Official last day of medicine

This morning we took the shelf exam—it was the most ridiculously hard test I have ever taken in my life. Only one person left before time was called. The pass percentage is determined by the national average—hopefully it will be really, really, low.

Tonight the Christian group is having its welcome barbecue for the new first years. I can remember that when I went to it as a first year I thought the third years were so unbelievably far ahead of me—now I am one, crazy. Afterwards my Bible study group will meet to discuss Daniel 8—I’m going to have to read up in Matthew Henry before I go.

I thought I didn’t have to go to orientation tomorrow until 8, but when I got home I had an email waiting for me that said my residents want to meet the students at 6. I guess it’s a good thing that they want to meet us beforehand, but I am not looking forward to getting up at 4:30. I called the senior resident to find out where to go after orientation, and after telling me just to page him tomorrow when we are done with orientation, he said something about the 2nd year residents being gone for the weekend, and how it was just him on 24 hour call. Before I hung up, he told me to enjoy the weekend (???). Are we seriously going to get the weekend off? That would be unbelievable, and totally not what I expected from surgery! Although really I would just like to get started right away, but I suppose I should enjoy little breaks in my schedule when I can because I sure can’t expect them to come regularly. Of course he might have meant something different, so I will go in expecting to work the weekend.

I also had an email informing third and fourth years that now that the new parking structure is built, we can park in the coveted lot right across from school (which I have craved and longed for for the last two years). The only problem is that the lot we used to park in, while being an absurdly long walk from the school, is actually considerably closer to the hospital. Nuisance. So the first and second years hate the lots they’re in, and want ours, and we kind of want theirs. Oh well, the price of status I suppose (it’s kind of funny, when I walk through school, or go to the library, I am now one of the most senior people—as soon as I enter the hospital I am lowest of the low—weird contrast).

Transition

Today was my last day at the VA. In a way I am ready to move on to something else, and in a way I am going to miss it. I got my last two patients on Sunday, one was an 87 year old man with abdominal pain. Turns out he has some small bowel obstruction, but no one knows why. The most common cause is a side effect of surgery, but he has never had abdominal surgery. We discharged him today and he will follow-up with GI as an outpatient. The other patient was a 75 year old man with COPD, coronary artery disease, and a newly diagnosed recurrence of squamous cell carcinoma in the right middle lobe of the lung. He was scheduled to have a triple bypass and tumor removal on Friday, but came in with a severe exacerbation of his COPD. We started him on steroids which helped him a lot, in fact he is being discharged today, but he won’t be able to have the surgery. My attending thinks he shouldn’t ever get the surgery since his risk is so high, and he could definitely be right.

This morning I rounded and wrote notes on my patients for the last time. I had evaluations with my attending, who said I did a good job and brought up the suggestion that my personality is probably more compatible with internal medicine than surgery, though he didn’t want to dissuade me from surgery if that is what I want to do. This isn’t really a surprise, I’ve known for a long time that most students interested in surgery are a lot more out-going than I am, and I definitely do not fit the stereotype of the typical surgeon. He could be right, maybe when I do the surgical rotation I won’t like it, but he could be wrong too—I’ve met easy-going surgeons. Should be interesting.

Tomorrow morning I have my shelf exam, then I have the afternoon off. The Christian Medical Association chapter at my school is having its welcome picnic for the new first years in the evening, and then my Bible study group will meet afterwards. Then Friday morning I will start surgery at my school’s main hospital. I’m hoping that I get at least one day off this weekend.

Field trip

Yesterday while I was on my break the other medical student and her intern discharged all my patients! The DVT patient was accepted to the domiciliary (Yes!!!), and he finally decided to give himself shots, so he was able to leave this morning. Since most of our patients are gone, we didn’t really have anything to do this morning, so our senior resident took us on a field trip. Basically we wandered around the hospital looking for interesting things to see. We stopped by physical therapy and watched one of our patients do leg raises, stopped by dialysis and watched patients hooked up to the dialysis machine, and lastly went by the pulmonary lab to watch a patient getting a pulmonary function test. After sitting around, eating lunch, and going by the VA store (a bizarre collection of sales tax-free candy, TVs, MP3 players, coffee makers, T-shirts, games, etc) for candy, our attending stopped by and lectured to us about mechanical ventilation which was interesting because I have never had a lecture on it before. Around 2:00, we got a patient from the ER who had been having abdominal pain since Monday, most likely he has an obstructed bowel. He will have to be seen by surgery, all we can really do right now is give him IV fluids since he hasn’t been eating or drinking much. He is a really nice 87 year old man which is a nice change from the unpleasant patients I’ve had recently.

Before I left, the attending dropped by again and asked if we wanted him to bring pizza on Sunday (call day). We all started to hem and haw and politely indicate that if he really wanted to we would love it, but the senior resident just came out with a loud “heck, yeah!” Unfortunately, I have to work on Sunday, but I am really excited to get tomorrow off—I will be able to sleep in as long as I want for the first time this month (and probably the last until my golden weekend [medspeak for Saturday + Sunday—how sad is that that we need a special term for full weekends] at the end of September). The only problem is that now I'm so used to having to get up I'll probably wake up at 6:00 and not be able to go back to sleep.

I have to take the shelf exam on Thursday, then I will start general surgery on Friday—I’m looking forward to it, but one of my friends was on the same rotation last month and he had to work 75 hours a week—I’m hoping that I will have slightly more lenient residents.

More call

Yesterday we were on call—we had lecture from 1-5 though, so I missed the first patient my intern got and only saw the second. He is an LPN at the VA hospital I am rotating through, and was admitted to the hospital for shortness of breath and bloody cough in June. He was treated with several antibiotics, and improved within a couple days although no one was sure exactly what was going on. They let him leave with two weeks worth of antibiotics. They had taken three sputum samples from him and were going to culture them for acid fast bacteria (includes species such as the tuberculosis bacterium), but these bacteria take months to grow out. Two days ago, one of the cultures came back positive, so they called him back in and he was put into isolation. My intern and I went to the ER to see him and had to gown up and put on special masks. He didn’t have any symptoms except for worsening shortness of breath. We admitted him, and this morning the pathologists said that he does not have tuberculosis so he was able to come off of isolation.

I didn’t see my other patient (DVT and blunt affect) this morning, but he is doing fine. He wouldn’t have to be in the hospital if he was willing to give himself two shots of anticoagulant for a couple days until his oral medication kicks in, but he is afraid of needles so wasn’t willing to do that (so instead he has a constant IV, and gets four blood draws a day). We would be able to just have him come into clinic for shots, but he is living out of his truck so we couldn’t safely discharge him. He has an appointment with the VA domiciliary, so hopefully he can go there and continue treatment.

The resident let me leave today after I had done everything necessary for my patients--unfortunately I have to go back for a case conference in a couple hours, but at least I had time to get my haircut and finally get a blended coffee (different coffee shop, but this time I specifically asked if they could make "ice-blended" coffee) which was very good. My barber told me that he had just been in the VA for 8 weeks for pancreatitis--fortunately he was very happy with the care he received since it would have been a little awkward for me if he wasn't.

Short call

Yesterday we were on short call (we take new patients until 4:00). I got two new patients. The first patient was a 49 year old man who literally has absolutely no facial expression whatsoever (“blunt affect” is what I wrote in my note) who came into the ER complaining of a swollen and painful right leg, the classic sign of deep venous thrombosis (blood clot in leg). Ultrasound confirmed this. He has also had pain and numbness in his feet for the last four years for which he takes ibuprofen. He hasn’t seen a doctor in eight years since he had his first DVT. Since he has had two DVTs, and his uncle had one, most likely he has some medical problem that makes his blood clot more easily, meaning that he will have to stay on warfarin (originally used as rat poison) for the rest of his life.

My other patient was a 75 year old man who was brought in from a nursing home due to fever and confusion. He has a recent history of pneumonia and has a urinary tract infection, so we have to put him on medications that will cover both infections. The nursing home gave him a lot of IV fluids since he hadn’t been eating or drinking much, which caused an exacerbation of his heart failure, so we also had to start him on diuretics to get rid of excess fluid. Now we just have to watch to make sure he doesn’t go in the opposite direction. When I went to see him he was very lethargic and couldn’t do more than open his eyes for a couple of seconds before going back to sleep, so I couldn’t get a history from him, meaning that I had to search through months worth of notes on the computer. The physical was pretty poor as well, I couldn’t hear his heart or lungs well since he was snoring so loudly. This morning he was a little more alert though, so I was able to hear them all right. Hopefully he will get even more alert so we can start feeding him and giving him his oral medications (he’s on exactly thirty medications altogether) again. Reading through his records he seems like a character—often yells at the staff when they tell him he shouldn’t smoke/go outside in 100 degree weather/etc, and there was apparently a “hit and run” incident in which he (I hope) accidentally ran into another nursing home resident with his motorized scooter and just kept on going. For some reason I keep getting patients who are while not actually mean or rude, do not exactly add sunshine to my day either.

Nothin' to do

Today I was expecting to be really busy because my team was on call. Turned out not to be the case. I went in at 7:00 although I only had one patient to round on and our attending wasn’t going to come in until the afternoon to see our new patients. I went to see him (the grouchy guy who had the G tube put in yesterday), he was doing fine so it took about 5 minutes to write a note on him. I talked to his night nurse for a minute, then later his day nurse called me with a question about his medications and let me know that she was going to write up the night nurse because apparently she didn’t give him his antibiotics and let him go without fluids all night. Then I heard a really sad story from the other medical student about one of her patients—essentially his wife was coming in to tell him she was leaving him, then taking off on a plane to go to another state. In addition, the man had called the police last night to ask them to arrest his daughter because she didn’t bring him his clothes in the hospital. He also called her and threatened to call the fire department and have them break down her door. He also happens to be for all intents and purposes disabled, and cannot go home (in another state, not the same one his wife flew to) by himself. I read the nurse’s note giving all the details, it was about 20x longer than any nurse’s note I have ever read. Very, very sad; and very, very bizarre (actually there are some even more bizarre details that I am leaving out). It’s hard to believe that things like this happen in real life.

Around 10:00 we went to see the autopsy on my patient who died yesterday. It wasn’t really as hard to see as one might expect because the body is so completely dead. It’s distasteful, and I definitely would not want to see an autopsy every day, but I didn’t really have any particularly strong emotions watching it—the patient was gone, it was just the shell that remained and we could see what caused the patient to leave by examining the shell. The findings were pretty much what we expected, although they didn’t prove that the patient died of TRALI. The blood bank is going to have to examine the blood that he got, and it could take weeks to hear back from them. Further research: about 15 people a year die from TRALI, it occurs in about 1/5000 blood transfusions, and about 5% of those people die.

After that, we still weren’t getting any new patients, and we had taken care of our old ones, so we sat around eating donuts for a while, read up on medical stuff, had lunch, then decided to check out the new resident’s lounge. No one knew where it was because no one’s ever had time to go there, so we went to the right floor and wandered around looking for doors with code panels. We tried a couple, then found the right one. Hoping (but not expecting, this being the VA) for a nicely furnished comfortable room with a big screen TV, soda machine, cappucino machine, video games, etc, we found more what we expected: a barren room with old chairs, a small TV from the early ‘90s, and a couple year old trashy celebrity magazines. We watched some movie on TV about a surfer who starts figure skating for a couple of hours while the resident, intern, and other student (I ended up being the only male there) read the magazines and gossiped about all these different celebrities and movies I have never heard of. It was very weird, no one hearing them talk would guess that their IQ and education level puts them in the top 1% of the nation.
At last, we got a patient. I interviewed him and did a physical exam, then wrote it up only to find that we were admitting him to Heme/Onc meaning he won’t be under our care anymore starting tomorrow. Leaving me with one patient who’s going to extended care on Monday. At least I got to see a patient though, the other student never did because no more patients were admitted—so basically we kind of wasted a day. While I was writing up my H&P the other student went out to get pick up dinner for everyone. We finished off the day with a blood draw on a really nice lady with cancer—thankfully, I got blood on the first try so we didn’t have to torment her too much. Then we got to go home a little after 7:00 instead of having to stay til 10:00. Boy does time go more slowly when one has nothing worthwhile to do. I guess we should really enjoy days like this when we can.

Update

Yesterday was short call. I did an H&P on a new patient who came into the ER because he claimed to have taken four times his usual insulin dose because he was frustrated by having high blood sugars for the last week. He said that he felt confused and lightheaded. Only problem is that his blood sugar in the ER was 397 (normal 80-120), making it highly unlikely that he had actually taken insulin. He had an extensive psychiatric history of depression, borderline personality disorder, alcohol abuse, cocaine abuse, and participated in a daily program through the VA. On Monday, he claimed that the program kicked him out after two years, and he was really angry at first but now he “just didn’t care”. We consulted with psych, and what actually happened was that he skipped the participation part of the program and just showed up for lunch, so they asked him to leave for the day, but he could come back the next day. So, the most likely explanation is that he wanted attention so pretended to have overdosed himself. He’s medically stable though, so we were able to discharge him today.

My UTI patient had his Gtube put in today instead of having to wait for Monday, so we should be able to discharge him to extended care after the weekend. Oddly enough he’s been quite a bit more cooperative over the last couple of days.

My nice patient died. It was a really sad situation—yesterday he improved considerably, and we were getting ready to bring him back to the regular floor from the ICU—his family saw how much he improved and thought that he had gotten completely better, they were laughing and called us “miracle workers”, unfortunately they didn’t know how inaccurate that title is. Most likely he had a bad reaction to the plasma transfusion called TRALI that occurs in 1/5000 transfusions. I came in late to the hospital because we had lecture this morning, I looked in the computer to see his labs, and then went down to the ICU thinking he would be awake and even better than he was yesterday. When I got down, my resident and attending were writing the death note. Later in the day, we all went down to see his son and daughter-in-law who were in the room with the body. They were both crying and making comments about how they wished they could have been there, but they thought he was getting better. They immediately agreed to an autopsy, because they thought that he would want one so we could learn if there was some way we could avoid outcomes like this in the future and maybe save another patient’s life. The autopsy will be tomorrow, and my attending asked the pathologist if we could watch it. I’m not looking forward to it, but I feel like I should see the whole thing through. I never talked to him about his religion, but I saw on his chart yesterday that he had listed himself as Baptist—I hope that is true.

Attending switch

Yesterday my team was on call. I spent a long time getting and writing up an H&P on a new patient, then he was transferred to Heme/Onc (cancer doctors) so my entire H&P was basically a total waste and now I don't have a new patient. Oh well. He was kind of interesting, he was an elderly man with stomach cancer that had spread to his liver. He was sent to the ER by his primary care doctor because he had a temperature of 103 degrees. He didn't feel sick and had no symptoms other than a little abdominal pain he's had for months. That morning he felt cold, so he got into his car and turned the heat up full blast then fell asleep for two hours (it was over 80 degrees outside yesterday), woke up, and could barely walk. Then he drove to his doctor's appointment.

Today we got a new attending so things were a bit disorganized as he tried to catch up on all of our patients. He does things a bit differently than our old attending which might be hard to get used to, but it should be a good learning experience to see different styles. He wanted to round this morning at seven, so I had to get there at six--I was not a happy camper this morning, especially since I didn't leave the hospital until after nine last night. Tomorrow I don't have to be there til seven though, so I should be able to manage that.

My patient with the UTI (whom I mentally refer to as "Oscar" [think Sesame Street]) should have had a tube put into his stomach for feeding purposes a long time ago since he can barely swallow and probably has pneumonia from inhaling food, but along with breathing treatments and heparin shots has refused it. Problem: he needs assisted living and they will not take him without a G tube. My intern basically told him point blank that he will either get the G tube and go to assisted living, or slowly starve to death in the hospital, so he finally agreed. I had to convince him this morning to let the nurse put in an NG tube (goes through nose into stomach) until the radiologists put the G tube in. We'll see how long he keeps it in--I'm sure I'll hear about it tomorrow morning.

My other patient, the one with ascites and pleural effusion, is not doing well at all. It looks like he has developed severe pneumonia, he had to be moved to the ICU this afternoon as his oxygen saturation went down to 70% (normal is above 97%). The resident doesn't think he has much longer.

On a lighter note, I have been looking forward for days to getting an ice-blended coffee since I have not had one for months and I seriously need sugar and caffeine these days. I had it all planned out how I would try a coffee shop I have never been to before right after lecture today, and have dreamed about the creamy, sweet, cold taste all week. So today I went there, but couldn't see anything like what I wanted (frappucino equivalent) on the menu, so I asked the guy behind the counter if they had blended coffees. When he seemed really uncertain, and mentioned he had never heard of a frappucino I should probably have seen a red flag. He pulled out the list of ingredients for their different coffees, I saw a caramel one, asked if he could make it blended, he said yes, so I said I'll have that. He proceeded to make a regular hot coffee and gave it to me. There was a line forming behind me, and he seemed really new and not very self-confident so I didn't have the heart to tell him that it was the opposite of what I wanted (this was my good deed for the month). It tasted pretty bad for a hot coffee too. I almost drove to another coffee shop I had seen, but decided that paying eight dollars in one day for one coffee was not a wise use of my money. Maybe tomorrow. Or Friday. Lesson: Don't count on worldly material things.

Blood II

This week started off a bit easier than last week, I got to go home at 2:30. We haven’t gotten any new patients since Friday (but we’re on call again tomorrow), so we just had to take care of the ones we’ve had for a couple days. The man with the UTI has become a real grouch (well, when I say “become” I actually mean “become more of a”--every morning I've gone to ask how he's feeling he looks at me like I'm an idiot and says "well I'm in the hospital, you should tell me"), he won’t let respiratory therapy give him breathing treatments and he won’t let the nurses give him his heparin shots that he needs so he won’t get clots in his legs from lying in bed all day. He also refuses to take oral antibiotics so we have to keep him on IV. He’s stable though, so as soon as we can we’re sending him off to transitional care.

The pleasant patient with the pleural effusion/ascites shocked everyone today by coming back positive for hepatitis C—we had just ordered the test as a formality since he doesn’t have any risk factors for it other than several blood transfusions decades ago. Unfortunately, this makes the likelihood of his having cancer even higher. He was supposed to get an ultrasound guided paracentesis today, but his liver function has decreased his clotting ability so the radiologist won’t do the procedure. We’re giving him vitamin K shots to get his clotting back to the point where he can have the procedure. He’s also getting a CT scan which should show any tumors (I think).

The man with the bacteria in his blood has to have blood drawn every day until his cultures come back negative, so I jumped at the chance to draw it today. My intern said I could do it unsupervised now that I’ve done it a couple times. I got all the stuff, got the front desk to print out the labels, and set up the stuff in his room. I found a vein in his left arm, went for it, got blood on the first try, and with needle in my right hand and syringe in my left in one smooth, intricate motion that was beautiful to behold got 20cc of the precious fluid in under a minute. Then I went to the right arm… Poor Mr. “G”. I tried twice to get the needle into a fairly prominent vein with no success (well, actually he did bleed, but unfortunately not into the needle). Crumpled with failure, and shoulders slumped under the blow of defeat I went to get my resident. But then she couldn’t do it either, so while I felt really bad for Mr. G (who remained placid through the entire ordeal), I felt a lot better about my own (lack of) skills. We had to get the IV team (nurses who spend their entire day doing nothing but sticking people) to come, and it even took them a couple tries although they eventually got 12cc which was just barely what we needed (to clarify this story, for blood cultures one must get blood from two different sites). They left him with a nice egg-shaped mass on his arm.

Blood

Today ends my 65 hour work week. Yesterday my team was on call and I did three H&Ps, which I was really happy about since I badly need the practice. My first patient was a man who came to the ER from the nursing home because he had a temperature of 103 degrees. It was 97 degrees when he arrived at the ER, I haven’t figured that one out yet, but his white blood cell (cells that fight off infection) was hugely elevated. He had had a non-productive cough since May, and a catheter changed on the 10th, so pneumonia or a urinary tract infection were both strong possibilities. The urinalysis ended up showing that he had a UTI, but the chest xray was also questionable so he may have both.

The second patient was a very nice but slightly demented man who came in because a blood culture that his doctor did came back positive for Enterococcus fecalis infection. Looking through his old records, he has been hospitalized several times for the same infection, treated with a plethora of antibiotics, then the infection comes back. It was thought that he had endocarditis, especially since he has an artificial valve, but several ultrasounds have come back negative. We started him on vancomycin and gentamycin I believe, and will have to draw blood for blood cultures every day until they come back negative. I drew blood for the cultures for the first time today (I’ve been wanting to draw blood for years!) and managed to get his vein on the first shot. It was really fun.

My third patient is a really nice man who hates to take medications (he’s on two as opposed to the 20+ that every other veteran I’ve seen is on) but always does what doctors tell him. He came into the ER because he has had severe pain over his left ribs. The ER ruled out heart attack and pulmonary embolism with EKG, cardiac enzymes, and CT scan, making the pain most likely musculoskeletal. The CT scan showed liquid in the base of his left lung, and I could tell that breath sounds were decreased there and it was dull to percussion. I came up with a differential diagnosis for pleural effusion, but then it was noted that the CT scan was suggestive of his having cirrhosis of the liver and moderate ascites (liquid in his abdomen) which changed things. The intern tried to do a paracentesis (sticking a needle into the abdomen to get a sample of the fluid), but could not get any out. The radiologists will try later today using ultrasound to guide them. The patient is hilarious, by far the nicest I’ve had yet. He repeated about 20 times that whatever we needed to do was fine by him. When I saw him this morning he had refused pain medications and you could tell he was miserable even though he wouldn’t admit it. Later, the resident told him he had to take the pill, so he did (because he always does what the doctor tells him to), and was raving the rest of the day about how much better he felt, and how the pain was gone. He repeated the story several times in his Southern drawl making him the favorite patient of the whole team. Unfortunately, the most likely cause of his ascites is liver cancer. I don’t go back to the hospital until Monday, so I won’t find out til then what he has.

On call, post call

I have worked 25 hours in the last two days. Yesterday my team was on call, I did an H&P on a 61 year old man who came into the ER because his ankle hurt from dropping something on it on Friday. We admitted him because his blood pressure was about 80/50 and a blood glucose of 346 (normal is about 80-120). He has been dizzy for several months, with significant worsening over the last three days. He had a heart attack in 2000 for which he needed sextuple-bypass surgery (he needs 1-2 more bypasses), he has COPD, horribly controlled diabetes, atrial fibrillation, hypertension, hyperlipidemia, kidney failure (dramatically worsening in the last month), and a couple other things I can’t remember right now. We put the ankle pain at the bottom of the priority list.

I interviewed another patient who has pseudoseizures which I had never heard of before. Apparently (I can’t find much info on them) they are psychologically induced, but the patient is not doing them intentionally. I watched him have several, and they looked like real seizures, but he does not lose consciousness, can remember them, never bites his tongue or hurts himself, and he can talk during them. There isn’t really anything we can do for him, he was discharged this afternoon.

My endocarditis patient with worsening acute renal failure was all set to go to a transitional care unit. I talked to the social worker this morning, and she got the transitional care people to put him on the waiting list for a bed. Then he started coughing up blood this afternoon. It is most likely due to little bits of the infection in his heart breaking off and traveling to his lungs. The intern wasn't happy, the resident will be even less so when she comes in tomorrow.

Today, being a post-call day, was long because one of the interns, the resident, and the senior medical student had to leave at noon since they were at the hospital all of last night. The other intern and I had to make sure that all their patients had their labs and consults in. Tomorrow is short-call for my team, meaning that we admit patients in the morning, so hopefully I will get to do another H&P, because I really need the practice.

Livin' la VA loca (that was really corny, sorry)

It feels like it’s been a lot longer than three days since I last updated my blog. I am really enjoying my time at the VA now that I’ve gotten past the first two days—I always get exhausted the first two days I start anything, even something I really like, then I am fine with it. I don’t even mind getting up at 5:30 am anymore. I am still trying to figure out how I am going to fit the studying I need to do into my schedule.

I don’t remember particularly what I did Wednesday, but yesterday was my team’s on-call day. I was hoping to get a new patient, but when there hadn’t been an admit by 7:45, the resident told me to go home since there wouldn’t be time to do a full history and physical on a patient even if one came in (students are supposed to leave by ten on call days). I was a bit disappointed, since I have only done one H&P and I badly need more practice. Oh well, there’s always next week. My intern was at the hospital from 7:00am yesterday til noon today, he admitted 6 patients and covered all the patients of the other three medical teams.

This morning students had an hour lecture, so we weren’t able to pre-round on our patients. I only had one anyway though, the endocarditis patient has had a steadily rising creatinine level, showing that he is going into kidney failure. The nephrologists aren’t sure what is causing it, it may have something to do with an immune response to the infections.

Although I didn’t admit him, I am now also going to cover a chronic alcoholic who came in last night with low blood sodium and high blood sugar. He is really a mess, he has sores from lying in his own excrement for several days. Tonight I need to read about alcoholism so I will know what to do when I round on him tomorrow. His phosphate levels were also low, so the intern and I had to research (mostly by calling the pharmacy—very helpful people, pharmacists) how to treat it, then we got the order in. I had to talk to the social worker about him so that once he’s stabilized he’ll have somewhere to go (my intern, who was on call last night, left at noon so I had to make sure all his patients got the follow-ups and labs they needed, the other intern had to oversee her own patients, my intern’s patients, and the sub-intern’s patients, so I covered as much as I could of my intern’s patients, and the other student covered as much as she could of the sub-intern’s patients to help out the other intern), that was kind of weird but very neat to actually have a little bit of authority, it was like he was really my patient. Then, I had to talk to residents from consult services about my other patients which was neat since they talked to me like I was in charge of the patients (which was fine as long as the other intern was also listening, I am definitely not capable of handling that by myself). After we got all the labs and orders in, I reported to the intern on call tonight by telling him what each patient would need. I have no idea how he is going to be able to keep 20+ patients he’s never spoken to before straight, that is really amazing. Now to study…

First day of VA

Today was my first day at the VA—it went very well. Everyone on my team (an attending, a senior resident, two interns, a fourth year student, and another third year student) is very nice and I think it will be a fun rotation. I have two patients whom I will follow til they are discharged. One is a man with endocarditis (bacteria growing on one of his heart valves). Once the infection has cleared, he will have to be given IV antibiotics for more than a month. The problem is that he is a drug abuser, and therefore cannot be released to his home if he has a direct route into his bloodstream. He will have to go to a transitional home until the line can be taken out.

The other patient was admitted this afternoon, and I will have to present him to the attending tomorrow. He has a history of heart failure which started worsening two days ago when he stopped taking his diuretic. His legs were huge, and had severe pitting edema (when I pushed my finger on his leg and then removed my finger it left a dent in his leg). Treatment will consist of restarting him on the diuretic, hopefully he can go home in another day or so.

I forgot to mention yesterday my best case of the day: earwax removal. The doctor had to irrigate the man’s ear until nasty chunks of wax started coming out. Then, he accidentally splashed himself, so he had me finish the irrigation while he cleaned himself up.

First day at VA

Today was my first day at the VA—it went very well. Everyone on my team (an attending, a senior resident, two interns, a fourth year student, and another third year student) is very nice and I think it will be a fun rotation. I have two patients whom I will follow til they are discharged. One is a man with endocarditis (bacteria growing on one of his heart valves). Once the infection has cleared, he will have to be given IV antibiotics for more than a month. The problem is that he is a drug abuser, and therefore cannot be released to his home if he has a direct route into his bloodstream. He will have to go to a transitional home until the line can be taken out.

The other patient was admitted this afternoon, and I will have to present him to the attending tomorrow. He has a history of heart failure which started worsening two days ago when he stopped taking his diuretic. His legs were huge, and had severe pitting edema (when I pushed my finger on his leg and then removed my finger it left a dent in his leg). Treatment will consist of restarting him on the diuretic, hopefully he can go home in another day or so.

I forgot to mention yesterday my best case of the day: earwax removal. The doctor had to irrigate the man’s ear until nasty chunks of wax started coming out. Then, he accidentally splashed himself, so he had me finish the irrigation while he cleaned himself up.