Wind of change

So, lots to tell from these past days. I'll start with the "highlights".

Yesterday was my last day of renal consults. And I actually felt sad about that. Jen asked me whether I needed an evaluation. Before I could respond by saying "no, thanks", the attending chimed in with "don't worry about that I'm on top of it". Uh-huh, I am being evaluated now? I felt tempted to ask who she was going to send that evaluation to but refrained. She said I had nothing to worry about there, I was a "ten". Uhm, OK. Now I'm hoping that's not on a scale from 1 to 100. Anyway, renal days are over. I'll miss 'em.

Today is May 1st, started on a new service. I was actually scheduled to do regular cardiology for all of May but so was another student from Germany that arrived a few days ago. That's why CS spontaneously arranged for me to go join the heart failure team, basically a different kind of cardiology service. She asked me to come to the EKG conference this morning .. at 7:45am, mind you! So I did. The conference was good, strongly reminded me of the electrolyte conferences nephrologists hold. I guess the EKG is to the cardiologist what lytes are to the nephro guy. And similarly, the conference was almost equally sophisticated.

Afterwards, CS paged the heart failure team. The fellow was a little busy .. as was to be expected on the first day on the new service. Problem was that she also just received a new resident from Boston University who didn't know the way around the hospital (later on told me he spent an hour in the morning trying to find where he was supposed to go), didn't have a pager and didn't have access to the computer systems here. So in addition to having to deal with the patient collective of a new service, she had to get this resident settled in. Naturally (from what I gathered from listening to CS's side of the conversation), she was not so happy about having to deal with a new medstudent on top of everything. Oh, by the way, Tuesday afternoon is her clinic.

That's why my new fellow said she'd meet CS and me later and CS let me go for a second breakfast after the one at the EKG conference. So I went up to A700 around 9:30am, sending a text message to one of the two new Germans that had started today that I had time to show them where they could get free breakfast. I figured they'd probably be working on getting IDs and the likes right about now. So I sent the message and went up to A700 to find all other German medstudents were already there. So I guess my work there was done. I spoke to them shortly, went to the back to get my usual bagel and orange juice, came back and they were gone. Guess they hate me or something.

Anyway, I sat down and started peeking into one of the papers on heart failure that CS had printed out for me before. Shortly thereafter though, I was relieved by the student that I'll be sharing the cardiology services with this month. He was brought back up there by his resident and told to see the "conference", meaning morning report later on. We chatted for a while until one of the chief residents called us in for morning report. The case presented was a somewhat-interesting patient CDCD (as I just learned .. circling the drain awaiting celestial discharge) whose disposition seems to have raised numerous ethical dilemmas. Before I could find out what happened to her, around 10:30am, my pager went off and Carolin asked to meet me.

She brought me in to my "new team", which was basically that fellow I told you about earlier with her new indian resident who was in bad need of some orientation and access credentials. The fellow started rotating pretty much at that point, between the signout list she had opened on her computer, talking to the new resident, receiving pages, "welcoming" me, introducing all those people around her and mentioning that she had a consult. She asked me whether I could see this patient. Now at this point I got a flashback to my very first day here. "It's kind of a crazy day, could you just go see this one?" The new fellow did not quite exhibit the same amount of grace and good humor while massively multitasking but nevertheless, the resemblance was striking.

Anyway, while she was still spinning on that chair trying to get things for the day organized she pointed to one of the nearby laptops, asking me to get started on the patient right away. So I started collecting information from the computer. About 20 minutes later, she was ready to go on what would turn out to be her own little version of rounds, including a little tour for the new guy. Which would be the resident. She rounded just with us, without the attending, because - naturally - he was in clinic. As she would be later on, which I had already mentioned. But I actually only learned these facts about halfway through the pretty small list of patients on the heart failure service. Apparently, what she was discussing with us was our preparation to round with the attending later.

Ain't that something.

The clock was advancing towards noon-ish, at which time the fellow had to leave to her clinic. She handed me a sheet listing the patients on the service, asked me to look up the serum levels of immunosuppressants on three of them and to see the new guy until "rounds". I asked when that would be and she replied it'd be whenever the attending gets out of clinic, an indefinite amount of time that he will page us at.

The resident stated he would get lunch now and started walking out the ICU in the wrong direction, so I printed out the map of the hospital that had served me so well before for him and sent him on his way to "au bon pain".

In the meantime, I would have liked to go to Grand Rounds and eat lunch but that would have meant I'm out of the game until 1pm with no idea when the attending would want to round and be presented with my first patient on this service. So I went there right away. The case was rather straightforward, what kept me busy was the fact that I had extremely negligible experience dealing with heart nuclear scans, echos and catheters, all of which this 32-year-old guy had had. But I worked through his chart and computer files in the usual manner and talked to him for quite a while afterwards. He was a nice guy. Lawyer. Tall, bulky, but lean. He bench presses 250 pounds, he told me. I wouldn't dream of that. What team am I on again? Heart failure?

I'm glad I remembered that before automatically asking him for a urine sample. Might have wanted to do a tox screen though. He sounded like an upstanding guy but his muscular shape seemed pretty borderline towards having used stuff to get a little edge in the weightlifting game.

Anyway, back to the day. I was just about done with him around 1:30pm, going back to the T elevators to go down to the lobby. I wanted to get some candy from the gift shop to make it through the day and also in order to break a $20 bill. I'd probably need $1 bills for the bus later. Because I was scheduled to meet a friend tonight. A friend who lives in Berlin that I haven't seen in many years. She was in Chicago with a friend and she would be here until tomorrow morning. The three of us had a date in the Signature Lounge on the 95th floor of the Hancock Building tonight at 7pm. Even though I'd need about an hour to get to downtown from here, I was confident that I'd make that given that I've never really had to stay longer than 6pm.

Boy, was I wrong.

Anyway, on my way to the elevators, I met the Indian resident. He expressed his relief that he had found his way back from "au bon pain" to the fifth floor, where the patients were. He seemed a bit surprised that I had seen the patient by now and said that he would have wanted to see the patient with me. So I took him back there with me. Unfortunately, the patient was about to leave for another echo (with contrast this time) and that would mean his chart goes with him. So the Indian resident and I sat down at the nurse's station, I logged in with the credentials I still have from Jen (he won't get his until at least Friday), gave him a 5-minute-crash-course on oacis and left him reading the little info on the patient there was while I headed down for candy, change and a double-chocolate muffin at "au bon pain".

Muffin in hand, I went right back up. By now, it was around 2pm. I asked the resident whether he knew when the attending would be out of clinic to round with us. He said he had heard someone say "around 3". Ouch. And I had actually been under the illusion that I'd have time to go the extra lecture on preeclampsia at 4pm in the lecture hall today that my old attending and Jen had recommended to me yesterday. If we were to start rounding at 3, that would probably not happen. But hey. This service was tiny compared to renal before.

During that time, I counted April's renal consults that were still on Jen's and my list in oacis. There were 115 patients total, 3.8 per calendar day, 5.5 per workday (which is when consults are most often called for). I saw only 25 of these patients, which works out to 1.2 per working day. I believe there were only two days in the month where I did not see a consult alone. At any one time, there would be roughly 22-30 patients on the service.

Compared to this service, which apparently actively carries 7 patients right now, plus the new one I got today that was able to bench press me lying flat on his bed (as compared to the renal patients, more than half of which were on one of the ICUs, most of those intubated).

So you'd think we would be done somewhat quickly wouldn't you.

At 2:30pm I did dare to text-page our fellow that I was done with the patient and whether there'd be anything else we should do awaiting the advent of the attending we had never seen yet. She actually called me back and said that our attending was just about to be done in clinic, I should hang on a few more minutes. After a few more minutes, I decided to go to the bathroom while the resident was hovering over the phone. When I came back, he said that the attending wanted to meet us in the echo lab. So we went there.

In the echo lab, the other cardiology team with the other German medstudent was already happily rounding along, their attending apparently teaching them intermittently on the interpretation of cardiac echos. The resident and I waited outside for ten minutes. And another ten. Around 3pm (so the prediction was going to be correct) the attending showed, with a pharmaceutical doctor in his tow. After we had gotten acquainted for about 30 seconds we went into the dark lair where echos were evaluated on screen and the attending started a discussion with the cardiologist sitting at the computer about residency programs, research, this-and-that attending and just about anything until after maybe 10 minutes we started looking at the echo of "my guy" before I had even presented his case. Didn't seem to matter much for two reasons .. one was that the attending apparently already had heard the gist about him and the second reason was that he really didn't have much on his echo. Which was good. The guy was 32 after all.

So around 3:20pm we got out of there. The attending declared that we would now have to see the transplant patients first, since that was what the pharmaceutical guy was here for. And first on the list was the 12-year-old heart-transplanted kid from Japan. 12 years, man. Myocarditis is a bitch. So we went all the way over to the children's hospital and spent the better part of the rest of the hour watching the attending while he was talking to this kid's whole family from Japan via an interpreter, examining the child and having various discussions with the huge crowd of various health care providers ranging from nurses to physicians to case managers to the pharma guy. My only contribution was the tacrolimus level for this little guy that I had looked up around lunch. It was high.

While they were still discussing, it got very close to 4pm so I found a nearby computer and text-paged Jen that I wouldn't make it to the lecture, asking her to pay extra attention for me.

Shortly after 4pm, the attending seemed satisfied for the day with the child's healthcare.

So we headed back to the adult building. We met a nurse practitioner on the way. The attending now declared that we would have to see an "NP" case now. This guy wasn't on our lists. We went up to the sixth floor to this 60-ish-year-old patient that had lost both his legs to peripheral vascular disease, had received a combined heart-kidney-pancreas transplant almost 10 (!) years ago, was now developing a squamous cell carcinoma on his neck and still came on to the female nurses and docs on this floor. Can't really blame him though because he was right, they were "lookers" as he pointed out. So after that took about another 20 minutes, we walked back to the elevators around 4:40pm. The attending looked at his watch and stated that he actually had to be interviewing someone for a job here at 4:30pm and was scheduled for a meeting with "his boss" (whoever that is) at 5pm. He was fully aware that we had seen one out of the seven patients on the list of this service and apologized, saying he was afraid this may become "a long night".

Uhm, kay.

So he took off. The resident asked me whether we should go for coffee then since it was going to be a long night. Very funny. So we went down to "au bon pain", I got a cookie with m&m's in it and a bottle of water and sat down with the Indian. We talked for a good while - about airplane companies, his family, the transplanted playa, stem cell research, abortion, religion, God until we were tired of talking. All the while, I was sending cell phone messages back and forth with the friend from Berlin that I was supposed to be meeting. At around 6pm we gave up waiting down there and went up to the residents' workroom where I had actually started this blog entry close to six hours ago.

I saw both other new Germans there who were obviously done for the day, one of them preparing something for tomorrow it seemed. CS also stopped by and I tried to tickle some sympathy out of her for the fact that the one day that I actually had some kind of social activity planned out here in over a month I would be spending a "long night" at the hospital it seemed.

And I really couldn't just go - not without presenting the patient I had seen to the attending. That's really, truly, unthinkable. Naive and optimistic as I still was (can you imagine me optimistic? I was!) I still thought I could maybe make it. Down in "au bon pain" the Indian had offered to take me downtown in his car after rounds. He would even let me change quickly at home.

So when the attending finally paged us around 6:15pm, I still had a glimmer of hope that I'd only be late for the Signature Lounge and that I'd get to see the girls before they went on through the country. The attending said we should meet him in the D5 ICU in "around 10 minutes", he was still seeing yet another patient there. The guy was seeing yet another patient that wasn't even on our list. I urged the resident to come with me to D5 right away to see what the heck was going on.

And there he was, standing amidst the on-call D5 team. One of the residents of that team had been on renal consults with me before. So in between the vivid but somewhat repetitive discussions on what to do with this patient that was CDCD I asked that resident whether they had curbsided our attending on this. He looked puzzled and replied that he was "their attending". Apparently he was double-staffing D5 and heart failure.

That's fine. There's not really much to do on the heart failure team. But at some point, you have to actually start doing it!

The attending did no such thing. As I watched the minute hand of the clock on the wall calmly tick towards 7pm, they were still talking circles around this patient's care and how they should *not* wake the attending if he coded at 4am.

After 7, the attending apologetically turned to us and declared to the ICU team that he would now have to see to it that we would get home. How nice. The problem was that by now, I had understood that this guy just doesn't do quick consults. In the subsequent rounds he did with us, he initially flipped through the charts a bit faster but other than that did not really change his pace. Thankfully the patient on ICU was intubated. For the other ones were not and boy, did this guy have time to talk to them.

I was still constantly pushing back my calculations, deciding to skip changing and having myself be driven downtown right away but it was just no use. At 7:45pm, when we still hadn't come by my own patient, I wrote to my friend that I was sorry.

And I really was. I was really looking forward to seeing her again as well as getting an excellent opportunity to see the Signature Lounge and to get out of my apartment, maybe even to find some kind of attractive side to this city.

But I guess that's Internal Medicine for you.

Talking, talking, fiddling around with numbers and medications and some more talking.

But here's the scary part. The attending did an incredible amount of talking to all of those patients. But - he did it well. I actually *liked* listening to him. He's such an example of speaking to patients on their level, comforting them with compassion and care but at the same time being absolutely but NOT brutally honest. He could relate to them, be their friend instantly yet still emanate a respectful exterior and they'd still be smiling at him and nodding when he would speak about the direst truths.

After I had given up hope on the Signature Lounge, he actually wanted to let me go at 8:30pm, right after having finally seen (and talked extensively to) my one patient for the day. But at that point a patient's daughter (of a patient we had seen right before mine) asked to talk to him. And I voluntarily stayed at that point, because I really did enjoy listening to him talk to patients. Since it was decided that my plans for the night had to be scrapped, I also went along to the follow-up on the last patient. Here, even the attending showed signs of fatigue but I still didn't regret tagging along just for hearing this guy speak to the patient.

It may be partially blamed on severe hypoglycemia on my part after having skipped lunch and dinner today but in the end I couldn't even be mad at this attending for ruining the one glimmer of a social life I was going to have here.

I'm so weak.

And right now it's ten after midnight, my blogging time is clearly feasting on my sleep and I do feel worn out and hardly able to keep my eyes open.

Good thing that I can type blindly.

Too bad that this has probably been too long for any of you to still be reading. If you are, I congratulate you. If not, I'm sure I'll be reading this myself around ten years from now. Or probably not. I'll have too many interesting new things then to spend time on I hope. If not, I'll be smiling right about now plus ten years.

Allright. That's enough. It's even clear to me now that I need to sleep. So I will. Soon. Bye.