Day two

Allright, I'll try to do this. The last entry was written in the residents' workroom on the fifth floor - internet is fast there and I needed some uptodate.com information. But let's start at the beginning.

After saying goodbye to Trillian who is on the plane back to Munich for about another hour now, I walked to the hospital today since it was raining. I arrived around 8:45am. Beautiful. I went up to the residents' workroom on the fifth floor and started reading yesterday's patient's labs while paging Jenn to "touch base", as she likes to say. Also I needed to tell her that CS had arranged for me to present one of my old patients to the director of the cath lab at the hospital, as I remembered this morning. That was scheduled for 10:30am-11am. Jenn said that wasn't a problem, she would need me to see another patient before rounds at 1pm though. And she had decided to give "my" patient 20mg of Lasix this morning. So far so good. While I started jotting down the new lab values of my hypercalcemic patient (they draw blood every 8 hours here it seems .. internists ..), I paged the resident, Justin, that I couldn't make it to the conference at 10am for donuts and coffee.

I used the time between 9 and 10am to try and get up to date on the hypercalcemic patient. When I went up to her to give her another physical exam, the girls from physical therapy were just about to start working with her. And I was pleased to see that my theory about physical therapists also seems to hold true in this country.

After a bit of fun with the girls from PT and the obviously improved patient I went back to the workroom to page Carolin and print out my old admission note of the patient I was going to present to the attending from the cath lab. Carolin said on the phone that she'd come to the workroom at 10:20 so I used the time to review the old note - I had seen that patient in November of last year, so almost six months ago. Carolin came and led me to his office, where we waited for him to finish his conference call.

When he was done, Carolin introduced me to the not so tall but in-shape and intimidatingly serious attending. Despite his stern exterior we started out with a friendly but very business-like discussion about how studying and graduating works in Germany, what my own plans were and what I'll be doing here in Chicago. He probably wasn't so pleased to hear that internal medicine was actually a required part of the final year and that in that respect I hadn't chosen to be in his specialty. But he didn't let it show. Anyway, he then asked me whether we should focus on my written note or on my oral presentation. I chose the oral presentation, since I wouldn't really be doing pure admission notes here on the consult service anyway.

So I started to present that patient as I normally would and the attending took notes. When we were briefly interrupted by a phone call, I had a chance to look around his office and see the same kind of intimidating plaques and certificates on the wall, firmly linking this director of the cath lab to a certain medschool in Boston and one of the many awards was indeed for teaching. I finished my presentation and he, being a true American, started by saying that I did "a perfect job" before starting to criticize what I did. But I think it went pretty well nonetheless.

After a pleasant goodbye with him at 11:15 I went back to the workroom once more. I had another hour and 45 minutes for my second patient. She was going to be a bit more complicated than the last one, having a sudden rise in serum creatinine after a cycle of multiple chemotherapy drugs last week for her Hodgkin's lymphoma. As I started reading about her on the computer in the workroom, something weird happened.

Green-grayish goo was sprayed in thick drops over my notes, my computer and me from the left. This was accompanied by a rather big commotion in the room, there were about ten people in the tiny room rushing towards the resident next to me who apparently had lost her cup of broccoli soup out of her grip, causing it to fall down and land with a splash. She sprayed a good portion of it on herself, but considerable amounts also landed on my head, my keyboard and the note I was writing the new patient on. Luckily, almost miraculously, only minimal amounts had found my pants and coat. The people in the room were busy cleaning the resident that dropped the soup, jokingly asking her whether she seized. No one really paid attention to me as I got Kleenexes out of my pocket and started crisis management. After clearing the worst parts of the soup off of myself and the computer I tried to save the note but it was beyond presentable unfortunately.

So I got up and set out to find Jenn's office by myself for the first time. After several pit stops on maps posted at the elevators and discussing the map with one secretary I did find the place eventually. In there, I got a new inpatient consult sheet. With that, I went back to the workroom. It was noon by the time I had the labs and similar info on that sheet and was up on the sixth floor to see the patient. Before even going to her I paged Jenn again and expressed my doubts that I could come up with a very thorough or even intelligent workup, assessment and plan in the remaining hour by myself. Jenn regretted to inform me that she had two new consults in the meantime and really couldn't come to my rescue. So I said I'd do the best I could.

And not surprisingly I wasn't feeling very good about my second patient on the way to rounds, since even on the way there I could think of at least three things that I had forgotten to look up on this patient. And they were obvious things because even I could think of them. Things like how long she had been on her present medication of antibiotics, antifungals and antivirals. Or her exact liquid intake and output over the past few days. Kidneys, dude. Think! Yet again, after the rest of my presentation, these things did, of course, come up. The attending smiled and said that "we will have to get more info on this patient" - I'm not sure if he was disappointed, if he was he was rightfully so, but he didn't show it.

Somehow I still feel in this haze at the hospital - I can't really think straight, especially not about medicine. I constantly feel under time pressure and a plethora of everyday things is still totally unfamiliar. I lose my bearings walking around the place, something I don't usually do. I feel like I can just about stem the tasks I am given in the time I have but nothing gets done thoroughly. And if something unexpected happens, like broccoli soup, it can seriously mess with my timetable.

I think there is two things that I'm lacking and if I had at least one of them, I wouldn't miss the other one so much. One is time, the other one is a working familiarity with all things renal. After four months of surgery and four months of anaesthesia, now several years after the semester I learned medicine in, I feel about as far away from nephrology as from Munich.

Anyway. Since Justin, the resident, had seen another two patients too we actually had to present five new patients total to the attending, including discussing what happened to the old ones. After discussing what to do with them intermixed with a lot of teaching from the attending as usual, it was 2:30 when we got up from the office to actually start rounding them. First, we looked at their urine samples in the lab, though, as always. Then we visited all of them individually. On the way there the attending kept quizzing us, that was becoming a habit. Oh and he did remember to ask me about the assignments he had given me yesterday, the effects of different diuretics on serum calcium and the effects of calcium on the ECG.

And I do have to confirm yet again the old prejudice against American medical professionals. Physiology is not their forté. The right answer to the question "how does digoxin work?" is not "it inhibits the sodium-potassium ATPase" but "it increases contractility and decreases AV conduction".

So you can actually replace the question "how does xy work" with "what are the effects of xy on the system". This is valid even if the question is rephrased to a "why does xy do yz?". For example - if asked "why do thiazide diuretics lead to hypercalcemia" the right answer is actually "because they lead to increased calcium reuptake". People start looking at you funny if you start with the answer any German teacher would expect by talking about basal or luminal transport systems in the distal tubule and ionic potentials driving the calcium out.

Results count here, apparently. And they do have a point, that is what does count in the end and that is what you should really try not to get wrong by trying to explain it from the bottom up and getting confused. The attending does seem to have a weakness for pathophysiology though and is thoroughly pleased if I sometimes do know why something is the way it is.

Seeing all those patients and finishing up my note on the Hodgkin patient that was lacking lots of important stuff as well as looking at some more urine took until 5. After that, I did run down to "au bon pain" in the lobby and got myself a cookie before I went back up to the resident workroom and read a bit about Fanconi syndrome, my assignment for tomorrow, taking a break to write the first blog entry today that is right below here.

By now, Trillian has informed me that she has safely landed in Munich and is on her way back to town. In all likelihood, CS and BT will have all three of us over tomorrow for a barbecue (if the weather permits) and hitting a bar afterwards.

Chicago kicks butt! (Insert picture of me complacently waving to the east coast here).

Thank you Amsterdam and good night