Condo!

Yes, I know it's been over a week since my last post, but I've been busy :) After finishing up my sub-i on Friday, Adrienne and I loaded up the car and drove down to southern Indiana. We ran the Derby Mini-Marathon in Louisville, KY on Saturday (miserable race; it was very, very hot, and we were not ready for that kind of weather!). Then on Sunday, she drove me to the Louisville airport and I took off for DC. I stayed with one of my Army friends on Sunday, and then on Monday, I became a homeowner! I now officially own an 800 sq ft condo in Rockville, MD (and am officially poor--I can't wait for those active duty paychecks to start coming in!)

I promised pictures way back when, so here they come:

This is the kitchen (obviously). Don't you just love the gold walls? :) Other than that (which will be gone after today), I love the kitchen--granite countertops, nice cabinets (although a bit tall...), and new Maytag appliances.

Here's the living room. Not the best depiction of the gold walls (that'll be the next picture), but pretty decent shot of the large picture window.

And here are the infamous gold walls. Yes, that's on every wall of the living room, kitchen, and bathroom. It's getting painted today.

The bedroom. The maroon is going to be gone, too (apparently, the seller also had a lot of Chief spirit...)

And the bathroom. The gold isn't as obnoxious in here, but it's going to be replaced by a greenish (Contemplation is the name of the Behr color).

So that's the condo! I'll post more pictures of the progress as it's being painted and furnished.

Mollaret's Meningitis

Early in the morning on Monday (when I had been awake for 24 hours already and had another seven left to go before I went to bed), we had a new patient come in through the ED with viral meningitis. When we went through her old ED records, we found out that this was her fourth hospitalization for viral meningitis, which we thought was a bit odd. So we searched online and discovered a disease called Mollaret's meningitis, which is recurrent aseptic (non-bacterial) meningitis, most often caused by HSV-2 (the herpes virus that causes genital herpes; HSV-1 is cold sores). Interesting enough, most people with Mollaret's meningitis report never having genital herpes. So we sent her CSF (cerebrospinal fluid, from the lumbar puncture) to the lab to be tested for HSV-2. It's a test that takes a couple of days to come back, so we didn't have an answer yet when we discharged her today. Well, it came back positive this evening, which confirms Mollaret's. No treatment is required, since it's a self-limiting course (translation: lasts 2 days with treatment and 2 days without), but since this is her fourth hospitalization for viral meningitis, my attending is going to call her in a prescription for Valtrex (herpes medicine; you might recognize it from the commercials: "I have genital herpes." "And I don't." "And now we're doing something about it." etc).

So that was my fun discovery for the day (and since I was the one who told my attending that we should check for HSV-2 to see if this is Mollaret's, I now look really impressive). It's pretty rare, so it's kinda cool that now I can say that I've seen it.

Last call as a med student!

Yes, that's right--it's my last call as a medical student. The next time I spend the night at a hospital, I'll have real responsibilities. That's kinda scary.

Not much has happened so far today (yesterday? I guess it is technically Monday now). We had one discharge and one transfer from the ICU today, which left us open to one new patient during the night, and what a new patient. I still can't figure out why he's on the ID service. He's here for altered mental status and really has no infectious issue at all. And because he has altered mental status and came from an outside hospital, we had no OSU records, he couldn't give a history, and all we had was a stack of records from the other hospital. They didn't include anything useful, of course, just endless copies of his med lists and his lab reports. Wonderful. And then the intern had me staff the admission (phone the on-call attending about it so he can decide what to do). Fortunately, I had worked with that attending before, so it wasn't a nerve-wracking experience.

Anyway, my resident wanted me to stay awake all night (so I can experience getting 80 IQ points dumber by staying awake for 30 hours?), so right now I'm just trying to find something to do to stay awake between pages about blood pressure and foley catheters. Only ten and a half more hours, and then I will never again have to experience med student calls. That will be a great feeling.

Weekend!

Wow... I'm actually posting when I'm not on call. Amazing.

Yay for the weekend! It's not really a weekend, more like a day off, as I have to go in on Sunday (and am on call that night). I spent the entire day looking forward to having Saturday off, as pathetic as that sounds (I really don't like this rotation).

Aside from working 13 hours a day, six days a week, I've been dealing with trying to get my mortgage approved. I'm a bit surprised that USAA is having as many problems with this as they are--I would think that they would be accustomed to working with people getting promoted and moving, but they seem rather confused about the fact that I'm about to be making more than three times a month than I did on my last Leave and Earnings Statement. I've been sending all sorts of documentation proving the fact that I'm about to be stationed in DC and will be promoted to captain (and will get paid as such). I think everything is in order now, but we're getting close to crunch time--I settle on the condo in a little more than a week, and I need to have this mortgage approved by then.

Anyway, back to what has been going on at work. Our census is still really low, and all of those patients are really simple, except the one with TEN who was transferred back to us from the burn service. He's a lot better now than he was before--his skin is healing nicely. His mouth and throat are still sore, which makes it very painful for him to eat, so we were going to put a Dobhoff feeding tube down his nose to his stomach (it's a temporary bridge until he's able to eat enough again). My resident wanted me to do it to give me the practice, but he couldn't have chosen a worse patient for me to practice on--someone with a very raw throat is not the best person to have an fairly inexperienced (at this procedure, anyway) med student to practice on. It irritated his throat too much, and he started coughing up blood, so we had to pull the tube out and told him that he's going to have to try to eat, and if we need to, we'll try the tube again on Monday. Not my best moment.

I don't really have any big plans for my "weekend". I'll probably go running tomorrow, and then spend the rest of the day lounging around and enjoying not having anything to do--and thinking about how glad I'll be to have this rotation behind me.

My post-callness

Being post-call is kinda nice, if you ignore the whole being-completely-exhausted thing. Actually, last night wasn't too bad. I went to bed a little after midnight, and didn't get any pages until about five. It was so strange that I asked the intern I was working with if nurses were bypassing me and paging him directly, but he said that he thought I was just doing a good job of triaging pages and didn't need his help.

I did get one page that turned out to be a problem, the one right before midnight. A nurse paged me saying that one of our patients was spiking a fever, which was new, and rather worrisome considering the fact that he was already on two broad-spectrum antibiotics. He has a spinal abscess (blog of infection on his spine) that was biopsied yesterday afternoon, so I was imaging all these scenarios of bacteria spreading throughout his bloodstream and him becoming septic. So I asked the nurse for the rest of his vitals, which were vastly different than his previous vitals, and really made it look like he was septic. So I told her that I would be ordering a fever workup (blood cultures, urine culture, chest x-ray) and that I'd be up to see him in a few minutes. I called the intern, who agreed and told me to add a bolus of fluids (one liter of normal saline in an hour), and said that he would co-sign the orders as soon as he was done admitting a patient to another service.

So I went to the patient's room, and found him sleeping rather comfortably. Confused, I checked his vitals chart, and everything was completely normal. So I tracked down the nurse and asked her what was going on, and she was rather confused by the normal vitals as well. So I found the PCA (the person taking the vitals; don't ask me what it stands for, because I don't know), and he confirmed that my patient's vitals were normal last time he checked. I decided to check the vitals sheets on the other patients in the room, and discovered that a roommate had a fever and the vital signs that the nurse read to me. I informed her of the error and called the intern and told him to cancel the fever work-up and explained the situation.

So this morning, I talked to my intern and told him what happened, and we decided that even though nothing happened, I should write up an incident report. It's not tattling on the nurse, but simply pointing out a 'near miss'. If I hadn't been on, the page would have gone to the intern, who would have ordered the same workup. But he wouldn't have seen the patient for at least half an hour, until he was done admitting the other patient, and by then, the fever work-up would have been done for nothing. This kind of things are how medical errors happen.

Anyway, after that whole debacle, I came home, crashed for about an hour, and ran all the errands I don't have time to run any other time. Not quite relaxing, but I did get a lot accomplished, so I guess that makes up for it.

Another night of call

I just realized that the last time I updated this was the last time I was call. Oops. I guess while I'm a captive audience here in the hospital with nothing better to do (such as watching tv, going for a run, or sleeping) is the only time I remember that I actually have a blog. Sorry about that.

As far as what's happened since the last night on call... not much. See patients, see patients get better, send them home, repeat. I took off early on Friday to head down to southern Indiana for Adrienne's bridal shower and bachlorette party, which was a lot of fun (the bachlorette party more than the bridal shower). She has a fairly large extended family, and at one point, one of her second cousins or something made a comment to me about how strange I must find it that Adrienne knows all of her extended family. I said not really. It was nothing new to me!

We went to a dueling piano bar for the bachlorette party--lots of fun. I'll leave it at that.

And then Sunday was Easter and Easter dinner with Adrienne's immediate family (plus future mother-in-law) before we loaded back into the car in time to take her sister to the airport (her younger sister is a grad student at Harvard). Then it was back to Columbus, where I went for a quick run, ate dinner, and went to bed (after forgetting to call my parents--sorry) fairly early in order to get up at my usual 4:30 for another fun and exciting day as a sub-i.

Standard stuff for the last few days. Most of the patients are fairly simple--cellulitis, give them a couple of days of IV antibiotics before sending them home on pills. Right now, most of our patients are pretty stable, but we have room for three more on the census, so I might have to deal with admitting three new patients from the ED. For the meantime, though, I'm going to be looking forward to this:

In case you can't read that, it says "You are no longer covering for IM Infectious Disease Pager (INF). That is the best page one could ever receive. It means no more random pages about a patient's perfectly normal temperature or mild hypertension, and a few hours of sleep are on the horizon.

Anyway, now that I'm done eating dinner, I should probably go find my intern so we can pull a dialysis catheter out of a patient's femoral vein (ah, I bet you wish you had my life...)

On-call again

Yes, I am on-call again... ugh. Tonight I have (almost) real responsibilities, though, so it's a much better experience. The infectious disease pager was forwarded to me, so now every time a nurse has a question about vital signs or medications, I get the page. Most of the questions thus far have been fairly simple--so far I have gone and talked to a patient about why he needs to take his medications, told a nurse reporting that a temperature had a fever that he can have Tylenol (I talked that over with the intern first; I can't just arbitrarily prescribe medicine, even Tylenol, and had to defend why I didn't think the fever was a sign of serious infection), and turfed a question about pain medicine on to the resident. At some point, we'll probably have a slew of admissions (we discharged quite a few people today), so that'll keep me busy, but for the meantime, I'm debating whether or not I should go find a call room and crash until the pager goes off again.

Other than the multitude of discharges, it was a fairly typical day. I arrived at 6:15ish, saw my patients, and we did the whole rounding thing. My patient with the reaction to Bactrim was officially transferred to the burns service today, because they finally realized that his HIV wasn't really an issue, at least compared to fact that his skin was falling off. He was by far the sickest on our service. The man who is growing fungus out of his lungs is now also growing mycobacteria (the same group of bacteria as tuberculosis and leprosy, but it isn't TB or leprosy), so I decided that he's just cooking up a microbiology lab in his lungs. Thoracic surgery was going to take him to the OR today to cut out the fungal badness, but they had too many emergent surgeries today, so now our patient is on their schedule for early next week. He is not happy about having to wait around in the hospital that long (and because he's on IV antifungal meds, he can't just go home and then come back next week). Other than that, everyone was fairly stable--improving, but not quite ready to go home. I also got to show off my future-preventive-medicine-ness: our patient with TB finally had three negative screens for TB, which means that we were able to take him out of isolation. He said he had done this before, but the Ohio Department of Health didn't have records of it. So I called ODH, informed them of the situation, got their fax number, and then called the microbiology lab at the hospital and asked them to fax the microbiology reports to ODH so that they were aware of the situation. It was a proud moment for future preventive medicine physicians everywhere, I'm sure.

Happy Birthday to Mom!

Happy Birthday, Mom!

Today started as a fairly typical sub-i day on the infectious disease service. I went in, saw my eight patients (the entire hospital is full, so each service has more patients than we're supposed to--we had 14, and we're supposed to have 12), and then went on rounds and made plans on them for the day. I have the two actively sickest patients--the patient with lymphoma and growing fungus out of his lungs, and a patient who came in Friday with an allergic reaction to Bactrim (sulfa antibiotic). He came in with some facial swelling and a mild rash; he now has toxic epidermal necrolysis, which is a severe reaction that causes skin (>30% of the body surface area) to slough off. He's being followed by derm, burn surgery (they're essentially burn patients when missing that much skin), ophthalmology, ENT, speech, and nutrition (as well as infectious disease, of course). He's getting a lot of IV fluids and IV antibiotics and still isn't doing that great, but he's always pleasant and polite when I go in and talk to him. It seems like the nicer they are, the worse they do. At this point, he has a 35% chance of mortality. I hope he makes it.

After rounds was Tuesday didactics, then I went back up to the conference room to work on my notes, but my resident and intern sent me home early as a birthday present :) So I got to go home and relax for a few hours. Adrienne and I went out to dinner and ice cream, which was a nice way to spend an evening before going on call tomorrow :( Two and a half more weeks, and then my work for med school is done. I can't wait.

Post-call

I was on call last night. Never a fun situation. I really don't like being on call.

The day started fine--all of our patients were either getting better (as is the goal) or staying the same, and several had improved to the point that we were comfortable discharging them. Unfortunately for me, all of those were patients I was following. It's unfortunate because it meant that not only did I have to fill out their discharge paperwork (I can't fill in discharge medications, but I can write summaries of the hospital course and lists of the procedures they had had while hospitalized), but that I had room to pick up more patients once they were gone. I was sure that meant that I would be up all night admitting new patients.

We did learn a few things about the patients during the day as well. We decided to take a field trip down to the radiology reading room to see about our TB patient's CT scans from the hospital he was at (they had sent a CD with the scans) to see if his disease was getting better, worse, or staying the same. We decided that his TB is getting better (his lungs were showing signs of healing), but he currently has a pneumonia, so it's not exactly an ideal situation. He's still hanging out in the isolation room until we can clear him. Another one of my patients had a new read on his lung culture. It turns out he's growing two different kinds of fungus in his lungs. One we knew about and have been treating him for; the other was a new discovery, and not a good one. For starters, the anti-fungal medicine we have him on doesn't cover the new fungus. For two, that particular organism is a pretty ominous sign in someone with cancer (he has chronic lymphoma), and the medicine used to treat it (amphotericin B, for anyone out there who watches House) is pretty hard on the kidneys, and his kidneys were already not doing great. In other words, this guy is a train wreck, and doesn't even realize it (he's always cheerful and comfortable when I come in and chat with him): he has cancer, kidney failure, fungus in his lungs, vasculitis in his skin, atrial fibrillation in his heart... The list goes on and on. He's being followed by infectious disease (my team), pulmonary (lung docs), nephrology (kidney docs), thoracic surgery (lung surgeons), rheumatology (for the vasculitis in his legs), and hematology (for his lymphoma). That's a lot of doctors for one guy.

Anyway, our census was pretty low at the beginning of the evening last night. We can have up to twelve, and we had eight, which meant that we had room for four more. We heard fairly early in the night about two that were supposed to come in: a woman with meningitis and another with possible TB. Neither of them came. We did get a guy from the ED with a newly diagnosed sulfa allergy, though. He had just been hospitalized, and during his last stay, it was discovered that not only was he HIV positive (with a CD4 count of 49--normal is about 1200, and AIDS is anything less than 200), but had two opportunistic infections. He was sent out on Bactrim, a sulfa antibiotic, to treat those infections, and came in with a massive rash and swelling in his face and airway. He didn't need to be intubated, but did get steroids and benedryl in the ED for the allergy. So we had to admit him to watch him and change up his medications. He's doing fine, although is still quite swollen and completely covered in this rash. Apparently, sulfa allergies aren't uncommon in HIV positive patients, which is unfortunate, because most get Bactrim to keep from getting the types of infections that HIV positive patients get.

As far as the calls from the nurses, allergies seemed to be the special for the evening. We have a girl (OSU undergrad) with bacterial meningitis who had been getting ceftriaxone for the past week. Well, last night, right after she finished her dose of IV ceftriaxone, her face got pretty swollen. I got the call from the nurse, who tried telling me that that was a medication for her, despite my insistence that she had been getting it for the past week. Well, we went in and saw her and, sure enough, her face was pretty swollen. We can't figure it out--most allergies would present a long time before a week after the medicine was started--but we gave her some IV benedryl, and she's looking better now. We're going to try to give her benedryl before the ceftriaxone for her next dose, and if that doesn't work, we're going to have to change her to another antibiotic that doesn't have as much data for bacterial meningitis (all of the studies on treatment of bacterial meningitis show that ceftriaxone is the best antibiotic for it).

I did manage to grab a couple of hours of sleep (on the world's most uncomfortable beds, in a room I shared with two other med students on call), between admissions and calls from the nurses, but I was still pretty out of it during rounds this morning (I'm fairly worthless when I'm post-call). Three more nights of call as a med student left, and after that, the next time I'm on call, I'll have actual responsibilities... kinda scary.

Still figuring out responsibilities

Being the first day of the month, the ID team got a new intern and attending (the senior resident changed yesterday). This meant no more working with Dr. Para (he was one of my attendings when I was on ID last year, and wrote me a letter of recommendation for residency), and finally figuring out what my responsibilities will be for the month.

The day got off to a rocky start. Since I didn't know what time my new intern was going to be showing up for sign-in (hearing from the night team how the patients did overnight), I pre-rounded on my patients ("my patients" being the six people on the service who the third year med students are not following). Pre-rounding is one of my least favorite things to do. You go in at some ridiculous time to the patient's room, wake them up, check their vitals, listen to hearts and lungs, and chat with them when they'd rather be sleeping. Then, an hour or so later, they get woken up again and asked the same questions when the rest of the team comes by for rounds.

Anyway, so I pre-rounded, then introduced myself to the new intern, and then it was time to "run the list". That means going down the census and discussing how each patient is doing before rounds. I figured this would be a standard running of the list, which means you just give the vitals and say if they had any complaints overnight. I have been doing this for two years, after all--I know what the resident needs to hear. Well, my resident decided (without telling me beforehand) that he wanted us to practice our presentations before the attending showed up for rounds. So I had given a very concise summary of the last twelve hours, and he proceeded to correct my presentation. I've been giving patient presentations for awhile now; I think I know what I'm doing, but the resident then corrected everything I said and painstakingly walked through how I should present to the attending. Grr.

As it turned out, Dr. Maher has a great sense of humor and only likes pertinent points, so my presentations were pretty much exactly what he wanted.

Anyway, that was how we spent the morning ("morning" being 6:30-2). Then I grabbed lunch, wrote patient notes, filled out discharge instructions (which the resident then felt the need to show me how to do, even though I had already done it). We got a couple of new patients in the early afternoon, which the med 3's picked up, and then another new one, which I picked up (too many new patients in one day makes third year med students nervous). It was a great case for me, too: a patient with TB, transferred from another hospital. So I had to contact the Ohio Department of Health, get his TB records, figure out his treatments, and try to decide why he hasn't been getting better (he has been on treatment for two months; should be showing some signs of improvement). Figuring all of that made for a late afternoon (I left the hospital at 6:30), but at least I was doing something that I'm good at.

Hopefully the resident will realize that I'm a semi-competent medical student soon. This could get very frustrating very fast.