Horseshoes

You know the saying "horseshoes up your ass"? Well, I think I have at least one jammed very far up my rear! Explains the big ass I guess ;-) The Internal Medicine rotation is supposed to be the busiest rotation of the year. Long days, juggling many patients, going to seminars and bedside learning sessions, and long nights of being on call with no sleep because nurses call you in the middle of the night for Tylenol orders. By the end of 8 weeks, students are exhausted and need an entire weekend of sleep just to feel normal. At least this is how is worked for some of my friends that have aleady done it.

Me? I go to the hospital at 8am where we have 1 hour of teaching. I am done seeing my 1 (yup that's right...one) patient by 9:15. I putz around until lunch when we have another hour of a lecture (and free lunch) and then usually another hour of teaching specifically for us med students. Then I putz around even more until 3:30-4 when it may be more acceptable to go home. My last 4 call shifts have afforded me AT LEAST 6 hours of SOLID sleep (my record is 8) and I have had maybe 2-3 calls from the wards each shift, none for Tylenol and none after 1am. My only complaint is that 'pager sleep' is not real sleep...my subconscious is still awake and ready to go and I am tired the next day ("poor me", as Firey Redhead would say!)

My only patient right now is actually being followed by the GI doctors and surgeons, so my senior resident told me that I don't even have to see him every day.

What's so hard about internal medicine?

I better knock on wood.

Update

So I told my patient. It was actually easier today than yesterday when the patient was more prepared for the news. At least they didn't cry today.

We went through what HIV is and the basics on what it does if left untreated. Then we went through a bit on how treatment drastically improves outcomes, especially if patients are compliant on their meds. We tried to keep a positive spin on things, but it's hard to, given the history of the disease and pop culture. We're discharging the patient tomorrow...I hope they do well.

Other than that, I'm on call right now, eating pizza (coconut curry chicken...mmm) and having a mocha. I'm waiting either to get paged or to admit someone in the emergency department. Cross you fingers I get sleep again!

White lies?

There are many, many things that I like about my 'job' (or that I will like when I am a practicing doctor). I like interacting with patients and their families, I like making a difference in peoples' lives, and I like the medicine. Giving bad news is not one of the things I like.

Today, I had to tell a patient about their HIV status. HIV tests are done in 3 parts: screening test, supplementary test, and confirmatory test. My patient had all 3 come out positive (so they have a new diagnosis of HIV), but so far we've only told them about the screening test (I told her that we're waiting until tomorrow to get the final results). Before I receive a hundred comments about how evil that is not to tell the patient the whole truth yet, here are my reasons for only disclosing part of the truth now:
1) I wanted to guage how the patient will react and give them a chance to tell me their concerns and ask any questions
2) I wanted to offer the patient a chance to arrange to have a loved one come to the hospital to hear the final results with them so they can offer moral support.
3) I needed more time to get the HIV social worker informed so she is prepared to see the patient soon afterwards.
4) I wanted to give the patient more time to think about what they may want to ask us tomorrow.

Having said all of that, if I was in the patient's position, I would just want my doc to be straight up with me and lay it all out on the line. None of this beating around the bush crap. Then you wouldn't have any of the worrying that you have HIV or hoping that the final result may be negative. Part of me wishes I had just told her all of it, but I thought a lot about how I wanted to handle this and it was the reasons above that I chose my actions, right or not.

Even though giving bad news is part of the job and I need to learn how to do it, I am acutely aware that it takes practice to do it well. Being a medical student and having all these 'first' experiences makes me feel sort of bad for the patients. Us med students are essentially using some patients as guinea pigs (i.e. I'm going to practice giving bad news today). I take comfort in the fact that I know I care about my patients and I have developed a rapport with them while they've been in hospital so they're not hearing it from a total stranger. That doesn't make it any easier...for them or for me.

A virgin no longer

It finally happened. One of my patients passed away yesterday while I was post-call i.e.sleeping. The same patient I blogged about last time. I knew it was going to happen sooner or later, but it doesn't make things easier. I had spoken with the family and the patient and we all thought it was best to transfer her to the palliative ward. I would have preferred to do it last week, considering she was getting worse, but my attending still had hope. Still, it was tough to come in this morning to find out that not only had my patient been transferred, but that she had passed away. I hope she went peacefully...she was ready to go.

On another note, last evening I attended a seminar put on by a friend of mine about how to get into family practice residencies for next year. I learned a lot...some things to think about and prepare for. One thing I did learn was that one rotation that I am confirmed for is an Obs/Gyne rotation. Cool, I thought to myself...I'm gonna want some more practice catching babies and in gyne surgeries if I want to be a GP. I found out that my preceptor only does reproductice endocrinology (for same sex couples) as well as sexual reassignment surgeries (ie sex change operations) in a town 1 hour drive away. HELL NO!!!!! I think it would be a super cool elective and I'd learn a whole bunch, but for me, I just want the basic man-and-woman-make-baby-it-comes-out-of-vagina/C-section type of experience. If I'm gonna be a rural doc, I don't think there's a huge market for that type of experience. I'm currently trying to get out of that one!

I've also recently set a new record for time slept when on call! My last call shift was Monday night. I had one admission to do from 7-8pm, then I ate dinner (sushi with my senior resident), watched TV for a bit (enthralling School of Rock movie), and went to bed at 11pm. Awoke refreshed at 7am for rounds. No pages in the middle of the night! That's a whole 8 hours of uninterrupted sleep!!!!!! Has to be a record! FYI- call shifts are usually sleepless- we average 2-4 hours total and this is usually broken up throughout the night! But wouldn't you know it, I went home 'post-call' and slept another 2 hours! Oh lazy life! Here's to hoping that karma won't bite me in the ass!

Circling the Drain

I have an elderly patient right now who I don't know if they will be alive when I return on Monday. Friday morning, I arrive to the hospital to nurses buzzing around my patients room. Turned out my patient's oxygen dropped not too long ago and she was having lots of problems breathing. The nurses called the respiratory therapist to come in. The RT is a professional at managing airways and people in respiratory distress, but my patient has a "no code" status (=DNR=do not recuscitate) and refuses to have any invasive procedures done. I.E. she doesn't want to be put on a machine to help her breathe.

I examined her and ordered more STAT xrays and blood work and found she has pneumonia. So we began treating her for that. When I left yesterday, she was stable and on high flow oxygen.

After I had the chance to reflect on my patient, I kept thinking that I didn't know how I was going to feel if she passed away today (or any other day). On the one hand, I would feel like I did something wrong or didn't do enough to keep her alive. But on the other hand, maybe this is her time and nothing I do will keep her alive and we should just keep her comfortable and let her go. This goes against anything we've been taught in medical school...to NOT do the prescribed protocol for any given illness. Yes, I believe in a patient's autonomy and thier right to chose what happens to them, but it's hard to accept doing nothing when your job is to make people better or cure them.

As a medical culture, we don't do death well. Sometimes I wonder given all our technological advances, new medications, and research we can allow people to live longer. But at what quality of life? At what point do you take a step back and say "enough"? This very issue is something my own family is struggling with.

I think it would be good for me to do a rotation in palliative care next year. It would be a difficult rotation, but would allow me to get a different perspective on things. Until then, I'm not sure to hope my patient is alive or to hope she has passed peacefully when I get back Monday. In the words of Doris Day (one of my grandmother's faves): que serra, serra (whatever will be, will be).

the first half was easy

So, I feel a bit guilty after not having blogged for quite a while. I apologize. Honestly, I have a reason though!

I am now in what we call "the BIG 3" (internal medicine, surgery, and pediatrics). Each block is 8 weeks long, unlike the rotations I've done before that last anywhere from 1-6 weeks. I am in internal medicine which is who takes care of you if you're sick and in the hospital (but no surgery). We can consult the other specialties if we need it, but generally, we take care of the sickies! And let me tell you, it's a lot of work.

I am at an urban inner city hospital that has a lot of people with what I like to call "alphabet soup"...HIV, HepB, HepC, IVDUs (intravenous drug users). I am aiming to make that a term that I can use to present a case to my supervisors. Not brave enough to use it yet though! All of my patients are really nice and really sick. None of them have died on me (yet). I have had 10 patients that I have taken care on my own so far and have discharged 7 of them. I have 3 patients right now.

I have been on call twice so far. The first night on call...admitted one patient... got no sleep...period. Sickies on the wards kept calling us. We get paged to the wards if the nurses need something in the night or if the patient is getting sicker. My scariest call was a page from a frantic nurse at 3am. Patient woke up suddenly short of breath. Extensive history of medical problems and had just gotten out of ICU a few days before. Why I get the call to take care of that one is beyond me!!! Me: racing upstairs to find the patient in severe respiratory distress, working really hard to breathe, but stable. After getting a brief history and doing a perfunctory physical exam, order a STAT chest Xray and ECG, bloodwork, and give him aspirin (in case it's a heart attack)...then crap my pants and call my senior resident on call. I'm in over my head here!!! He came, agreed with me and my actions and reassured me that I was right to call him. The nurses should never have paged me with this patient...they should have gone to a real doctor (specifically him). We thought the patient had a blood clot that went to his lung and needed a CT scan. He was already on the proper meds for that and he was "no code" (ie DNR= do not recusitate) so there was nothing more we could do for him. Gets your heart pumping at 3am let me tell you! Got home at 2pm the next day after making sure my patients were stable and clearing up the loose ends. So exhausted!!!

Contrast this with being on call last night. Admitted 2 patients earlier in the night. 6 calls from the ward. Not a single one of them after 1am!!!! Solid 'sleep' from 1am-7am (unheard of in internal medicine!) Then my boss comes, buys us coffee and breakfast, and we present the cases we admitted overnight and go visit them. Sleep with a pager over your head is the most anxious sleep ever. I'm sure I willl learn, but the thought of my pager going off when I'm deep in sleep gives me palpitations and keeps me awake no matter how tired I am. It'll come to me I hope.

Been involved in a conflict over a patient of mine between us (CTU=clinical teaching unit aka internal medicine) and rhumatology. Those buggers! My patient is a sweet old lady and we worked her up for having trouble swallowing and weakness. No tumors founds. Rhumatology consulted. Me and my supervisor pretty convinced she has some inflammation in her muscles (called polymyositis) and put her on a powerful anti-inflammatory drug. I find this morning that the patient is being seen by the vascular surgeons becausee rhumatology wants a biopsy of an artery in her head. I had to step in while they were taking to my patient. Not only has the patient refused any invasive diagnostic testing so far, but we already have a diagnosis that explains all her symptoms and why she's getting better on our treatment. I didn't want to get involved in an argument between specialties (nor is it my position to) so I paged my boss and he came flying down the hallway absolutely pissed a those rhumatology vultures!!!! Love it when the boss backs you up! I can't believe that a specialty that has been consulted on a case has the power to order invasive procedures without asking the people that are actually managing the cases. Something is wrong there!

Just one more thing to say. I'm raging mad at my faculty regarding our 'electives' for next year. Initially I got my top pick, top location, and my preferred date (I was excited because I could check out a residency program at the same time). 3 days later, I now have my 3rd choice (1.5 hour commute from my place) but the same dates. I'm not pissed at my rotation, but I'm pissed at having it changed on me for absolutely no reason. Would be nice if someone let me know about it before I get a formal letter in my email from a different facutly confirming my elective and I have to go back and figure out what happened. I'm just pouting because it didn't go my way. Remanents from growing up an only child...I'll get over it.