Snow = no test

After all the stressing and cramming for my exam on last friday it turned out that we had a huge snowstorm and the exam was cancelled. Some of my classmates were bummed because this means that they have to study over the break and can't quite relax as well. I am fine with it. It just means I have more time to prepare. These exams cover so much material that there is no way you could ever be fully prepared. It has been said that even physicians who have been practicing for years will still miss a handful of the questions on these national shelf exams. 

Now I have 2 weeks to relax and enjoy the holidays and do some studying. The exam will be scheduled sometime in the beginning of January. I start pediatrics on January 5th. I will be on that rotation for 6 weeks. I am not super excited about dealing with the crazy parents demanding antibiotics and other treatments that they saw on TV or heard about from a neighbor. The thing that can be difficult about kids in suburban populations is that the parents are so emotionally involved that it can be difficult to have a rational conversation with some of them. However my rotation is going to be in the city and will be inpatient so I will be dealing with a poorer population with some really sick kids. This should be very educational. I have heard that it is a good rotation. I am not sure how much if any, outpatient clinic there will be on this rotation. 

Internal Medicine Exam

My last day of Internal Medicine was Wednesday and since then I have been studying for my shelf exam which is tomorrow. This is the exam that every medical student in the country takes after their internal medicine rotation. I think that the national mean is a 74%. In order to get an A in the rotation you need to beat the national mean by 0.25 standard deviation above the mean. In addition to getting above the mean you also have to get an A on your clinical rotation. The clinical grade comes from ratings from the doctors you work with during the rotation.  We shall see how it goes. So far I have been able to beat the mean on the exams from my previous rotations. Hopefully I can keep that trend going. 

I start pediatrics in January.

All Star Wrestling

Last night I was on call and the craziest thing happened. I got a call from an attending physician in the community and he said that one of his patients with a history of cardiac problems was being admitted for an unexplained hemoglobin. He asked my team to take care of the patient. The patient was a 79 year old male that had a history of 2 open heart surgeries (CABG = bypass). He also had a polyp removed from his colon in 2003. Whenever any male over the age of 60 has a declining hemoglobin we worry about an internal bleed. The bleed usually is coming from the colon and often it turns out to be colon cancer. 

The patient's entire family (1 son, 4 daughters and his wife) were all there. It was like a family reunion. It was way past visiting hours but no one mentioned that to the family. I came into introduce myself and examine the patient at about 10:30 pm. It was like a hornets nest with all the family asking me questions like; what is wrong with our dad? are you going to run this test or that test? why aren't you doing this or that? Everyone has suddenly become an expert and wants to question everything. I spent extra time explaining everything to the family. Once you get beyond the surface level of knowledge the family members quickly became lost and realized we knew what we were doing. 

As I was examining the patient and explaining things to the family I realized that the patient that was sharing the room on the other side of the curtain was becoming agitated. He was not my patient. He looked like he was in his mid thirties and had a rough go at life. I looked like he may be detoxing. As the examination went on he became more distressed and finally while I was listening to my patients heart I was jumped on and punched by the neighboring patient. He had stood up on his bed and lunged / jumped through the curtain and on to me. He was on the other side of the curtain so I did not see this coming. He knocked me onto my patient and I quickly stood up and turned around to see what was going on. The neighboring patient was yelling and swearing and saying he was going to kill me. He was obviously hallucinating and in the middle of severe alcohol withdraw. I tried to calm the patient down and signaled a nurse to get security. My patient's son wanted to fight the alcoholic patient and I had to convince him to back down. The daughter's and wife were hysterical and 2 of them were crying while my patient was yelling at them to calm down. 

I had the nurse call to try and reach the patient's attending who is infamous for not returning pages and not being available. Security arrived and began to wrestle with the patient and try to restrain him. The patient was tough and put up quite a fight. In the mean time the attending never called back and the nurses were panicking because they needed to sedate the patient but without doctor's orders they were not allowed to administer any medications. This wrestling match had been going on for over 30 minutes. We moved my patient and his family to a different room. The nurses came up to me and asked if I would order a medication for sedation for this alcoholic patient. Given the circumstances I said I would help out and I ordered some ativan and the nurses were able to sedate the patient. Before putting the order in I ran it by my senior just to cover all the bases and she was fine with it and thought I made a good choice. 

I finished up with my patient by doing a rectal and finding blood in the rectal vault and then transfusing 2 units of blood as his hemoglobin was dangerously low. I went to my call room and laid down in bed and just started laughing out loud. "What a crazy night!" I said to myself and then realized how happy I was and how much I loved this job. 

Code Blue

"Attention! Attention! Code Blue in the holding area Repeat ......."  I was quietly writing some notes on one of my patients at 2:30 in the afternoon. I had a post prandial urge to snooze and could envision the bed in the call room. It would be so nice to just lay down for 10 minutes but I knew that was not going to happen. I quickly got up and made my way down to the holding room which happened to be only just down the hall from where I was. Given my proximity I was the first "doctor" on the scene. "Oh great! I thought, it is just me, what am I going to do?" Immediately I started recalling all of the life saving procedures that I had been taught and read over about 1000 times. I ran up to the side of the bed where all the nurses had gathered and saw a lifeless shell of a body laying in the bed. It was a 95 year old women with aspiration pneumonia who had stopped breathing and had no pulse. 

The nurses moved out of the way and I yelled for a crash cart. I immediately listened to her chest and could not detect a heart beat and there was no detectable pulse. I check her airway and could find no obstruction. I yelled out for her code status and I was told she was full code which meant full effort resuscitation  was in order. I started doing chest compression and yelled out for an ambu bag. One of the nurses started bagging the patient. At this point all the residents started to descend on the scene, thankfully. I moved out of the way so that they could take over. We usually switch off doing chest compressions to avoid fatigue.

We put a monitor on the patient and confirmed that she was in asystole which is one stop before complete flatline. We kept doing chest compressions and started to push various medications. After 15 minutes of running the code we were able to bring her back. We had to intubate her and have the ventilator breath for her. We stabilized her and transfered her down to the ICU. The patient has no family that claims her, no next of kin, no friends, nothing. It was a sad situation. She never fully regained consciousness and later that afternoon in the ICU she died. 

What a day! This was just one of my patients from the day. There is never a dull moment and you never know what is lurking around the next corner.

Broken Freezer

I was on call all night last night and I had several cool patients admitted to my service. There were 3 guys all between 19 and 25 years old who work for a manual labor pool. They report each day to work and take whatever assignments they get and go work for the day. When I was in high school my parents made me work for a labor pool so I am familiar with the miserable nature of this job. These 3 strangers were chosen to work for a large meat warehouse that had a giant walk in freezer break and had tons of spoiled meat to get rid of, I told you these jobs suck. Maybe this is why I stayed in school but I would never admit this because that would only give my parents the sweet feeling of success and I am not ready to relinquish my angst yet. 

These guys reported to the job and worked all day long hauling out thawed, spoiling carcasses out to a dumpster. They had to mop up the blood and clean the freezer inside and out. Several times during the day they all complained of headaches and fatigue and some nausea but they did not think too much of the symptoms, being young macho men they figured it was nothing and continued to work through the symptoms. They finished their job and collected their pay and left to go cash their checks. My patient, a 19 year old male, made it home and had a near syncopal event and fell to the floor. His mother knew something was wrong and forced him to go to the hospital. He worked his way through the ER with some vague symptoms but was ultimately admitted due to his decreased cognitive function. He was having difficulty remembering things and at one point forgot where he was. He was worked up for the flu and some of the more common culprits and then admitted to my service. 

Once I got my hands on him and spoke with his mother in great detail it was not long before we had tied his onset of symptoms to his work activities in the freezer. I spoke with some of my senior residents and we decided to run a carbon monoxide level on him. A normal city/suburban dwelling non-smoker will have an average carbon monoxide level of 2-3%. A person with a chronic lung disease will have a level of 5-9% or so and a smoker will have a level of 10-15%. An average non-smoker will start having symptoms at 15% and get sick at much higher than that and if exposure continues the person can progress to expiration. My patient's carbon monoxide levels came back at 29%. He was lucky that he did not die.  We had been treating him with oxygen therapy and when we confirmed the carbon monoxide poisoning we put him in the hyperbaric treatment that our facility is fortunate enough to have and his symptoms resolved. 

We figured that the motor that was part of the broken freezer was leaking carbon monoxide into the freezer which was a closed space and the workers were exposed to toxic levels. The funny thing is that our facility is one of the few in the area to have a hyperbaric chamber and the other 2 workers had similar symptoms that had progressed and they each separately went to separate hospitals where it was determined that they had carbon monoxide poisoning. They were transfered to our facility to have the hyperbaric treatment. Today it was like a labor pool party as the 3 reunited and complained about their horrible job. We all had some good laughs when I told them some of my war stories from my days on the labor pool circuit. They did not believe that I had worked at a labor pool but when I started in on some of my experiences they soon realized I was the real deal. You can't make this stuff up. 

The good news is that all 3 patients were cured and discharged for home and should do ok but may have some short term cognitive difficulties with memory etc. They will return to base line and it will be nothing more than a funny story. They were fortunate. I have to go now, my car is running in the garage, I am warming it up so I can take a nap in it.....

New residents and my last 2 weeks

Today I got a whole new group of residents and started my last 2 weeks of my internal medicine rotations. It is really more a week and a half because my last day of rotations is next on Wednesday 12/17 and then I have a day to study and my national shelf exam for internal medicine will be on Friday 12/19. Then I will be off for a couple of weeks before I start pediatrics at a Chicago hospital. 

My senior resident for this next couple of weeks seems to be a little hard core. She is going to be the chief resident next year and has made herself a name amongst the other residents by being rigid. How does this affect me? If we have a slow afternoon or some time available a more relaxed senior resident may say "why don't you call it a day and go home early" and a rigid senior would say "why don't you stay late and write up a report on COPD and present it tomorrow during rounds" This is why students have such variable experiences on their rotations. You could rotate at the same hospital and have 2 different experiences based on who your senior resident is. I have had fairly decent senior residents and great interns up to this point on this rotation. We will have to see how this last couple of weeks go. 

Tonight I have to prepare a presentation  on hypertension and the criteria for diagnosis and treatment. I will give the presentation tomorrow. It should not be too difficult as the subject is not that complex and I have studied and had so many patients that I have treated with hypertension that I should be able to do the presentation without any extra reading. 

What is that in your urine?

I have a patient right now who is an 87 year old man who has a history of prostate cancer for which he had a TURP = transurethral resection of the prostate. He has a bunch of other illnesses as well. He presented to the ER with abdominal pain and suprapubic pain a couple of days ago. I have been working him up to figure out why he has had this abdominal pain. He is extremely sick and probably not going to make it much longer. We did a bunch of imaging studies looking for a small bowel obstruction or diverticulitis or a colon caner, etc. but nothing showed up in any of the studies. 

The other day I put a catheter in hi so that I could monitor his urine output and watch his kidney function. He is incontinent so I figured a catheter would be win win. Yesterday I noticed that his urine was rather clumpy and dark in color and looked like it had something floating in it. I sent the urine out for analysis and order some imaging of his abdomen and pelvis. It turns out the clumpiness in his urine is fecal matter and the imaging showed a rectovessicular fistula had formed. Basically a hole in his rectum and his bladder formed and a connection between the 2 structures formed. He now passes crap from his rectum into his bladder and out his urethra. I have consulted urology to see if they want to fix it or maybe colorectal surgery will fix it. We have to take into consideration his age and condition. If we determine he is hospice which means we think he has less than 6 month left of life the we will not do the procedure and just try to keep him comfortable. What a crappy situation. It was interesting trying to explain this to his adult children and answer their questions; "you mean there is sh*&# coming out of my dad's d%#%?!!