Friday, November 28, 2008

VA Stairmaster and Hospice Week

This was a short week because of Thanksgiving, but a lot was packed into it. On Monday after geriatrics rounds, I went around with the chaplain and the Hospice nurse practitioner to visit the Hospice patients. Two of them wound up dying within half an hour of one another. Somehow, it didn't seem as bad as some of the other patient deaths I have seen. I think a lot of it was that they were comfortable and the families were there. Also, they all had time to prepare. It was sad, but not depressing.

Tuesday I had my own consult, and it was a tough one. The patient has stage 4 lung cancer with metastasis to the brain, which has caused seizures and dementia. So he really doesn't understand what is going on. But I did my best to explain what Hospice was to him, and he agreed to have a Hospice nurse come out to his home. Wednesday we had a patient who didn't speak much English, but fortunately his family was there to translate. They decided to take him home to his native country to die, which seemed sensible to me. Dying in a hospital is so undignified, especially if it's in the ICU.

The Hospice nurse wrote me an incredibly nice evaluation for my portfolio. She was really upset though when I told her that I didn't want to do medicine and was thinking of doing something with less patient contact. She told me it would be a waste of my talent at working with patients. Considering how much I hated my medicine rotation, it always surprises me when someone says this to me. It makes me doubt myself a little. But I keep thinking about how only five weeks of inpatient medicine made me so miserable, and how the residents were so miserable, and I just don't think I can do it for three years.

I was off on Thursday for Thanksgiving. Friday was a holiday for the UP students, but not for us. So I was the only student who showed up, and I was running around frantically trying to help the nurse practitioner cover the other students' patients. She wanted me to stay in the afternoon too. But I told her that I had to leave at lunchtime because we have classes on Friday afternoons. That is usually true, but we didn't actually have class today because it was our free Friday afternoon. (We get one free Friday afternoon each month.) I was annoyed that she expected me to stay in the afternoon. It made me feel like she was taking advantage of me. I had already come in for the morning even though I could have easily gotten away with not coming in at all. It was enough. I care deeply about doing the right thing, but that doesn't mean there are no limits to what people can ask of me.

I forgot to describe the VA "Stairmaster" last week. The hospital is six floors tall, and the Stairmaster is actually one of the stairwells. The walls in that stairwell have been painted with motivational exercise statements and pictures. There are also colorful charts telling you how many calories you burn doing various activities, depending on your weight. One of the UP fourth years who had rotated at the VA before had told me that they play music in this stairwell sometimes, but I hadn't heard it before. Well, on Monday, they had turned on the music. Since the Hospice patients are on more than one floor, I had several opportunities to go up and down the VA Stairmaster. They played all kinds of things, from country to pop to jazz. Every time I went into the stairwell it was a completely different genre. I was thinking last week that the VA Stairmaster was kind of silly, but now that I've been in there with the music playing, I like the idea. They should post a schedule for what they plan to play when, though. I have decided that I really don't like climbing stairs to jazz!

Friday, November 21, 2008

Geriatrics Patients

As mentioned previously, I'm basically spending my days seeing geriatric inpatients in the mornings and outpatients in the afternoons. It still takes me at least an hour and a half to see each one. Since I'm on geriatrics, all of my patients were either in Korea or WWII. Most of them have multiple serious medical problems like heart failure and COPD, and they also have other issues like dementia, difficulty walking, or side effects due to polypharmacy (multiple drugs). The patients themselves can be quite the characters. One patient with moderate dementia wanted to tell me an off-color joke, and another had post-traumatic stress disorder. Many of them are depressed also, especially the inpatients. I am sure it doesn't help that we're getting close to the holidays.

This afternoon I had POD/ARM. It was on clinical trials. The talks were good, but since I have taken the MS course on clinical trials, I had already seen them all. After that, we had a class meeting on the research year and how to sign up for electives, advanced cores, and areas of concentration. Considering that I have done all of those things already (geriatrics is one of the advanced cores), it was pretty pointless for me to stay. But I had some time to kill anyway, because one of my surgery rotation patients was back in the hospital for another operation. I wanted to go see him after he got out of the PACU (post-anesthesia care unit). He was a bit groggy, but I think he was really surprised when I showed up. I probably won't get to see him again since I'll be at the VA all of next week, but at least I had the chance to stop by today.

Next week I am on Hospice. It is a palliative care service for people who are expected to die within the next six months. I'm interested in palliative care, so I'm looking forward to it.

Tuesday, November 18, 2008

Geriatrics at the VA

I started my Geriatrics rotation at the Cleveland VA yesterday. This is the first time I have ever been inside the VA hospital, and it is surprisingly nice. The floors are all wooden, and there is a lot of cool, funky furniture and artwork in there. A lot of the rooms are single. The patients wear what I can only describe as pajamas with the VA logo on them. The funny part is that the logo says, "property of the government" right there on the patients' chests. There are five students on the rotation: me and four fourth years from the UP. The faculty always ask us what we want to go into here just like they did at CCF. I'm the only one who still doesn't know, because these fourth years I'm rotating with are all going on residency interviews already. So I always have to explain that I'm only a third year!

For this whole week, I will be spending my mornings on the GEM, which is the geriatrics inpatient floor. I've only been seeing one patient per day, mainly because these patients are incredibly complex. I was joking to a friend that they couldn't be much different than a lot of the patients I saw on General Inpatient Medicine at CCF. But actually, they are a lot more challenging because most of these patients have dementia, delirium, or both. The main difference between dementia and delirium is that dementia is a permanent state of altered cognition, while delirium is usually a temporary, fluctuating state. The reason why it matters is that delirium is sometimes curable if you treat the underlying cause, but dementia (like Alzheimer's disease) usually isn't curable.

So the schedule basically goes that I come in each morning around 7:30 AM and see my inpatient. He has moderate dementia and is also recovering from a post-surgery episode of delirium. What fascinates me the most about working with him is that he is actually capable of performing several activities of daily living like feeding or dressing himself, but he has to be coached. For example, he can use a knife and fork to cut his pancakes and eat them, but only if I tell him what to do, step by step. Otherwise, he picks the pancakes up with his fingers. I can understand why these patients are difficult to manage at home. He is just as docile as a young child, but also just as dependent. It would be impossible for someone to stay there and constantly coach him all day long.

We have team rounds at 8 AM on Mondays, Wednesdays, and Fridays, and a lecture at 8 AM on Tuesday and Thursdays. (We start rounds at 9:15 AM on Tuesdays and Thursdays.) I was a little worried about the rounds, but they've been surprisingly short and painless. This is mainly because we only have half a dozen patients on the team, as opposed to the two dozen we would have on Medicine at CCF. Today's lecture was on delirium. After rounds, we finish seeing our patients and writing notes if we haven't already. I've been getting in early enough to get everything done before rounds, so it gives me the rest of the morning off to get other things done.

In the afternoons, I go down to the outpatient clinic. Again, these are mainly patients with dementia. Conducting the interviews can be a huge challenge, because a lot of the patients aren't able to focus on the discussion very well. As you can imagine, it's pretty hard to perform a mini-mental exam on someone who constantly goes off on illogical tangents or confabulates (makes up stories to fill the gaps in his memory). The other thing about the mini-mental is that it's specific but not very sensitive. This means that there aren't very many false positives (i.e., most normal people will not come out with a score that suggests impairment), but there are a lot of false negatives (people who are demented but score high enough to suggest that they aren't). The reason why there are so many false negatives is that someone who is highly educated (beyond high school) can often compensate for their cognitive deficiencies. So basically, if you have a college education or beyond, you would probably be able to "beat" the mini-mental even if you were mildly or moderately demented.

Friday, November 14, 2008

Done with Micro

This has been a very easy and relaxing week. I come in around 8 AM, hang out with the med techs for a few hours, go to a lunchtime talk, go on afternoon rounds, hang out and read for a few more hours (or maybe go to another talk), and I'm out of there around 4 PM. I went to the gym for the first time in about six months on Tuesday. I get a full eight hours of sleep every night. It's amazing. That being said, I'm ready to move on. I've covered most of the benches in the lab by this point, and I feel like another two weeks in here would probably be two weeks too many. There's a lot to be said for two week rotations. They're long enough to give you a taste of the subject, but not long enough to bore you.

I turned in my mini-clinical portfolio yesterday. This is a two page essay talking about what I did well and what I need to work on after my first block of rotations. It wasn't hard to write the essay at all. But putting in the citations was a huge job, because every eval from each attending has exactly the same title. So each time I wanted to cite someone who had written more than one eval for me, I had to open every single eval by that person in RefWorks until I found the one I wanted. I hate RefWorks more than I can possibly express in words. It's the most user-unfriendly program on the whole planet. I don't think the people who wrote it could possibly make it harder to use if they actively tried.

Today's FCM class was on dealing with difficult patients. It wasn't one of the better FCM classes we've had, but it was ok. They had standardized patients pretending to be the difficult patients, but they weren't very difficult. I've dealt with much more challenging real patients already. Plus, there wasn't enough info in the case scenarios, so it wasn't even clear what the problem was. Tonight I am having dinner with a couple of the UP students I rotated with last month, and then I am going to spend the rest of this weekend doing basically nothing.

Friday, November 07, 2008

Getting to Know the Bugs

I'm continuing to work my way around the medical micro lab. So far I've done two days at the blood culture benches, one day at urine cultures, and then today was acid-fast bacteria (like tuberculosis). The labor-intensiveness of it all continues to amaze me, as does the ignorance of so many of the people who call down to the lab wanting answers, and wanting them yesterday. These are occasionally residents who are calling, and they are not stupid or uneducated people. A few of them just don't have any clue whatsoever about what goes on in the medical labs. Some doc who called for a stat culture is now a running joke among the med techs. (Stat means that the doctor wants something done right away. The joke is because the med techs can't force the bacteria to grow any faster just because some doctor ordered the culture stat!)

At this point, I've started getting pretty good at identifying gram stains of bacteria, and even some of the more common pathogens on agar plates based on how the colonies look. E. coli grows flat, pink colonies on a MacConkey plate. They look very different than the more spherical, slimier Pseudomonas colonies, which are also pink. Staph and Strep, two gram-positive cocci, both look like little purple balls under the microscope. But Staph forms clusters and tetrads, while Strep forms chains and pairs. Plus, the shapes of the cells are a little different. The Staph cells are more spherical compared to the almost teardrop-shaped Strep cells. The coolest thing I saw under the microscope this week was Candida yeast. I had never thought about this before because gram stains are mainly used to stain bacteria, but it turns out that yeasts stain gram-positive. What was cool is that I could see their pseudohyphae, and some of the yeasts were even budding.

I've been continuing reading a few hours each day. I wish I could have learned this much micro last year or the year before. You really don't get the same effect from looking at pictures in books or online that you get from viewing the slides with an experienced med tech who points out the relevant features for you.

This morning after hanging out at the acid-fast bacteria bench, I had my POD/ARM class. It was part II of the innovations session, and I was expecting it to be yet another exercise in pain. Instead, it turned out to be really interesting and useful. We learned about what kinds of things were patentable, how patents work, what criteria CCF uses to decide if a patent should be pursued, how spin-off companies get started, and more. If someone patents anything while they're at CCF, they would get 40% of the royalties. This is not as farfetched as it might sound. At least one of the CCLCM fifth years has a patent. My classmates and I had a lot of questions, and I didn't spend the whole time staring at the clock. Those are excellent signs that this was a good talk!

Tuesday, November 04, 2008

Medical Microbiology

Yesterday I started my Medical Microbiology elective. Medical Micro is a department of Clinical Pathology. When we sent all of those blood and urine cultures off during my medicine rotation last month, this is where they wind up. It's not the most exciting rotation because I don't get to do very much in the lab, but it's interesting to see what's involved with processing the samples. I have a lot more appreciation now for how much time and work is involved. The other main thing we do is go on lab rounds each day to look at whatever interesting pathology has come up. That's pretty neat because you see all kinds of bizarre path at CCF. Yesterday we saw Strongyloides (parasitic worms) from brain tissue. Today we saw Yersinia enterocolitica (bacterium) from a blood culture, which is also unusual. I was at the bench where that was found, so for once I knew more about the case than any of the residents or fellows did. Ha!

I also learned that a medical technician is a two year degree, while a medical technologist is a four year degree. Medical technologists can get a job as soon as they get out of college, and it's a very high demand field with a shortage of workers. There is a training program for it here at CCF. It sounds like a pretty good deal for someone who doesn't want to be in school for eight years, only to follow up with a minimum 3-4 years of residency.

These past two days have been very chill and relaxed. Yesterday I came in at 9:00 and left at 3:30. Today was a "long day" because I came in at 7:30 and left at 5:30. Tomorrow I have to be in at 9:00 again. I have three or four hours every day to spend reading, which I absolutely love. Compared to medicine and surgery, this feels like some kind of vacation. Even the weather today was gorgeous. Just to reinforce that I made the right choice not to jump into Core II right after finishing Core I, this morning I ran into one of the UP students who was on Core I with me. I asked how OB/gyn was going, and the general gist is that it really sucks. Uh oh....

Sunday, November 02, 2008

Tips for Doing Well in the Internal Medicine Rotation

If you've been reading this far, you know I'm not a huge fan of internal medicine. But one thing about rotations you hate is that you don't want to take them twice. So, here are my thoughts on doing well on inpatient IM:

1) Don't complain. Everyone hates scut work, most people hate being on call, and a lot of people hate rounding for hours and hours. But no one likes hearing someone else gripe about it.

2) Do as many procedures as you can. Tell your intern that you want to learn to do procedures. Be around while the team is on call. I got to do a lot more at night when there were no attendings around.

3) Read about your patients. Medicine is a huge subject, and it can be overwhelming to figure out what to read. It's a good idea to get a general text to use (I liked Step Up to Medicine). But you should read in greater depth about the diseases your patients have from a more detailed and authoritative resource like Harrison's or UpToDate.

4) Offer to help your intern do their scut work. That way, you'll both get done sooner, and your intern will hopefully repay you by teaching you something (or even better, letting you go home early).

5) Participate in rounds. Insist on presenting your patients when the team gets to them. Join in on the team discussions as much as you can.

6) Fill out your patient logs DAILY. As painful as keeping up with logs on a daily basis can be, it will be a lot more painful if you try to enter them all at the end of the rotation, or even at the end of the week.

7) When you're preparing to present post-call, don't try to keep all of the info on each patient in your head. Write notes to yourself on an index card, or print out your note from Epic so that you can use it to jog your sleep-deprived memory. One great strategy is to print two pages of your note to one piece of paper. That way, you won't be constantly shuffling the pages while you present.

8) Check on your patients and make sure there isn't anything they need. A lot of patients are lonely in the hospital, especially on weekends and holidays. You're there anyway, so you might as well brighten someone else's day. Plus, you might learn something interesting that will help the team take better care of that patient.

9) Get to know the support staff. Tell them your name, and find out theirs. Ask your patient's nurse how the patient did overnight. Talk to the social worker and case manager about your patient's disposition.

10) When you're rotating at CCF, you will be wearing a long white coat, and people will mistake you for a resident. Always try to act like the future doctor you will become, but don't ever lie about your actual status as a student.