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!

Living Life

Two quick thoughts about psych before heading off to bed for the night.  First, as much as I hate it, it really forces me to count my blessings and realize how good my life really is.  I've been seeing a lot of depressed patients recently, and I'm realizing that they generally have very good reasons for being depressed; many of their stories are heartbreaking.  I should really never complain about anything again ever...what little trials I have to deal with, what minor crosses I have to bear, are completely insignificant compared to the true suffering some of these people endure.

Second, and more positively, psych is not a super time intensive rotation.  So tonight I was able to take a couple of hours and get together with some classmates I haven't seen in a while, to just chat and catch up and do the kinds of things that normal people do.  Remember when as kids it was the most boring thing in the world to sit at the table while the grown-ups talked?  Now I understand the attraction.  When you're just chatting with a group of great people (particularly when sitting around a table of delicious food), there's not much else that needs to be happening to make it a great time.  We've known each other for only 2 1/2 years, but it feels like we've been friends all our lives.

So yeah, I guess the point of tonight's post is what the title says.  One of my favorite quotes of all time is from Gandalf in The Fellowship of the Ring: "All we have to decide is what to do with the time that is given to us."  On a day to day level, I think that means helping the people we can, counting our blessings, and taking advantage of the opportunities for good times with friends and family.  To live life means to see the grace given to us in each new day and to make the most of it -- work, play, and (most importantly), pray.

That's all for me tonight...time for sleep.  Hope everyone's doing well; till next time, peace and God bless!

Not much to say

For better or for worse, a relatively quiet day on the medical front.  My very depressed patient went home over the weekend, apparently improved; I pray that everything goes well and she doesn't bounce back anytime soon.  I don't know if she'd be able to handle that.  My other patients...well, not much has really changed.  Did see on fairly young guy today who was floridly, classically manic.  Like with bells on.  We had a guy who played at being manic for our OSCEs (Observed Standardized Clinical Exams) that I thought did a really good job.  But the guy today was absolutely textbook.  From what the resident was saying, I might never see that again in my career, so this guy was a great patient to be exposed to.  Really friendly, really polite, but with VERY loose associations and absolutely no insight or judgment.  Really a riot though.

Otherwise, a few minor activities in the afternoon (research meeting, mandatory neuropathology lecture, required observation of an AA meeting which actually turned out to be much more enlightening than I'd feared) and a walk home through the cold, snowy night in Pittsburgh pretty much rounded out the day.  Still excited over the last few Patriots games and hoping they can keep this going (36-7 over the 9-3 Bears in Chicago?  A week after a 45-3 dismantling of the 9-2 Jets?)  You have to think the rest of the NFL is getting a little nervous right about now.  Of course, the Patriots have always done better when expectations were low, but hey...

Anyhow, hope everyone is doing well.  I'm counting down the days till Psych ends and I get to go home for Christmas -- 7.5 for the former, 8 for the latter.  Can't wait!  Till next time, folks, peace and God bless!

Some days you get the bear...

...but today was one of those days when the bear got me.  The whole week has been busy between seeing patients, trying to put together presentations, working on my scholarly project, etc, but today was exhausting and depressing.

It didn't start off too badly.  One of the attendings brought in hot chocolate and doughnuts, so the day had a pretty promising beginning.  And it looked like our list was fairly manageable -- just a handful of follow-ups to see, most of whom we'd seen at least a few times before and appeared to be progressing well.  We had a pair of new consults to see over in Magee, but that was it.  Seemed like it was shaping up to be pretty easy -- maybe we'd get out early!

...Yeah, not so much.  I went in to see my first follow-up patient, a woman with recurrent medulloblastoma whom I'd seen three or four times before today.  She had been cheerful and smiling the last time I'd talked with her, and had apparently been making good progress.  So I figured it'd be a routine visit, just a couple of minutes.  She still wasn't sleeping well, she said, but otherwise things were going ok.  I asked a little more about the sleep and then asked how her mood was.  She was fine, she said, but her answer seemed just a little off.  So I prodded very gently but got nothing new.  I was getting ready to leave the room, just asking my last questions, when I noticed that she seemed to be struggling to keep her face under control.  Soon she was crying.  Turns out she wasn't fine after all.  She was horribly depressed, barely finding enough energy to keep going each day, struggling with the uncertainty of her diagnosis.  She'd been trying to hide it (very successfully) because she was desperately afraid that we'd make her stay in the hospital longer if she told us, and the one thing she wanted more than anything in the world was to go home and see her kids.  There was much more to the story, but it's not for sharing.  Let me just say that the burdens on this poor woman's shoulders would have been enough to break my back ten or twelve times over.  Regardless, rather than the five minutes I had initially intended, I ended up spending over an hour in that room, dealing with something that was completely out of my reckoning.  After I had talked with her, I was drained, overwhelmed, and kind of scared -- scared enough to call the resident and basically tell him that I needed to talk with him immediately.  First time I've ever felt that inadequate to deal with a situation.  Hers is a horribly sad story, all of which came out at once today.  I was privileged to be the one the hear it, but it affected me badly for the rest of the day.

This, of course, is on top of another patient who's been in the hospital for over 4 months for a partial small bowel resection secondary to mesenteric ischemia.  The other day, one of his family members passed away before he had a chance to see her and say goodbye.  Now it doesn't look like he'll even be able to go to her funeral because he's simply not well enough.  And then there was the patient who once served in the armed forces but turned to cocaine when she fell on hard times and lost, in quick succession, her son to Child Protective Services, her boyfriend (who blamed her for the boy being taken away), and the baby with whom she was pregnant.  Also, she's been living in boxes on the street for the last couple of months because she had nowhere else to go and had been forced to turn to prostitution to earn money.  Such a horrible story...

So yeah, bit of a rough day.  And then I came home and I'm pretty sure a mouse has taken up residence in my apartment, so we'll deal with that tomorrow.  Hopefully things will get a little better from here.

Anyway, hope everyone is doing well.  Till next time, peace and God bless!

Lipstick on a pig

Another week down.  Spent part of the morning today doing electroconvulsive therapy (ECT), which is used as a treatment for major depression refractory to other medical management.  Yeah, it's exactly what it sounds like.  No, it's no fun whatsoever.  Basically you take a pair of electrodes, place them on an anesthetized patient's head, and zap their right temporal lobe (or both temporal lobes) with anywhere from 5 to 100 joules to induce a seizure.  This in turn apparently results in the release of most or all major neurotransmitters in the brain, helping by some mechanism to fight depression.  It also directly stimulates facial muscles causing an excruciatingly painful-appearing grimace (note: in fairness, it's not actually painful -- the patient is still under anesthesia).  Yeah, it's a fairly primitive treatment all dressed up in pretty clothes and lipstick.  However, although I hate the whole idea of ECT, both the literature and anecdotal evidence from some patients indicate that it can be pretty effective.  Still, I'd rather never be within several miles of ECT ever again if I can possibly avoid it.

The rest of the day was ok.  I'm still not a fan of psych, but at least I'm getting involved and am getting some worthwhile teaching.  That's pretty much all I'm hoping for out of this rotation.  No particularly interesting cases, unfortunately, so no good [HIPAA-compliant] stories.

Not much else going on at the moment.  I'll be back with more thoughts sometime in the near future.  Till then, peace and God bless!