Internal Medicine Day 2: I made sense of this rotation?

So I think I've finally figured out how internal medicine works.

 So in the end, all the patients in the hospital get divided up among the students with interns and residents looking over everything.

Yea... its a shitstorm.

Every morning at 7am, all the students, interns (aka 1st year residents), residents, and the chief resident gather in the cafeteria where Dr. L who is the attending in charge in the morning conducts "table rounds". Basically we go through the whole list of patients and the people who were covering patient care overnight summarize each patients illness, and what was done for them overnight and if there were any major changes. Dr. L likes to give mini lectures based on each patient and is an amazing teacher. He is like freaking Dr. House, he thinks of all these crazy other diseases we could test for just for the learning experience, and has great pearls of wisdom on even the everyday things like pneumonia and sepsis.

After this, the residents meet briefly with their interns while the students grab breakfast. Then after breakfast the intern meets with his students and tells us the plan for each of our patients and gives us things to do for them.

Now we are basically on our own until noon. We take this time to go see our patients (average patient load per student is usually between 2-4), make sure their labs are ordered/done, and write up their chart/discharge summaries. If they need any procedures done, we get to do them, or if we don't know how, we bug our intern to show us.

Usually around noon we either have another lecture, or we have "grand rounds" where we walk around to each patients bed, and the student makes a formal presentation of the patients case and what we are doing for them. This can take awhile especially because the attending in the afternoon, Dr. P, likes to "pimp" us: aka grill us on our medical knowledge.

An example:
-Student: "Mr. Smith is an 80 year old male presenting with pneumonia and ...."
-Dr. P: "stop. What is the most likely pathogen causing community aquired pneumonia in this aged patient? How about nosicomial pneumonia?"

And so on....

After "Grand Rounds" and subsequent crying hysterically in the supply closet/lunch, we are again left to our own devices to either continue catching up on paperwork/patient care, or go study in the library.

At 4pm sharp, the whole group again convenes to go over the whole list of patients to decide what needs to be done overnight for every patient, and the responsibilities are handed off to the residents/interns/students who were assigned overnight duty that night.

Then we are free!!! And that's a typical day on Internal Medicine. I'll have patient stories tomorrow, promise.

Family Practice Day 1&2: $$$$$$$

So I started working my family practice rotation, which is basically 8 weeks of working in a doctors office.

I got assigned to a super chill place. The preceptor is awesome and anytime there isn't much going on he will take time to teach you some cool tricks of the trade like how to give painless shots, or how to draw blood on anyone easy (hint: a blood pressure cuff is involved).

The actual site is really cool, there is even an "office" for the students. Actually its an exam room with extra chairs thrown in and 7 of us fit in there, but still. Its an office. An office!!!! With places to sit and study!!! And plenty of needles in the cabinet to practice with!!!

One thing I'm learning a lot about is how to make money. Family practice physicians make almost nothing, sometimes nurses are paid more than they are. So this doctor has become a master of balancing insurance crap while making sure every patient gets awesome care. But because there is so much pressure on family practice physicians to cover their expenses, a lot of the practice becomes centered around making money.

 Its not really my favorite way of thinking but it is good to know. I'd prefer to think that I'd be doing things for patients because they need it, not because they might need it and the office will get more money from the insurance company that way.

But other than that its been super slow so far. Maybe thats cuz my only other significant experiance was the ER. But it could also be that there are so many students here we really only get to see a couple patients a day if we split them up. On the bright side, we have had a lot of time to bond. Actually planning a poker tournament tomorrow in our office, using alcohol wipes and butterfly needles as chips.

Here's to hopefully an easier time than the last rotation :)

Things I saw today:
-A patient who needed refils on medicine
-A patient who had headaches cuz she is anemic and hasn't been taking her iron pills

Day 15 ER: Last Day

So here it is, my last 12 hour shift in the ER. This month, I officially spent over 180 hours in this place.

It was kind of a bittersweet feeling. At first I thought this place would drive me crazy with how unorganized everything is. But this rotation granted me a lot of freedom to practice a ton of patient care. I got to pretty much do everything for a patient, from the initial exam, to ordering diagnostic tests, getting medications, and performing procedures. And from what I've heard from other students, you don't get this kind of freedom in other rotations. One student told me that in surgery you are lucky if the attending lets you hold a retractor, let alone suture the patient.

Anyway, today was pretty much your standard day in the ER. Lots of super ghetto people who were raised to believe that the ER is the place to go when your joints hurt (even though there is a FREE clinic for that stuff literally next door), then complain and become verbally abusive when we don't see them for hours because we have patients with acute issues.

There were nursing home vegetables sent in because their mental status has changed.... usually meaning that they could respond to verbal commands before, but now just lay there. So we did a basic physical, ran a bunch of labs, then told ICU/Internal Medicine it was their problem. Usually a good kind of patient to practice listening to heart sounds on, because they usually have some kind of cardiac issue, and they don't care if you take forever to listen to their chest.

Towards the end of the day another med student, who's last day it was today as well, pulled me aside and said in a whisper: "I've secured a laceration case in the Fast Track area, its all ours, lets quietly go over before another student/resident sees and takes it"

So like ninjas we exit the ER and go down to the fast track area. She had already grabbed everything we would need and laid it out on a bedside table. For our last case in the ER, she had found: a nursing home patient who had a laceration on his scrotum.

What.

How does that even happen.
He had a deep, Y shaped cut along the whole front surface of his ballsack.

The patient couldn't or wouldn't tell us, and the nurse we called at the nursing home wasn't forthcoming either.

Anyways we got to work. The patient kept saying "Get off my balls!!!". At one point he grabbed my elbow and tried to bring it to his face.

 "Don't bite me sir!!" I said

"Don't have real teeth anyways" he grumbled as he let go.

One of the nurses came over to see what was causing the big commotion. He said, while laughing, "honestly I'm taking his side, I'd try to bite you too!".

Anyway, it was a memorable last case for the ER rotation. Suturing some old guys scrotum.

See y'all in September for Family Practice, probably won't have anything exciting to say there :(

ER day 11: Procedure day

I went to go see my first patient of the day, all I knew was that the nursing home was sending him in for "unresponsiveness", and that's all he'd been triaged as. I go over to the bed, and shit. The guy was blue.

I left the bed ran over to the attending at the nurses station and said like a cool doc: "I think we need to intubate nursing home guy, he's REALLY cyanotic". So then I was helping the attending intubate the guy, then place an NG tube on him. Pretty exciting start to the day.

Maybe 20 minutes later, another patient arrived that needed a central line put in. Whenever that needs to be done in the ER, they usually call for the surgical resident to come and do it. Being the overexcited little bugger I am, I asked the surgical resident if I could watch, and promptly dumped my ER duties to check it out.

The central line was cool. It was kinda like an ABG, in that you are taking a big needle, and basically trying to hit a hard to get blood vessel. They had to thread some big thing up it tho, and there was something involving a scalpel (I did end up getting called away halfway thru), but in the end, they actually sutured the thing into the patients skin.

For awhile, there wasn't much going on, so I sat at a computer pretending to be busy.

I figured something cool would come along soon, and I kinda didn't feel like seeing the boring cases like pediatric fevers, or old people with arthritis pain today.

Then I got the call.

"Are there any medical students here?" The charge nurse asked. Oh oh me!!!!

"Dr. S over in the fast track area wants to see you".

Fast track is a small area off to the side of the ER where they take the less critical patients. I walked over there, and Dr S was standing there next to Dr. B. Dr B is a double specialized plastic surgeon and Ear Nose Throat (ENT) guy that we sometimes call in to consult on cases. Dr B loves to teach, so anytime he is in the ER, he likes to have students and residents around.

Dr B asked "Hey Alanna! You're the ER student today right? Did you happen to see any surgical residents over there?"

(ok I did, but fuck them) "No sir I didn't". (I know I'm bad)

"Well they are missing out. I guarantee you won't see something like this again" he told me.

And then he brought me over to the patient. This guy had a bike accident, and he managed to tear his ear half off. He showed me how some of the cartilage had become necrotic and black already. We basically had to cut out the dead cartilage and tissue, then reconstruct the ear using tissue from behind the ear and skin pulled down from the skull. He taught me a bunch of plastic surgery stuff while doing all this. Then came the awesome moment. "Ok kiddo, want to show me your suture abilities?"

"Yes sir!!!" So he let me do a bunch of the sutures in the less complicated parts. It was really awesome because he was critiquing me as I did so, and I think I got a lot better at it with his help. In the ER, they usually don't care so much cosmetically, they just want the two ends of skin to come together. But he showed me how to do some plastic surgery grade sutures, and how to make sure it will look good when you are done.

So that was my procedure filled day. I'm off to take a nap, have night shift again tonight!!! See you later :P

ER Day 7: Office Politics

You know those awkard "political" moments in the workplace? I had my first experience with that today. I was spending some time in the Pediatric ER today (basically the back corner of the ER where they stuck a couple cribs). I saw a bunch of people bringing their kids in with fevers to get some free motrin, a couple ear infections, then the holy grail of the day: a rash!!!

Rashes are kind of fun to diagnose in kids. Based on the distribution of the rash, associated symptoms, and timing of onset, you can create a cool differential and narrow down the list of suspected causes. For some reason rashes are one of the things that really stuck in my head. Anyways this kid had a very classic rash presentation: he was young- only 10 months old, the rash was on his hands, feet, and in his mouth. The kid had no fever, up to date on his immunizations, and no other symptoms except the rash. My thoughts immediatly ran to coxsackie virus. Some other students at the hospital were saying they've seen a lot of cases of it recently, and the presentation was exactly like coxsackie aka "hand food and mouth disease". I told the mother my clinical suspicion, but that I had to run it by the attending.

I went up to the attending in charge for the day, and gave an oral presentation of the case and my clinical suspicion and treatment plan. My attending disagreed.

He believed it to be related to the childs history of eczema (which was a valid point, it could have been, but it really didn't look like it.... who am I to say, I'm still a newbie). The attending then goes on to explain that if it is an eczema related flare up, he had to chose between treating with steroids or antibiotics. If he gives steroids and there is a bacterial infection there, the rash will get worse. But if there is no bacterial component and gives the antibiotics, the rash will also get worse. The attending decides to call in a pediatric resident for a consult.


When the pediatrician comes down, I follow like a diligent student to learn how a pediatrician evaluates the patient (and also to play with the patient's adorable twin sister). The pediatrician does a quick exam and looks at the rash and says: "This just looks like coxsackie". The mother turns to me and says "thats what you said!".

I decided to let the pediatrician give my attending the news, and didn't mention the case again.

Things I saw today:
-A grade 4 bed sore (you could see her muscle and almost down to her bone!!)
-Pancreatic cancer patient with a likely DVT (cancer patients, especially pancreatic, tend to clot easily and are prone to them)
-Fluid overloaded renal failure/congestive heart failure patient that we intubated

Things I did today:
-Replaced a suprapubic catheter solo (the attending just handed me a kit and said "you've seen one done? go do one")

http://splicd.com/CcKmAuhpOBE/213/224 (pretty much how I felt when I was doing it)

-Did an arterial blood gas by myself
-Helped intubate our fluid overloaded patient

ER Day 5: Sutures and Good News!

This was originally going to be a post about today (which was a mixed bag of craziness), but I just got some awesome news so I'll be brief.

Today started out with the weekly Residents Confrence. Basically the first hour is a Morbidity and Mortality meeting for the ER where we discuss a case where a patient died, and how to do better next time. The case discussed today was for a patient that had come through the ER a few weeks ago (before I got there) with NECROTIZING FASCIITIS. Which was kinda cool because I got to learn more about it, just wish I actually could have been there... I wanted to see the case!!!!

After The Morbidity and Mortality meeting, there were a few lectures by medical students on cool cases they've seen. They basically present the case and how it was managed, then lecture on the disease for about 20 minutes. I have to go next week, I still haven't decided which patient to present on. Plus I kinda suck at presentations so I'm really starting to procrastinate this...

After all that, one of the attendings showed up with a present for us all. He had grabbed a bunch of expired suture kits and a ton of chicken legs from the grocery store. He sat all us medical students and residents down and helped us practice suturing for about an hour. I stationed myself next to a resident doing a rotating interm year at the hospital before going on to a surgical residency next year. He was able to really help me learn "surgical grade" sutures. (ER residents and students are usually content if the edges of the skin meet and if the ties aren't going to come apart anytime soon. I wanted to learn the RIGHT way to do it.) I got to practice my suturing skills later on an actual patient (under supervision of said future surgical student), so I'm feeling a lot more confident about them :).

And on to the good news.

When I got home from the hospital today, I saw that I had an email stating that my USMLE scores had been released and could be downloaded from their website.

I was really scared to download it, but thanks to some encouragement from a certain ginger, I opened it and saw....

I passed my USMLE :)

I got the score I needed to pretty much do whatever haha. I found a table that somewhat represents what the scores means for residency applications. The bottom line indicates the lowest scored applicants a particular program will look at, and the top line indicates the score that almost always merits an invite to interview for a program.

And since I have off tomorrow, I'm off to do some celebrating. Toodles :)

Day 4 ER: My first Spanish Word

We shall not speak of the horrors that happened on my third day in ER (my overnight shift) suffice to say, I'm not looking forward to my next overnight shift, and I can cross ER off of my differential list of possible residencies.

Today for some reason, everyone decided to cut themselves. I had many many patients that needed suturing. Within the first hour, I had a kid who cut his head running into a door, another kid who cut his eyebrow with a fishing lure somehow, and a man who stepped on a broken piece of glass. I guess one good thing about getting this rotation out of the way first is that by the time I get to surgery (which is now top of the list of specialties I'd like to do) I'll be kick ass at stitches.

I know I've mentioned this earlier, but I'm starting to think that rotations are the best kind of diet. Seriously, in 12 hours, you really only have time for a quick snack now and then.

 I am glad I started carrying around granola bars in my pocket. What with all the bloody cuts today, the last think you want to be is lightheaded. The sight of a lot of blood + no food for a long time= fainting medical student. So thankfully I wasn't a cautionary tale to young medical fledgelings and was able to keep from feeling faint all day :).


So ready for a story that made me happy but sad at the same time?

My last patient of the day, was as per theme of the day, a laceration case. He was a young man from El Salvador who was brought in to the ER accompanied by some Police. The poor man, as it turned out, had been beaten and hit with a broken glass bottle by a gang. He was cut and scraped all over. His shoulder was badly hurt, and he had several deep gashes on his hand and forearm where he tried to shield himself from the glass. The gang took the money he had just recieved for a weeks work ($500). He spoke very little english, and at first he was just so upset and shocked he could do little more than sit on his stretcher and cry.

The resident and I brought him into the room and started to give him some morphine for his shoulder and start numbing his arm with lidocane for the stitches. The resident knew a little spanish, mostly the word "dolor" (pain). While the resident was injecting him, I tried to keep him distracted by talking to him. I asked about where he was from, and what he did. He said he worked for a construction company and proudly showed me some pictures on his phone of some tile work he did. I also learned that it was his birthday.

What a day this poor man had!! While we were working on his stitches, I got him laughing by saying that we would give him an extra shot of morphine as a birthday present. He asked what it would do, and I said "much better than cervesas" to which he laughed. Somehow, after such a wretched thing to happen, he was able to laugh and have such a good humor while having people sew him up. We did give him another shot of morphine when we were finished as promised (although the poor guy really did need it).

Anyways, just in that little space of time, I felt that I had seen the worst (gang violence against an innocent) and best (laughter and good humor in horrible circumstances) of humanity.

Thats my two cents for the day. I have tomorrow off, and another night shift on monday..... wish me luck.....

Things I saw today:
-Cuts
-Cuts
-More cuts
-Pseudotumor cerebri (!!!)
-a possible hyperparathyroidism
-Diverticulitis

Things I did today:
-Assisted in suturing
-Followed nurses around to learn the basics of drawing blood for labs, getting arterial blood gases, and refreshing my knowledge on doing EKGs.