Saturday, April 29, 2006

Miscellaneous

Rock Star

In non-DoRo business, Neil Young began streaming his new album on his website yesterday. It should go on sale soon; I'll definitely pick up a copy.

Rolling Stone's take: On the album, whipped up in just two angry weeks earlier this month, Young takes aim at the war in Iraq and President Bush -- through songs including the Bush-basher "Let's Impeach the President."

Living With War features what Young describes on his Web site as "metal folk protest" and "a metal version of Phil Ochs and Bob Dylan," recorded with "a power trio with trumpet and 100 voices."

Doesn't get better than that.

Super Star


Today is draft day in the NFL. The Chiefs picked Tamba Hali, a defensive end out of Penn State, in the first round. His story is pretty compelling.

Fading Star

Luna, my pet rat, passed away earlier this week. Sister to Zoe, she'll be missed.

Time to study ambulatory pharm. Wii!

Friday, April 28, 2006

DoRo

Day 28:

Fun day on DoRo. Lunch was good. Ready for a weekend.

Thursday, April 27, 2006

DoRo

Day 27:

Truman is rated as one of the most "wired" hospitals in the country. No matter where you are, it's always possible to find a computer terminal nearby. Because there's only a limited amount of desk space, though, some of the computers have been specially built into moveable carts. A couple weeks ago, my senior partner told me the acronym he used to describe this particular type of computer and asked me to guess what the letters stood for. I tried many combinations of words, but none of them were quite right. Finally, bemused by some of the phrases I had strung together, he told me what his acronym actually stood for: "Computer-On-Wheels."

We were walking near one of these computers today when he casually remarked to me, "Whoa, look at that COW!" You should have seen the faces of the two nursing students who happened to be standing next to it as we passed by.

Wednesday, April 26, 2006

DoRo

Day 26:

I think it's easy to forget that our patients (for the most part) don't live in the hospital 24/7. It's not that doctors and medical students are inept at communicating with them; rather, certain things become so routine to us that we simply forget how alien some terms and phrases may seem to the typical patient.

For example, I asked a 42 year old woman in clinic this afternoon when she had had her last mammogram. She told me, "November." I asked about her last pap smear and after giving me a funny look, she once again said, "November." In actuality, her last mammogram had been the previous July, but for one reason or another, we figured out together, she had confused the terms "mammogram" and "pap smear" in her head and had thought the two were the same thing.

Another time, I was with a fellow student who asked a patient if he had ever had a "pulmonary function test." The patient thought about the question for a couple seconds, then confidently wheezed to us, "Nope! Never had one of those!"

The other student might have moved on with her interview, but I wasn't thoroughly convinced by the patient's answer (even though it was gasped out with such conviction), so I quickly interjected, "You've never had a test where you breathe into a tube in a machine?"

"Ohhhh... yeah," he replied. "Where they sit ya in a machine and you puff into a tube? I've done that before, sure. Over at [such-and-such a hospital]."

Miscommunication happens. Simple as that. (And goodness only knows how much I've missed - and will continue to miss - through poor questioning technique.)

The moral of the story: just remember how much jargon is out there. You can't ask every patient about "nausea" and expect them to give you an accurate answer. Ask about belly pain, stomach ache, feeling sick to one's stomach, etc. Clarify, clarify, clarify - the three golden keys to a sound medical history.

Tuesday, April 25, 2006

DoRo

Day 25:

The power of observation.

Doctor: "How often do you take your Lasix?"

Patient: "I take it every few days to help reduce some of the swelling I get. Is that okay?"

Doctor: "Sure, sure. You mostly get swelling in your ankles and feet, right?"

Patient: "Umm... I'm kinda missing those."

(The patient had had both legs amputated below the knee.)

Monday, April 24, 2006

DoRo

Day 24:

The difference between a resident and a medical student... A patient wanted something to make her mouth less dry during the day. The student looked in the patient's chart and noted that a lozenge was already on the med list orders. The student then proceeded to instruct the patient, "The next time your mouth gets dry, just ask the nurse for Cepastat. Understand? Cepastat. It's spelled C-E-P-A-S-T-A..."

At this point, the resident interrupted the student and suggested to the patient, "Just ask the nurse for something to make your mouth less dry."

Sunday, April 23, 2006

DoRo

Day 23:

So tired....

Saturday, April 22, 2006

DoRo

Day 22:

Technology definitely has its advantages. Using the hospital's computer software, I'm able to remotely check my patients' charts, lab values, nursing notes, vital signs, etc. whenever I like and from any location. What does that mean? Well, it means I can save people's lives from here at home while wearing nothing but my underwear. And given the alternative of working in just my skivvies at TMC, everyone in the healthcare field should be thankful for the wonders of the information age.

Friday, April 21, 2006

DoRo

Day 21:

After rounds this morning, Leah's birthday party at lunch (with a fantastic cake made by Alicia), and clinic/hits this afternoon, I helped cook dinner with Lauren and some other APOers across the street at the Ronald McDonald House, a place where the families of sick kids from out-of-town can stay while their loved ones are in the hospital. Our menu was fairly breakfast-oriented and simple from a culinary standpoint, but I think it turned out pretty well. Brian fried up bacon on one stove burner while I prepared sausages on the other, and when all was said and done, a couple of rather large pools of grease were the only remnants of the havoc we had wreaked upon one now-depleted barnyard. T'was good times, good times.

Oh, and I apologize to any vegetarian readers for the graphic content of this post (at least I didn't describe the acrid smell of sizzling animal flesh in the afternoon...).

Thursday, April 20, 2006

DoRo

Day 20:

You meet all sorts of interesting people on DoRo. Take, for example, the 70 year old guy who came in with cellulitis on his left elbow yesterday. Looking like a cousin of Mark Twain, he had had two stents placed in his heart about five years ago. His current occupation: professional street-fighter.

Wednesday, April 19, 2006

DoRo

Day 19:

When rounding, medical students are expected to present their patients' status to the rest of the team in a relatively formal manner, running through all the important details of a particular case (e.g., a patient's subjective complaints, the history of his present illness, pertinent lab values, your physical exam findings, assessment, plan, etc.). If you know your patient well and don't fumble the delivery of said information, you come out of presenting a patient feeling pretty good. But the fear of screwing up, at least for me, always causes a slight adrenaline rush just prior to the attending physician calling out, "Who has room 215?"

This morning I was presenting a patient I admitted the previous day, a 41 year old African American male with a one-day history of hemoptysis (coughing up blood), shortness of breath, left sided flank pain, and significant crackles in the left lower lobe of his lungs. His past medical history was significant for AIDS, coronary artery disease, myocardial infarction, deep vein thrombosis, and a host of other ailments. A fairly fit-looking guy, he appeared ten years younger than he actually was, and his demeanor suggested a youthful spirit still resided within his body.

So when I began presenting this gentleman's case earlier today, I felt like I was nailing all the particulars pretty well; when the attending physician asked what his lipid levels were, I had the ones drawn from last November ready. The supervising resident threw a couple softball questions my way, and I swatted them down with no problem too. But out of the corner of my eye throughout this whole process, I could see Dr. K, our Pharm.D., just waiting to pounce with a question of her own. And sure enough, just as I thought I had made it into the clear, she probed, "What antibiotic is he on right now?" Phew, easy question, I thought. I told her we had started him on Levofloxacin 500 mg. Then she posed the follow-up: "And what effect should you be concerned about with this patient regarding his dose of Levaquin, given that he's also on Coumadin? Surely you remember from pharm?"

Hmmm... no, I surely didn't. I ventured a guess about the cytochrome P450 system, at the same time (correctly) thinking that wasn't what she was looking for. She gently pointed this out, and went on to talk about the effect this particular drug interaction can have on a patient's INR (his was therapeutic at 2.78, but after a three-day course of the antibiotic, it might double, she said, launching into a discussion of vitamin K metabolism, anti-coagulation factors, and so forth). "Just something to be aware of," she finished.

Not quite "pimping," by any stretch, but man, I wish I could have gotten that question right. Impetus to hit the books, I suppose.

Tuesday, April 18, 2006

DoRo

Day 18:

The usual dull buzz of nurses and doctors quietly working on the general medicine floor was broken this morning as I first arrived at the hospital. Just as I was getting to the Red Unit, a patient in one of the rooms started to vocally protest his dietary orders... loudly enough for all the floor to hear. He walked out of his room, gown wide open in back, gray hair atop his head a massive ball of frizz, and started shouting, "I'm being starved here! You understand? I'm being starved to death! I've been here eight times befo', and I ain't never been starved like this! I want my breakfast, not whatever this NPO bullshit is... I'm being treated like a prisoner, and it ain't right!"

Security showed up and let him vent some more, while the nursing staff and everyone else just went about their business, ignoring the angry, obviously hungry fellow now pacing up and down the hallway. Someone must have called his doctor (he wasn't one of our patients), because I heard a nurse eventually tell him that the resident had changed his diet from nothing by mouth (NPO) to a less restrictive order. He calmed down after that, his rumbling belly's concerns momentarily taken care of.

Just goes to show you - hospital food can't be that bad.

Monday, April 17, 2006

DoRo

Day 17:

They say it's only a matter of time... While working in a hospital has its perks (e.g., the cafeteria food), it also has its downsides, including the very real possibility of eventually becoming sick yourself. One by one, team members are supposed to fall victim to one ailment or another while on DoRo. I suppose it's the consequence of spending so much time around folks who are ill. Dr. R had the sniffles in clinic on Friday, Rishi developed them over the weekend, and now, I too feel some nasal congestion coming on.

It's not too bad yet, but if I have the same bug that the two of them had, then my immune system's in for a workout in the days ahead. Ah well, my T cells needed some strength training anyway. Hand me a box of Kleenex and I'll be fine.

Sunday, April 16, 2006

DoRo

Day 16:

We switched our attending physician today; for the next two weeks, Dr. R (my regular docent) will be taking over for Dr. S. The whole service was new to him, so rounds took a little longer than normal, but for the most part, everything went smoothly. And I picked up a new vocabulary term today...

Gravity Rounds: the process of starting rounds on the fourth floor and moving downward (3rd Floor GMF, 2nd Floor ICU, 1st Floor Emergency Dept.).

Saturday, April 15, 2006

DoRo

Day 15:

Borrowed from Danielle:


A robotic floor buffer can easily get confused. We have this machine (actually, I think there are 2 or 3 of them) in the hospital and it is about the size of a file cabinet. Its name is MAX and it is a self-propelling automatic floor cleaner/buffer. It glides along the floor, cleaning and buffing I guess, and once it is finished with that hallway, it waits by the elevators until they open, it gets in, turns around, and rides the elevator up to the next floor to clean and buff some more. First off, it is the weirdest thing to watch... some file cabinet getting on to the elevator ahead of you. But secondly, it gets confused really easily! Like today, MAX tried to get off the elevator, but there were people standing in the way, so he just kept scooting back and forth, back and forth, like a wary kid on the highdive- “should I go now? No. Now? No. Now?” Then finally, one of the residents says “Hey, clear the way for MAX!” The sea of white coats part, and MAX scurries off around the corner. Freeky.

Got Birthday?

Holy cow, Dad's an udder year older (and that's no bull)! Even though we're deeply moooooved by your age, don't have a cow - we haven't put you out to pasture yet.

Happy Birthday!

Friday, April 14, 2006

DoRo

Day 14:

It's all about timing. This morning during the residents' chairman rounds, the topic du jour was what to do when a patient codes. The cardiologist giving the presentation asked the audience a number of questions, drew all sorts of crazy diagrams on the whiteboard, and lectured on everything from ventricular tachycardia to WPW. Just as he was drawing to a close, the hospital intercom crackled to life, and a voice declared over it urgently, "Code Blue, Oncology. We have a Code Blue, Oncology."

The code was cancelled about thirty seconds later, but still.... talk about perfect timing.

Thursday, April 13, 2006

DoRo

Day 13:

I helped a 64 year old woman dying from lung cancer open her juice box today. You wouldn't believe how rewarding that felt.

Wednesday, April 12, 2006

DoRo

Day 12:

Dr. S's Positive Rule of Lipstick: if your patient has put on lipstick, it means she's feeling better.

Dr. S's Negative Rule of Lipstick: if your patient has smeared lipstick all over her face and teeth, it means she's crazy.

Happy Birthday...

:-)

Tuesday, April 11, 2006

DoRo

Day 11:

Open your book. Read about a medical topic. Close your book. Repeat.

That is the essence of a beginning medical student's life. There's a lot to learn, and you're expected to learn it.

But flipping through the pages of a textbook can only take you so far. No matter how hard you study something, at the end of the day, all you've really done is memorize a list of words and facts. Necessary? Definitely. But these actions alone deny you the big picture.

In other words, sometimes you just have to see something to get it.

For me, this became apparent today when we rounded on a 22 year old patient with central diabetes insipidus (inability of the kidneys to conserve water, which leads to frequent urination and pronounced thirst). Before seeing him, I could have told you DI causes a person to pee a lot, but it wasn't until I glanced at his catheter collection bag that I truly was able to appreciate the significance of the underlying pathology.

In fact, when I first looked underneath the bed to find the collecting bag, I didn't even see it. My eyes scanned the customary location and passed right over the container which was full of urine two or three times before I realized I was staring right at it. The liquid inside was not just clear... it was crystal clear. Like, natural springs, purified bottled water clear. I really didn't believe it could be, according to my toddler vocabulary, "peepee." But it was.

And just like that, a medical topic previously known to me only through books became, pardon the pun, just a wee bit clearer.

Monday, April 10, 2006

DoRo

Day 10:

In case you were wondering where days 8 & 9 were, well, they were lost to the weekend. (And I didn't think anybody really wanted to hear a detailed recap of how I spent the bulk of my time... napping on the couch while listening to the Royals game on the radio.)

Today, I'd like to write about Dr. Z, our supervising resident. About 5'10" or so and probably in his late 20s, he carries an air of briskness about him - his face is always cleanly shaven (even post-call), the short blonde hair above his brow carefully spiked this-way-and-that, a colorful necktie cinched tightly beneath a well-starched collar. Though he is not stern by nature, the small round glasses perched ever so neatly on the tip of his nose afford him the look of a young schoolmaster, an image drawn to perfection when he glares over their shiny gold rims to scold a patient for smoking.

He walks to-and-from places with unbridled haste, and his buoyant step is only rivaled by the even greater urgency of his speech. As you might imagine, he's a fairly animated, high-energy sort of person and seems to have a bottomless well of enthusiasm. (My hypothesis: his pep either comes from years of practice as a cheerleader or he's simply taking uppers.)

For the two or three people who might get the reference - think Mr. O'Neil (the math teacher) as a doctor.

When first introduced, he described himself as "very anal" and to a certain extent, that's an accurate characterization. For example, he wasn't happy with how students were charting their notes in the computer (using our attending physician's previously laid out criteria), so he typed up a 4-page, single-spaced example (with explanations) for what he wanted to see in the future.

Hailing from Seattle, he went to school in Iowa and chose TMC-Children's Mercy as his first choice for a Med-Peds Residency. Although still needing to whip out his Palm from time-to-time to look up some details, by-and-large, he knows his stuff. He's sharp on the floor and confidently states what he wants to do.

He also appears eager to interact with his students. While joining us for the Mexican potluck we had last Friday, he joked and gossiped along with everyone else, seeming completely at ease among his younger colleagues. He even demonstrated his osteopathic skills (he's a D.O.) by performing several adjustments on Heather's back, per her request. Without hesitating, he expertly placed his hands alongside her spine, and with a swift jerk and a forceful push, he snapped her vertebrae into better alignment. The loud crack was audible across the room and over the hubbub of students' voices, and we all sort of collectively gasped at the noise. A moment of shock registered on Heather's face too before she gleefully exclaimed, "Hey, that feels pretty good! Do it again!"

So he did.

Friday, April 07, 2006

DoRo

Day 7:

I was debating in my head whether I wanted to write about the pneumothorax that occurred during placement of a central line or about the patient whose positive HIV results were accidentally disclosed to him (by a social worker/nurse?) before they should have been... and then I decided some days, it's best to just go to bed.

And that is where I shall be for the weekend, as I'm off for the next two days before beginning my 19-day marathon of saving lives, Gold 6 style.

Thursday, April 06, 2006

DoRo

Day 6:

The art of doctor-patient communication:

Dr. Z: Mr. 'Jones,' we need to draw your blood. Why don't you want to let us do that?

Mr. Jones: Doc, you can't squeeze blood from a turnip.

Dr. Z: That's right, turnips don't have blood. But you're a human being, so you do.

Wednesday, April 05, 2006

DoRo

Day 5:

Let's say you have a patient who needs a CT scan, but they're too big to fit into the machine. What do you do?

One option, I learned today, is to send them to use the machine at the zoo.

Tuesday, April 04, 2006

DoRo

Day 4:

Hands: it's surprising how much they can say about people. You meet a new patient, you shake his hand. After finishing your history and physical, you leave the room the same way. And in the time in between these two grasps, what a patient does with his or her hands (and what you do with your own) says a lot to the other person about who you are and what you're feeling and thinking.

From the moment your palms meet one another's, each person begins to size up the other; you get a sense of who exactly it is staring back at you. Is their skin hard and calloused from a long life of toil and labor or is it softer, daintier? Does the grip try to sap each ounce of strength from your own mitt, as though your hand was but a washcloth needing to be wrung out? Or is the grasp barely a flopping of the wrist? How long does it last? Two hands or one? Each question sheds some small ray of light on who we are and where we've been.

Some patients keep their extremities hidden under the safety of their bed sheets, staring up at you like children newly tucked in for the night. Others fall at the opposite extreme, gesturing excessively and emphatically in an effort to get some point across to you. "It hurts here, doc," wouldn't have quite the same effect if the statement was missing the accusatory aim of an index finger directed at the offensive body part.

You see the cut-up hands, dirt and grit beneath the fingertips, of the man brought in by the police, his big, worn paws now shackled to the bed railing. You see the purple nail polish, complete with white smiley faces, on the fingernails of the 29 year old woman with lupus, her skin ravaged by an autoimmune disease process that you can do little about.

You see the medical student's hands, filled with charts and order sheets, constantly sifting through the pages in a hurried search for some lab value hidden therein. You see the old woman - the one who just lost her son - wring her hands over and over and over again, left through right, right through left, again and again. And again. She does the same with her feet, a constant massage of one with the other, emotional energy leaving her grief-stricken body in whatever way it can.

You wish that she would stop this endless squeezing and straining, but then you notice you're running your fingers through one another in just the same pattern.

Lesson learned: we speak with our whole bodies, hands down.

Monday, April 03, 2006

DoRo

Day 3:


PEGGY HILL, KING OF THE HILL: "We should have given Bobby a pager. He might have become a drug dealer, but at least we would always know where he is."

Sunday, April 02, 2006

DoRo

Day 2:

The hospital is a big place. People are constantly coming and going. Some are there visiting sick relatives, others arriving for and leaving from doctors appointments, emergency room visits, trips to the pharmacy, and a whole range of other locales around the building. Their paths known only to themselves, each individual navigates the maze of corridors and elevator shafts on courses almost ant trail-like in nature, weaving routes to and from destinations unknown.

On a normal weekday, it is often difficult to even walk through some of the ground floor hallways because of the bustle of human beings there, some of whom move at a decidedly slower clip than most of us. But spending an entire Sunday in the hospital, the pace of things seemed, if not slower than normal, at least less "dense." People were not as easily lost in the crowd - faces (and the stories that went along with them) stood out to me.

One such example: the forty-something year old African American woman who rushed into the emergency room, hair frazzled into a sort of formless afro. She was wearing a gold-colored outfit, complete with matching flip-flops, and worry on her face. She asked about her daughter, and a nurse directed her to the sixth floor. Two hours later, while I stood in line for lunch at the cafeteria, this same woman caught my eye again, this time standing just a few feet to the side of the cash register. While my eyes were inexorably drawn towards her unique footwear, I couldn't help but overhear a bit of the conversation she was having on her cell phone. "Are you sitting down?" She repeated the question for the third time. "Okay. You sure? Well... Myra's losing her baby. Yeah, her baby. No, they don't know why. No, they can't do nothing for her..." The cashier called my order, and I lost track of this nameless woman and her family's story forever.

Holding my lunch in its tidy white Styrofoam container, I made my way to one of the elevators (on my own ant trail-like path) and found myself surprised to be the only one going up. I only managed one floor, however, before the lift (don't I sound British?) stopped and a Caucasian woman, maybe thirty or so and fairly pretty, got on and asked me to press the button for the 1st floor. She had shoulder-length brown hair, was wearing a black t-shirt and khakis, and obviously was lost, as we were already on the first floor. I asked if she meant the ground floor, she said "Yes, thank you," and I pressed the button for her before exiting on the 4th.

I hurriedly ate my lunch and rushed back to the E.R. to do another admission. On my way there, I found myself wandering through one of the medicine wards, where I was greeted with a warm, toothless smile and a "Howdy there!" from a gray-haired peach of a little old lady; she was one of the patients we had rounded on earlier in the day and was being ushered somewhere in her wheelchair. I returned the smile and added a slight head nod in her direction for added effect. Each of us continued on our separate ways.

Some time later, while sitting at a desk near the back of the E.R. writing a history and physical, a side door I hadn't even noticed beforehand opened and five security officers came walking through, each with a hand clasped tightly to an apparently newly apprehended criminal. Before I could even begin to feel surprised, they had disappeared around the corner, dragging along the pretty woman from the elevator, hands now locked firmly in handcuffs behind her back.

Lesson learned: you'd be surprised how interesting things can get when you pay even the slightest bit of attention.

Saturday, April 01, 2006

DoRo

Day 1:

My unit (Gold 6) began DoRo (pronounced "dough-row") today. For those of you unaware, DoRo is a two-month internal medicine block that each unit of medical students completes once per year. We have a total of nine students, derived equally from Year 4s, Year 5s, and Year 6s (I'm a Year 4, so this is my first DoRo).

Students are expected to check-up on patients in the hospital every morning, check any labs, write progress notes in patients' charts, and then do sit-down/walking rounds with the residents and attending physician each day. This normally takes most of the morning to accomplish; after that, students are expected to attend noon conference, where a presentation on a different medical topic occurs each weekday. The afternoon is left for new admits, discharges, checking up on any pending labs, as well as plenty of other paperwork and assorted odds and ends. Docents (our attending physicians) also use this time for didactic learning sessions. Students take night call with their residents, as well, helping to admit any new patients to the floor.

I followed my senior partner Mike around the hospital today as he helped "show me the ropes" of inpatient care. He'll be beginning a family practice residency at KU-Wichita after he graduates in two months and is a stand-up kind of fellow. We'll be on call together tomorrow night.

My goal is to post at least one short item about each day I'm on DoRo, but I won't make any promises to that effect. I'm motivated right now, but what can I say - I'm no Danielle. ;-)

Also, please be aware that patient names, other identifying information, etc. will be changed to ensure I'm in compliance with HIPAA (the Health Insurance Portability and Accountability Act). Just FYI.

So, without further ado, today's anecdote: we were rounding on a 58 year old white female with severe jaundice due to liver cirrhosis who had been having trouble breathing the day before. The patient was fairly lethargic and didn't answer questions very actively. After listening to her breath sounds, the attending physician, Dr. S., asked the resident, Dr. A., what the patient's oxygen saturation level was. Dr. A. answered back, "She's at 97." At this point, a bit of life must have come back into the patient, because her eyes flashed open and she forcefully belted out, "I'M NOT 97!!!"

Lesson learned: the sedating effects of disease and pain medication combined are nothing in the face of getting a woman's age wrong.