Friday, November 28, 2003

New attending, different style


I am in the last week of my internal medicine rotation. I have been fortunate to be able to spend this week with a new attending. He is double board certified in internal medicine and pediatrics. So far, my attendings have been pretty laid back. He is not. He is quite demanding and formal. However, it is great to work with him, as he really teaches. For example, over the weekend (yes, I had to come in on Saturday and Sunday this weekend), he sent me to see patients and asked me to write a SOAP note on them. Then he came down to see the same patients. Before seeing them, he asked me to 'present' the patient -- basically use my SOAP note to update him. The last part of the note is of course, the plan. He asked me what I wanted to for the patient today. This, by the way, was an unconscious patient in the ICU on a ventilator! Well, I gave him my plan. He told me to write them out on the yellow 'Physician Orders' sheet and then he signed them! It was pretty cool. I felt like I was managing the patient. Of course, not all my presentation went as well. Sometimes, I was completely lost. Well, rather than tell me what to do, he would ask questions. The answers led to the plan. For example, I wanted to get a CBC on a patient we suspected of having an infection. He asked me "What is the life span of a WBC?" To my shame, I did not know. He said, "Guess". I guessed 20 days. A 4th year medical student guessed 2 months. The answer: 4-6 hours. Oops!

Oh well... one can't get them all...

Wednesday, November 26, 2003

Internal Medicine Wards

Tuesday, November 25, 2003 BLS and the last few days on the Internal Medicine Inpatient Service
7:42 PM

I was excited about today because I was going to do the BLS course. I reported at 8:00 am and found that there were only three candidates for the course. The instructors, Heather and Lory were lively, humorous and gave us enough practice. We learnt to do CPR, remove foreign objects obstructing airways and use the automated emergency defibrillator. We worked with dummies of an adult, a child and an infant. At first, I thought, ‘I will never remember this stuff, especially in a panic situation where something like this might actually happen.’ Now I think I will. At least, I’ll remember enough to do some good.

We rounded with Dr. W again. As usual, he asked some questions to which D (another medical student) and me did not know the answers. Oh well, this is the learning experience. I wrote out the discharge orders for P C (a patient on the service) – my first discharge order! I was amazed to learn that this illegal Mexican in the United States received such excellent medical care, a free glucometer, insulin and all the treatment he received, even though he has no money to pay for any of it. I must salute the charity and generosity of the US healthcare system that can still support such cases in these days of expensive healthcare. At the same time, I wonder at the justice of a legal, honest hardworking individual who has some insurance having to pay for healthcare to the extent that it might bankrupt him or her.

The rest of the afternoon, basically we hung around with one of our interns while she gave us ‘busywork’ to do – look up a patient’s drugs in the computer, fill out some papers, etc. I spent the time reading a portion of a chapter from the Washington Manual on my PDA.

At sign-out, we had only 9 patients left on our service. Interesting to see if we pick up several tonight. Y (another intern) is on call. I hope to be able to round on several patients tomorrow and learn more about them to present to Dr. W.

Tomorrow is my last day on the Dr. K's service (one of our attendings) before I shift over to Dr. M (a pulmonologist and critical care specialist) on Monday – December 1. This will begin my second month in internal medicine. I still feel like my head is swimming and I don’t know anything. Although, during this past month, I have:
Learned to write admit orders
Learned to write progress notes – wrote LOTS of those!
Learned to write discharge orders
Learned to write scripts
Learned CPR
Attended two codes
Learned about the importance of preventing DVT in hospital patients
Learned about the 5 W’s of post-operative fever.
Learned about the evaluation of chest pain and its treatments.

This is off the top of my head. I have seen quite a few things – it is taking time to put it in perspective.