A Promising Start

It's later than I anticipated, so just a short post tonight.  Didn't end up doing much today...in typical Pitt Med fashion we were told to be at the hospital by 8:15 but the residents were told they were supposed to meet us at 9.  Oh well, gave us a chance to chat for a while.  By the time we met our team they had already admitted 3 of 4 patients for the day and the senior resident decided just to have my classmate and I more or less take it easy.  On the whole, though, it seems like the resident will be awesome and the attending appears to have an interest in teaching, so this should be ok.  The interns also seem great but they'll be switching on Wednesday, so we'll see what the new ones are like.  Anyhow, so far so good...we'll see what tomorrow brings.  Till next time, peace and God bless!

Internal Medicine, Part the Second

So after a month at the VA, now I start down the hill at Montefiore.  This promises to be a widely different experience for a number of reasons.  For example, in a couple hundred hours spent at the VA, my team admitted exactly one female patient, whom I did not take care of.  Thus, I haven't done a history and physical on an adult female since...jeez, since Ob-Gyn (aka the worst rotation in medical school). It'll be interesting to see how this goes.  Also, attitudes tend to be very different at Monty vs. the VA.  While there were a few vets who were tough to get along with, it really was only a few.  Most of them are wonderful for a medical student to work with because they let us try things (like the I&D -- that's "incision and drainage" for the non-medical folk in the audience -- I performed on a relatively large abscess the other day), they forgive mistakes, and they don't blame the doctors if they choose not to follow medical advice.  Oh, and they also tell really great stories sometimes.  We'll see, but I think those things are likely to be scarce in Monty.  On the other hand, I hear that my team is pretty good and my teaching attending is a doc I've known since the first day of medical school, so I'm cautiously optimistic.

Before embarking on the second half of this rotation, though, I need to write about one patient to close the door on the first part.  One guy I took care of was a spry old fellow in his early/mid 80s who'd been having left lower quadrant abdominal pain for a number of weeks.  He finally "made the mistake" (his words, although jokingly) of telling his wife who insisted that he come to the ED.  "I thought they'd give me some pills and send me home," he said.  Well, there aren't too many things that cause LLQ pain in an adult male, so the ED doc got a CT scan which showed hydronephrosis (a swollen, obstructed ureter).  The radiologist thought there might be a pyelonephritis (kidney infection), but the urologists disagreed.  The guy had blood in his urine, they said, and it looked to them like he had a hematoma in his kidney that was gumming up the works.  So he was admitted to our service for workup and monitoring until urology could stick a scope up there to see what was going on.  It didn't seem all that concerning.  If he had an infection, we'd hit him with ciprofloxacin (an antibiotic) until we could get cultures back; if he had a hematoma, urology would take care of it when they scoped him.  Except it didn't turn out that way.  Two days later my resident got a call from the urologist.  After she hung up, she turned to me.  "He has cancer.  Transitional cell carcinoma.  It was all over the pathology."  I asked if she wanted me to tell him.  Fortunately I had an awesome resident -- she shook her head.  "It's not your job.  If you want, we can go together."  So I went upstairs while she ran a quick errand, but Murphy's Law being what it is, I immediately ran into the veteran's wife.  Apparently she had already heard from the urologist, but all she had gotten was "It's cancer" before the uro guys were whisked away to their next case.  She was understandably distraught and had numerous questions that I tried to answer.  After a few minutes my resident found me, answered the rest of the wife's questions, and then gathered everyone in the patient's room to break the news to him.  He dealt with it surprisingly well, but it was still the first time I'd ever had to be part of a conversation to deliver such an unexpected and frightening diagnosis. I'm sure it won't be the last.  Fortunately, my resident provided me with a terrific example of how to go about delivering bad news that I'll hopefully be able to draw on in the future.  Also of note, we initially expected a pretty grim prognosis based on what urology had seen.  It looked like a high-grade cancer, and we feared that it would also be high-stage.  But when we did our staging, it didn't appear to have spread even to the local lymph nodes -- potentially a very good sign.  So we'll see what happens, but at least the outlook isn't as bleak as we originally thought.  Prayers for him would be very much appreciated.

Anyhow that's all for tonight.  If I'm not on long call tomorrow, I'll post about my first day at Monty in the evening.  Till then, peace and God bless!

American heroes

Yeesh. So much for New Year's resolutions. Internal medicine isn't particularly a good rotation for trying to post frequently. One quick thought before I head to bed, though...I'm working up at the VA this month and it has been a very interesting experience. The vets, as you might guess, are a pretty variable group...some are polite, some are not. Some are willing to work their tails off to get better, some are not. Some are the sweetest, most amazing people you could ever hope to meet and others are crusty, tough old codgers. But boy, what an honor it has been taking care of them. I've had multiple patients who served in World War II...can you even imagine? Guys who fought Rommel in North Africa, who served with Patton in Europe, participated in the invasion of Italy...just unbelievable. I've talked with countless Vietnam vets who were derided for serving their country...I hope I'm able to express to them, even a little bit, the enormous debt of gratitude we owe them for their service. I've met younger guys who fought in the Gulf War or in Afghanistan. What do you even say to them? How can you possibly thank them enough for what they've done, what they continue to do? I've met guys who have received multiple Purple Hearts, who have earned medals for their gallantry in combat. And yet almost to a man if you tell them that they're heroes they'll laugh at you. "I did my job," they say. It's never been more of an honor to do mine.

Anyway, that's all for tonight. Don't know when I'll next have time to post; hopefully before too long. Till then, peace and God bless!

Starting the new year

Gah, break was far too short...I felt like I barely got home before I had to turn around and come back to this place.  Not surprisingly, at the moment I pretty much hate Pittsburgh with every bone in my body, but I know that'll moderate pretty quickly.  Unless the Patriots and Steelers happen to meet in the AFC Championship game.  At that point all bets are off.

Anyway, I started internal medicine today...sounds like it's going to be a bit of a grind.  We work 6 days a week (only because we're required by law to have at least one day off) and since I'm up at the VA the burden both in terms of patient load and in terms of the complexity of the individual patients is very high.  On the one hand, that can mean some pretty late days; on the other, it means a lot of responsibility (which is great fun and great learning).  I'm cautiously optimistic about the next two months, and even though it's definitely NOT the population I want to work with long-term (the vets are generally a lot better than most adults, but even they just can't compare with the kids) I think there will be a lot of opportunities to learn and grow as a person and as a physician-to-be.

One of my New Year's resolutions is to post on here more regularly.  We'll see what happens.  With a bit of discipline I'll have more updates for you tomorrow.  Hope you all had a merry and blessed Christmas and a very happy New Year!  Till next time, peace and God bless!