Medical School 2020, Year 3, Week 19 (Internal Medicine)

Internal Medicine clerkship starts at 7:00 am. My classmates and I meet the clerkship coordinator at the hospital coffee shop to receive schedules and team assignments. Gigolo Giorgio is frustrated we did not receive our schedule a few weeks ago to allow us time to plan Thanksgiving and Christmas. We can choose five days off within the next six week block in addition to two post 24-hour call days. The IM service treats weekends the same as weekdays. Giorgio complains, “I could have scheduled those five days to go home for Turkey Day.” 

Each IM team has two interns, a senior resident (PGY2 or PGY3), an attending, and a medical student pair. For this block, our team happens to have an additional (third) medical student. The attending rotates every week. 

We sip coffee as the clerkship coordinator goes through the rotation schedule for 30 minutes. The senior residents for each team come down, introduce themselves to their respective medical students, and whisks them away to meet the rest of the team. Sleek Sylvester, Ditzy Diane, and I are stuck waiting for about one hour trying to reach our senior resident. It turns out to be her day off. We locate an attending from a different team who says that three medical students should not be on one team. We follow him to locate the clerkship coordinator. She informs him that we have an extra student this rotation so the team will have to manage. 

We wait around until noon. The interns have academic half day after rounds so our entire team is off at lectures from a nephrologist. A senior resident from a different team sends us home around 2:00 pm: “Your team isn’t taking any admissions today, and the senior is off. They already finished rounds so just head home.”

The next day we get in at 6:30 am. We still do not have any patients assigned to us. Our senior resident, a 6’3″ Vermonter with a six-month-old, sits us down to go over expectations. “It is all going to depend on the attending. Some attendings will be okay with the medical student going down to the ED to interview the patient first. Some will want the intern and medical student to tag team. I’ll usually pop in to see if the patient meets admission criteria or needs ICU level of care. The most frustrating thing you’ll experience is doing a really great exam and you come up with a detailed assessment and plan, all to hear that the patient is going to go to the ICU.”

How many patients should an individual student follow? “Depending how busy we are, between 2-3 patients. I try to have medical students follow patients that they admit. Step downs and overnight admissions are always harder to understand. Leave those to the interns.” Advice for rounding and presentations? “You have to feel what the attending wants. Dr. [Bubbles] likes things a little shorter once he trusts your judgement. Watch the interns today, let’s head up for rounds.”

We head to the conference room for morning report at 7:15 am. Interview season is upon us so there are 30 fourth-year medical students (hoping to obtain residencies) in the front. Our senior resident comments, “You’ll notice that all the attendings show up on interview days, even if they have no interaction with residents at all. It’s pretty funny seeing an attending that never teaches us reflect for ten minutes about the good ole days and tidbits on how to read a CBC (e.g., monocytes are the first cell line to respond in an aplastic crisis).” A senior resident from a different team presents a case on leukostasis in acute myelocytic leukemia. Leukostasis occurs when there are so many blasts (immature blood cells from the bone marrow) in the blood that the increased viscosity leads to uncontrolled clotting and bleeding in every organ (disseminated intravascular coagulation). The patient died from a hemorrhagic stroke.

We meet our attending on the 4th floor PCU (Progressive Care Unit, with round-the-clock monitoring of vitals; essentially synonymous with “Step Down Unit”) for rounds. He’s a balding, quirky 58-year-old with round high-power glasses. Sylvester jokes that he looks like Bubbles from Trailer Park Boys. The interns are busy writing notes. We gather outside a patient’s room, and the intern presents overnight events and any changes to the current plan. If there is an overnight admission, or a new admission the attending has not seen, the intern will present a full H&P (History and Physical). The presentation is primarily an opportunity for the intern to practice articulating medical information; the attending has already looked carefully at the chart. The team then walks into the room and the attending takes over to ask the patient some questions. This may be the only time that the attending sees the patient in a 24-hour period, but Dr. Bubbles likes to return later in the day.

There are several COPD exacerbations from poor outpatient management and persistent smoking. There are two old ladies in a shared room both admitted for COPD. We are considering sending the first one to skilled rehab given her poor support system at home. The attending asks, “Do you have any help at home?” She responds: “My two sons don’t give a damn about me except for my money. You guys don’t give a damn about me.  I haven’t slept in four days, I’m just going to walk out of here. Where is my cane? God dammit, I left it at home.”

[Editor: In the Victorian era, arsenic was known as “inheritance powder.” And it would be interesting to see whether the American health care industry’s passion for elder care would survive the elimination of Medicare.]

The other lady is in a similar mood. Outside, the senior commented, “Well someone is having a bad hair day.” The attending smiled, “That will get you when you haven’t slept in four days. Let’s get her to sleep.” The intern asked, “Melatonin?” The senior responded, “No! Something that will work. Let’s try her on ramelteon or trazodone.” We finish rounds around 11:00 am. The attending returns to his office while the rest of us go to the residents’ lounge.

While the interns type at Epic, our senior resident goes over management of atrial fibrillation and congestive heart failure. Some of the medical students on other rotations join in the teaching session. We’re all clueless, even on these basic IM topics.

Sleek Sylvester and one of the interns step out for the first and only admission. Ditzy Diane and I are each assigned patients that have been here for one day. We read up on our respective patients and introduce ourselves later that afternoon. We get sent home at 3:30 pm by the senior resident: “Tomorrow is our call day, so we’ll be here pretty late. Get some studying and sleep before.”

Each team is “on call” for one or two times per week. The on-call team allocates admissions to the rest of the teams. Most teams want 12-14 patients post-call depending on the comfort of the senior resident with his or her interns. The call team also responds to all codes in the hospital outside of ICU beds. 

I get in at 6:30 am to preround on my patient, and try to get away for morning report at 7:15 am. Sleek Sylvester, Gigolo Giorgio and I lack the knack of extricating ourselves from conversations and we’re all 10 minutes late to the morning report. 

During morning report we get a page for a “code blue” (patient with no pulse). We run up seven flights of stairs (the elevators are excruciatingly slow) to find ten people standing in the room with a 60-year-old man who recently underwent a radical tonsillectomy for squamous cell cancer of the pharynx. Our Vermonter chief steps into the crowded room, which contains no doctors, and asks if anyone is leading the code. No answer. One nurse is performing CPR while another is trying to get a blood pressure. The other eight people are essentially spectators. “Fuck, okay, let’s begin.” He immediately takes over. “How long has he had no pulse?” “What happened when you walked in?” “What’s his blood pressure?” “Can we get an EKG?”

I step up to take over compressions from the nurse who is sweating and has been performing compressions for several minutes. Diane and Sylvester line up behind me and we switch every 2 minute ACLS (Advanced Cardiac Life Support, standard algorithm to respond to cardiac arrhythmias) round. The nurses say that they found him hemorrhaging “from the neck”. We activate the Massive Transfusion Protocol to transfuse 6 rounds (1 unit of blood, 1 unit of platelets, and 1 unit of FFP per round) in rapid succession. Anesthesiology and the surgical critical care teams are also paged.

The anesthesiologist shows up after five minutes and, due to all of the blood, struggles for six minutes to intubate the patient, but eventually succeeds. The surgical critical care chief arrives five minutes behind the anesthesiologist and identifies the bleeding as coming from inside the mouth, not the neck. She stuffs gauze down the patient’s throat. We  perform compressions for about 20 minutes, with his pulse coming in and out. I grab the ultrasound machine, which comes in handy when they ask for better venous access. The critical care intern places a femoral central line. We transfer the patient to an ICU bed, where his pulse returns, and then wheel him to the OR. Diane, Sylvester, and myself are all following. I tell them only one of us will be able to scrub into the surgery. We settle on Diane. But when push came to shove with the elevator doors closing, I jumped on. Sorry Diane. 

I scrub into surgery, and peek into the mouth as the ENT surgeon identifies a failed clip on the tonsillar artery. He cauterizes the pulsating artery and places several more clips. The tonsillar artery hemorrhage led to aspiration of blood leading to respiratory arrest, then cardiac arrest. The ENT surgeon asks, “Who stuffed the gauze down the throat? That saved his life. It was never hemorrhagic shock that led to cardiac arrest.” (i.e., it was blood in the lungs that starved the heart muscles of oxygen, not loss of blood).

The senior resident: “It was like something out of the movies. That was awesome. I’ve never had something like that.” Everyone, especially the medical students were congratulating him on a smoothly run code. He responded, “White coat doesn’t mean anything. You just have to take charge. Code Blues are algorithmic, it’s pretty simple compared to a rapid [Rapid Response Code] where you have no idea what you are walking into.” For me, this was the first code in which the patient actually survived. (Unfortunately, when I checked on his chart over the weekend there were notes of severe neurological deficits.)

With rounds complete, we head back to the resident lounge to work on notes for the remainder of the day. We have four rapid codes. The first was induced by a double dose of metoprolol for atrial fibrillation. She had taken one dose at home, and was given another 50 mg dose in the hospital when the doctor continued her home medications in Epic. The other three rapids were opioid-related: overdoses leading to respiratory depression and acute mental status changes. The senior instructs the nurse to administer narcan, the patient comes back. One patient had two rapid responses called because the narcan wore off. Senior resident: “Narcan is a short acting drug, some of these opioids act for a long period of time.”

The interns and I admit two patients throughout our call day. One intern is a fully licensed Iranian physician retraining so that she can practice in the U.S. and the other is a young American preoccupied with planning his next beach vacation (booze-lubricated encounters with women will be a big part). Each H&P is supposed to have a full examination including neurologic. The American intern doesn’t even press on the patient’s belly, and listens one time for each anterior lung field over the gown for a patient in respiratory distress. (If the patient had a pneumothorax or pulmonary congestion, we would have missed it). The Iranian doesn’t know how to calculate maintenance fluids on a patient who requires aggressive fluid resuscitation due to acute pancreatitis. As we walk up to the lounge, I suggest we get an abdominal ultrasound to evaluate for a gallstone obstructing the pancreatic duct.

Statistics for the week… Study: 3 hours. Sleep: 6 hours/night; Fun: 0 nights. I work Saturday and Sunday through early afternoon. When the attending leaves, the residents will typically let the students go. Four of us grab lunch at Gigolo Giorgio’s favorite hole-in-the-wall burrito spot.

The rest of the book: http://fifthchance.com/MedicalSchool2020