Thursday, September 27, 2007


One of the more inscrutable whims of whoever it is that determines the requirements for internal medicine residency this year has been to require a "subspecialty month" in which we see a week of clinic in ENT, Ortho, Ophtho, and Psych. This week has been ENT clinic for me, and it's beeen a leap back in time.

What I mean is, I am basically functioning as a fourth year medical student. I don't know any of the surgery, so I can't really contribute there, and my idea of a clinic visit is at least 30 minutes long, so I'm not fast enough for surgery. These guys have are double and triple booked in twenty minute time slots, and they are rarely behind. On the plus side, I've seen a lot of scopes and procedures that I probably won't ever again, unless I go into general internal medicine, get really fancy in my own practice, and decide a nasopharyngeal scope is a worthwhile investment.

I've survived though and today was actually fun, even for an internist. Just when I was about to slide into the quick, only-the-highlights ENT exam on a patient, I figured out she had something more serious than just hoarseness wrong with her, and we ended up needing a fairly involved thyroid workup. That's something I know how to do. And then one of the later patients needed to be scheduled for surgery, and the ENT doc I was working with wanted to do it tomorrow. He looked at me and said "with this guy's cardiac history, anesthesia is never going to take my word on a physical so seriously that they'll approve surgery on this short notice. Can you do the H&P and write 'internal medicine resident' next to your name? They'll take that, I'm sure." So I did, and I don't think the surgeons minded my 25 minute exam, because it meant one more case on the schedule for tomorrow. It was nice to be recognized for expertise in my field, even if it is considerably premature.

Tuesday, September 25, 2007


I usually love clinic, even now that the patients I see call me doctor, and I have to have a plan pretty much figured out within half an hour of seeing them. What I don't like is patients like Mrs. Fortnight.

Mrs. F showed up in clinic to be seen for hospital follow up. See my hospital has a policy that every patient is seen in follow up within a month by the intern who admitted them. No matter how complicated, or how many other medical problems they may have. I admitted Mrs. F about a month ago because she was dehydrated and low on magnesium, but of course, this being internal medicine, she also has heart failure, an obscure and ill-characterized propensity to lose electrolytes, chronic diarrhea, Parkinson's, depression, and diabetes. She's the kind of patient who can make almost anyone wish they had picked another specialty.

So she shows up in clinic, and right away the complications start. The triage nurse checks her blood pressure and gets a value of 90/30. This is not good. However, blood pressure machines are not infallible, and any abnormal value they give you should be rechecked. So the triage nurse duly rechecked the pressure three times, getting the same value, but still using the machine. When I came out to see what was holding up my clinic, I found they had not checked the pressure manually. I did so and got a completely normal value. Meanwhile, the nurse had checked a blood sugar and found a value of 232. This is also bad. Especially since my patient hadn't eaten since the night before.

Things never really went uphill from there. She had stopped the magnesium I had started, which necessitated a stat magnesium check. She hadn't rescheduled two appointments with specialists that she missed (and needed.) She hasn't ever written down her blood sugar when she checks it, and neither she nor her husband can tell me where it usually is. She was surprised when I told her she should check it with every meal. 90 minutes later I am an hour behind on clinic with two patients yet to see in the morning session. Goodbye lunch.

I felt bad for her, but there's only so much I can do, and I'm only supposed to be seeing her for her dehydration follow up. She has a regular doctor who should be taking care of all these other complications. But evidently he's doing a poor job. Maybe though, she's just minimally adherent to her regimen from him, like she was from me. So, schedule follow up with her doc, get her a glucose level diary, counsel on foot care, schedule follow up with subspecialties, refill Sinemet, smile, bid goodbye.

Next patient, rinse and repeat.

Please, dear reader, bear this in mind the next time your doctor is late for an appointment.

On the positive side, I finished my infectious disease rotation, and my attending was singularly complimentary in my evaluation. He asked me to consider applying for fellowship in his department in two years too, so we'll see. I did love it, but the siren song of cardiology is still ringing in my ears.

Monday, September 17, 2007

More jokes

My attending is just non stop with this kind of thing. So today he was telling us how he modeled coccidiomycosis in mice...

"So we gave the mice some barbiturates to sedate them, a little 'mouse roofie,' if you will, stuck a tube in their noses, sprayed the cocci down there and pulled it out. Then the mice woke up, called the cops, and claimed they'd been violated. All in the name of science."

Saturday, September 15, 2007

Unusual stories

I love old people. That's a huge reason why I'm internal medicine, but even with the exposure I've gotten so far, I am occasionally startled by the stories they tell. So I was when talking to a recent patient the infectious disease team was consulted on. He's a 90 year old guy who fought in WWII, starting in North Africa with the original American landing and going through with Patton to Italy and then landing on D Day in Normandy. The reason we were consulted was because of a positive VDRL test and concern for neurosyphilis, and while asking this guy about it, he told us "yes sah, I knows when I got the syphilis. It was in Italy. We was mostly worried about the gonorrhea, you know, 'the clap' we called it. But the was worth it." Straight out of Hemingway. I actually thought of Papa's story "One Reader Writes" while hearing Nick's side from that hospital bed.

It reminded me of another patient I recently saw too, a very sweet 87 year old woman, who when I saw her was having some adhesive bandages pulled off. The nurse joked to her as she winced that "it's a bit like a wax job, right ma'am?" Miss Elsie (as she insisted we call her) looked seriously at her and said "I used to wax. *pause* When the sailors came to town." She then smiled a look of mischief at all of us as she settled back on her pillow.

So yes, surprised, though I surely shouldn't be, to realize that my patients were young and foolish and wild once. It adds a depth of humanity to them, and I try to imagine what Miss Elsie looked like at the height of the Jazz age, or whether Private Stone, seeing Europe from the back of an Army truck, thought twice about the Italian girl he left behind. I wonder too, what became of her, and whether she's telling some Italian medical resident about the dashing American who contributed to her own medical history.

The stories are often sad or bittersweet, but I like hearing them, and though I'll never know the details or even the endings, it definitely brightens my day knowing there is more to my patients than penicillin. Perhaps 'brightens' isn't the right word. But humans are a tragic, noble, and foolish kind of creature, and seeing them "warts and all" does more each day to help me appreciate our little world and the kind of sense we all strive to make of it.

Tuesday, September 11, 2007

Subspecialty musings

While sitting in conference today, I leaned over to one of my fellow interns and mentioned how pleased I was to have had both days off this weekend. He leaned back and whispered "two day weekends are proof of the existence of God."

It takes so little to cheer us now.

That said, my current rotation, infectious disease, is fantastic. Interesting subject matter, a sane patient load, and I'm only in the hospital 12 hours a day, 5 days a week. I could get used to this. Adding to the enjoyment is my attending, with whom I share a rather offbeat sense of humor. While discussing the impossibility of getting a particular lab drawn he quipped "but you might as well follow that order up by writing 'end world hunger' as your second line. The nurses are about as likely to do either." Later he said "that's like writing a progress note with cut out words from a newspaper. You can dream about it, but you probably shouldn't." Oh yes. I am entertained.

Saturday, September 08, 2007

A break, for real

I'm finally finished with the wards, which means that after two and a half months, I have two days off in a row. Having one day off a week is fine, it's the biblical model and all, but I've found that it is tough to really do much with it except sleep. That's all I do anyway. But now, with the glorious luxury of having the entire weekend off, I'm left planning hikes, and listening to music, and enjoying life in general a lot more than I was.

Which leads me to an unrelated topic. A while ago I reviewed KT Tunstall's album here, in one of the sporadic music reviews I post. Apparently that got the attention of her promotion company, because I got an email this week which included a video from Tunstall's upcoming album, "Drastic Fantastic," and a number to reach her agent, along with an invitation to interview her. That's not probably something I have time for just now, but it is fun to get an email offering to include me in something besides obscure bank transfers from shady Nigerians who can't spell.

However, if there is anyone out there who really wants to interview Tunstall, I have the contact info for her agent and will pass it along. I can also report that the video is fairly straightforward, with a vague narrative thread and constant flashing between camera angles showing people having a good time. I don't understand why this is now cool, but no matter how much I like a song, I'm not going to spend any of my free time getting aggravated by the apparent epilepsy or ADHD of a video director. The song itself though sounds like her hits from the last album. Quite catchy, and now it's stuck in my head. I'm betting this will do well too when it comes out September 18.

Now I'm off to luxuriate.

Sunday, September 02, 2007

First on the scene

Even before I wanted to be a doctor, I used to imagine being the first person to arrive at some great tragedy, saving the day with my Boy Scout first aid skills. I've learned a lot of first aid since then, all the way through ATLS and ACLS, but still, I've never had to use it outside of the hospital. I'd never seriously considered it even, for despite the nature of my job, there was still a division between me at work, being a doctor, and me at home, being a 20-something guy with a cheap car and a nice stereo.

Until last week.

I had the unique opportunity, late one night after dropping a friend off at her apartment, to be the third person on the scene of a rather horrific motorcycle accident. When I pulled over and ran up to the site, I did have a vague idea that "I might do something good here," but it was shattered when I saw the one victim. Even though I'm not a surgeon, it didn't take medical training to realize there was nothing I could do for the dead man, who had hit a retaining wall while traveling maybe 100 miles an hour. (He had passed me moments before, and my last uncharitable thought as he sped over the hill was "he's going to get himself killed driving like that.")

The guy who got there ahead of me was taking a pulse when I ran up, and he looked up at me and said "I'm an ER tech, and I don't think there's anything we can do." I looked at the double amputation, the blood all over the road, and the apparent high neck fracture, and responded "I'm a doctor. And there isn't." We called 911, of course, but there was no bleeding to stop, and the EMS guys called him dead on the scene.

Two things stuck with me from that night. One, I called myself a doctor, claiming a certain level of expertise, intentionally. And I didn't feel inappropriate doing so. I also watched, with part of my mind amazed at the change, as the seven or so bystanders now on the scene seemed to relax. I think they all needed to know that there wasn't anything to do, and they felt bad not doing something, despite the horror of the situation.

Two, even as I called myself "doctor" I felt a bit guilty for not doing anything. This bothered me for quite some time actually, until I realized that it is actually my job to make that kind of call. It is my job to take the information I have about a patient, compare it to the knowledge I have of my abilities and resources, and decide how to proceed. And here I had few resources to use on a patient with two major arteries severed and no longer bleeding, implying he had exsanguinated. I think I made the right call, but it still was painful not doing anything while waiting for EMS to arrive.

The crowd started to drift away, having had their fill of voyeurism. The victim's fellow motorcyclist (who had missed the retaining wall and come back) knelt by the body, nearly hysterical. The guy didn't look more than 18 or so, and I realized, with a bit of a start, that I was moved myself. Oddly reassuring, because, having seen so much death in the MICU and CCU lately, I was beginning to wonder if I was losing the ability to really care about my patients.

There are at least two ways of caring, I think. It is possible to be emotional and tearfully connected to another. But this form of caring does a physician little good in an emergency, and that is where I demonstrated, at least at first, another kind of caring, in bringing my assessment of my talents to bear on the situation. There is time for emotion after all the action has been taken.

I'm not sure what this kind of perspective means to my life as an internist. Internists are supposed (especially by surgeons) to be the hand holding type, remaining emotionally connected with patients always. Perhaps I am that on some level, but I think this is why cardiology, and especially interventional cardiology, appeals to me. It will allow me to apply my internist's mind to an emergent situation like that faced in surgery. And if I go that route with my career, I will need that perspective on caring.