I know kung-fu

This is my favorite story from my Internal Medicine rotation, and it didn’t even happen to me. But, the hilarity and the moral of the story make it worthwhile to pass around.

The paramedics and EMTs often drive around our parts of the city, responding to calls or just looking out for people in trouble. One very hot mid-morning in July, they brought in an 80-something-year-old Korean man who we will call Mr. Kim (I never actually knew his real name). The EMTs found Mr. Kim looking unkempt and disheveled, diaphoretic (sweating), and leaning against a really fancy-looking apartment building. They brought him into the hospital, thinking he had dementia and heat stroke or dehydration. He had no ID or wallet, just a pair of keys. He spoke no English, only Korean. While in the ER, he kept trying to get off his bed and leave the hospital, and all he could say in English was, “I teach kung-fu!” All the doctors and nurses and ER techs were like, “Whatever, silly demented Asian dude who keeps trying to leave the hospital and doesn’t know what’s good for him,” and slapped on some arm restraints to keep him stuck to the bed. So, all afternoon he was sitting cross-legged and strapped to his ER bed, telling anybody who would listen that he taught kung-fu, and pantomiming random kung-fu movements at passers-by.

Finally, one of the interns on a different team was down in the ER to pick up his own new patient, and looked over and said, “Hey! That’s Master Kim! He taught me kung-fu when I was a kid!” Everyone went, “FOR REAL?!” And the intern said, “Oh yeah, he’s really famous — he teaches at West Point and stuff like that. His kung-fu studio is nearby. And actually, I think his apartment is close to here, too, because I went there once as a kid when he had a big party for our class.” So, of course, everybody is freaking out because maybe he’s not so demented and not so silly and didn’t need to be rescued.

Cut to a few hours later, when Mr. Kim’s daughter comes into the ER in search of him. She’d been looking all over town for him when he didn’t show up for his afternoon class at the kung-fu studio. She had called our hospital’s ER, but we didn’t have him listed as a patient because we’d spelled his name in some ridiculous way (this is the same hospital that gave me a nametag that read “Sue Change,” so it is not so surprising). She came in anyway, because she figured a name difficulty might have come up.

And the truth? The truth was, he had been disheveled and sweaty because he had just finished teaching his morning kung-fu class. That really nice building he’d been leaning against was his own apartment building. He couldn’t tell us any addresses because he just walked every day from his apartment building to his kung-fu studio and back. He had been trying to leave because he knew he had an afternoon class to teach.

The only thing that made it slightly less embarrassing for us and the profession of medicine was that he really was dehydrated on a disgustingly hot and humid day, and really did have some dementia that had gotten him in some trouble before. His daughter was very understanding and nice and our ER department was really apologetic, but still.

What I love most about this story is that he didn’t need us at all, but that health care people, in an act of hubris, patronizingly took him to the hospital to “protect” him and dismissed his talking as rambling crazy talk. This will forever be known as the time we kidnapped a patient from in front of his own apartment building, then restrained him when he rightly kept trying to leave. Whoops.

Liar liar, pants on… Oh wait, nevermind.

During my Internal Medicine rotation, I had a patient who was picked up by EMS after he fell down and couldn’t get back up. He was pretty bruised and incoherent, so the ER people went through his bags and found discharge papers from a different hospital in New York, dated 2 days prior. The point of discharge papers from the hospital is to summarize why the patient was hospitalized, what was done (test, imaging, surgeries), what was found, and medications that the patient has to continue taking (and for how long). The patient gets a copy of their discharge summary and is supposed to bring it to their primary care doctor. (There are, of course, plenty of patients who don’t have the means to have primary care doctors or who have to use the ER as their primary care doctor, but that is a rant for another time.) The listing of the “admitting diagnosis” is generally listed in order of importance, and can contain other existing medical conditions. For example, if a patient came in for a heart attack, but also had pre-existing hypertension and then was found to have early type II diabetes mellitus and high cholesterol, all of those would be listed in the discharge summary after the diagnosis of a heart attack. My point is, other medical professionals (oooh, I just got a tiny thrill when I realized I am part of that group) read the discharge papers and depend on them as a succinct and honest summary of what happened.

So anyway, we read the discharge summary from the other hospital, and the leading diagnoses were “ethanol intoxication” and “mechanical fall,” which is just a fancy way of saying he was drunk and fell down. Well, that would explain the falling down and incoherence, right? It would be consistent with his liver function enzyme tests, which basically said that he had alcoholic liver disease and some liver failure. Because alcohol withdrawal can cause seizures, the ER is pretty aggressive about medicating any signs of alcohol withdrawal. So, they started this guy on a higher dose of medications, but it meant that he was even more out of it, and more incoherent. After a lot of time, we finally figured out what he was trying to say, which was that he was visiting New York from Scotland, and was trying to get in touch with old friends and family members he hadn’t seen in a long time. Further, he didn’t know where they were, or where he had been in the 2 days between when he was discharged from the other hospital and when he was brought to our hospital. Some of the details that he gave sounded pretty incredible, like how he used to be a musician in a band, and in the British Royal Navy after that as a longshoreman, and that he hadn’t seen these family members in over 30 years, and that he was friends with some kind of famous people. We asked if he had had any alcohol to drink, and he said no. But, given the discharge papers and his liver enzyme profile, we were kind of like, “Yeah, right,” and kept medicating like he would go into alcohol withdrawal.

A few days of treatment later, we tapered him off the medications and his speech cleared up. Once it cleared up, the patient was really able to give more details about where he’d been while in the US, and then gave us phone numbers so that we could check out his story with friends and family in Scotland. He also swore that he hadn’t had alcohol in two years, but did say that he used to drink “a lot,” which, in Scottish terms, must mean a LOT a lot. Anyway, I also called the other New York hospital and got in touch with the physician whose name was signed at the bottom of all the discharge papers. When I got him on the phone, I asked about the course of the hospital stay. The last question I wanted to ask was if the patient had actually come in with “ethanol intoxication” as the cause of his falls. And the physician was like, “Um. No.” I said, “Oh, really?” And he said, “Actually, we did a urine toxicology screen, and he was clean for everything; no alcohol, no drugs.” Understand that the discharge summary is not written until the day the patient leaves the hospital. So I said, “Well, then why did you write that the primary diagnosis was ethanol intoxication?,” which came out a bit rude, but I think a fair question, given that he flat-out said that they’d written a diagnosis that the patient didn’t have, and which also led us think that the patient had been lying to us for days.

We also finally got in touch with the patient’s friends, who told us the patient’s stage name from his days in the band. And lo, Google search turned up plenty of proof, including photos and interviews and discographies of the band. So, in the end, here was the tally:
1. Patient says he was in a band: true.
2. Patient says he hasn’t had anything to drink: true.
3. Patient says he is in town to see family and friends he has not seen in years: also true.
4. Patient says he is childhood friends with semi-famous actor: true, and they were raised in the same town.
5. Patient says he was a longshoreman: well, I stopped checking facts at this point, because he was up 4 points to our 0 points, and there was no way we were going to make up this deficit.

Anyway, the moral of this story is, people might lie about the little things, but I think they don’t tend to make up hugely untrue stories about who they are, and what they’ve been doing for the last 2 weeks. Maybe this way, I won’t get jaded about how “all patients lie” and will listen to their stories, no matter how outlandish the stories seem. But then again, my next rotation is in psychiatry, so perhaps not for this next set of patients who say they are Batman or psychically connected to Oprah.

My hypochrondriasis is incredibly prescient

Hey, remember when I told everybody that an insulinoma would explain my Insta-Bitch? Well, all that self-awareness made me actually pay attention to insulinoma as a disease, even though it is very rare. It paid off, though, because it was the answer on my exam last week! The question was a case presentation of a woman brought in by her friend, because the woman had been eating tons and gaining weight suddenly, acting generally irritated and anxious, and had a headache lasting weeks. I was reading it and not understanding what the question was trying to hint at, and thought, “Huh, that sounds like me when I’m hungry…. OH HEYYYY, insulinoma is an answer choice!” Very exciting. Good job, unfounded paranoia!

For the record, though, I did not see an insulinoma while on my Internal Medicine rotation. So really, the exam was not representative of my actual Internal Medicine rotation at a certain Manhattan hospital. Had the test been truly representative, the patient in the question would have been a 50-something-year-old male, probably homeless, with hypertension or high cholesterol or poorly-controlled diabetes (or all three), current or former smoker/drinker, coming in for shortness of breath or chest pain after drinking all weekend/doing cocaine/losing his medications (all things that happened). It’s like a really tedious and frustrating game of Mad Libs.

It’s the end of medicine!

[This post goes out to Grace, who I probably scared when I simply messaged her, "NO MORE MEDICINE, WOOHOO!" on gchat, and then disappeared. I later got a message from her that said, "WAIT, are you quitting med school?!" No, I am not. I think this story illustrates a growing difference in our vocabularies. Med school is tearing me apart from real life and real English!]

This past weekend was the end of my Internal Medicine rotation, which was my first rotation in 3rd year. If you’re thinking, “Wow, I didn’t realize she was on the same rotation since July; that seems really long,” you’d be right. It’s friggin’ long. Internal Medicine is a 10-week rotation in 3rd year, and it’s the longest rotation we do as students (3rd or 4th year). In fact, it used to be a 12-week rotation (meaning three whole months, ack), but this year, the school shortened the rotation to 10 weeks, because students in the past had asked to have extra time to explore other specialties as 3rd year students. Our choices were really wide-ranging and exciting, but instead of seeing something that I probably wouldn’t end up choosing as a career (ie, radiation oncology or dermatology or preventive medicine (I didn’t even know what this was when we were ranking our choices, but NOW I find out it would have meant working with the New York Department of Health on outbreak investigations(!) and Adolescent STD Education, maaaaan that would have been SO COOL dang it)), I decided to really take a look at a field I have been interested in since 1st year: I’m doing my elective in radiology! It’s funny because I came into med school thinking I could do anything except radiology because I didn’t think I would be able to stand sitting in a dark room all day. Imagine my surprise during 1st year when I realized I really liked looking at films, and was clearly a visual learner. Radiology keeps jumping in and out of my Short List of Possible Specialties (it has always lived on the Medium List), so much that I’ve now nicknamed it “The Siren Song of Radiology,” because while the specialty appeals to me so much, but the competitiveness of the field and the very real possibility of having to move to some really faraway place (such as a Dakota!) for residency makes it seem like a pipe dream. Anyway, we will see how the next 2 weeks go. One point for radiology: I don’t have to start until 9 AM every day! That seems luxuriously late, after 10 weeks of getting to the hospital before 7 AM.

In any case, when I say that I’m done with medicine, I don’t mean that I’m dropping out of medical school. Within the medical field, the word “medicine” has a very different meaning. To the New Me, “medicine” and “medical” mean having to do with Internal Medicine, internists, and basically anything that doesn’t have a procedure involved with it. Think pills, not scalpels.

Though I’m finished with the rotation, I have so many stories that I have been meaning to write about. (To blog about? That phrase just seems so wrong for me to be saying about myself. Would that make me a… blogger? Uh, I just threw up in my mouth a little at the idea.) I’m thinking that I’ll take advantage of these next 2 weeks of easy-peasy 9-to-5 working to catch up on storytelling. Here’s a good one to end with for today: at the end of each rotation, we have to fill out evaluations. One of the questions asked how many hours we worked per week, not counting the hours we stayed VOLUNTARILY (the word was in all caps). This was problematic because we are often told that we can leave, but it’s not like I’m going to take off at 2 PM simply because my interns don’t know what to do with me. Similarly, I have been on call and told that I could leave if I wanted to, even though technically we are supposed to stay for the duration of call. It’s a sticky situation because I don’t want to appear as though I don’t care, but I am sure that if I played it right, I could have been out of the hospital by 4 PM most weekdays (which is the absolute minimum we are expected to stay, as dictated by the school, not by our residents or interns). Does that mean that any time I’ve spent after 4 PM is considered “voluntary”? Of course not. But it wasn’t all against my will, either. I ended up splitting the difference and estimating that I spent 10 hours a day on non-call days plus 14 hours a day on call days, plus 6 hours on Saturdays, which came out to a rough estimate of 65 hours a week. 65. That is bananas, you guys. I will now proceed to scoff at anybody who complains about a 40-hour workweek (including the Old Me from 2004-2006).

Home is where the heart is (not really)

Today was a Sunday spent on call, which meant that I had a full day of work, plus on call duties (haha, I said “duties” — this will get funnier as I tell my story) until 8:30 PM. Whew. I came home so tired and hungry that I bought dinner at the first restaurant I saw after getting off the bus and ate it in 10 minutes at home.

One of my patients came in with anemia that had never been investigated, and the anemia was severe enough that they were thinking of transfusing her. One of the things to check when someone has anemia is to see if they are bleeding from the stomach or intestines. To test this, we do a stool guaiac test. To get stool guaiac, you either have to wait for the patient to have a bowel movement and go after the stools with a swab, or you do a digital rectal exam on the patient and then smear the gloved finger on the stool guaiac test paper. And by “you,” I mean the medical student; and by “the medical student,” I mean me. (Man, you guys are really wishing you’d never asked how med school was going, huh?)

I was reading the directions on the stool guaiac test kit, and noticed that the test kit was manufactured by Beckman Coulter, with an address in Fullerton, CA! How weird is that? This stool guaiac test kit came from the same enormous office building that I drove past twice a day, every day, on the way to and from high school for four years. I can totally picture the building now, in my mind. It’s on Harbor Blvd. just north of Imperial Highway, and I think south of Lambert. I think it’s now across the street from an Albertsons/Sav-on distribution center.

Awww, Fullerton. I guess this just means that no matter how far I go or how weird my life gets, my past homes are always right there with me. Sometimes covered in stool.

(By the way, gathering the necessary items for the stool guaiac test made my front left coat pocket home to a seriously weird collection of items: 4 vinyl gloves (I double-gloved for this), 2 packets of lubricant, 1 stool guaiac test kit, 1 reagent bottle, and stickers with the patient’s name and date of birth printed on them. Sometimes I feel like MacGyver. But with lube.)

How do you say ‘parenteral nutrition’ in Chinese?

One of the patients on my team (and by that, I mean that she is not my patient, but I do see her regularly on rounds) is a woman who is Cantonese- and Mandarin-speaking. For the big, long, important conversations with the patient and her family, the team uses a trained translator. But for the day-to-day, “how are you feeling?”/”do you need pain medication?”-type questions, I get pulled into the room quite often. I have to tell you, there is nothing that makes me feel more useful than getting paged by my attending physician (the boss of all of us) so that I can translate between her and the patient.

Sometimes, though, this comes back to bite me in the ass. Yesterday, I got called into this same patient’s room to discuss the feeding tubes she was getting. As of now, she is getting total parenteral nutrition, meaning that a mix of calories and vitamins are being put directly into her veins. If you think of food as traveling from mouth –> stomach –> intestines –> bloodstream (via absorption), then you can see how bypassing everything can sometimes cause problems, and not be the best solution, though it’s easiest to start an IV line. On the other hand, placing a direct tube into the stomach or intestines requires a slightly larger procedure, including anesthesia, even though it more closely mimics actual eating because the feeds are more food-like and less chemical parts-like. And even though this patient had already had a very long conversation with the translator the previous day about the need to switch to a stomach tube, she wanted to re-hear the reasoning. And I have to tell you, it amazed me that I remembered the words for “intestine” and “blood vessels,” though I was totally stumped on how to say “feeds” and “feeding tube.” I settled on the Chinese equivalents of “food-like liquids” and “tube in stomach for food-like liquids.” Someone asked me to translate “eating by mouth isn’t possible because she can’t protect her airway and might aspirate the food into her lungs,” which completely tapped me out as far as my vocabulary goes. I ended up saying something long the lines of, “using the mouth to eat isn’t possible because you can’t protect your air tube, and might cough and choke on the food after swallowing.” That’s close enough, right? I mean, I doubt all native English-speaking patients understand “aspirate” when we say it. This is what I tell myself, anyway.

Interestingly, the nurses on the floor (who are English-speaking only) were worried that she had a flat affect and might be getting depressed or feeling hopeless because she wasn’t talking to anybody. But this idea seemed ridiculous to my attending physician and anybody else on the team who has seen her talking to her family or to the one Chinese-speaking physical therapist who walks her around daily or to me. With people with whom she can converse in Chinese, she is super chatty and animated. It’s good to remember that a shared language (even through my crappy vocabulary and her weakened voice) can be simple but make the biggest difference in a day.

Naively, I told my mother this, and she is now ridiculously pleased with herself for having insisted I speak in Chinese with her and for having forced me to go to Chinese school for 10 years. Like she needed more ways to know she’d raised me well. I’m sure she’s told anybody who will listen. She will dine on this for years decades.

Can’t buy my love (maybe)

Earlier this week, I had a very nice patient who had a case of community-acquired pneumonia. His case was pretty simple, and he had no significant ongoing medical conditions. He spoke pretty good English, but as it wasn’t his first language, there were some instances of language problems. For instance, the first day, I asked about his bowel movements (please note: this blog will probably talk about bowel movements regularly (haha, “regular” talk of bowel movements — see what I did there?). I’d guess that on an average day, I spend about an hour’s worth of time talking about, asking about, or hearing about poop). When I asked if he was having any diarrhea, he said no. Later that afternoon, he told an attending physician that he’d had three episodes of “like water” bowel movements. So, instead of asking about “diarrhea,” I ended up having to ask exactly WHAT each bowel movement looked like, since “diarrhea” was not good enough. The day he finally started having formed bowel movements (which is what we call normal poop), he spent a good two minutes talking about how it was “soft” and “not as hard as normal” but how it wasn’t “like water” or “coming out fast” anymore. I’m SORRY, I know this is gross, but you all ASKED how med school was going, remember!

Anyway, he was ready to leave after almost a week, and in the meantime, I’d gotten to know him and his wife pretty well. His wife’s understanding and use of English was much more limited than his, so there was a lot of pantomiming and waiting for her to get the English word from her husband or from a dictionary. In any case, she’d asked a few times if there was anything I needed, and I had gotten the impression that she wanted to give me a gift to express her thanks. And what we’ve learned over the year(s) is that we first try to say no to a gift and tell the patient (or patient’s family) that we treat all of our patients the same no matter what (which is true, except maybe I might smile for real for patients who actually like me, and don’t yell at me). Then if the patient still insists on giving a gift, we can accept if the gift is within the patient’s capabilities — nothing outlandish or that cost them too much. So, on the last day of my patient’s hospitalization, his wife brought me a gift! My first gift from a patient while in medical school! (To be honest, though, this one will have to take a backseat to the first gift I ever, ever got from any kind of “my” patient, which happened when I was still working in clinical research, and one of my patients gave me a very sweet gift when I told her I wouldn’t be around anymore because I’d gotten into med school and was moving away. Anyway, that is an aside that deserves a longer post at another time.)

What was the loot? Well, the wife is an artist, so she made/bought (I’m not sure) a small origami folding that looked like a kimono, which was mounted on a backboard and ready to hang. It’s about 4″x6″, maybe? And, there was a small drawstring bag that had been dyed with a design of a fish on the outside. It was all very cute! Somewhere along in our conversation, it sounded like she was also a writer and wanted to write about me, or something. She ended up giving me her business card, and she wanted me to stop by her studio office (I swear!) to discuss something I couldn’t decipher, but I’m not going to do that. As much as I liked her, it was her husband who was my patient, and I’m pretty sure socializing with patients once they are out of the hospital violates some code from some policy. And anyway, I’d feel a bit creepy doing it, even if it meant my praise-mongering self would get written about. Hey, maybe she blogs! Maybe she is writing about me RIGHT NOW in her non-English blog! That would be awesome.

A new vocabulary

The first full week of my internal medicine rotation is over, and I feel like I’ve lived four lifetimes in the interim. At my hospital, everybody is divided into teams consisting of 1 attending physician (someone who has finished residency and is no longer in training), 1 senior resident (someone who is in the latter years of residency in internal medicine), 2-3 interns (someone who is in the 1st year of residency), 1 fourth-year medical student (commonly referred to as the “sub-intern” because he is doing a sub-internship rotation), and 2 third-year medical students. So, in total, the team can have between 7-8 people. With your team, you “round” on patients, presenting them to the attending physician in a surprisingly regimented manner, and giving your assessment of the patient’s problem(s) and possible solution(s).

A typical day for me last week looked like this:
6:30 AM – arrive at the hospital, check in on my patients to see how they’re doing.
7:00 AM – morning sign-in, where we get updates from the overnight team (aka, night float).
7:30 AM – if there are new patients from overnight (usually from the ER), we get info on them from the senior resident, and go get a patient history and physical exam.
8:15 AMish – meet with the senior resident to go over what we got on history and physical exam. This is key because the senior resident will figure out what we’ve missed and give us time to fill in the blanks before the attending physician shows up.
9:00 AM – finish up seeing old patients and learning about new patients.
10 AM – meet with the attending physician and the rest of the team for actual rounds.
12 noon – conference with other med students (we are excused from anything the team might be doing, to attend noon conference).
1 PM – squeeze in a lunch
1:30 PM – do all the things that the senior resident and attending physician said you needed to do, check up on blood labs, run around trying to get appropriate signatures, hope my patients don’t crash or do something crazy (like throw up or fall down or pass out on the bathroom floor, all things that happened last week).
4 PM, in theory – sign out patients to the on-call team, and leave the hospital. I have been leaving around 5 or 6 PM, though.

Oh, and guess what? Internal medicine has work 6 days a week! They tried to make it better by having Saturdays run from 7 AM to 12 noon, in theory, but as you can probably tell from the above schedule, most of the work happens from 7 AM to 12 noon, anyway. Fabulous.

Each team is on call every 4 days. Call consists of staying late from 5 PM to at least 7 PM (but usually 8 or 9 PM), until the night float team comes to the hospital. My first weekend on this rotation, we had call on Thursday night, which meant that we didn’t have call Friday, Saturday, or Sunday. This was referred to as a golden weekend. Between working nearly a full day on Saturday and cleaning/cooking/laundering like a madwoman on Sunday (my only day off), it did not feel quite so golden.

I’m sure I’ll have really great stories to report soon, but as for now, I have to get to bed because I have to be up by 5:45 (!!!) in order to get to the hospital by 6:30. A patient asked me the other day, “Do you live here?” and I kind of cried a little to myself because, well, at that point, I was seeing him before he ate breakfast and after he ate dinner. Sigh.

Rookie mistake!

Today was my very first day as a third-year medical student. My very first rotation is a 3-month rotation in internal medicine. Today was interesting. We didn’t start until 10 AM, though for the rest of the rotation, I expect to be at the hospital well before 7 AM from Monday to Friday, and by 8 AM on Saturdays. Yes, there is a half-day of work (at least) on Saturdays. It’s still better than studying for the Boards, don’t get me wrong.

Anyway, today was the first day, and I got lost in the hospital only twice. Great success! In addition, I went to take the blood pressure of a patient, and needed to get a reading with the patient lying down and with him sitting upright. When I asked him to sit up, he said he was a little dizzy, and asked if he could have extra time sitting up. I said sure, put down my pen and paper, and exited the room to give him a few minutes. When I came back, the patient had vomited all over my pen, paper, and his bedside table. Oh, man. There is only one thing I fear, going into third year, and that is vomit. I’d said as much during our orientation week, and it’s as though the universe was saying, “GET OVER IT” in as obvious a way as possible, on the very first day.

Lesson learned: never ever put things down and walk away from them, if you want them back. Also, apparently, some patients will say they feel dizzy when they in fact feel nauseated. Potato, potahto.

Grace and Claire will be happy to know that I wore my new beige cotton blouse from BCBG that they peer pressured me into buying when we went outlet shopping and I said I needed new work clothes. The shirt did not get vomited upon. Success!