Man, when did I start sucking at updating??

My Medicine sub-I ended last Friday, and I spent the following weekend dreading Gyn Onc and seriously doubting my life choices. I really enjoyed Medicine, and could definitely see myself functioning as a Medicine resident. I was even giving some serious thought to which career paths might appeal to me. It's funny, top of the list was pulm/critical care, and we all know how much I hated that rotation when I was a brand new third year and hadn't seen many really sick people before.

Then I started my Gyn Oncology sub-I. Long story short, I'm not doubting my career choice anymore. On day 1, I got to help take care of some hyperthyroidism and some acute renal failure, AND helped remove a big ol' tumor from a woman's body. As my friend Hannah would say, it was the best of both worlds.

On day 3 the team was short on residents, so I scrubbed out of the tumor debulking I was helping with, to go "drive" a hysteroscope (camera used to look inside a uterus). With close supervision from an attending of course. That pretty much made my day. Also day-making was the fact that the staff's scrambling for assistants to help with all the cases ended when the chief said "I'll send my sub-intern." Do you know the feeling of walking into an OR where you are wanted and expected and being waited for so the case can start?? No, you probably don't!! I can't even describe it. I never knew such a thing existed.

Yesterday I scrubbed in on a vaginal hysterectomy. That means the whole operation was done through the vagina. I'm not going to lie, that's no fun as the medical student. I understand that it's the most minimally invasive way to do the operation, which is good for the patient. But I couldn't see jack, and it was uncomfortable to boot. It did seem like it was a pretty cool operation to do, though. Phenomenal surgical powers...itty bitty operating space. I'll have to let you know how cool it is when I actually do one in a few years. For now, I definitely prefer open bellies.

Coming up in my next entry: More stuff about med school! Get excited.

Here's the story of a patient whose case has given me a lot to think about. It was an elderly guy, well into his 80s, who came in with a few months of poor appetite and weight loss. Early lab tests showed that he had some kind of obstruction in his liver. Now, at this point, for me and my colleagues, the question became not "what's wrong?" but "Exactly how widespread is this cancer?" The answer, unfortunately, was "Extremely."

The first morning after the results of the CT scan, I decided that I wouldn't go see this patient by myself. I waited for my resident, and we went in together. This was a good decision, because he was far better than I would have been with answering the family's questions about such things as organ transplantation and stem cell* treatments. I realized that while I knew such things were't options, the patient and his family didn't yet have the frame of reference to know that. I have to remember that sometimes the obvious facts aren't actually obvious at all.

Over the following week, my team tried to help this patient and his family come to terms with the fact that he is dying of widespread cancer. Right before coming into the hospital, this guy was still driving, running his own business, helping his wife around the house, all that stuff. He thought he had a stomach bug that wouldn't go away, and suddenly he has cancer. By the time he was discharged, he and his wife still weren't fully ready to process the situation. What was really difficult for me, as the medical student, was giving them information while trying to let them hang on to their hope for a cure. Part of me really wanted to tell them, "You cannot make plans to go to Mayo and Hopkins for experimental treatments! You need to stay home and enjoy spending time with your family!" But I didn't, and I can only hope that he can process and accept things with time.

(*Re: Stem cells. This appears to be the generic term that people use for "miraculous cure." They often can't articulate just what they want the stem cells to do, they just want them to be used, somehow, to do something, to make everything all better. This case was not the first time I've heard that term thrown around.)

Hello, good readers. My final week on the Morgan service is being broken up by a nice weekday off. That would be today. I really appreciate the time off after working eight straight days (Saturday and Sunday were call/post-call), but I can't help but feel like I'm missing all the action.

Speaking of action, I got all I wanted on Saturday, when one of my patients had a lower GI bleed. Of course, this patient happened to be housed in a part of the hospital that's separate from the main building. By pure dumb luck, I'd gone over to that wing to write my notes, because I knew there'd be no residents over there and I was guaranteed to find an available computer. The administrator types (who I doubt have even crossed paths with a real live patient in years if ever) insist that this wing of the hospital provides a level of care equal to that of the main Medicine and Surgical stepdown floors. They are deceiving themselves and the patients, because in the event a patient declines rapidly, that is a long run. I know, because it took my resident approximately three hours and forty-seven minutes to make that run after I told him I needed help with the patient. Or maybe it just felt that way.

ANYWAY, I was sitting at the computer when I found out my patient had started to poop pure blood. I went to her room, where the charge nurse was saying "When the doctor comes... oh there she is!" I thought, "You are incorrect ma'am, there she is not." But, despite an increase in my overall sphincter tone, I stayed calm and I didn't blank on what to do! ABCs/vitals, a second 18g IV, retrieved a consent form for blood transfusion... And then my resident arrived and I was quite happy to let him take over. The patient ended up not needing any drastic interventions, so in the grand scheme of things it wasn't much of an event. We didn't know that going in, though!

Sorry guys, I am having trouble keeping up with the updates. Taking call every fourth night has been affecting me a little more than I expected. Since I've been spending those nights at the hospital, it's like two of every four days is completely taken up by either hospital stuff or sleeping. Then, for some reason, I'm always even more tired the day after I'm post-call (for example, today!). That means I only have one day of every four in which I feel totally normal. To put it simply, this is kicking my butt. I don't know how people like grorx, who are taking call every third night, are doing it.

That said, with the rotation halfway over, I'm still really enjoying my time on internal medicine. Enjoying it so much that I was briefly thrown into some serious doubt about my career choice. The medicine residents work really hard, and complain a lot (all residents do), but overall they seem to genuinely enjoy what they're doing, and like having students around whom they can also convince to love what they're doing. It's hard not to want to become one of them. I get the feeling that I won't get the same vibe from my next rotation. I could be completely wrong about that, and I hope I am!

I'm already pre-call again tomorrow! Geez Louise.

Thursday was my first call night of the year. It started out pretty slowly, with no new admissions and no issues with any patients for the first few hours. Then, about 6pm, it all started. The service "caps," or reaches its limit, at eight new admissions. We got our eight within about five hours. I ended up evaluating a leg fracture, possible bowel ischemia, pancreatitis, and a new rash in a patient with autoimmune disease. Around midnight, the resident, intern and I sat down to talk about our patients and write our notes. I was able to get all of my notes written in about an hour. (It's amazing how much easier it is to write a note without the book reports we had to do as third years.) I stuck around to help with any cross-cover issues, but even that was slow.

I slept from about 1am to 5am Friday morning, then got up to get ready for rounds (which are always early on post-call days). I goofed a little on one of my presentations, mostly because I totally lost my train of thought mid-sentence. Nobody seemed to care. After rounds, the team got some coffee (chai for me) and got to work putting in consults and following up on all the stuff that was done overnight. Then it was time for Morning Report, which, amazingly, I made it through without nodding off even once. I attribute that partly to caffeine, but mostly to learning about the "Violet Beauregard" species of zebrafish, which swells up like a blueberry when a certain gene is knocked out. I also went to noon conference, though I shouldn't have because I kept falling asleep. This is kind of pitiful, since when I'm taking call for real four hours of sleep will be a ridiculously high amount.

The rest of the weekend was basically spent either sleeping or socializing. Friday night, I went out to dinner at a place where the menu included "spoonfuls" of soup. Probably won't be going back there. Then I went in for rounds on Saturday morning, which were pretty short. Saturday night, I went to a friend's birthday party, which included fireworks when the cake was brought out. Not sparklers, not firecrackers. Fireworks, up in the sky. Crazy!

I guess I'll post more about this week, next week. Bye bye for now!

Everybody says that fourth year flies by, so I am trying to enjoy each day as it comes. So far so good!

Yesterday the team was on short call, meaning we were responsible for morning admissions. However, there were so many admissions during Monday night that we simply got three patients from that load, who had already been seen. Tomorrow will be my first long call day and my first chance to truly pick up patients of my very own. I'm excited. I've followed a couple of patients, presenting on rounds for the first time today. It'll be good to actually have someone for whom I've worked on the initial diagnostic puzzle. I'll let you know how it goes!

Well, my last "first day of school" ever is now over. As I've mentioned before, I am on the Morgan service, which is general internal medicine. Both my resident and my intern seem really nice. Proving that the medical community really is a small world, my intern is the brother of a Medicine resident that I often took call with last year, and the brother-in-law of an Ob/Gyn resident with whom I'll be working next month. My attending also seems really nice so far. I was asked a total of ONE question today on rounds. The rest of the time, the attending did a lot of teaching that wasn't prefaced by pimp questions. Understandable for the very beginning of the year. It could have also been because the team was post-call today, so the residents needed to get home. Tomorrow might be more pimp-tastic.

After today I am once again eager to sing the praises of the breadth of General Medicine. Among other things, I saw diabetic ketoacidosis, a huge nonhealing leg wound with possible underlying bone infection, pulmonary edema, gout, and lower abdominal pain in a female that required a pelvic exam (which was done by me). Cases discussed in morning report included intractable nosebleed in leukemia and serotonin syndrome. Noon conference covered the treatment of shock. Basically, these people know a lot about a lot.

The moment I really knew that this year is going to be different came right after rounds. Some random, tedious busywork sprouted up, and my resident looked me in the face and said, "Don't worry about it. That's the type of stuff I'd send a third year to do." Ba-dow.

Today is my last day of internal medicine. The final exam is tomorrow but I'm not counting that as a day because all of the learning should've been done by then. Tomorrow I'm going to fly through that test, then beat feet to the airport. Normally I wouldn't fly home for anything less than a long weekend. But the past few months have not been normal and I really need to see my mommy and daddy. Since I saw them last, I have gone through the stress of Boards studying, taking the Boards, starting third year, and going through a whole clerkship. Crazy!!

"LaKedra, if this patient had florid acute renal failure, you would know what to do, and that's great. But this is outpatient. It's back pain." -My attending

That about sums up my experience with general internal medicine in the outpatient setting. My attending quizzes me about management, and I stare at him blankly because the patients don't need five thousand labs and imaging studies. I'm slowly learning that if I say "Aleve" I will be right 80% of the time.

I am really enjoying outpatient though, not just because of the schedule. It's cool to see the doctors interacting with patients whom they've treated for years. They get to really know the patients and their whole family. I'm pretty sure that whichever specialty I end up in will have some aspect of long-term patient relationships. And also some aspect of days that start at 8am instead of 6am.

This morning we had our "orientation" to the outpatient portion of the Medicine clerkship. It was as fun as orientations usually are. I am however, grateful for the fruit, bagels, and assorted biscuits we were given. We also got our clinic assignments. For the next two weeks we'll be spending time in various outpatient clinics. The bulk of my time will be in general internal medicine, with one of the attendings I had on Morgan. Tuesday afternoons will be in Hepatology clinic with one of the attendings I had on GI.

I'm pretty happy about my assignments. I just wish I'd gotten some time in a cardiology clinic. Going into the rotation, I naively thought, "It's internal medicine. There's no way I'll leave the rotation without some experience with heart stuff." Guess what... if you get a Morgan block and two Rogers blocks*, with zero time in the VA and zero time on the Harrison service, you just might. Of course, there are people who got very little renal experience, very little pulm, very little GI... I don't know why my lack of cards bothers me so much. But it does.

Anyway, after orientation, I went to Eskind to study for a bit, and then to clinic. First lesson learned: seeing patients in the outpatient setting is very, very different from inpatient. I know that's a stupidly obvious thing to say, but my life for the past nine weeks has been inpatient medicine. My novice-level clinical judgement of "sick patient" vs. "not so sick patient" is based on the people I saw in that setting. Today it hit me that even the patients who didn't look so bad were still sick enough to have been admitted to the hospital. They were not walking out of the room and driving home when I was done talking to them.

Finishing up on Pulm, a.k.a. MICU-lite, has not helped my perspective either. For a little while I was unsure about my ability to interact with patients who weren't actively trying to die right in front of me. The first patient of the day had 'elbow pain.' I don't mean to belittle the patient's problem at all, but I have not been placed in a position to know what to do with elbow pain. Part of me was thinking "Elbow pain?? Come back when you're on IV pressors, then we can talk."

Another cool thing about the outpatient block is the hours. I am off Monday morning, Tuesday morning, and all day Wednesday. Too bad this is only lasting for two weeks.

Tomorrow's the real test. GI clinic, the bread-and-butter cases of my probable future career. I'll keep everybody posted on how that goes.

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*Interesting fact: With 9 straight weeks of VUH rotations, I logged more hours at VU Morning Report than most of the Medicine interns up to this point. Of course, they'll be going all year. And for the next two years.

My resident was awesome enough to give the med students the weekend off, so today was my last day on Pulm. You may have noticed that the sun shone more brightly and birds sang more sweetly today. As I said the other day, the main thing I've learned on Pulm/Critical Care is that I don't think I'm meant to work with patients who need critical care.

Apparently, some people are surprised to hear this because of the time I spent working in nursing homes for my Emphasis project. Allow me to clear something up. Geriatric does not equal critically ill. Most of the patients in nursing homes are doing pretty darn well. They might be incontinent, or senile, or unable to walk or feed themselves, but for the most part they're just hanging out. They may be 90 years old, but they're not actively trying to die every single moment. (If they were, they'd be in the hospital, probably on the Pulm service!!) For about two thirds of my patients on Pulm, we were trying to get them well enough to go to a nursing home. Patients in nursing homes are stable. Critical care patients are not. And that is the difference.

All my complaints aside, I did learn a lot on this block. Give me a chest Xray or a chest CT and I'll read it, no problem. I feel reasonably competent at managing supplemental oxygen. And I no longer freak out when patients become acutely ill in front of me. Victory.

Yesterday I bombed a pimp question in a patient's room, and felt stupid. Today I watched that same patient begin to die and felt helpless. We're hoping she hangs on long enough for her husband to get in from out of town. It's awful.

The main thing I've learned while on Pulmonary is that I don't like it when the majority of my patient population is critically ill.

1) Was the acai berry just invented or something? Mere months ago, I'd never ever heard of it, now I can't escape it. The salesperson at Whole Foods tried to convince me that it's the best thing ever. "OMG it's so full of antioxidants!!" Guess what! So are carrots, which will not cost me $8 an ounce. Vitamin A is not new.

2) Baton Rouge is getting its power turned back on, one neighborhood at a time. My neighborhood is not one of the lucky ones, yet. My parents think they may have electricity again within the next couple of days.

3) I'm sure you're all aware that there's another hurricane, named Ike, heading for the Gulf of Mexico. My mom tells me that people are putting up signs that say "Go away Ike, Tina doesn't live here." So wrong, but so funny.

4) This morning, one of my patients called me 'aloof' while I was pre-rounding, and then yelled at me during rounds. Wonderful.

5) I have, at maximum, ONE more call night on Internal Medicine. I might be able to go the rest of the week without taking call! That's a big might, though. Fingers crossed!

6) Atlanta Bread Co. lunches are still my least favorite of our boxed lunches, but today I discovered that the ham sandwich is way better than the chicken salad sandwich.

7) The highlight of my day was discovering that the hospital gift shop sells grape sodas, and then immediately finding a dollar in my white coat pocket.

8) Today I finished my 27th H&P, meeting the "quota" set for us at the beginning of the rotation. I won't cry too hard if I don't exceed it by much.

9) I need to start seriously studying for my clerkship exam. I probably should've started doing that several weeks ago. And that is one way third year resembles the first two years.

Hello good people!! I hope you all enjoyed the long Labor Day weekend. I was on call Sunday but my resident let me go because it was slow. She also told me not to come in on Monday. Of course, I squandered my free time. I could've gotten so much reading done. I could've written the book reports I've been putting off. Instead I took several naps and watched a marathon of "The Suite Life of Zack and Cody." That's right. However I did get a long workout in each day. So I wasn't a complete waste of space.

Since it's a new month, Rogers Pulmonary has a new resident and new interns. The interns both went to med school here, and I knew them, so in my head they're still medical students. I keep accidentally calling one of them by a nickname, which isn't the most professional thing in the world.

As far as the actual service. Every day, just when I think there can't possibly be another COPD exacerbation in the whole wide world, there are five more. If you smoke, please, PLEASE stop. There's a good chance you will end up looking 85 years old when you're only 50, needing to sleep with a machine forcing extra-oxygenated air into your failing lungs so you don't die.

So, I'm beginning to think that every day on pulm is a rough day on pulm. I took call last night with one of the interns. The team got three admissions and I picked up all three. The intern was awesome. She went over all the physical findings, let me do all the orders and went over all the imaging studies with me, which really helped during rounds this morning. She also let me try to put in a feeding tube, but I failed that miserably. Now I have heard from my classmates about how incredibly easy the things are to put in, so I got down on myself a bit. But I've since realized that the patient with a recent brain bleed and a trach tube whose main means of communication is flapping their arms probably wasn't the best choice for learning. So I don't feel so bad about that anymore. And then, there was some serious drama about a patient being taken off life support. I was not in the best emotional state when I left last night.

Today was our first day with a new attending, who we'll have for the rest of the block. He reminds me a lot of my Morgan attendings. That means he asks a lot of questions. As much as I've complained about this block (every day so far), I'll at least come out of it knowing my way around a chest x-ray.

Tomorrow is my first full day off since the 17th. I'm so excited I could cry.

Yesterday was a rough day on the pulmonary service. Two of my patients got terminal diagnoses. Harder for them than for me, of course. But emotionally draining nonetheless. I'm still sucking at presenting in my own opinion but I don't think it really matters. We get a new attending soon... I'll wait to see what he wants from me.

This morning we were discussing patients in the radiology dept when we got a page about one of them. The intern just said, "He's satting in the 70s and coughing up blood," and the next thing I knew we were sprinting from radiology to the round wing. Translation: patient looked bad so we booked it across the medical center. It woke me up, that's for sure. This time I was not quizzed by the attending. She was too busy arranging for the patient to be sent to the ICU. Proving my point that pulm gets the sickest patients.

By the way, my team (attending, fellow, resident, two interns two med students) is 100% female. And I, at 5'11", am only the fifth-tallest in the group. I'm sure we make for an interesting sight.

Guess what, y'all. I am posting this entry from my shiny new 16GB iPod touch. This thing is pretty amazing. Granted, I mostly use it to waste time during morning report and lectures. Like right now! By the way, I kinda rock at touchscreen typing.

Today is day two of pulm and it looks like a busy busy service. I picked up two patients yesterday, though I'm only doing a full h&p on one of them. We had 4 new patients by 9 this morning. I'll probably get one. At this pace I'll blow our quota of 27 h&p's out of the water. The resident told my partner and me that she expects us to carry four patients at a time. The most I had on Morgan was three. GI... is such a distant memory. Did I even have patients on GI? Anyway, four will be a challenge.

Also, of the services I've been on pulm seems to have the sickest by far. Maybe it's just that people in respiratory distress look the sickest... but this was the only service where I was told from the start what to do if a patient looks about to crash. Yikes.

So far I'm handling the sputum pretty well. Of course over the past few weeks I've seen some spectacular rashes, had a patient miss pooping on my shoe by centimeters, and have touched a LOT of feet. Sputum? Not a problem.

Btdubs, the entry title is a quote from one of my interns about a patient who got a ridiculous number of antibiotics thrown at his cough.

Today was my last day on the general medicine service. For a while I entertained the possibility that I would get the final weekend of the block off, as I had when I was on GI. However, my team had call yesterday. So not only do I get zero break between blocks, I had to miss grorx's birthday funtimes. SIIIIIGH. And now it turns out that my call schedule on Pulm will be different than on GI, so I don't even know when I'll have call next. I like predictable, and this is not it.

Looking back on my time as a general internist, I learned A LOT. I admit, going in I thought that we'd be shepherding people off to specialists all the time. But the general team managed many, many things without much 'outside' help. The knowledge base of my attendings was staggering. They would diagnose somebody's weird rash, then the altered mental status of the patient in the next room, then the recurrent blood clots of the patient in the next room, then the kidney failure of the patient in the next room. I was in awe.

Even when we did consult specialists, it was the Medicine attending's job to take all the different recommendations and decide what to do with them. For one of our more complicated patients, there was input from nephrology and infectious diseases and cardiology and hematology, but the final say on everything came from our attending. He described it as being a project manager. Between that and the bottomless fund of knowledge, I have a newfound respect for general internal medicine. Which is good, since I'd have three years of it before specialty training.

I still love GI, but the attending turnover on that service was a little crazy, and there wasn't much bedside teaching. That's probably because rounds tended to be 45 minutes. Morgan had excellent teaching, but rounding for three hours got old pretty fast. I'm hoping that Pulmonology will be a happy medium.

Today was our first day with a new attending. I felt a little out of sorts, presenting new patients to someone whose expectations I didn't really know. My last attending, while being very nice about it, made it explicitly clear what he wanted from us. For example, if you started to present your physical exam and the first thing out of your mouth wasn't the vital signs, he would interrupt you and say "First, give me vitals." That sort of thing. By the end of our two weeks working together, I wasn't getting interrupted, because I knew by then what I was supposed to do. Today I expected interruptions, got none, and didn't really know what to do!! I think I rambled on a bit too much. Sort of thinking, "You're not stopping me.. you must want me to keep going... what do I say now??" Hopefully next time I'll have my act together a little more.

My second week on the Morgan service over, I can definitely see how some people could be drawn to general internal medicine. More on that later.

I picked up two patients while on call Monday. They both got discharged today. My rotation partner also picked up two patients. His are probably going to stick around for a while. Twice now, we've had the chance to pick which new admission we want to follow, and both times he's picked the rocks who stay in the hospital for many many days. It's just unlucky, since all the cases seem pretty straightforward initially. It's only later that they turn out to be ridiculously complicated.

One of our complicated patients decided to become acutely ill while we were rounding this morning. We walked in to find the guy in some fairly serious distress. My attending turned to the other student and me and asked, "What do you do when you come in and see a patient like this?" My partner gave the correct answer, which is check ABC's: the patient's airway, breathing, and circulation. In other words, make sure the patient is fairly stable. Then other stuff about making sure there's IV access and that you have or are getting the tests you need. A reasonable answer.

Apparently, what I do in such a situation is stand there, freaked out, doing nothing but silently open and shut my mouth as my inner dialogue says "Shiiiiiiiiiiiiiit." Once again proving that I'm not clutch. Maybe I should be giving more thought to radiology and pathology.