Half time

This is where we spent the last two nights of our honeymoon. And although it has been some time ago now, I will never forget our experience there.

The first half of the internal medicine rotation is nearing, and I can't begin to tell you how much I have learned. Not only that, but what I'm learning is far different from anything learned by reading a book. They say we learn best by doing; well, they is correct. There's nothing like admitting a patient with some rare disease and then reading all about it at home and how I will spend the next few days treating the person.

The residents/interns/attendings switch rotations at the end of the month. Yes, even attendings get assigned a month of ward or clinic duty here and there, just like on House. I suppose what I'm getting at is, yesterday was my last day with Andreoli and that team; today was a whole new bunch (sans one intern) of interns, a resident, and an attending. The students, however, don't change locations until the beginning of next week. This gives us some continuity between groups - those patients covered by the students can easily be made familiar to the new interns and resident during the students' last few days on the ward. Almost everyone is moving either between wards and clinic, or perhaps from one ward to another. I, however, not only am on wards again, but I am on the same team. In other words, our new team today is the team stuck with me through the end of August. The other three students with whom I work will change on Monday and be replaced by two others. It will almost be an all male team, except the attending and that one intern who also didn't change locations. The two of us will stick out seven out of our eight weeks together (they started in July a week before we did).

I've seen a lot in these last few weeks. I've seen large, draining chest tubes go in guy and stay there for a week draining nasty fluid, a few different venous lines go in or come out of folks, I assisted on a lumbar puncture (spinal tap) (which I probably shouldn't have since the guy was HIV positive); I've seen some patients wither away to death and others come back from looking like death was near; and I've seen diseases at the VA that one is much less likely to come across while working at University. This is because our patients, the veterans, come to us, and only us. Other people can to to University, Baptist, St. Vincent, their little clinic in PoDunk BluffVille, AR, or wherever they want, thus spreading out the locations of rare conditions. The vets, on the other hand, come to us a total train wreck - sick as hell and unable to go anywhere else.

Another thing, even more gratifying than anything else, is that most of my patients really seem to enjoy my company. I even had one of them tell me today that I was the light of his day - he was referring to the otherwise bleak overview of his care by the nurses and others at the VA (more on this later). Others have just flat out said, "I like you Dr. Bradley." Yes, I have been called Dr. Bradley - no new Dr. Bears yet, though. It's not that I'm a better people person than the interns and docs on the team - it's just that I only have three or four patients at a time to take care of, meaning I can spend more time with each one of them answering questions.

But I have learned other types of things, and have had some not so good experiences as well. I have come to realize the unbelievable unreliability of some of the nursing and assisting staff. Our team has a wonderful social worker, a greatly knowledgeable pharmacist, etc - I am not referring to any of them. It's the nurses and their aids. We want to monitor a patient's urine output, but we can't rely on what has been recorded except on rare occasion when we know there is a trustworthy nurse on our side. I want my patients to get their pain meds on time so we can get a potentially painful procedure done on time and pain free, but I often have to hound them until it gets done. Now there are many of them, particularly on our floor, who are just wonderful and will bend over backwards to get anything you want done, done. But when we have patients on another floor, the simplest of things can be a huge fiasco. It most aggravates me when I see a note written by a nurse, perhaps even an APN or PA (advanced nurse practitioner or physician's assistant) from an outside clinic, that claims no abnormal physical findings on a certain part of the exam when it is clear as daylight - it may even be behind their chief complaint. The inaccuracy of some of the charted notes about these patients makes life difficult sometimes.

In other news, still anxious to get to the new (used) house. We've got colors for the walls picked out and painting supplies purchased. Just two weeks until we begin painting and moving. Come over for dinner sometime.

Our house

In the middle of nowhere.

Here are some photos:

Yayness!

So this week has been a good week, so far. We are finally on the brink of getting a rental house - perhaps by tomorrow we will know for sure whether or not we get the current candidate. My patients this week have been fairly good learning cases. I got to watch Interventional Radiology place three draining chest tubes in one of my patients. I am glad I wasn't him, though, it looked like he was in terrible pain for most of the procedure. With the tubes still in place and draining into measured containers, the tenderness remains. One of those sites drained 100cc's of pretty nasty looking fluid at the time of tube placement - that's a fair amount for lung tissue - and it was up to me to deliver it to the lab myself. He has also had his hand "drained," a couple massive lymph nodes in his neck drained, etc. I don't think there is anywhere else we can poke the poor guy. He is, however, in a much better mood now that he isn't in respiratory isolation, cut off from the world outside his tiny hospital room. Then there are my other two patients, both of which aren't very mentally oriented, but for different reasons. One is an older demented man with some psychiatric and movement disorders that have faded over the last few days, but their etiology remains unknown. I don't know that there is much we can do for him other than send him home under the care of someone else or a nursing home. The other man was self-admitted for detoxification from his alcohol and cocaine use. With constant Ativan sedation, he isn't very responsive to loud speech or even touch. Surprisingly, unknown to him or anyone else before now, his kidney function is less than optimal, so we need to figure what the problem is while he's there. To top it off, Dr. Andreoli is planning on taking us students out to lunch on Friday. I am curious as to his choice of restaurant and whether we will run into any Nobel laureates on the way.

The second reason for a good week is the USMLE. In retrospect, most discussions about the USMLE weren't necessarily pessimistic, but nonetheless about the tiring task of weeks of studying. Now, the scores have returned, and the work was well worth it. I scored a 254 - but let me put this into perspective. Every year, the average is between 200 and 220, with a standard deviation of about 15. So, even if the average this year is at the higher end at 220, my score is still more than two standard deviations above the average. For those less familiar with the Gaussian curve, this means I should have scored between the 95th and 99.7th percentile. This makes me very happy, to say the least. My goal was to score a 240, and I thought that might be pushing it. Surprises sometimes come. Our class as a whole, though, didn't score as well as classes past and future, as is our apparent inescapable fate.

One final thing is a job opportunity that has come my way. That's right, a job whilst in medical school. I don't know if I will get the position yet, but here's how it works. I will be a technician for the cornea bank at the eye center. I will be on call for a week at a time, but only rarely will it be two weeks in a row. It's beeper call, which means I can go home, go out to eat, sleep, etc. and just go in when needed. The call hours last from 4PM to 8AM. If and when I go in, here's what I do: for those patients listed as organ donors, or least after having expressed desire to donate their corneas, I go see these patients in the morgue after they have passed on. It is my job to enucleate (remove) their eye and then transport it back to our lab. There, I will remove and process the cornea for storage in the cornea bank. The pay is acceptable - 20$ per night on call, $110 for every case done or $65 for every half case done, and mileage. Since these are dead patients, they can work around my schedule and the other three techs, the doctors, and residents are all very understanding of my position as a medical student and my priority to my patients. While sleepless nights happen occasionally, they aren't all that common. Better yet, this is right down the alley of what I want to do and it will look great on a resume. I'm pretty excited about what the next few days/weeks will bring.

After the first week

I still feel like I am where I belong. Not as a student, but in medicine in general. I enjoy doing what I do, even if I did have to spend the week looking like an idiot trying to learn the ways of the ward, and I have a ton yet to learn. Perhaps I will describe a typical day to you.

I arrive on the floor around 7AM, since, for now, I am new to this and arrive a little early to give myself extra time to get things done. On a day I am carrying three or four patients, which is most days from here on out, I see two patients between 7 and 7:45 after reviewing their charts for any overnight events. You never know when your patient fell overnight and required a head CT because no one will tell you, not even the patient if they hit their head hard enough. I then make the ten to twenty minute trek over to University Hospital where those of us students in the IM clerkship have a daily (except on Wednesday) one hour lecture. I then go back to the VA and see one or two more patients before 10 AM. At this time, Dr. Andreoli arrives and we go over any X-rays, CT scans, or MRI's which might be useful. Andreoli then inspects our clothes and our pockets for labeled pens before we head off to see our patients. Our team usually carries between 15 and 20 patients, each of which requiring a stop by the entire team in the morning. Frequently, in between patients, Andreoli will drill (pimp) us in the hall; sometimes it's about something pertinent to the patient we just saw, and other times it is only pertinent to him in the form of history about some famous doctor we've never heard of. One might ask just how famous are these doctors, then? I can't give an answer for this one. When rounds finish around noon or slightly before, the upper level resident runs through the list of patients and comes up with plans as far as what to do about them. Then it's lunch time. Often times, there is some conference we are expected to attend. Sometimes there is lunch at said conferences, but sometimes there isn't. Unfortunately, these too often require a trek over to University. After lunch, we head back to the VA and write notes on all of our patients - the so-called SOAP notes where we address the Subjective and Objective aspects of the patient's condition, followed by an Assessment and Plan for patient care. By this time, we have sent some patients home, and others have come to us. It is up to us to then go do complete histories and physicals on these new people. After all of that is done, and the gathered information is written up into the patient's chart on the computer, it is time to go see our other patients to see how they are doing. At last stop, it is wise to take one final look at the patient's chart at the end of the day to see what actually got done and what got put off until the next day. And, of course, mixed in all of this is the occasional little task to complete or lecture by our ward's director to attend. All in all, the average day on wards ends between 5 and 7PM. They make for long hours, but they usually go by at a decent pace. Tomorrow, I begin my first of a twelve-day stretch without any days off. Good times.

In other news, we finally looked at a rental house today. Aside from it being pretty far out west, it's not a bad deal. It's a three bedroom, 2 bathroom, 1200 square foot house for $850 a month. The best part is, there aren't any neighbors right next door, and the area is pretty heavily wooded. It would be a good deal, but I want to look at a few closer houses yet. It may not be too long before we move out of this dang apartment. Of course, if we do decide to move to a larger place, this will undoubtedly come with a higher rent than what we pay now, and I will just have to put off getting a new car until my truck dies beyond repair (i.e. spontaneous combustion, alien abduction, drowning in the river, nuclear holocaust, etc).

Day One

OK, so I won't post daily about what I do day in and day out, but some days require special recognition. One of these days is the first. The first day of anything is a new experience worth writing about.

I met, for the first time, the team with whom I will be working for the next four weeks, if not the next eight. There's an attending (Dr. Andreoli), an upper level resident (Dr. Morgan), two interns (first year residents whose names I can't remember), an acting intern (fourth year medical student), and four of us lowly third years - really a fairly large team. I've talked about the infamous Dr. Andreoli before, and it's all true. First of all, there was the picture perfect view of the entire team moving from patient to patient as a unit while one of the residents or the AI presented the patient's most recent findings to Andreoli. It was as one sees in any movie depicting such events, I had just never seen it in person until now. This process went on for roughly two hours. Before we even went to see patients, he noticed my choice of shirt for the day. It was a sort of dark lavender, not a stark violet, with a primarily silver tie, and he absolutely hated the shirt. In fact, his exact words were, "You should burn that shirt immediately when you get home." I won't, I like the shirt and Rachel's mom would murder me. While on my case, he decided to examine the contents of my coat's chest pocket to ensure my pens weren't labeled with some drug or pharmaceutical company. To his dismay, they weren't, and he therefore couldn't steal them from me like he did one of my colleague's, even though his pens weren't labeled; they weren't "trinkets" as Andreoli likes to call them. Because of his disdain for my shirt, he later asked me to justify my existence on this planet by giving him the top three possibilities for a differential diagnosis on a patient we saw. I knew one, but not the other two, therefore making me useless, at least to him. Of course, neither did any of the residents correctly name the other two top possibilities. However, most of his questions didn't even pertain to the care of the patient. Most of his questions were about past Nobel laureates, inventors of medical procedures or devices, culture nonsense, or about one of many famous physicians he has supposedly met or lived near to in his brilliant career.

Despite what it may sound like, Andreoli is a decent man. His bedside manner is great. He charges a dollar to any member of the team who doesn't let the female members through the doorway first. He refers to his patients as ladies and gentlemen, not merely females and males. And, all in all, he's a great educator and great with students - you just can't let his silly insults get to you. They are otherwise harmless. Tomorrow, after arriving at 7:30 AM, I will have to write progress notes on two patients after doing brief histories and physicals on them, and then I will present them to Andreoli on rounds. It will be time to be insulted again, though hopefully not about my clothing this time. By the end of the week, I should have a routine down and it will only be a matter of learning about different kinds of patients for the remainder of my stint on internal medicine at the VA. I go home at night, read some about the patients I am taking care of and their diseases, and move on. Nowhere near the volume of studying compared to the last two years. I will be working every other weekend, so I will have a couple blocks of 12 straight days of working, but oh well. Above all, I am glad I have started my rotations with internal medicine. It is the basis from which all other specialties arise, and we get to actually apply what we have learned the past two years (whereas in other rotations, our two year's worth of lecture is near meaningless). Future updates about internal medicine will likely include what seem to me to be interesting cases, so don't get too bored.

Blogs 2 and 3

In lieu of me writing stuff about the wedding and honeymoon, I direct you to Rachel's blog (a link can be found at the right of this page). It gives the same basic ideas, albeit from a different point of view, that I would likely give. After having blog 2 nearly complete, it failed to save like it should have and I don't feel like re-writing it all. By the time I would feel like it, it would be too far past the event to really matter, especially after having read Rachel's blog.

Sorry for the disappointment, if there is any.

U Smile

Hello again. This is the first in a series of three blogs, each detailing events which happened in the last couple of weeks. I should have no problem filling this space over and over again with little tidbits of information. This particular blog pertains to my medicinal career.

That pesky little national board licensing exam is over, long over in fact, hence the title of this blog. U SMiLE is an often used slur of the acronym USMLE. I don't know if this particular slur is simple optimism or overt cynicism, but there is no smiling during said exam. Of course, a big smile spread across my face when I finished, but this wasn't due to answering 350 obscurely worded clinical vignettes with joy. Several people have asked me how I feel I did. These are people who, naturally, weren't taking the test themselves, because as anyone who takes the USMLE or its entourage of practice exams knows, how you feel you did is meaningless. I will say this: I didn't walk out of there wanting to pull my hair out due to frustration, like some of my less fortunate colleagues. I know of some who felt as though the test went horribly (even though these are good students who always do well on exams), and even one or two who left crying. There are even a few malingerers who have yet to take the exam (mostly those who keep pushing it back, a highly frowned upon practice), even though we start school next week. But, alas, it's all done for me. Scores will arrive sometime around July 18, and I anxiously await. Let's not discuss it between now and then, eh?

In other medical news, I have begun a collection of old medical things. While on our honeymoon (details to follow in the third of this series of blogs), we visited a few antique shops when the idea dawned upon me. Someday, I will have an office, or perhaps a patient waiting room. And what is a waiting room without cool, old, medical trinkets lying around on glass shelves behind glass doors which will require constant washing to remove the nose and finger prints of little children? So far, I have acquired three objects. The first is a book from the 70's called, The Encyclopedia of Common Diseases. The second item is an old mercury bichloride bottle for medicinal purposes. It even lists the antidote to poisoning: "Give milk or white of eggs beaten with water, then a tablespoonful of soap or baking soda in a glass of warm water and repeat until vomit fluid is clear. Then give milk or white of eggs beaten with water. Call a physician." So remember kids, before calling the doc or 911 or anything, scramble around the house looking for eggs, water, soap, and baking soda, with a source of heat for the water, an egg separator since Lord knows you don't want the yolk, and an egg beater, watch the victim vomit a few times, repeat, and then pick up the phone to call for help. We have drugs for this nowadays, it takes out a lot of the guess work I suppose. The third item found is a book from circa 1910 called "Hygiene and Sanitation." It appears to be like some sort of manual/textbook every 100 year old physician should have. I can't really say any more about either book since I haven't read them yet (if ever).

While my scores in northern Arkansan antique shops won't likely prepare me for the coming months, some emails have begun filtering through which likely will. We have started receiving various emails from course directors and fourth year students, many of which contain potentially useful attachments. All that said, I am beginning to get excited about this year. It's a complete turn around from the last two years, and it will take a lot of getting used to for all of us. I recently discovered I will be working under the notorious Dr. Andreoli as my first attending. Andreoli is a name dropper, a student pimper of boundless sorts (he charges his students and residents money if they get stuff wrong), and he hates corporate sponsorship (i.e. no drug rep pens and paper). He's like television's Dr. Gregory House, but with a better bedside manner, I should hope. He's even a nephrologist, though he's not a snarky Brit. I can handle this. I think I can match his sarcasm (have you met me?). Only time will tell. I have him for four weeks, and the remainder of my internal medicine rotation is yet to be decided. Many blogs will spew forth from this coming experience, and I hope you will read on. But this is all for now, and I will soon write about the wedding and honeymoon, blogs 2 and 3, respectively.