Friday, October 31, 2008

End of Block One

I took the NBME (National Board of Medical Examiners) exam this morning. We had yesterday off from clinic to study, but I mainly spent the whole day in bed and just did a little reading. There is nothing that I'm going to learn in one day that I should have learned in the past four months. This NBME is a practice Step 2 test that is now optional for CCLCM students but still required for UP students. The good thing about the test being optional is that it is not at all stressful for us. The downside of it being optional is that it is now only offered at Case. I went over there with some of my friends from the UP, because I still get hopelessly lost every time I try to find my way around the Case medical school buildings. The test itself didn't seem too bad. I think I probably did better this time, even without specifically studying for it.

After the test, we had to go back to CCF to meet with the BAT (Block Assessment Team). This time they just had us all meet as a group and we went through to give our suggestions about each rotation. They also gave us a free lunch. We were supposed to have individual meetings with the BAT afterward, but fortunately the faculty decided that it wasn't necessary. I went and met with my PA and then went home.

I am incredibly grateful to be done with Medicine for good. If I were still on this rotation, I would have had another black weekend this weekend. My team was joking with me on Wednesday that I could still come in and take call with them if I wanted. I told them I'd try not to feel too bad for them while I was sleeping in tomorrow! Now that I think about it, they really got screwed, because this weekend is the end of Daylight Savings Time. So they are going to have an extra hour on call since they both will be on in the middle of the night when the clocks get switched back.

Some of my classmates are going to the Weatherheadless Ball at the business school tonight, but my exciting plans for Halloween include a fluffy pillow and a down comforter, both of which I have seen way too little of over the past few months.

Wednesday, October 29, 2008

Last Call

We have a new attending this week, and I think it's fair to say that she doesn't like me very much. It probably didn't help that when she asked what specialty I want to go into, I was in a particularly foul mood and told her that I didn't want to do any of them. I'm so sick of internal medicine, and I'm REALLY sick of being asked what specialty I want to go into. My senior knew I was in the College program and helpfully piped up that I was going to be a researcher, not a clinician. That's not really true, but at least it ended the discussion.

At another point, the attending asked one of the other residents (not mine) why he had ordered a test that wasn't necessary to make the diagnosis. The resident said he had just wanted to see the results. I thought the attending would chew him out for ordering a purposeless test, but instead, she told him that if he had ordered it for educational purposes, that was fine with her. And people wonder why health care is so expensive! Our last attending had always emphasized how important it is to not order tests unless the results will change your management, and I agree with that philosophy.

Yesterday was my very last night of call. It wasn't a particularly good one. I guess all these long days and long nights were catching up with me, because last night I was really dragging. By 3 AM, I couldn't keep my eyes open any more and told my team I was going to bed for a few hours. I had just gotten all settled in the student call room when my pager went off. It was my senior wanting me to come down and see a patient in the ER. Swearing to myself, I got dressed again and went over there.

During the interim ten or fifteen minutes that it took me to do this, the patient was moved to one of the medicine floors in the H building. The senior told me to go to the H building and examine the patient. Now I was really pissed, because I had gone through the H building on my way to the ER from the call room. I went back to H, located the patient, woke her up again, examined her, and found nothing noteworthy. When I caught up with the senior, I told her that I wasn't sure what I was supposed to have found. She said she thought the patient might have had one eyelid drooping lower than the other, but it was very minor. I struggled to keep control of myself. Then she said with utter sincerity, "See, wasn't that worth getting up for? It's such an interesting case!" I contemplated strangling her to death with her own hair, but managed a weak smile. By that point, it was already 5:30, so I went to go preround on my patients.

Today was my last day on General Medicine, and I hope it wasn't too obvious when I dozed off during rounds this morning. We did have an interesting moment though when one of our patients wanted to check himself out AMA. It was freezing cold and snowing hard outside, so the attending asked the patient where he was going to go, how he would get home, and what would happen if he went outside with no coat on. The patient didn't have a good answer for any of those questions, and the attending decided he was delirious and wouldn't let him leave. We wound up pink slipping him. I got to go home at 1 PM since I was post call, and I have tomorrow off, ostensibly to study for the NBME on Friday. And that is the end of the General Medicine rotation.

Saturday, October 25, 2008

Facing Fears of Contaminated Blood

Yesterday morning, I did my second point/counterpoint. This debate was about how to counsel a woman who was BRCA-positive and had an extensive family history of breast and ovarian cancer. I was charged with arguing the pro-surgery viewpoint to prophylactically remove her ovaries and breasts. The opposing position was to monitor and screen her regularly. Since we don't have any way to biochemically or radiologically detect ovarian cancer until it is probably too late, screening women at high risk for ovarian cancer is really an untenable position. After the debate was over, I told the facilitator that the debate should really be about whether to use prophylactic surgical management versus medical management with an anti-estrogenic drug like raloxifene. At least that would be a real debate, because screening is known to be ineffective for preventing ovarian cancer, while prophylactic surgery is known to work in most cases. For those reasons, I thought only screening her for ovarian cancer was tantamount to malpractice. He agreed that the debate was too one-sided, so I think future students will have a medical versus surgical management debate instead.

In the afternoon, we had a POD session on innovations. It was awful. First, we got a one hour talk about the CCF Innovations office and how they would work with us if we had something we wanted to patent or whatever. I'm thinking, all I want to do is survive the next week of IM! Then, we had to break into small groups to work on projects. Our biomedical engineer facilitator gave us a problem and told us to innovate, as if you could order people to come up with creative ideas on the spot like that. The project was on designing a better artificial knee implant. I had been up late the night before preparing for P/CP and had a night of call ahead of me, so I wasn't in the mood for this nonsense. When the guy asked if I had any suggestions, I said no. Then he asked if I had any engineering background, and I said no. After that, he pretty much just ignored me, which was fine by me. I even managed to doze off a little. When it was over, I went to the cafeteria for dinner and then caught up with my team.

Last night wasn't too bad for a call night. I spent most of it with the intern, who, like I already said, is awesome. He let me do a bunch of procedures. First, we had to get an ABG (arterial blood gas) on one patient, so he asked me if I wanted to draw it. Well, I hadn't ever drawn one before, but I said I wanted to, and he walked me through it. Fortunately, things went well and I only had to stick the patient twice. Unfortunately, getting an ABG drawn is extremely painful for the patient. I don't know why drawing blood from an artery hurts so much worse than getting it from a vein, but it does. This patient was semi-comatose, but he could definitely withdraw to pain! I have no idea if he could hear me when I apologized for hurting him, but I hope so.

The intern and I took the ABG down to the lab ourselves instead of sending it through the pneumatic tube so that we could be sure it got done right away. However, we wound up neglecting to fill out some form that needed to go into the bag with the blood samples. So a few minutes after we left, the lab paged us, told the intern they couldn't run those samples, and asked us to bring over new ones with all the proper labels and paperwork. That was aggravating, because obtaining the blood for an ABG is very unpleasant for the patient, and the samples did have labels on the actual tubes of blood. But the lab was firm, insisting that the labels on the tubes had gotten smeared or could get smeared or would get smeared. Anyway, to make a long story short, I got the opportunity to draw a second ABG, and this time I hit it on the first try. But I felt really bad about having to do it at all, and we didn't tell the patient why we needed a second sample. Of course, I'm assuming he was even aware of what we were saying.

Later, we went to try to start an IV on a patient that the nurse hadn't been able to stick. I don't understand why the intern on call is expected to do sticks that the nurses can't get, when the nurses have way more experience starting IVs than the interns do. But we got called, so we went to try. The patient was really dehydrated and obese, which were major contributors to his being a hard stick. The intern tried first a few times but couldn't get it. Then he asked if I wanted to try, so I did. The patient was calmly lying in his bed and didn't jerk at all when I pierced his vein. I got a little flush of blood, but the needle came out again. After one more cautious attempt, I gave up. The patient's IV would just have to wait until a phlebotomist showed up in the morning. Normally I'm not the kind of person who has unsteady hands while performing procedures, but last night I did. Plus, I probably didn't try as vigorously as I could have, because that patient was known to be HIV+.

This was the first HIV+ patient I had ever knowingly encountered, and I was thinking later about how mindful I was about his HIV status the whole time I was poking around in his arm. Being stuck by an HIV-contaminated needle is every health care worker's nightmare. When the intern first asked me to try starting the IV, I had a fleeting thought of refusing. There would have been no repercussions if I had refused. I am only a medical student, and there was no inherent expectation that I would try to start that IV. But I tried anyway, even though I was afraid. I tried even though the entire time, the thought that this patient's blood contained the HIV virus was in my conscious awareness. But I managed not to be overwhelmed by that fear even though I was so aware of it.

As a preclinical med student, you tell yourself that your fear of contracting HIV would never interfere with your sense of duty to help patients. But somehow, the situation is a lot more ambiguous when you're poking an HIV+ person with a hollow needle, and the only thing preventing his blood from contacting your bare skin is a thin, latex-free glove.

Tuesday, October 21, 2008

My Last ICU Visit

I met my new intern and resident yesterday. The new intern is really cool. He is going to be a neurologist, and he's another intern who loves teaching. Considering how bad my neurological exam is, I can use all the help I can get. Our first call together as a team last night was fairly uneventful, and we all got to go home early today since we are post call. But I only got a few hours of sleep last night, and overall I still feel pretty cranky and even a little bitter about the whole overnight call thing. Q4 call (every fourth night) sucks. You're always either on call, about to go on call, just getting off call. I have decided that I don't want to do any residency that requires Q4 call.

As promised, I stopped by the ICU on Monday last week to see my heart failure patient. I went into his room to find him intubated and sedated. Over the weekend, he had coded. When I went into the room, I pulled one of the chairs next to his bed and held his hand. I asked him to squeeze my finger if he could hear me, and he did. Then we just sat together like that for a while. For the rest of the week, I came in every day to sit with him for a few minutes, and every day he squeezed my finger when I asked him to let me know if he heard me. During one visit, his nurse saw me sitting there and asked if I was taking his pulse. “No,” I said. “I’m just holding his hand. He knows we’re here with him.”

Today, I got to his room just after a code was being called off. He had arrested again, and this time the code team hadn’t been able to revive him. Everyone had left except his son, who I had never met before. He asked me if I had brought the papers for him to sign. “No,” I said. “I’m a medical student. I came here to see your father. I’ve been coming to see him every day.” The son said something about how his dad didn’t want to be kept alive on a machine, and thanked me for taking such good care of his dad. Then he left me alone in the room with his dad's body to go searching for the paperwork.

At first, I was really put off by his seeming lack of emotion, as well as the fact that he had not ever come to visit his father in the hospital. But everyone deals with their grief differently, and maybe that was what he had to do to cope. At any rate, I am glad that I had the chance to know his dad, because he was a really great guy.

Friday, October 17, 2008

Drawing Boundaries

I found another old friend (a patient) waiting for me when we went on rounds last Monday. Taking care of her was a challenge for any medical team. She had multiple major medical problems, both physical and psychiatric, that made her a difficult patient to manage. She found it difficult to be flexible. In particular, she was resistant to adapting to the frequent changes in the treatment plan or her daily routine that are the norm in any hospital. Whenever she got upset enough, she would sign herself out of the hospital AMA (against medical advice).

I had done her H & P when she came on the Cardiology service the first Friday I was there, and I spent a lot of time talking to her and her husband during my black weekend. My goal had been to keep her in the hospital all weekend so that we could cath her heart on Monday morning. Each time I left the room, I joked with her, "You'll still be here the next time I stop by, right?" She laughed and said she would. Even though there were some minor rough spots, we managed to get through the weekend without her demanding that someone bring her AMA papers. She had her cath, which turned out normal, and she was released from the hospital.

Now, one week later, she was back. Since I knew her, I asked my residents to let me follow her. They were more than happy to oblige, because she had done nothing but complain since landing on the General Medicine service. I checked on her several times during the day and encouraged her to have some patience with the doctors, who were doing their best to help her. Tuesday morning, I found multiple notes in her chart from the night nurse describing how she (the patient) had accused her (the nurse) of disliking her, and purposely avoiding helping her. I talked to the day nurse about my patient's psych history, and asked him to please keep an eye on her. The patient calmed down and was getting along fine with the day nurse.

One of the things that upset this patient the most was when she didn't get her breathing treatments on time. She really did have severe COPD (chronic obstructive pulmonary disease), but she would also work herself up whenever things weren't going according to schedule. I went home Tuesday afternoon after reminding the resident to put in orders for the patient to have her breathing treatments every four hours all night long. Wednesday morning, I came in to find her in the sorriest state I had ever seen. She could barely breathe, and she was very tachycardic. Somehow, the order for her breathing treatments had been discontinued, and she hadn't gotten any treatments all night long. No one had noticed her, because she had been given extra lorazepam in the evening to help her sleep and keep her calm. In her drugged state, she hadn't been able to complain, and the night nurse understandably hadn't gone out of her way to check on this patient in depth.

I listened to her heart and lungs, then went to get my senior. We got the respiratory therapist to come to her room stat to treat her. We also took her off the lorazepam. I spent a lot of time talking with her and her husband. She wanted to leave, but the residents and I convinced her to stay. So she did, and the next couple of days passed uneventfully. Yesterday evening when I was finished with my short call, I went by to tell her that I had didactics today and wouldn't see her in the morning. I promised that I would come by this afternoon before I went home. Her husband gave me their phone number and told me that I should come over for dinner some time. But at some point during the night, she got upset again, demanded that the resident on call bring her the AMA papers, signed herself out AMA, and left.

I was worried about her and even thought briefly about calling her at home, but I decided it was best if I didn't. Although she has a psychiatric disease, she is fully competent to decide that she wants to leave the hospital AMA. But I felt a little guilty when I heard that she left while I was gone. I was sure that if I had been in the hospital overnight, I could have again convinced her to stay. Maybe I could have, and maybe not. But it dawned on me that my approach to her was becoming personal as opposed to professional. I wanted her to stay in the interest of her own health, but I also wanted her to stay because I felt like it reflected badly on me as her health care provider if she left AMA. Of course, her leaving the hospital does not really reflect on me at all. I was the one who had been making her decision into some kind of referendum of my performance as a clinician.

Monday, October 13, 2008

General Medicine Service

I came in this morning to be pleasantly surprised that I already know my senior resident. Last year, she worked with my longitudinal preceptor in the outpatient clinic sometimes, and that is where I met her. My new intern used to be a pharmacist before he went to med school, which is pretty cool. I am only working with the two of them for this week, because the residents change rotations on Monday of next week.

My new attending holds sit-down rounds instead of going room to room. Then he goes to see the patients on his own afterward, leaving us to do whatever scut needs to be done before the noon conference. I like this system a lot better than when we all had to go on bedside rounds with the attending! The team discussed all of the patients, and then my senior and intern, who were post-call, went home. I had gotten yesterday off, so I didn't get to go home. But there wasn't much to do this afternoon with all the team gone, so I had plenty of time to read. All in all, not too bad for a first day.

Thursday, October 09, 2008

Heart Failure and EKGs

This is my last week on Cards. I should have had to be on call again this weekend, but since I'm switching to a general Internal Medicine (IM) team next week, I lucked out and will get the whole weekend off. I'm grateful for that, because it's been a hectic past couple of weeks.

Yesterday and the day before, we had two EKG sessions led by one of the chief residents. They gave us sample EKGs and helped us go through them and practice interpreting them. Since my cardiology attending is the CCF guru of EKG and has been doing impromptu teaching sessions with my team over the past two weeks, I came in already feeling pretty well prepared. Then last night, my intern was going over EKGs with me in the ER while we were on call. Like I've said before, this intern really likes to teach, and I've learned a lot from him over the past two weeks.

I am still following one of the patients we were consulted to see in the ER a while ago. He had come in short of breath with a 25 pound weight gain due to an exacerbation of his congestive heart failure (CHF). Because of retaining so much fluid, he had the most impressive pitting edema (swollen legs due to excess fluid) that I had ever seen. Saying that his edema was pitting means that when I pressed on the swollen ankle with one finger and then let go, the pit made by my finger would stay visible on his ankle for a few minutes afterward. It's almost like how a piece of clay will still have an indentation after you push your finger in and then take it out.

Anyway, he had so much excess fluid in his body when he showed up to the ER that he couldn't even lie down--if he did, his lungs would fill up with fluid, and he wouldn't be able to breathe. He also couldn't walk because it made him too short of breath. So he had to stay sitting in a chair all the time. In spite of that, he was cheerful and joked around with me. We spent an hour in the ER going through his history and physical until my team came down. Then my intern admitted him to the floor.

The obvious solution was to give him an IV diuretic (similar to a water pill) to try to get some of that fluid off, which is exactly what we did. However, it created a real catch-22: every time we tried to increase his dose of diuretic, his kidneys would start to fail. But if we decreased the dose of diuretic to improve his kidney function, he would gain back a few pounds of fluid, negating the progress we had made in diuresing him. After several days of this stalemate, the team decided to transfer him down to the heart failure ICU. He still had so much fluid on him that he had to stay sitting up in his chair all the time, and he couldn't walk, talk or lie down without becoming severely short of breath.

Now that he's in the ICU, he isn't my patient any more. But he and I get along pretty well, so I have still been stopping by the ICU to check on him when I have some time. Today, he introduced me to some of his friends who were visiting him, and I told him that I'd come by again on Monday when I get back. Unfortunately, so far, the ICU team isn't having any more luck with diuresing him than we did.

Sunday, October 05, 2008

Black Weekend

It's entirely possible that this has been my worst week since starting medical school. Thursday was another full day of rounding and scut, so it wasn't any more boring or awful than any of my other days on IM so far. But on Friday, I found out that my last surgery patient had died. Even though I wasn't on the surgery team any more, I had been checking his electronic chart each day all week to see how he was doing. I knew he wasn't doing too well since he had been admitted to the ICU earlier in the week, but I kept hoping that he'd pull through. When I checked on Friday, I saw that he had been disconnected from all life support and had died soon after. That put me in an even worse mood to begin my black weekend.

A black weekend means that you get no day off for the entire weekend. In other words, you work for 12 straight days, from Monday of one week until Friday of the next week. Whenever you have a Saturday call, that's a black weekend because you come in Saturday morning at 7 AM and leave at 1 PM on Sunday. Then you still have to come in Monday morning at 6:30 AM like normal. I came in on Saturday already feeling cranky because I didn't find out that we had a 30 hour call until Friday afternoon. My confusion was because on surgery, weekend calls started at 6 PM and were over the following morning at 8 AM. So I blithely made plans for yesterday, only to be told by my intern the day before that no, I had to be here all day.

Being in the hospital on Saturdays is not much different than being in the hospital on weekdays. You still round on the patients, do scut, and write notes. The school gives us money for our call meals, which is a really nice perk. But as I found out, that call money can't be used at lunchtime, only for dinner and breakfast. So I still had to pay for my lunch even though I was on call, which annoyed me too. After lunch, I went back up to the floor and was standing right outside of a patient's door when a code was called. It wasn't one of the patients that I was following, so I didn't really know her. But I went into the room with everyone else.

Codes may look cool on TV, but they're pretty awful when you're there in the room for one. The code team members were compressing the patient's chest, and she was flopping around in the bed like a doll. I could hear her ribs cracking, and then the anesthesiologist intubated her. The team defibrillated her a few times and got her pulse and blood pressure back. The patient's family was outside the room, and her husband was crying. I went out to be with them just as the chaplain arrived. A few minutes later, one of the code team responders came out to tell the family that the patient had been resuscitated and they were moving her to the ICU. He said very matter-of-factly that the patient was in very bad shape and might die. The husband started sobbing even harder, and the responder just said, "sorry," turned, and walked away.

There have been plenty of times here and there when I have thought that I probably made the wrong decision to go to medical school, but that was one of the times it hit me the hardest. What really got to me was watching that responder's back as he walked off to go fill out his paperwork.

Wednesday, October 01, 2008

Inpatient Cardiology

This is my first week of inpatient medicine/cardiology. I think it works a little differently at the other hospitals, but at CCF, we spend two weeks on inpatient cards and three weeks on inpatient general medicine (IM). Most people do IM first, but I have been scheduled to do cards first.

Monday was not the greatest start. I had paged my senior resident a few days earlier to find out when I should get to the hospital and where to meet, and he told me to be in the medicine residents' room at 8 AM. So I showed up on time, but then I sat around for the next hour and a half while he wrote his notes. Fortunately I had brought something to read, so it wasn't a total waste of time. At 9:30, we met with the attending and the rest of the team and started rounding. This made me realize two things: first, I really hate rounding for hours at a time. Second, it felt pretty weird to be wandering around the hospital floors all morning when I had always been in clinic or in the OR by 8 AM up until now. I think this has been the first time that I've been up on the floors while it was still light out!

After rounding for what seemed like an eternity but was actually only a couple of hours, we went to the IM noon conference. I had been to a few of these before, but not every day like now. They're not the most exciting things either, and I think the biggest reason people like to go to them is because we get free food. Then, we basically spent all afternoon doing scut. Scut consists of things like contacting outside hospitals to get medical records, sending faxes here and there, and making phone calls to various people. It's not very exciting, but it's still better than rounding because at least I'm doing something.

Monday night, I got to go home around 6 PM, but last night I was on call. That pretty much involves admitting people and answering pages from the nurses for this or that. The bad thing about call for the residents is that not only do we have our own team's patients to worry about, but we also cover the patients for three other teams as well. It's impossible to really know the details about 80 different patients, and the pages keep coming in nonstop all night long. The good thing is that seeing the patients is fun, and now I have two of my own patients to follow. They came into the ER and I did the H & Ps (histories and physicals) before we admitted them. After that, I got to sleep for a few hours.

This morning I saw my two patients again on my own before I met with the team for rounds and presented them to the attending. After my first kind of disastrous surgery call experience, I have gotten better about being more organized when I present. Right before rounds started, I printed out all the notes I had written so that I'd be able to remember the details and all the test results from the ER, along with the most recent lab values and vital signs. My patients are both very sick with multiple diseases, so there is a lot of information to collate. Since we were post-call, we got to leave at 1 PM after we signed out to the other team. 30 hours can seem like an eternity, especially when it's all you can do to keep from nodding off right in front of the patients and the attending while you round the morning after call.

Besides me, the attending, and the senior, there is also an intern on the team. He is really awesome. Since he wants to be a cardiologist, he is very enthusiastic about cards and has been going out of his way to teach me and help me with my notes. I've been doing extra scut for him in return, not only because he's nice and it gives me something to do, but also because I felt sorry for him. I think medicine interns must have the worst job of anyone with an MD. But when he found out that I had to take overnight Q4 call (every fourth night) with him and the senior for my whole rotation, he told me that he felt sorry for me! I hadn't realized that at a lot of other med schools, students aren't required to take overnight Q4 call. That does not thrill me, but at least I get the rest of today off. Tomorrow I will be back in at 7 AM to round on my patients.