There seems to be another recurring theme - my very first patient on a new service apparently regularly turns out to be case report-worthy.
Remember, the patient I saw on the very first morning I started in this hospital was the deaf-mute lady that ingested 50,000 units of vitamin D per day for an entire year and came in wildly hypercalcemic.
I also told you about the young guy yesterday that could easily bench press me. Turns out, heart failure apparently was the right service for this guy after all. (Actually, general cards, electrophysiology as well as we ourselves were all consulting on this same guy.) During rounds today (that thankfully ended with only two hours of overtime), we got a call from the general cards attending that had evaluated this guy's cardiac MRI, who was apparently very excited about it. So we went to his office and had a look. He demonstrated patchy hyperintense infiltrates in the myocardium very much consistent with sarcoidosis (or maybe some other form of myocarditis). We call-conferenced with the electrophysiology attending and my current attending on the heart failure service received kudos for actually having come up with sarcoidosis on the differential in this guy even before the MRI.
So we (fellow, resident and I) had our work cut out for ourselves .. look up sarcoidosis and its manifestation in the heart till tomorrow.
So that's what I'll get started on while still here in the hospital, since I'll need access to uptodate and medical journals.
But I'm hungry, tired (got only 5 hours last night) and my feet hurt up to the knees.
Surgery suddenly looks very attractive right now. My feet are going to hurt anyway and at least I won't have to think anymore.
Blog to you later.
Wednesday, May 2, 2007
Tuesday, May 1, 2007
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.
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.
Saturday, April 28, 2007
"Ummm, I'm thinking about math."
That was the answer from the guy on "my" team when I asked him what his major was. He was a first year college student.
Then those kids started kicking my ass on the basketball court again.
I'm old.
Then those kids started kicking my ass on the basketball court again.
I'm old.
Wednesday, April 25, 2007
Oh!
And looking at the post below I just realized that I forgot to tell you what prompted the post's title .. "routine".
I meant to tell you that I finally had a routine down in the morning, going up to A700 in the morning after having thrown my jacket into the residents' workroom, picking up the current list of patients on the consult service in the dialysis unit on the way, then paging Jen from one of the phones in the kitchen, putting a halved bagel into the toaster, pouring orange juice into a cup, at which point Jen will return the page, I talk to her, after which the bagel is done and I put some toppings on it, after which I go sit down at a computer and check up on old patients in the computer or, if I'm lazier than that, I'll just check my mail, read the news or start blogging.
I did the latter today, but was rudely interrupted by the first later-to-be-cancelled consult in mid-breakfast as you can read in the post below.
Blog to you later!
I meant to tell you that I finally had a routine down in the morning, going up to A700 in the morning after having thrown my jacket into the residents' workroom, picking up the current list of patients on the consult service in the dialysis unit on the way, then paging Jen from one of the phones in the kitchen, putting a halved bagel into the toaster, pouring orange juice into a cup, at which point Jen will return the page, I talk to her, after which the bagel is done and I put some toppings on it, after which I go sit down at a computer and check up on old patients in the computer or, if I'm lazier than that, I'll just check my mail, read the news or start blogging.
I did the latter today, but was rudely interrupted by the first later-to-be-cancelled consult in mid-breakfast as you can read in the post below.
Blog to you later!
Routine
Yesterday, the service was back up to its usual five consults. Most notable exception was that my patient for the day was in the ER again, a place I still like to go to. Although I'm far from being an expert yet, nephrology is already becoming a bit monotonous. If I imagine focusing on the kidney for a significant number of years, like my attending would approve, it doesn't seem like that could still be interesting then. And I don't feel like one has to be particularly smart to do it. There's a large but still limited number of diseases a kidney can have and it still holds true that hearing hooves usually signifies horses. And figuring out the occasional zebra will certainly be satisfying but rare (and we're here at a good university hospital in a consult service that deals with the cases the primary teams cannot or will not figure out - so pretty selected collective of patients already). I'd still rather be in the ER, obviously things were less repetitive in there.
That said, it's not completely boring here. Physicians mix things up by overdosing people on Lasix last night, for example, poor guy's in the ICU and probably deaf right about now. I guess I shouldn't go into details on that.
And another interesting mix-up happened .. apparently someone was very much post-call and wrote an order for DDAVP (desmopressin, basically vasopressin with an arginine attached) for a patient with a sodium of 120. Apparently they got it confused with another medication starting with "D": Demeclocycline, a vasopressin antagonist, after having been awake for too long. I guess we're all human.
(Disclaimer: These stories are needless to say purely fictional and any resemblance to actual events or persons is, of course, coincidental.)
(I started this post with breakfast in the morning. This is the third time I was interrupted and I'm continuing this draft, it's 7:30pm and I'm back home.)
So, where was I. Ah well, what does it matter anyway.
The reason I was interrupted so often today was that the two residents we had up until yesterday were done with their renal consults. We got one new resident today, but she was, of course, in clinic this morning. That left Jen and myself, Jen having a kidney biopsy scheduled. That's how I ended up with my first consult at 8:45am, when I had spent one and a half hours on it and was close to getting done she paged me again to let me know the primary team had just cancelled the consult. They'd send the patient home this afternoon. 20 minutes later I got another patient, HIV+ with PCP in the MICU. 33 minutes later, at 11:07am (I'm reconstructing this from my pager) Jen called again to inform me she was about to start the biopsy and given that this had taken more than an hour yesterday she would like me to get started on a third patient. I replied "Sure. So you're planning on rounding around 5pm, right?". I was trying to make sense of this guy in the MICU's chart again but failed miserably. He had apparently been turfed from one place to the next a lot, hitting one normal ward, one step-down service and three different ICUs in little more than a week. Naturally, they all had different kinds of flow sheets that overlapped (good luck trying to figure out ins and outs there) and medication orders were a mess.
To paint you a picture: One and the same medication, Bactrim, was showing up on the same day's medication sheet three times. Once as p.o. medication, with a "d/c'd" behind it, as in "discontinued". One more line saying "Bactrim", this time i.v. and with some number of mg/kg but no times of administration behind it. And a third line on that same page starting with "Bactrim", i.v. again, this time saying 250mg and followed by four different times of administration. Two of those time points were circled, two were crossed out, all carried some hieroglyphs around them - presumably initials from nurses but they could mean anything as long as you're not familiar with *all* of the abbreviations that could be used on these medication order sheets. It turns out that the circled times of administration are doses that are not actually given to the patient, while the crossed out ones are. And that's only one of the four different antibiotics this person has been given in the time he was there, not even speaking of the plethora of other medication this 69 y/o HIV, HepC, PCP, HTN, CRI now septic patient has been given over the past week. It took me probably about five minutes of deciphering interns', residents' and especially surgeons handwriting just to find out when the guy was intubated - namely yesterday.
I would have needed a very high threshold for frustration today, which, alas, I didn't have. It was frustrating that it still takes me forever to assemble the simplest pieces of information and I'm still not sure how I can speed it up.
The best way probably is to keep doing consults. Although it probably wouldn't hurt if someone at some point sat down with me and gave me an introduction into things like "a circle around a time point on the MAR record means that this dose was actually not given". Thank you, you've just saved me half an hour of grief and the recorded fluid intake on the flow sheet finally goes together with the fact that this antibiotic is administered in 500ml IVPBs.
You live, you learn.
That said, it's not completely boring here. Physicians mix things up by overdosing people on Lasix last night, for example, poor guy's in the ICU and probably deaf right about now. I guess I shouldn't go into details on that.
And another interesting mix-up happened .. apparently someone was very much post-call and wrote an order for DDAVP (desmopressin, basically vasopressin with an arginine attached) for a patient with a sodium of 120. Apparently they got it confused with another medication starting with "D": Demeclocycline, a vasopressin antagonist, after having been awake for too long. I guess we're all human.
(Disclaimer: These stories are needless to say purely fictional and any resemblance to actual events or persons is, of course, coincidental.)
(I started this post with breakfast in the morning. This is the third time I was interrupted and I'm continuing this draft, it's 7:30pm and I'm back home.)
So, where was I. Ah well, what does it matter anyway.
The reason I was interrupted so often today was that the two residents we had up until yesterday were done with their renal consults. We got one new resident today, but she was, of course, in clinic this morning. That left Jen and myself, Jen having a kidney biopsy scheduled. That's how I ended up with my first consult at 8:45am, when I had spent one and a half hours on it and was close to getting done she paged me again to let me know the primary team had just cancelled the consult. They'd send the patient home this afternoon. 20 minutes later I got another patient, HIV+ with PCP in the MICU. 33 minutes later, at 11:07am (I'm reconstructing this from my pager) Jen called again to inform me she was about to start the biopsy and given that this had taken more than an hour yesterday she would like me to get started on a third patient. I replied "Sure. So you're planning on rounding around 5pm, right?". I was trying to make sense of this guy in the MICU's chart again but failed miserably. He had apparently been turfed from one place to the next a lot, hitting one normal ward, one step-down service and three different ICUs in little more than a week. Naturally, they all had different kinds of flow sheets that overlapped (good luck trying to figure out ins and outs there) and medication orders were a mess.
To paint you a picture: One and the same medication, Bactrim, was showing up on the same day's medication sheet three times. Once as p.o. medication, with a "d/c'd" behind it, as in "discontinued". One more line saying "Bactrim", this time i.v. and with some number of mg/kg but no times of administration behind it. And a third line on that same page starting with "Bactrim", i.v. again, this time saying 250mg and followed by four different times of administration. Two of those time points were circled, two were crossed out, all carried some hieroglyphs around them - presumably initials from nurses but they could mean anything as long as you're not familiar with *all* of the abbreviations that could be used on these medication order sheets. It turns out that the circled times of administration are doses that are not actually given to the patient, while the crossed out ones are. And that's only one of the four different antibiotics this person has been given in the time he was there, not even speaking of the plethora of other medication this 69 y/o HIV, HepC, PCP, HTN, CRI now septic patient has been given over the past week. It took me probably about five minutes of deciphering interns', residents' and especially surgeons handwriting just to find out when the guy was intubated - namely yesterday.
I would have needed a very high threshold for frustration today, which, alas, I didn't have. It was frustrating that it still takes me forever to assemble the simplest pieces of information and I'm still not sure how I can speed it up.
The best way probably is to keep doing consults. Although it probably wouldn't hurt if someone at some point sat down with me and gave me an introduction into things like "a circle around a time point on the MAR record means that this dose was actually not given". Thank you, you've just saved me half an hour of grief and the recorded fluid intake on the flow sheet finally goes together with the fact that this antibiotic is administered in 500ml IVPBs.
You live, you learn.
Monday, April 23, 2007
Day off
Wow .. just one single little consult for the entire service today. And since I checked in after one of the residents this morning, he got it and I didn't even have to do it. Now I know what hem/onc service must feel like ;D
I had time for morning report as well as electrolyte conference today. I'm going to miss the latter next month. The attending - or should I say guru - at the head of the table has an extremely calm and wise aura about him as he infers incredible amounts of information from little more than about a dozen lab values and how they develop over time. Actually, the fellows go through the labs, commenting them, and the attending - who never heard about the case before either - asks questions. Questions like (I'm just making these up for illustration, don't even have a clue whether they make sense) "so, what would give you a urine osmolality this high with a TTKG (trans-tubular potassium gradient) of 5 in the setting of severe dehydration?" Or "what's the mechanism of renal failure in severe hypercalcemia with non-gap acidosis?" Uh, well, uhm .. luckily the fellows react similarly often enough, which makes it even more humbling and awesome when this attending kindly and most of all vividly describes (or leads us on the way of finding ourselves) the pathophysiology behind everything.
Yes, you read right. Physiology. This man does care about mere ions and ion channels and enzymes and pathways yet manages to not only integrate all that knowledge into an astoundingly accurate clinical picture of the patient (without history, physical exam or any other information, just part of their labs over one or two weeks!) but he also describes them as entertainingly and plastically as only Americans can. It's like a German professor in pathophysiology crossed with an American teacher.
He's awesome.
If my kidneys ever get sick, I'd rather have this man take a look at my labs for one minute than 10 other docs conferring for hours.
Oh, and I believe I had already mentioned that the pizza is good.
I had time for morning report as well as electrolyte conference today. I'm going to miss the latter next month. The attending - or should I say guru - at the head of the table has an extremely calm and wise aura about him as he infers incredible amounts of information from little more than about a dozen lab values and how they develop over time. Actually, the fellows go through the labs, commenting them, and the attending - who never heard about the case before either - asks questions. Questions like (I'm just making these up for illustration, don't even have a clue whether they make sense) "so, what would give you a urine osmolality this high with a TTKG (trans-tubular potassium gradient) of 5 in the setting of severe dehydration?" Or "what's the mechanism of renal failure in severe hypercalcemia with non-gap acidosis?" Uh, well, uhm .. luckily the fellows react similarly often enough, which makes it even more humbling and awesome when this attending kindly and most of all vividly describes (or leads us on the way of finding ourselves) the pathophysiology behind everything.
Yes, you read right. Physiology. This man does care about mere ions and ion channels and enzymes and pathways yet manages to not only integrate all that knowledge into an astoundingly accurate clinical picture of the patient (without history, physical exam or any other information, just part of their labs over one or two weeks!) but he also describes them as entertainingly and plastically as only Americans can. It's like a German professor in pathophysiology crossed with an American teacher.
He's awesome.
If my kidneys ever get sick, I'd rather have this man take a look at my labs for one minute than 10 other docs conferring for hours.
Oh, and I believe I had already mentioned that the pizza is good.
Sunday, April 22, 2007
Lake Michigan
Hello reader,
another little picture post.
I didn't find out the weather was so beautiful yesterday until I stepped outside on the way to the library. It was surprisingly warm again and I was wearing way too many clothes. Then again, I thought the library would probably be air-conditioned. Because I actually went to the library, shortly. It was pretty much deserted as it has been the only other time I had been there. Interestingly, their first floor is open 24/7 for your studying needs - and so far hardly anyone is in that huge, endless library even during the day. So I decided I wouldn't be in there either, took my stuff and left, riding my beach cruiser bike east
and further east
still going
east on 55th (can you feel the tension rising?)
crossed the metra tracks (almost there!), look to the sidewalk on the right to get an indication of the temperature yesterday
and boom!
The lake.
With a mild breeze and plenty of sunshine.
I sat down at the tip of the headland up there and got my book out. Took me about 20 seconds to get distracted not by these guys
and not the view
but those three people in the middle, walking away.
The two people on the right are married and from Finland, with him doing an internship with a law firm and her doing research in pharmacoeconomics here. The girl on the left is actually from Germany and also doing an internship in the law firm. They were here to kill time waiting for their tickets to Body Worlds that they had bought at 10am to become valid at 6:15pm. Apparently they sold tickets for the same day at that place that would make people wait more than eight hours to get in. Well, as you probably know any excuse is good enough for me when it comes to not having to study, so I talked to them.
another little picture post.
I didn't find out the weather was so beautiful yesterday until I stepped outside on the way to the library. It was surprisingly warm again and I was wearing way too many clothes. Then again, I thought the library would probably be air-conditioned. Because I actually went to the library, shortly. It was pretty much deserted as it has been the only other time I had been there. Interestingly, their first floor is open 24/7 for your studying needs - and so far hardly anyone is in that huge, endless library even during the day. So I decided I wouldn't be in there either, took my stuff and left, riding my beach cruiser bike east
and further east
still going
east on 55th (can you feel the tension rising?)
crossed the metra tracks (almost there!), look to the sidewalk on the right to get an indication of the temperature yesterday
and boom!
The lake.
With a mild breeze and plenty of sunshine.
I sat down at the tip of the headland up there and got my book out. Took me about 20 seconds to get distracted not by these guys
and not the view
but those three people in the middle, walking away.
The two people on the right are married and from Finland, with him doing an internship with a law firm and her doing research in pharmacoeconomics here. The girl on the left is actually from Germany and also doing an internship in the law firm. They were here to kill time waiting for their tickets to Body Worlds that they had bought at 10am to become valid at 6:15pm. Apparently they sold tickets for the same day at that place that would make people wait more than eight hours to get in. Well, as you probably know any excuse is good enough for me when it comes to not having to study, so I talked to them.
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