He finally ended up in the ICU today. According to the nurse, the CCM doc took one look at him and started the transfer process. Last I heard they were talking about intubating him. This one's gonna sting for a while. We had fixed him. He was better. He was going home. And then this, on our watch, while we were taking care of him. Yeah, I'm taking it personally. Yeah, I feel like I failed. It's going to be a while before I stop berating myself about the things I should have done differently. Damn it, he was BETTER! This didn't have to happen! There has to have been some way we could have stopped it...there has to be...
*Sigh* sorry, it's been a rough couple of days. Prayers for this patient and his family would really be appreciated. At this point it would be a miracle for him to leave the hospital in the same condition as when he arrived...anyhow, till next time, peace and God bless...
Thursday, February 17, 2011
Wednesday, February 16, 2011
Condition C
Long day = short update. Seems I was unfortunately right about the patient I mentioned last night. At first, it seemed like things were going much better today...he was more with it, alert, oriented, communicative. But as the day wore on it became clear that some things just weren't quite right. He was still running fevers despite being on antibiotics. He was still breathing too quickly. His heart was beating even faster than it was yesterday and it just looked ugly on the monitor...lots of PVCs, atrial fib, even non-sustained v tach. (Non-medical people: if you're really interested, you'll have to ask for a specific translation, because this one requires a lot of explaining.) And then his IV blew. And the IV team couldn't get access. And he started having longer runs of v tach. And his temperature went up. Without an IV we couldn't give him fluids, antibiotics, beta-blockers to control his heart rate, anything. So after ascertaining his code status with his power of attorney (my first time getting a code status on my own...more about that next post) I grabbed my intern and attending who decided to call a Condition C. Long story short, by the end of the day he looked pretty bad and was getting a central line from the CCM fellow. It's probably about 50-50 whether he ends up in the ICU overnight, and if that happens...well, we'll cross that bridge when we come to it, but I'm afraid it'll work out poorly.
So yeah, that's the update for the evening...wish it were a happier one. Now I'm off to grab a few hours of sleep before long call tomorrow. *Sigh* Till next time, peace and God bless!
So yeah, that's the update for the evening...wish it were a happier one. Now I'm off to grab a few hours of sleep before long call tomorrow. *Sigh* Till next time, peace and God bless!
Tuesday, February 15, 2011
Every now and again...
...you just have one of those days. Days that you wish you could just erase and forget even though you know there's a lesson in there somewhere. Days that leave you questioning yourself, your abilities, your competence and wondering if you've made a wrong turn somewhere in life. Days that rank among the most unpleasant of defining moments.
So I have this one patient. I've been taking care of him for a week now. He came in with viral gastroenteritis, a really common bug that's unpleasant for a couple of days (nausea, vomiting, diarrhea) and then goes away. We gave him some fluids, watched him for a day, and prepared to send him home. What's that you say? The bed at the nursing home has already been filled? You didn't even hold it for 24 hours? Oh, that's ok, because it's GREAT for people to stay in the hospital for a week when they're well. It's not like you can catch all manner of horrible nasty illnesses or anything. (...yeah, you see where this is going...) And sure enough, yesterday he spiked a fever to over 102 F. And started puking. And becoming tachypneic (translation: breathing faster than usual). He turned out to have pneumonia, probably from aspirating something or another. That would be bad enough. Except it's not the end of the story. You see, today his blood cultures grew out Gram (+) cocci in clusters. That means staph. Probably S. aureus. Possibly MRSA. For the non-medical folks: that's BADBADBAD. S. aureus bacteremia has about a 30% mortality rate. The last patient I knew who had it died. And oh-by-the-way, did I mention that because of his demographics and current condition he has about a 30% chance of not surviving the pneumonia? Or that he's immunocompromised because he's a transplant patient? We've been working on summary statements; here's one: this guy is NOT going to do well. Maybe he'll pull through. But even if he does, it's not going to be a short, easy process. It's going to take some time, and he's likely not to regain his former level of function. And as I worked on writing his note and putting his orders in today, I wondered what I had missed. Had I failed to see something that would have given some warning? Or worse, had I inadvertently done something that contributed to him getting sick? Had I missed some finding, some cue, some opportunity to prevent his nightmare in the first place? What could I have, should I have done differently? Where did I screw up? What did I do wrong? I'll probably never have answers to those questions -- I'm not even sure there ARE answers to all of them -- but I couldn't stop running through them in my head today. And as Dad pointed out, maybe that's not all bad. Maybe it's a thought process I need to allow myself to run through, as he called it, a "mini-M&M" [that's "Morbidity and Mortality" btw] that forces me to analyze my thought processes and holes in my reasoning, that helps me recognize patterns, gaps, and things I need to change next time. Because there WILL be a next time. Instead of an old guy with pneumonia, it might be a young kid with appendicitis, but many of the principles will still apply. Don't let your preconceptions get the best of you. Sometimes short-term discomfort prevents long-term death. Err on the side of getting help. Just because you're "only a med student" doesn't mean you're not right, and it ALSO doesn't mean your team won't listen to you. If something looks wrong, treat it like it is until you find out a reason. Too much information is often worse than too little. And no matter how sure you are that you've got a handle on everything, remember that the plot *ALWAYS* thickens.
Anyway, those are my musings for the evening. Prayers for my patient would be appreciated...we'll see how he does tomorrow. Hope everyone is doing well! Till next time, peace and God bless!
So I have this one patient. I've been taking care of him for a week now. He came in with viral gastroenteritis, a really common bug that's unpleasant for a couple of days (nausea, vomiting, diarrhea) and then goes away. We gave him some fluids, watched him for a day, and prepared to send him home. What's that you say? The bed at the nursing home has already been filled? You didn't even hold it for 24 hours? Oh, that's ok, because it's GREAT for people to stay in the hospital for a week when they're well. It's not like you can catch all manner of horrible nasty illnesses or anything. (...yeah, you see where this is going...) And sure enough, yesterday he spiked a fever to over 102 F. And started puking. And becoming tachypneic (translation: breathing faster than usual). He turned out to have pneumonia, probably from aspirating something or another. That would be bad enough. Except it's not the end of the story. You see, today his blood cultures grew out Gram (+) cocci in clusters. That means staph. Probably S. aureus. Possibly MRSA. For the non-medical folks: that's BADBADBAD. S. aureus bacteremia has about a 30% mortality rate. The last patient I knew who had it died. And oh-by-the-way, did I mention that because of his demographics and current condition he has about a 30% chance of not surviving the pneumonia? Or that he's immunocompromised because he's a transplant patient? We've been working on summary statements; here's one: this guy is NOT going to do well. Maybe he'll pull through. But even if he does, it's not going to be a short, easy process. It's going to take some time, and he's likely not to regain his former level of function. And as I worked on writing his note and putting his orders in today, I wondered what I had missed. Had I failed to see something that would have given some warning? Or worse, had I inadvertently done something that contributed to him getting sick? Had I missed some finding, some cue, some opportunity to prevent his nightmare in the first place? What could I have, should I have done differently? Where did I screw up? What did I do wrong? I'll probably never have answers to those questions -- I'm not even sure there ARE answers to all of them -- but I couldn't stop running through them in my head today. And as Dad pointed out, maybe that's not all bad. Maybe it's a thought process I need to allow myself to run through, as he called it, a "mini-M&M" [that's "Morbidity and Mortality" btw] that forces me to analyze my thought processes and holes in my reasoning, that helps me recognize patterns, gaps, and things I need to change next time. Because there WILL be a next time. Instead of an old guy with pneumonia, it might be a young kid with appendicitis, but many of the principles will still apply. Don't let your preconceptions get the best of you. Sometimes short-term discomfort prevents long-term death. Err on the side of getting help. Just because you're "only a med student" doesn't mean you're not right, and it ALSO doesn't mean your team won't listen to you. If something looks wrong, treat it like it is until you find out a reason. Too much information is often worse than too little. And no matter how sure you are that you've got a handle on everything, remember that the plot *ALWAYS* thickens.
Anyway, those are my musings for the evening. Prayers for my patient would be appreciated...we'll see how he does tomorrow. Hope everyone is doing well! Till next time, peace and God bless!
Monday, January 31, 2011
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!
Sunday, January 30, 2011
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!
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!
Thursday, January 20, 2011
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!
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!
Tuesday, January 4, 2011
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!
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!
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