Sunday, January 19, 2014

Internal Medicine

This post conforms to the blog rules.I am one week in to my second month of inpatient medicine, and I am run-down. I have seen a lot of sick people and learned a lot. It has been exciting, emotionally draining, and physically taxing. I wish I could tell you the story of the man with an enormous malignant pleural effusion, the story of the man with a hemoglobin of 1.8, the story of the man whose foot was amputated in the middle of the night, the story of the man with a failing heart, the story of the woman who presented with flu and was found to have leukemia, the stories of the several people found down, the story of the pregnant woman with flu, the story of the man with the three-foot aortic dissection, and the story of the man I thought was having a heart attack but who was really lying to me about his cocaine use....

Daily Mass and meditation have been hard to get to, and that sends me into a tailspin of scrupulosity and humiliation. However, I was able to go Mass almost every day in the past week and formation is still going on. When you read this, please pray for my bishops; they are making some important decisions and need your help!

My schedule now looks like this:

4:50 Rise, MP
5:30 Drive to work
6:00-8:00 See patients and write notes
8:00-12:00 Round with resident or intern
12:00-1:00 Noon Conference with residents (Midday prayer doesn't happen during the week)
1:00-5:00 Lecture, studies, or other learning with resident or interns
7:00 Mass, EP
8:00 Home, mediation
9:00 Bed (NP doesn't happen much right now)

Unless I am on call (working 6:00-9:30), then I exempt myself from Mass and meditation.I am on call every fifth day, and this means that there are some days I work on Sundays and Saturdays. The day after call ("post-call") is also a workday, so if call lands on a Friday, I work Saturday (that happened this past week.) If call lands on a Saturday, I work Saturday and Sunday. The residents call this a "black weekend," but because of the way the call schedule works, it is always followed by a "golden weekend" of both Saturday and Sunday off. Obviously, when call was on Sunday once, I went to an anticipatory Mass.

When I'm on call, my team picks up the new patients coming in to the hospital. This means that I am sent down to the Emergency Room, with nothing but my notebook, pen, and stethoscope, and asked to write an admission note (an H&P or history and physical exam) on the person. This means I need to find out all about them. Why did they come in? If for pain, where/when/how/how bad is it, and what makes it better/worse? Have you had this before? What other problems do you have? Surgeries? Family history? What medicines are you taking? And then, I ask them the "review of systems," basically asking about every other medical symptom I can think of, even if unrelated to their chief concern, so that I have a complete picture and can make an accurate diagnosis. Then, I examine the patient and attempt to make a diagnosis. I meet the intern outside the patient's door or in the physician's work room in the ER, and "present" the patient. "Mr. So-and-so is a 45-year-old white male with a past medical history significant for diabetes and CVA in 2001 who presents with a four-hour history of dizziness...." I consolidate my whole interview and exam with the patient into a one-minute presentation that ideally ends with my assessment and plan. This is all terrifying, but fun.

Two days before the call day, I am "on codes." A "code" or "code blue" is called when a patient goes into cardiac arrest. I carry a special pager on code days that goes off whenever a code blue is called, anywhere in the hospital. When that pager rings, it flashes where in the hospital the code is, and I immediately drop everything and walk/run there. I have been to three total, I think. There are usually plenty of people at a code, so I usually stand in the background. I gave chest compressions once. All three times, the person died. (The survival rate to hospital discharge from a code blue is extremely, extremely bad--don't let the medical dramas fool you.)

What does a medical student do in the hospital? I come early and see the patients assigned to me (usually three, yesterday four). I go into their rooms, (usually) wake them up, and ask them how they're doing. I follow up on their pain, nausea/vomiting, breathing, constipation/diarrhea, urine output, medicines, etc. Then I examine them. It's amazing how natural this is becoming! Then, I update them on any test results that I have seen and they haven't been informed about yet. I always leave big news for the resident or specialist, but if there is something simple I can tell them, I do. I ask them if they understand everything that's been told to them. Often, the answer is "no," and I know enough to help them understand. Then, I ask if I can do anything for them, and if not I leave and find a computer.

I pull up their chart in the EMR and write a progress note, including what I think should be done for the patient that day. Should we continue the IV fluids? Should we give a diuretic? How long have they been on that antibiotic and is that enough? Should he be taking a beta-blocker for that telemetry strip? Should we try an enema? Should he have an ABG? Can we adjust the FiO2? Do we need to consult someone? Can they go home today? If they have multiple problems (and almost everyone does), this takes longer than the actual patient encounter. Juggling lung disease, dizziness, heart failure, and acute kidney injury (for example, as I am with one of my patients right now) is a very tricky business. Managing pain is another huge undertaking. And making sure all the medicines are working for the patient is work as well, especially when they are often on so many! I like to really prune back the list, but sometimes it's impossible. Admission for a single heart attack (with no other medical problems) earns a person about eight drugs, right off the bat.

I submit my notes before 8:00, which is when the interns review my notes and see those same patients. They usually formulate their plan without taking mine into account (my notes are more for my education than the patient's care), but I have had some take some of my text and use it in their notes! Sometimes I round with them, but more often I join the "upper-level," a second-year resident. She has to see all the same patients again, too, because she checks the interns' work (and the attending physician checks hers). This is how doctors train! Daily practicing medicine with less and less supervision.

Rounding with the upper-level, we present the patients outside the door or while walking and then go in and see the patient together. We are supposed to know everything about the person--down to the last lab test result. So, I carry around a single sheet of computer paper per patient, crammed with an organized and traditional shorthand full of medications, symptoms, and results for up to fourteen days. For example, writing numbers in the four "fishbones" at right gives me 22 test results. Because each result has its traditional place (the white blood cell count always goes to the left of the CBC fishbone), I don't have to write down "white blood cell count is" or even "WBC."

Noon conference is mandatory free lunch with lecture. Every day, we learn about something in medicine. I'm sure the upper-levels have heard some repeats, but repetition is the mother of learning. After noon conference, the med students have additional lectures and we also do practice questions or join the interns for some teaching. "Teaching" from a young doctor is different, depending on the doctor. With one of my interns, I trooped up to an ICU and we found a patient on a breathing machine so that he could give me a one-on-one mini lecture (with questions and practice cases all throughout it) on ventilator management. With another intern, we did practice board exam questions. With a third, I was left alone to read and do practice questions on my own.

As you can imagine, I'm learning a lot. This ended up being a respectably-long and mildly interesting post...I dive into IM again tomorrow and have a black weekend the next week, so I probably won't be blogging again soon. Pray for me, and for my bishops!

Friday, January 17, 2014

Can't breathe for the bureaucracy

This post conforms to the blog rules. When I become a resident, I won't delay patient care for the sake of my numbers.
When I become a resident, I won't intubate people without consulting the team.
When I become a resident, I won't forget to consult surgery for a pleurx catheter.
But mostly, when I become a resident, I won't delay patient care for the sake of my numbers.

Because when we do that, people who should have 5+L of fluid drained off of their lungs don't get squat drained for three days, and then they have mental status changes and someone intubates them without telling the team and they get placed in a medically-induced coma and have hypotension and SIADH while their spouse is watching all this heartbroken, slowly adjusting to the fact that he might not get his wife back.... So although the patient was terminal with an occult malignancy, we could at least have palliated during the last few months, instead of ending up on a vent and then withdrawing care because "she would never want this."

When I become a resident, I won't delay patient care for the sake of my numbers.

But when I'm a resident, I hope I still become attached to patients, even though that's painful. (Especially when people delay those patients' care for the sake of their numbers. I think I need some help with forgiveness. Oh look, it's time to pray.)