Surgery here I come!

Well, yesterday was my exams for internal medicine. Today I am on call (only until 5pm though!) and I have time to reflect on yesterday.

My written exam went fine. Ity's always such a crap-shoot. no amount of preparation prepares you for standardized american exams that do not correspond to the experience you've had in a rotation. I've decided to stop studying for them as it is a waste of time. I will study around my patients so I know how to manage them and for my on-ward performance, but for the exam...no way! Anyhoo, I finished the exam with time to spare, so I'll see how I did in a few weeks time.

The afternoon is a bedside exam. The way it's supposed to work is that you get assigned a patient at another hospital. You have 1 hour to interview them, do a physical exam, and come up with your differential diagnosis, investigations, and management plan (i.e. what you're going to do to figure our what is wrong with this patient). Then we meet with 2 examiners and present the case to them. Then they ask us some questions that usually have to do with topics in the patients case (physiology, drugs used to treat, and other random things). Then we all go back to the bedside and we demonstrate our findings on physical exam and they ask us to perform various physical exam skills. For example, some people were asked to demonstrate the thyroid gland exam. Some were asked to demonstrate the hip exam. Me? This is how my afternoon went:

I get to my patients room. She's a little old lady...chatty grandma to boot! I have to interrup her sooooooomany times (I do only have an hour to do this). 20 min in, she becomes acutely short of breath and isn't able to talk anymore. I freak out and perform a perfunctory respiratory exam on her (I'll be damned if my patient dies on me during my exam and I do nothing!) ring the bell for the nurses to come in. She takes her vital signs and starts a ventolin nebulizer on her. She settles a bit but she's still short of breath and I don't feel comfortable continuing the exam with her this way. So I called our emergency contact lady...who doesn't answer. I try for the next 15 minutes (rember we have an hour before our examiners come and I now have 30 minutes left). I finally get a hold of her with 20 minutes to spare. She hummed and hawed about what to do and finally decides to give me a NEW PATIENT! What?!?!??! I only have 15 minutes left. "Don't worry, I'll call your examiners and let them know what happened. Just do what you can".

So I go to my new patient who happens to be 7 floors away so I took the elevator...mistake...it stopped on every floor down! I meet him. He's in isolation which means I have to take a few more minutes getting 'gowned and gloved'. He has MANY medical problems and I did the best history I could do in 12 minutes! No physical exam though!!! Didn't even use my stethescope on him!

My examiners came and were very friendly about the situation. I presented my (limited) history and tried to focus on "if I had more time I would have..." I didn't even have time to sit and regroup my thoughts on what was going on with him. And I hadn't even looked under his bandages (which was why he was there) so I had no idea what was under there! My examiners grilled me for a bit but that wasn't so bad...they usually ask a few leading questions. We only had 10 minutes left so we went to the bedside and met my patient. I wanted to at least examine him and see his legs. Took us 9 minutes to get him into the bed and get his legs uncovered. I opened my demonstration with "After ensuring proper lighting, exposure and patient comfort, the first thing I notice is the odor" Nuff said...welcome to my world!

My examiners said I did well considering the circumstances, but I certainly don't feel that was a good reflextion of what I'm capeable of! Oh well...I'll have to wait and see!

Next: plastic surgery here at the same inner city hospital.

Last CTU overnight on-call shift!

Yea me! I made it through internal med with my insanity intact! We have 4 more days of internal medicine left and tonight is my last on-call shift!!! Well, not really...our team is on call on Saturday...after our exam. But us med students only have to stay until 5pm. Bummer that I still have to come in the day after our exam, but at least we don't have to stay the night!!!

Hope our shift goes well tonight. So far, I've had a nice nap because I couldn't keep my eyes open this afternoon. I've done a bit of studying, so now I'm just waiting for an admission. I think this may be the calm before the storm. I just have a feeling.

I have 3 patients right now. 2 of them might not be discharged before I am done, but they are doing better than when they first came in. That's all I can ask. My other dude that left AMA and came back has decided to "change his life". He is now "done with drugs" and wants to move away after he is discharged so he can start a new life. Meanwhile he spends most of his day off ward with other sketchy patients and he hasn't been demanding his pain meds as he normally does. Hmmmm...methinks my patient is a LLPOF (lier, lier pants on fire). My awesome new abbrev.

Well, I must get dinner right now. I will be hiding until after my exams, so farewell to you all! See you soon when I come up for air!

Internal Medicine Wisdom

I've compiled a short list of things I've learned while in my internal medicine rotation:

1) The term 'internal medicine' is an oxymoron- roughly 20% of what I do day-to-day is actually medicine. The rest is hospital BS/admin work.

2) The hospital I am in is skewed- a lot of our patients are what I like to call 'alphabet soup'- HIV, HepB, HepC, IVDU, IDDM (diabetes) and they don't have garden variety anything. For example, a bacterial pneumonia usually doesn't have a complicated course...it gets better with antibiotics. My 5 patients with pneumonia however, have all developed complications resulting in surgical drainage of pus from their chest cavity and a long recovery from surgery.

3) There is a huge waste of health care resources- mainly due to hospital BS/admin work, but also from patients who repeatedly leave AMA (against medical advice) only to return the next day with the same problems. Our team has had one patient who has left every single day for the past week, only to return to emergency the next day expecting us to fix him. It's ~$400 billed to our healthcare system for a patient to be evaluated in emerg...that's not including a stay in hospital. Cha-ching. I know, I know, I'm cold hearted...but try having compassion when you've been called from slumber to admit this patient at 3am. NOTE: this patient was arrested the last time he left, but needed medical treatment in hospital (duh!). He is now handcuffed to his bed and is babysat by a large prison guard...no more leaving AMA for him!

4) A new hairstyle makes everything better.

5) I've got a lot to learn. Like, alot, alot.

6) The field of antibiotics is a very large black hole for me. I hope my patients never have infections because I won't know where to start.

7) I need to go back to my advice from way back in Obs/Gyne: sit when you can, eat when you can, drink when you can, sleep when you can. When on call, I'm usually very hungry, very thirsty, very tired, with sore legs from all the walking and stairs I do. I'm a slow learner.

8) Psychiatry has come back to haunt me! I have a cluster B patient (my fave!)...narcissistic and borderline all wrapped into one. Another patient with pretty bad anxiety. And yet another who I will soon diagnose with factitious disorder (no organic cause for her 'pain' she attributes to a car accident 3 years ago). 3 CTs, MRI, Xrays and operations all suggest it's all in her head!

That's all for now. I have to study.

On call toiletry bag

While I was reading Hiccups' blog, she was wondering what other people bring for their nights on call at the hospital. Here's what I usually bring:

1) underwear and socks (I don't think this needs explaining)
2) shampoo and soap (the hospital I'm at is sketchy and I feel dirty most of the time)
3) moisturizer (for after I wash my face) and mascara for the next day
4) lunch (I usually get some sort of takeout for dinner)
5) juice boxes (for the late night hypoglycemic attacks I get when I am paged)
6) popcorn (for group morale in the emerg department)
7) bear spray (to keep the nasty ER clerk away...just kidding, but I want to)
8) books to read (all to study with)
9) comfy runners (too much walking and stairs...amke me feel like I am working out)
10) chapstick (it's dry in this hospital)
11) bottled water (not going to attempt the tapwater here)
12) bravery...I need something to draw upon when I don't think I can do it anymore.

And I usually either walk or take the bus home the next day. It is dangerous to drive with sleep deprivation...akin to drinking and driving. Safety first you know!

PS- I find to keep my feet dry and less smelly, I have to take my shoes off any chance I can.

It had to come sometime

I guess I spoke too soon. I totally jinxed myself on my last call shift. That'll teach me to be so cocky! On my last call shift, I got 35 minutes of sleep and had to stay until 2pm the next day. It was a bit of a nightmare because in the morning, all the teams were switching over and we had new people, all the patients were being "geographically relocated", and there were no beds available on the wards so patients were waiting in emerg. Good times. Our team had to admit all 18 patients because all the other services (like HIV, hospitalist, family medicine) didn't have any beds available.

Today I am on call again. We shall see how it goes.

Tomorrow, I am heading to my dad's place for easter. It'll be a quick visit because I need to study for my exam coming up in 2 weeks, but I feel like I need a change in scenery for a bit. Plus he has a washer and dryer that I can use for free!!! Bonus! I am starting to appreciate the small things in life!

Wish me luck tonight!

Well, I'm on call again. Have actually had a good weekend so far. Had to stay a bit late on Friday...hospital bs. Nothing is simple when you're in the hospital. Studied a bit on Saturday then went for dinner for a friends' birthday. Now I'm back at the hospital for the next 30hours. I'll do a bit of studying but man, is it boring.

I can't believe we only have 3 weeks left of this rotation! Seems like yesterday that I had no idea what I was doing! This isn't to say that I know what I'm doing now, but at least I am able to operate the patient computer program to get relevant information! I'm even a bit more confident in assessing sick people when I get called to the ward, even though I still get palpitations when my pager goes off. This is part of our training is gaining confidence in our (limited) abilities.

A few things have bothered me about working in the hospital:

1) The evil unit clerk in the emergency department. I swear she's put on this planet to test how far she can go and still have med students be nice. She must also have boundary issues: she yells at us if we're in HER space. She's my classmates nemesis.

2) How every little thing is micromanaged and made an issue.
For example, my classmate had the experience where she was discharging a patient, but the nurses didn't think she should because the patient hadn't had a bowel movement for 2 days. For crying out loud! There are many, many, MANY people walking around in this world who are constipated, but because they happen to be in the hospital, it MUST be treated!!! Same thing for loose bowel movements (not diarrhea), headaches, nausea, fatigue, poor sleep, minor aches and pains, etc. Every little complaint a patient has is brought forward by a nurse, discussed by the team, investigated to see if it's something serious, and then treated.

3) Needing to write orders for things that patients can get themselves over the counter at the drug store.
Why do I have to write an order for Tylenol, or peptobismol, or ibuprofen or whatever if the patient can just as easily have someone bring it to the hospital for them or bring it from out of their purse? And for me, it's not as simple as just writing an order. Being a med student, technically, I have to go to the patient and get a history from them about why they need this drug, examine them, check their lab tests just to make sure the drug I give them won't harm them. Then technically I need to discuss this with my senior resident who can give me the verbal order for the drug, then I can write the order in the chart "Discussed with Dr. So-and-so". We make it a habit to write "prns" in the orders when we admit patients. This will ensure that these type of meds will be available for the nurses to use "as needed" so we don't get called in the middle of the night for tylenol.

4) Contact precautions for MRSA/VRE patients.
MRSA and VRE are what the media calls the "superbugs". They are bacteria that live on skin and usually don't cause a problem unless the skin is broken (ie infected wound) or it gets into the blood. The infection can't be treated with the standard antibiotics if someone has an infection, special ones must be used. With the population of patients this hospital has, it is rare that someone is NOT a carrier of these bugs. Problem is, if you want to examine these patients, you have to do what we call "gown and glove". You have to put special gowns on to protect your clothes, put gloves on and make sure you wash everything that goes into their room after you are done. Pens and paper included. For nurses this takes considerable time to do it many times a day. That fine and all if it would prevent the spread of these bugs and prevent infections, but here's my issue: if the patients are well enough, they are allowed to roam the hospital, go outside for a smoke, get food in the cafeteria, and do whatever they want. What's the point of contact precautions if these people are able to go around touching everything so other people can get their bugs? That's not even mentioning the fact that these people have been carriers long before they came to hospital and have touched god knows what in public places!

I think that's enough for now!