked up from the desk into the cubicle right across from me, the blue and red lights on top of the actual screen of the monitor flashed alternatingly, while the screen read multiple wide-complex QRS's in rapid succession - this was ventricular tachycardia. Inside the room were a nurse and a relative - the nurse poked her head out of the cubicle and yelled for the crash cart, while the relative gave a yelp and started to cry, before storming out of the cubicle, seemingly to make way for the influx of the ICU staff that was about to happen. While the nurse that was originally there opened the hinged glass walls on the front of the cubicle another nurse flattened the patient's bed before the rest of the ICU people including my consult team had the patient's bed surrounded and all I could see from the desk was the monitor.
That didn't look good though. The VT had apparently subsided and reverted into some kind of slow narrow-complex rhythm, maybe sinus brady, maybe junctional, couldn't tell from where I was standing. I did see the blood pressure from the arterial line around 60/40 and occasionally dropping further though. I knew nothing of the patient's history but her future seemed increasingly in jeopardy. At this point someone yelled to "call a Dr. Cart", which the ICU clerk right next to me did. Just moments later, the overhead public announcement system made another all-too-familiar overhead page to "Dr. Cart", this time calling to the bed I was standing at.
They started compressions right around that time and since there wasn't going to be much I'd be doing with the code, I grabbed the new EKG of my patient from the tech and compared it to the two other ones of that day. And I must have had that wide-eyed look of fear again - not only did her ST-elevations get worse in the lateral leads, I hadn't before noticed that she had had a solid 1mV R in lead III at 2am, that had become isoelectric at noon. Already then there wouldn't have been much blaming this on lead placement, since these are limb leads and the P axis did not change. But now, on this EKG close to four hours later, this lady did not have an R in III anymore, it was a 1mV Q.
I showed the EKGs to my team who were now more on the outer rim of the Dr. Cart crowd and the attending had an interesting way of putting it .. "oh no. She is losing voltage." Finally, things became more hectic with this patient and the attending told the patient that he'd say her odds were about 60% of having a heart attack and 40% of just having pericarditis and that he'd suggest they do a cath right away.
Outside the room, Missy voiced her concerns about this patient. She wasn't as sure about this patient having an acute MI as the attending and she was making a good point. The patient just wasn't symptomatic enough. Blood pressure was stable on the pressors and she just didn't have any pain. She didn't quite convince the attending though. He agreed that the clinical picture was underwhelming for this amount of EKG changes and that pericarditis was a more likely explanation - so the odds were maybe 40 to 60 or even 20 to 80. But even with only a 20% chance of this person having a huge infarction - can you afford not to cath her?
While the attending was talking to the primary team I followed Missy to the cath lab, where she was about to inform their people about the patient and show them the EKGs. On the way, she made another good point, being that the patient was severely medically immunocompromised and about to be wheeled through the hospital to the cath lab where someone would be poking wires around her freshly operated-on mediastinum. The cath wasn't a benign procedure.
This was a really tough decision to make.
Missy said that she was "only a fellow" and was afraid to be "too cavalier" in her opinion to rather "ride this one out" rather than sending the patient to cath. I disagreed in so far as I didn't find it cavalier to be seeing the whole picture and to be afraid the patient could die of overwhelming infection with totally clean coronary arteries just a week from now if we do wheel her to the cath lab.
When we returned to the ICU, though, the decision was basically taken off our hands. The attending cardiothoracic surgeon of the primary team answered his page and talked to our attending. Two new pieces of information prevented the cath - for one thing no one among all those people involved in this so far had been privy to the fact that during her transplant surgery, not only the pericardium but also the left atrium had been cut open for the anastomosis of the pulmonary veins. That was a good explanation of the cardiac enzymes and pericarditis on EKG and made them even more likely, still didn't quite rule out infarction though. However, the other piece of information was that the surgical attending expressly forbid us to use aspirin, clopidogrel or heparin even if we did find something on cath. The only thing he would let us put her on among the usual MI medication was a beta-blocker, which she got. With all those meds out of the picture and stents therefore not being an option there wouldn't be much point in a cath anyway, with angioplasty being unlikely to change much.
So unless a third set of enzymes would come back exceedingly high, there'd be no cath on her today. This will be something interesting to follow up on tomorrow.
After getting home this afternoon I met the sociologist again and he took me to one of the two places in Hyde Park to go out in, as I learned from him there. And apparently, he now also is a reader of this blog so I cannot say any more evil things about him. Rats.
During the several hours we talked I learned among many other things that the University, owning a significant portion of Hyde Park, actually and actively prevented more leisurely (read: alcohol-dispensing) places to open up around campus.
Shame on them!
Look, it's half an hour into Thursday already - my very final day in the U of C hospital. Time to finally write that summary report I've been promising, isn't it.
Well if you're waiting for that, just hope that no more exciting days come in the way.
And tomorrow afternoon the entire Chicago gang is invited to barbecue at CS's place.
I may just end up blogging the retrospective report from Germany - or maybe the plane. Some sky-high-blogging for the perfect circle. See! It did pay off to have read this whole thing for that beautiful sense of closure, right? RIGHT?
OK never mind, I should sleep.
Blog to you later.
But that was not the exciting part. Neither was my stroll afterwards, at around 11am to the cardiology fellows' room to check in with Missy. She said that she hadn't gotten a consult yet and with a smile on her face offered that if there wasn't a consult by noon, I should go home (the weather today is what other people would call gorgeous .. I actually liked the mostly air-conditioned interior of the hospital at that point). Even when she said that though, I knew that wasn't going to help her karma. It's those days where the morning seems like nothing's going to happen that come back to bite you in the ass. Which was good. I wanted to do consults. That's what I'm here for.
So I left the fellows' room thoroughly expecting the page that came half an hour later about a patient in one of the surgical ICUs. She had received a left lung transplant yesterday. Somehow I still have a high level of respect for lung transplants. But the way they have simply extubated the patient this morning, just about 12 hours after surgery and the way Missy would just send a foreign med student that's still coughing once in a while to see this highly immunosuppressed patient breathing with someone else's lung for a few hours now started wearing down this respect.
Anyway, I went up to that ICU and spent the rest of the time until noon getting started with the consult, jotting down her history and deciphering some of the surgical (i.e. minimal and cryptic) notes of the past days. The reason we were called was that the anesthesiologist who did the intraoperative transesophageal echo found severe mitral regurgitation. I looked at the pre-transplant workup and found a right heart catheter from just a few months ago numbering her pulmonary capillary wedge pressure at 1 mmHg which all but rules out any mitral regurgitation back then. That means if she had MR now, it would have to be rather acute. So I did check in on the patient - who was doing remarkably well, obviously having pain in her chest on day one post surgery but was very lucid and pleasant to talk to - before going back to A700 for lunch and an interesting infectious disease conference on endocarditis.
I had meant to go back to finish the consult about half an hour into the conference, after having enjoyed the excellent free Potbelly lunch. But the presenter from ID did such a great job presenting that I stayed until the end at about 1pm. So that's when I went back to the ICU.
After settling down again with the patient's charts (because they have two on ICU) I happily scribbled away at my consult sheet when the surgical resident from the primary team asked me whether I was from cardiology.
Sure.
- Oh good. Cardiac enzymes just came back positive. Did you see the EKGs?
There were EKGs? You drew enzymes? What's going on?
- Oh the EKGs are not in the charts, huh. Let me see if I can track down the nurse to find them.
And off she went after the nurse to get the EKGs. While she did that, I brought up the patient's labs on oacis and sure enough, she had had cardiac enzymes drawn this morning at 2am and again around noon. The latter ones had just come back positive with a troponin of 0.26 - with the 2am ones already at 0.16. CK-MB ratio was also mildly positive on both.
Just about after I had found this out, the nurse came around with two EKG's from the patient. They had almost identical time stamps to the two sets of cardiac enzymes, 2am and noon. The 2am EKG looked normal enough. The noon one had pretty impressive ST elevations in the inferior and lateral leads, yet not in the anterior ones. With scaredly-widened eyes I looked up to the nurse (the surgical resident had apparently taken off again) and asked her if the patient had chest pain with this.
Of course the patient had chest pain.
Duh. She had had her left lung replaced yesterday.
So this patient had chest pain, positive cardiac enzymes, a new onset of localized ST-elevations on a day after major surgery and I seemed the only one freaking out about this. That couldn't stay that way, so I paged Missy with a text page saying just that - something along the lines of "pt has cp (confounded by surgery), + enzymes and ST-elev. I think you". Apparently, as I later learned, I must have sent the page before I was done writing it because it ended in the middle of a sentence and before I gave a call-back number or my own pager number to identify who sent the page. This may have happened because I was showing Jen, who happened to be there, the EKGs and running to the patient's cubicle to look at the vitals on the monitor while writing parts of the page. Which was why Missy never called back.
Jen was seeing another patient and had come over to chat so I showed her those EKGs. Being a nephrologist, she said she hadn't been reading EKGs in a while but agreed this together with positive enzymes was likely to be either pericarditis or an acute myocardial infarction.
I knew this had to happen on a day that Missy wants to send me home at noon. With Missy not answering her page (which she couldn't as I only found out later) I went to the most extreme measures, came into the patient's cubicle and talked to her. And when asked about it specifically, she'd say that she had no pain in her chest - unless she moved.
Phew.
Her vitals were stable, on two pressors admittedly. But stable, and the patient had no chest pain at rest. Then again, she had a high epidural. I still didn't quite understand why I was the only one worrying there. I was about to send another page to Missy, when she came into the ICU around 2pm. She showed me the botched-up page that I apparently had sent and said that she had checked up on the other patients on the service that were a little more likely to be having acute MIs than mine not knowing where or who the page came from.
Oops.
So I gave her a quick run down on the patient's story and came to the enzyme and EKG part rather quickly. She was similarly relieved by the fact that the patient had no chest pain and a decent blood pressure of 100/60 and also pointed out the PQ depression hinted at in some leads that would make pericarditis more likely. But she asked for another EKG nonetheless, since the one we had was already two and a half hours old by then.
That's when the attending called to go start rounding in ten minutes. Missy had gotten another consult in the meantime (karma's a bitch), so we went down to that other ICU to at least grab that person's EKGs before meeting the attending in the workroom.
We relayed the most pertinent information about our patients to him upfront but he'd of course as always want to look at a maximum amount of "pictures" (read: imaging studies) on all the patients we were going to see. So that took a while and afterwards, when deciding which patient to see first, we went to see Missy's patient. She wasn't as critical as the patient in ICU but geographically closer. Guess that's what you get for being on a regular floor.
Afterwards, we finally went to see the freshly transplanted lady at around 3:45pm but we were apparently just in time, the tech was in the process of writing my patient's third EKG for the day. While we were kind of aimlessly standing around waiting for her to get done, I saw the first Dr. Cart being initiated in front of my eyes.
No, it wasn't on my patient.
I was leaning on the ICU's coordinating clerk's desk which was just a few steps outside of another patient's cubicle. Anyone who's ever been on an ICU knows they are noisy places with ubiquitous and incessant beeping coming from somewhere or other around the clock. There's so much of it you get used to it and you don't even consciously perceive it anymore.
Except for a few kinds of beeping - those ones where the monitor actually means business.
And this was one of them.
When I looked up from the desk into the cubicle right across from me, the blue and red lights on top of the actual screen of the monitor flashed alternatingly, while the screen read multiple wide-complex QRS's in rapid succession - this was ventricular tachycardia. Inside the room were a nurse and a relative - the nurse poked her head out of the cubicle and yelled for the crash cart, while the relative gave a yelp and started to cry, before storming out of the cubicle, seemingly to make way for the influx of the ICU staff that was about to happen. While the nurse that was originally there opened the hinged glass walls on the front of the cubicle another nurse flattened the patient's bed before the rest of the ICU people including my consult team had the patient's bed surrounded and all I could see from the desk was the monitor.
That didn't look good though. The VT had apparently subsided and reverted into some kind of slow narrow-complex rhythm, maybe sinus brady, maybe junctional, couldn't tell from where I was standing. I did see the blood pressure from the arterial line around 60/40 and occasionally dropping further though. I knew nothing of the patient's history but her future seemed increasingly in jeopardy. At this point someone yelled to "call a Dr. Cart", which the ICU clerk right next to me did. Just moments later, the overhead public announcement system made another all-too-familiar overhead page to "Dr. Cart", this time calling to the bed I was standing at.
They started compressions right around that time and since there wasn't going to be much I'd be doing with the code, I grabbed the new EKG of my patient from the tech and compared it to the two other ones of that day. And I must have had that wide-eyed look of fear again - not only did her ST-elevations get worse in the lateral leads, I hadn't before noticed that she had had a solid 1mV R in lead III at 2am, that had become isoelectric at noon. Already then there wouldn't have been much blaming this on lead placement, since these are limb leads and the P axis did not change. But now, on this EKG close to four hours later, this lady did not have an R in III anymore, it was a 1mV Q.
I showed the EKGs to my team who were now more on the outer rim of the Dr. Cart crowd and the attending had an interesting way of putting it .. "oh no. She is losing voltage." Finally, things became more hectic with this patient and the attending told the patient that he'd say her odds were about 60% of having a heart attack and 40% of just having pericarditis and that he'd suggest they do a cath right away.
Outside the room, Missy voiced her concerns about this patient. She wasn't as sure about this patient having an acute MI as the attending and she was making a good point. The patient just wasn't symptomatic enough. Blood pressure was stable on the pressors and she just didn't have any pain. She didn't quite convince the attending though. He agreed that the clinical picture was underwhelming for this amount of EKG changes and that pericarditis was a more likely explanation - so the odds were maybe 40 to 60 or even 20 to 80. But even with only a 20% chance of this person having a huge infarction - can you afford not to cath her?
While the attending was talking to the primary team I followed Missy to the cath lab, where she was about to inform their people about the patient and show them the EKGs. On the way, she made another good point, being that the patient was severely medically immunocompromised and about to be wheeled through the hospital to the cath lab where someone would be poking wires around her freshly operated-on mediastinum. The cath wasn't a benign procedure.
This was a really tough decision to make.
Missy said that she was "only a fellow" and was afraid to be "too cavalier" in her opinion to rather "ride this one out" rather than sending the patient to cath. I disagreed in so far as I didn't find it cavalier to be seeing the whole picture and to be afraid the patient could die of overwhelming infection with totally clean coronary arteries just a week from now if we do wheel her to the cath lab.
When we returned to the ICU, though, the decision was basically taken off our hands. The attending cardiothoracic surgeon of the primary team answered his page and talked to our attending. Two new pieces of information prevented the cath - for one thing no one among all those people involved in this so far had been privy to the fact that during her transplant surgery, not only the pericardium but also the left atrium had been cut open for the anastomosis of the pulmonary veins. That was a good explanation of the cardiac enzymes and pericarditis on EKG and made them even more likely, still didn't quite rule out infarction though. However, the other piece of information was that the surgical attending expressly forbid us to use aspirin, clopidogrel or heparin even if we did find something on cath. The only thing he would let us put her on among the usual MI medication was a beta-blocker, which she got. With all those meds out of the picture and stents therefore not being an option there wouldn't be much point in a cath anyway, with angioplasty being unlikely to change much.
So unless a third set of enzymes would come back exceedingly high, there'd be no cath on her today. This will be something interesting to follow up on tomorrow.
After getting home this afternoon I met the sociologist again and he took me to one of the two places in Hyde Park to go out in, as I learned from him there. And apparently, he now also is a reader of this blog so I cannot say any more evil things about him. Rats.
During the several hours we talked I learned among many other things that the University, owning a significant portion of Hyde Park, actually and actively prevented more leisurely (read: alcohol-dispensing) places to open up around campus.
Shame on them!
Look, it's half an hour into Thursday already - my very final day in the U of C hospital. Time to finally write that summary report I've been promising, isn't it.
Well if you're waiting for that, just hope that no more exciting days come in the way.
And tomorrow afternoon the entire Chicago gang is invited to barbecue at CS's place.
I may just end up blogging the retrospective report from Germany - or maybe the plane. Some sky-high-blogging for the perfect circle. See! It did pay off to have read this whole thing for that beautiful sense of closure, right? RIGHT?
OK never mind, I should sleep.
Blog to you later.
Thursday, May 24, 2007
Yes I am
still alive and kicking. I've been sick over the weekend and I actually took Monday off, partly because it's just annoying to be blowing your nose every few seconds but mainly because I just don't want to be responsible for a ton of ID consults on patients and staff just about a week from now.
When I did work last week though I kept surprising myself by having a lot of answers during discussions and rounds. Especially with this one attending that "rounded" with us at his desk (much like the very first renal attending). He was a stud, appeared very young and overflowing with confidence, obviously was working out and judging from the pictures in his office he had his trophy wife tucked away (OK now I'm going a bit too far). Obviously, he was knowledgeable - you don't become an attending for nothing here. So while rounding in his office with Missy and the female intern on the team as soon as I started presenting my patient he'd say that we were going to have a "guy discussion" from now on, which apparently meant that we'd leave political correctness and etiquette aside - which was very refreshing and fun.
I didn't see much of that attending - he only filled in for the regular one that day. But from what I have experienced and heard about him I guess he is an extremely - maybe overly - confident guy that will be your best friend and not worry too much about taking care of patients himself as long as everything goes well. Apparently though, the yelling starts if ever things go south and he may ultimately be made responsible for something he should have taken more care of. So he's a nice, extremely suave and cool guy and he does seem to know his stuff but I still wouldn't want him as my attending - whether I'm on his team OR his patient.
But like I said, my experience with him was brief.
Over the weekend, like I said, I was sick and didn't do much except raiding the pharmacy for cold medication that turned out to be placebos for the most part - including the facial tissues. The stuff they sell there really is a very bad joke. Unless you use at least three of those tissues at once you might as well blow your nose into your hand directly. While at home with my headache I did get started typing down an exposé of the mentoring project the Chicago group has been working on. As of last night, it was up to 10 typed pages, I'm still waiting for the rest of the group to read it and sign off on it so we can pass the first drafts on to the good people in Boston and Munich. But I have high hopes for the next project meeting tonight at 6pm.
In other news, the service has been very light these past days and I was able to attend a lot of conferences today. Among them was a so-called "code review" where they discussed a few of the Dr. Cart (=cardiac arrest) calls that had happened during the past week. Primarily, I learned two things: one is that they actually physically record their resuscitations. This includes the patient's EKG, ventilations, depth and frequency of chest compressions and even audio - audio! as in what the team is saying around the patient as they are coding them. That is so cool! The software gives you a full report, placing EKG reading, respiratory curves, chest compressions, end-tidal CO2 as well as information on whether or not the patient had a pulse at the time on time-synced visual graphs with the option of playing the audio at any time. That's so awesome for discussing what went right or wrong during the traditionally hectic conditions of a code situation which is exactly what they did. We have to have this in Germany.
And the other thing that I learned today was actually another piece of evidence that Americans are crazy. In a nice presentation on the benefit of post-code hypothermia the ED presenter mentioned this report, where investigators placed nine healthy volunteers (read: medstudents) under general anesthesia (yes, intubated and all!) to infuse them with ice water and see how their temperature drops. If you don't believe me, click on the link. Combine this with the concept of fecal transplants and you have definite proof beyond any reasonable doubt that these people are loco.
Allright, I'm going to let you go for now. I'll be done with the hospital exactly a week from today and flying back to Germany two days after that.
There are two things you should be able to expect from me during the upcoming days .. one should be a comprehensive review of the two months I've spent here and another should be a discussion on what the heck I want to do with my life (you definitely don't have to read the latter).
Blog to you later.
When I did work last week though I kept surprising myself by having a lot of answers during discussions and rounds. Especially with this one attending that "rounded" with us at his desk (much like the very first renal attending). He was a stud, appeared very young and overflowing with confidence, obviously was working out and judging from the pictures in his office he had his trophy wife tucked away (OK now I'm going a bit too far). Obviously, he was knowledgeable - you don't become an attending for nothing here. So while rounding in his office with Missy and the female intern on the team as soon as I started presenting my patient he'd say that we were going to have a "guy discussion" from now on, which apparently meant that we'd leave political correctness and etiquette aside - which was very refreshing and fun.
I didn't see much of that attending - he only filled in for the regular one that day. But from what I have experienced and heard about him I guess he is an extremely - maybe overly - confident guy that will be your best friend and not worry too much about taking care of patients himself as long as everything goes well. Apparently though, the yelling starts if ever things go south and he may ultimately be made responsible for something he should have taken more care of. So he's a nice, extremely suave and cool guy and he does seem to know his stuff but I still wouldn't want him as my attending - whether I'm on his team OR his patient.
But like I said, my experience with him was brief.
Over the weekend, like I said, I was sick and didn't do much except raiding the pharmacy for cold medication that turned out to be placebos for the most part - including the facial tissues. The stuff they sell there really is a very bad joke. Unless you use at least three of those tissues at once you might as well blow your nose into your hand directly. While at home with my headache I did get started typing down an exposé of the mentoring project the Chicago group has been working on. As of last night, it was up to 10 typed pages, I'm still waiting for the rest of the group to read it and sign off on it so we can pass the first drafts on to the good people in Boston and Munich. But I have high hopes for the next project meeting tonight at 6pm.
In other news, the service has been very light these past days and I was able to attend a lot of conferences today. Among them was a so-called "code review" where they discussed a few of the Dr. Cart (=cardiac arrest) calls that had happened during the past week. Primarily, I learned two things: one is that they actually physically record their resuscitations. This includes the patient's EKG, ventilations, depth and frequency of chest compressions and even audio - audio! as in what the team is saying around the patient as they are coding them. That is so cool! The software gives you a full report, placing EKG reading, respiratory curves, chest compressions, end-tidal CO2 as well as information on whether or not the patient had a pulse at the time on time-synced visual graphs with the option of playing the audio at any time. That's so awesome for discussing what went right or wrong during the traditionally hectic conditions of a code situation which is exactly what they did. We have to have this in Germany.
And the other thing that I learned today was actually another piece of evidence that Americans are crazy. In a nice presentation on the benefit of post-code hypothermia the ED presenter mentioned this report, where investigators placed nine healthy volunteers (read: medstudents) under general anesthesia (yes, intubated and all!) to infuse them with ice water and see how their temperature drops. If you don't believe me, click on the link. Combine this with the concept of fecal transplants and you have definite proof beyond any reasonable doubt that these people are loco.
Allright, I'm going to let you go for now. I'll be done with the hospital exactly a week from today and flying back to Germany two days after that.
There are two things you should be able to expect from me during the upcoming days .. one should be a comprehensive review of the two months I've spent here and another should be a discussion on what the heck I want to do with my life (you definitely don't have to read the latter).
Blog to you later.
Friday, May 18, 2007
Case report
The very first patient I had seen in this hospital - the one Jen sent me to see the morning of my very first day here - has just been presented to the residents in morning report. The 50.000 IU of vitamin D per day for months. The attending overseeing the presentation shook his head in the end and said this is something you will hardly ever see.
Except if you're a student fresh from Germany starting on renal consults.
Except if you're a student fresh from Germany starting on renal consults.
Wednesday, May 16, 2007
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.
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.
Tuesday, May 15, 2007
Americans.
Morning report today focused on long-term care of patients with chronic conditions like diabetes or hypertension and the difficulties we are faced with in that area. So the first case was on a 64-year-old african american female who was - of course - overweight. We were told the story of how she started out on one medication in 2003 and when her blood pressures never responded in subsequent clinic visits, how her regimen was gradually extended to four different blood pressure medications.
At this point in the slide show, the next slide posed the question "what else can you think of to optimize treatment of this patient's hypertension?" to the audience. I was convinced that I knew what this slide was going to show. To my surprise, what they were looking for here were the questions "is the patient taking her medications?" - all right, good one. "Can the patient afford her medications?" - uhm, I see. "Does the patient have access to her medications?" - as in - can she get her obese self to the pharmacy and back? I guess that's a valid question too. But that was it.
Whatever happened to "Did anyone ever talk to this patient about less McDonalds and more exercise?" Is educating people about sodium intake and physical exercise and the likes of that so out of fashion that it doesn't even come up in a discussion of the management of primary hypertension?
At this point in the slide show, the next slide posed the question "what else can you think of to optimize treatment of this patient's hypertension?" to the audience. I was convinced that I knew what this slide was going to show. To my surprise, what they were looking for here were the questions "is the patient taking her medications?" - all right, good one. "Can the patient afford her medications?" - uhm, I see. "Does the patient have access to her medications?" - as in - can she get her obese self to the pharmacy and back? I guess that's a valid question too. But that was it.
Whatever happened to "Did anyone ever talk to this patient about less McDonalds and more exercise?" Is educating people about sodium intake and physical exercise and the likes of that so out of fashion that it doesn't even come up in a discussion of the management of primary hypertension?
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