Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!

Inpatient Medicine - Finally

Well, I have finally started my inpatient medicine internal medicine rotation at a teaching hospital.  The first day was pretty exciting - we rounded on patients, I got to know my team, we hung out in the emergency department and admitted people, ran to catch a code blue, etc.  It had a very "Scrubs in India" feeling to it because the residents and the attending are all from India (except one woman from Bosnia?).  They are nice, but one challenge is they have very thick accents and are kind of clique-y.  One of them in particular has a very thick accent that I have a lot of trouble understanding, and I know he has trouble enunciating so I feel a little bad asking him to repeat himself all the time.  They all talk softly too, mumbling, so it is hard to tell what they are discussing unless I am super close.  

It's gotten a bit more negative as time goes on - first day I thought things were going to be good: I would follow a patient, the attending told me to pick a patient and a topic to research, and then I'd discuss it with them and present the patient.  My first day I wanted to follow a patient with COPD, but then she was going to be transferred to ICU where we don't really round or follow patients.  This was after I had already done a writeup and was preparing on that topic.  It was then suggested that I follow another patient - so I picked a man with liver cirrhosis and varices.  So that's two writeups and two topics I needed to look over that night, on the off-chance we went to the ICU.  When I finally try to present the next day, the attending corrects me on the order in which I was giving information, the standard form that were taught and how I've been doing it over the last year with no complaints from any of my preceptors.  After I do half a presentation,  then the resident I was working with filled in the physical exam portion (which was essentially what I would have said, minus two small findings), and another resident presented the next patient.  That person did the EXACT format of presentation that I did, but of course without being called on it.

To make things a bit worse, today the resident who has a thick accent wanted me to look up some information - how a medicine is connected to a condition.  I figured it was a "this is a good topic to know, look it up and we'll discuss it" type task, similar to what attendings have done in the past, and he didn't give me any indication it was otherwise.  After a 30 minute search on my usual online textbooks, all reputable sources like Harrison's and Current Medical Dx and Tx, I couldn't find anything linking the two.  I come back, told them what I found out about the topic and medication, and they tell me to just google it or search on pubmed.  I got pretty annoyed because I didn't know he was just scouting possibilities for research projects and there WASN'T an established link between the two things.  I go back to pubmed, which they spelled out to me as if I had no clue what it was even though I've used it a million times, and I still couldn't find a single article linking the two conditions.  Everything was consistent with what I had previously reported.  

Ultimately I found an article about use for the medication in the condition in general (which I had already described) and there was another medication he was curious about so I found a couple token articles about that, but I left in a rather sour mood after having to do almost 2 hours of busywork for no real payoff and reviewing an esoteric topic that I already knew.  

The topic I'm reading up on for the attending currently, bacterial meningitis, was something I read through yesterday - I must have read through 3 different full-length UpToDate articles, and where I thought there were holes in my knowledge I continued to investigate.  Wrote everything out, went and checked out the pertinent sections in my review books, and today he still wanted to give me more time because he said UpToDate isn't the best source and kept asking about random textbooks that they used back in India.  At least he approves of Harrison's and CMDT, but I read over the meningitis information in those texts, and it was verbatim what I found in the UTD articles, and actually was less detailed.  I understand that UTD is a quick reference and half the articles are short and to the point, but I went for the full-length meaty articles.  

Long story short: Feels like they underestimate how much I know without even testing me, or letting me go on when I try to engage in a discussion.  

Plus sides: There is night call twice a week, 8pm to 8am, and then morning rounds, usually get off around 11am the next day - meaning I get to sleep in the day before, study, eat at home, and then spend the night in the hospital, knowing I have the entire next day off.  Essentially reduces my number of shifts by two.  I am not sure if I have weekend duty, but if I can get by with just 3 shifts per week, I'll be pretty stoked.  

As far as rotations go, I got sub-internship at the program I plan to rank #1 - the guy who called was I think a rank higher than the lady who actually does the coordinating and he went over my application.  He commended my USMLE Step 1 score and grades, and liked my personal statement - tried to connect a bit with some things he's done as well.  It almost felt like an interview - which, in a sense, it was, but it felt almost like a residency-screening interview.  I'll assume that his positive feedback about my application indicates I have a good chance of getting an interview for the residency program (provided I don't screw up my boards and rotations between now and then).  

Called a few more places today, starting to get a few more things on board - I'm going to see about doing some easy rotations while studying for my Step 2's so that I can have more vacation left over for a potential trip to Europe.  I think I have ER and Surgery in the bag, and ICU and a Medicine Subspecialties should be easy enough to arrange since Touro has a few exclusive arrangements.  Still waiting on Davis to get back to me, but I'm not really holding my breath too much for them.  Also waiting on another program out there, but they just updated me that they're looking over the application and I should hear from them any day now.

Perhaps time to take a nap and then read up on more meningitis and do some practice questions.......