Yum...

A sudden crave for these... can't wait for my vacation in 2 weeks!

It's All about Discharges

Inpatient Medicine, at least at the resident level, is all about discharging patients. The problem with medicine patients in the hospital is that there are just darn too many of them, and most of them have multiple problems that we'll never be able to cure completely. What we do then, while they are sick enough to be in the hospital, is to patch them up nicely, as quickly as possible, so that they get a bit better for us to send them out of the way. Many of the patients' problems don't have to be fixed "in-house". In fact, sometimes they can't be fixed in the hospital (like controlling a diabetic patient's blood sugar). My favorite phrase to patients this month has been, "this can be followed up as an outpatient." To this effect, isn't inpatient medicine just an extension of emergency medicine?

More patients means more work for the residents, so it is only logical that we set "getting rid of our patients" as our primary goal. We pride ourselves when we brought our patient list down to 1 page (or even half a page); I get a "good job" compliment from my senior when I successfully discharged a patient (especially one who has been here for a long time).

We did bring our patient list down to less than 1 page - our lowest census since I started the rotation. Just in time for our anticipated busy call night tomorrow.

Why See a Doctor When I Can Treat Myself?

This afternoon I saw a patient in my clinic who has been taking her aunt's Lasix pills for a week to treat her "hypertension, headache and fluid retention in [her] legs". That's exactly what her chief complaints are on her chart - she pretty much self-diagnose her problems and treated herself. Her hypertension and other symptoms did get better - the only reason why she's in the clinic today is to get more of the medication because her aunt stopped giving her the pills (good for her). She doesn't even know what dose she has been taking.

Lasix is not the first line of drug to treat her hypertension and she could run into some serious problem if she starts developing hypokalemia at home.

This reminds me of the pregnant patient I saw last month who has been self-medicating with insulin for 3 years....

Moving out Rocks from a Rock Garden

Every medicine team has a few rocks. Rocks are patients who have been staying in the hospital for an extended period of time - their conditions don't change, and for any reason they are difficult to be moved out of our inpatient list; they essentially just sit there and not doing much. One of our rocks, an AIDS patient with extensive neurological complication, is obviously too sick and complicated to be managed at home but at the same time has really no reason to stay because we are not doing anything to his sickness. So I am happy to hear today that the family is thinking about transferring him to a nursing facility.

Another one of our rocks have been with our team since July - she has no medical problem except that she initially came in due to dehydration. It is then determined that she has dementia and is not able to take care of herself, so she is just staying in the hospital while her social worker works out her placement. Today we found out from the social worker that they have found a place for the patient and she can be transferred there within the next 2 days.

That's TWO rocks that we are going to move out from the garden - there's a definitely a sense of euphoria amongst our team members today.

24+6

I survived the first two 24+6 calls. "24+6" denotes the hours of the call - 24 hours of call time plus a maximum of 6 hours post-call time for education and transfer of patient care to the next call team.

As an intern in a busy service like Medicine, it means in most cases you don't get any sleep at all. Last night we had 16 admissions overnight amongst 2 interns and 1 student - and with me and the other intern in the team being new to this whole system (this is our first general medicine ward month) it didn't really help. We had some really interesting cases though, not just the usual "CP r/o ACS" kinda thing. We had a patient with lupus who came in with neutropenic fever and cutaneous lesions all over her body; a guy who was brought in after being found lying unconsciously in the hospital lobby; a guy with sickle cell disease who is stupid enough to stand in the back of a truck and fell off when the truck accelerated; a schizophrenic social admit... the list goes on...

Partly because we are not efficient enough, and partly because there are just darn too many things to follow up, I stayed until around 3:30pm the next day, which means I have worked for at least 28 hours straight without a second of sleep. I started dozing off while writing for patient's note, and felt like a zombie walking around the hospital. The good thing that my fellow intern and I noticed though is how fast we have already improved our efficiency a lot in one short week (with a seal of approval from our R2). Hopefully this will continue to improve.

Medicine

Today's my first day in the Medicine service. The Medicine department is huge here - there are at least 15 residents rotating in the medicine wards service at any given time with a daily total patient load that is way over the century mark.

It has been at least 2 years since my last medicine rotation in med school! It's a rude awakening of the reason I was drawn away from pursuing internal medicine - it's a service where discharging patients seems to be the main goal, rather than caring for them. At times, I feel that we are just patching patients' problems and send them out of the door as soon as they do a bit better. Let's see if my perception changes in the next 4 weeks.

Last Day of OB Rotation

Strange feelings today - I feel like I am going to miss my OB rotation. This is weird because for the past 2 months I have been bitching about the hours and the quality of the rotation, but when I signed out the patients to my colleague after this super busy morning, I had this weird sense of emptiness. Suddenly I am no longer following these patients....

And of course I'll miss delivering babies. But I am sure I'll be doing more deliveries in the very near future.

Jail Mom

We rarely discharge patients during our float nights, but a few nights ago I was told by a nurse to do one. The patient had an uncomplicated NSVD with normal postpartum course in the hospital; the only thing different about her is that she is a jail patient and has just come back from a court appointment. For the past 2 nights, I have been seeing this patient, with cuffs on her feet tied to the bed rail. She always smiled at me when I walked into her room, and grateful of the time that she was having with her newborn. I carefully selected my words when talking to her to avoid saying something inappropriate, but sometimes words just slipped out of my mouth:

"Try to walk as much as possible tomorrow." (What walk? With these chains?)

"Ms. K, it looks like you are doing well so we'll send you hom- (wait a second..) we'll discharge you from the hospital tomorrow."

"What kind of contraception are you planning to use?" (oops~ she probably has no need for that now.)

The patient was in the detention room when I examined her for discharge. She was crying the whole time and asked me repeatedly if she could see her baby one more time. I sympathized her, but I don't know her story enough to judge.

"Why did what you have done if you knew your consequences today?"
(早知今日, 何必當初)

*NSVD - Normal Spontaneous Vaginal Delivery

My (Future) Home - An Update

8/16/2006:




9/10/2006:

Under a Full Moon

What could be a better way to finish my last shift of OB night float than an action-packed night? The post-partum floor was a full-house with 40-some patients, and I did 3 out of the god knows how many normal deliveries. The residents were swamped with laboring patients all night long. It kept on going and going until I realized I had 2 hours to see 18 patients and complete all their progress notes by 6. Even though studies have proved it otherwise, it makes one wonder if there is really a connection between a full-moon and pregnant women going into labour?