Brown SOAP

さて外科チームの一日を紹介しよう。

オペ室の最初の症例は毎日朝7 時半から始まるのでResident たちはそれまでに病棟の患者さんの回診を終えて1 日の方針を立てなくてはならない。よってMiriamでは回診は5時半スタート、7時頃までに40〜50人を3 人のResident、3人のIntern、それに2人の学生で手分けして診察し、ガーゼなどの交換をし、progress note をカルテに書く。そして7時ごろに再度集まり、カフェテリアで朝食をとりながら全患者さんの容態を報告し、その日の治療方針を決める。そして7時半から、その日当直（on-call）のIntern を1人病棟に残して全員がオペ室に入る。

Vol.1にも書いたように、筆者のいた地域の中堅病院The Miriam Hospital は症例の数に対してResident の数が足りいない時もよくあったので、鼠径ヘルニアやリンパ節生検といった軽いケースは学生が第1助手をすることもよくあった。特に火曜日の朝一のケースはレジデントが全員必修のカンファレンスに行くということで、学生たちが第一助手として入ることが多い。症例の合間にはAttending と連絡を取り，各患者さんの治療方針を確認する（＊）。午後になると手の空いたResident たちが再び回診を始め、予定されていた症例がすべて終了したら再度チームが一同に会し，当直のIntern とResident に申し送りをして1日が終了する。

当直のIntern とResident はその日の症例のPost-op管理、夜間の緊急オペや、内科チームからのコンサルトの対応に追われることになる。当直明けの日（post-call）は朝の回診の後，1つか2つオペに入った後、昼前には帰宅することになる．Intern とResident は3人ずついるので当直は3日ごとに回ってきて、容態の不安定な患者さんがいない場合はResidentも家で待機することができる（Home Callという）。Providenceの周辺では外傷症例はすべてRhode Island Hospitalに運ばれるので、Miriamでの夜間の緊急オペは虫垂炎や血管系の症例が多い。

外科医たちの特徴としては、体力的にも精神的にも非常にタフであること、多数の患者さんの容態を把握する処理能力と迅速な状況判断能力、それに"sign out"と呼ばれる申し送りを頻繁に行うことでチーム内に逐一容態の変化を周知させ、誰が呼び出されても対応できるようにするというチームワークの良さが挙げられる。3日に一度は当直が回ってくるため、Intern・Resident一人一人が40〜50人の患者さんの全容態を常に把握する必要があり、傍から見ていても大変そうだなぁと常に思う。こういう環境で5年もいれば、チーフレジデントになる頃には外科サービスを統括する責任者として自立していくのであろう。


＊ MiriamはAttendingがプライベートの患者さんを連れてくるので、患者さん一人一人に違うAttendingがつくことになる。よって各オペ室および病院中に散らばっているAttendingとポケベルで連絡を取り合うのであるが、これがなかなか大変である。病棟各Attendingが所属する外科医グループというのがあり、夜間の当直などは各グループ内のAttendingが担当している患者さんを全員受け持つ。

アメリカの医学部の臨床実習において、外科の実習はもっとも体力的にも精神的にもきついものとして名高い。ブラウン大学では外科の実習は8週間に渡って行われる。元々は12週間と内科と同じ長さだったのだが、現在では外科8週間＋外科関連科目（放射線・病理・麻酔科・形成外科・整形外科・胸部外科などを含む）4週間を回ることになっている。8週間の外科実習は4週間の一般外科・2週間の血管外科・そして2週間の外傷外科またはSICUという内訳になっている。また一般外科はRhode Island Hospitalでは3チームに分かれており、Surg 1は消化器一般、Surg 2は直腸結腸中心、Surg 3は腫瘍とspecialtyが分かれてくる（The Miriam Hospitalは外科は1チームしかないので特に専門化することなく全部診る）。筆者に割り当てられたスケジュールはMiriamで一般外科を4週間、Rhode Island Hospitalで外傷外科を2週間、そしてVeterans Affairs Hospitalで血管外科を2週間であった。

ここで外科の研修について少し書いておくと、内科が3年に対し外科は5年間と長く、しかも2〜3年目または3〜4年目の間にリサーチの時間を取って基礎研究をする人も多い。1年目をIntern、その他をResidentと呼び、4・5年目のレジデントで各病院の外科サービスのトップになる人をチーフ・レジデントと呼ぶ（よって5年目になると自動的にチーフ・レジデントになるのだが、5年目のレジデントの中でのチーフという役割もある。）血管外科・胸部外科は一般外科を終えてからフェローシップを取ることになる。人気のある形成・整形外科は独立したプログラムを持っている（＊）が、医大卒業後最初の1年間（PGY-1）は一般外科のInternと一緒に研修を受ける。

1年目は病棟作業に追われることが多いが、サービスによってはレジデントの数が足りていないこともあり、1年目のInternや時には学生が第一助手になるようなこともある。外科はだいたい3日に1度（ひどい時は2日に1度）当直が回ってくるのだが、Internと2年目以降のResidentがペアになってそのサービスの全患者さんを担当することになる。命令系統としてはAttending→Resident→Internであるが、Attendingは通常すぐにはつかまらないので2年目以降のResidentの責任はとても強くなってくる。そうしたプレッシャーの中、2年目以降はなるべくORに入るので、4〜5年目になるとCommon CaseであればAttendingはただ傍で見ているだけでレジデントに切らせることもしばしばである。

（Vol.2 に続く）

＊ 整形外科に関しては、一般外科を終えてからフェローシップを受けるという道もある。こうすると一般外科と整形外科の二つの専門医の資格を取れる。

☆ 海軍病院

Newportは我が家からは車で50分ほどにある別荘地で、黒船に乗ってきたペリー提督の出身地ということで日本と交流もある。海軍クリニックには軍関係者とその家族、およびWar Collegeという学校に通っている学生のケアをしており、Navy内のPrimary Careを担っている。院内には2人のactive duty physician（いわゆる軍医）・2人のactive duty nurse practitioner・そして4人のcivilianのMDとPAが勤務している。このクリニックのMDは近くにあるNewport Hospital（一般病院）に患者さんを入院させることもあり、その際はAttendingとして病院まで往診に行く。特に軍関係者が出産をする時はNewport Hospitalに行くことになるので、産婦人科フロアの人たちはNavy Clinicの人たちをよく知っている。

海軍関係者は2〜3年でアメリカ国内のみならず世界中の米軍基地を転々とすることが多く、それはクリニックで働いている医療関係者も同様である。よってなかなか継続したケアをすることが難しく、「Family Medicineの概念を学ぶ」という意味ではあまり理想的な場所ではない。しかしながら家族全体を扱い、赤ちゃんからお年寄りまでの健康管理や疾病予防に関してアドバイスをしたりするという診療内容としては非常にバランスのとれた場所である。機器も揃っているので、X線写真がすぐ撮れたり膣頸管検査や精管切除の処置などといったprocedureも多いのが特徴である。そして何といってもかなり多くの人が、横須賀や沖縄の基地にいたことがあり、筆者が日本人だとわかると気さくに思い出を話してくれたりするのでこちらとしてもやりやすい。



☆ 実習内容

Family Medicineの実習内容は指導教官によって非常にばらつきがある。指導教官の後ろを着いていって診察風景を見せるという教官もいれば、完全に学生に最初から最後まで診察をさせる教官もいる。Navy Clinicの教官は、筆者が要望に書いたとおり、後者のタイプであった。
診察時間は20分。国防総省の管轄する電子カルテシステムを使って、患者さんと喋りながら入力していく。問診・身体診察が終わったら教官のところに行き、文字通り駆け足で症例報告をして治療方針を決めたら教官と一緒に部屋に戻って患者さんに説明する。Navyの教官は時間に厳格ながらも丁寧に指導してくれることで有名で、出身地である西海岸的なリラックスな雰囲気にもすぐに打ち解けることができた。（なおこのスタイルは内科の外来月間の時も一緒であった。）

☆ 講義・その他の活動

毎週水曜日はMemorial Hospital of Rhode Islandに学生は集まって、レクチャー・PBL・ワークショップなどを丸一日受講する。レクチャーの内容は家庭医学でよく扱う症例（腰痛・高血圧・風邪など）のアプローチや治療指針／ガイドラインを話し合ったりする。PBLでは、Wilson Familyという架空の家族が毎週2人ずつオフィスにやってくるという設定で、症例ベースのディスカッションをする。Wilson Familyは三世代にわたるイタリア系家族という設定で、6週間の間にお祖父さんは大腸がんが発覚、お父さんはアルコールに問題あり、お母さんはうつ病、娘は16歳で妊娠が発覚といったような"typical family"を扱い、各問題に関して家庭医学の視点でどうアドバイスをするか話し合う。ワークショップでは皮膚生検・血糖値の図り方などを実演したり、うつ病など文化圏によって異なる病気の捉えられ方を話し合ったりした。

内科が終わってすぐの身には、多くの内科系のトピックは習ったばかりということもあり、正直なところあまり新規のアカデミックな情報が入ってくることはあまりなかった。むしろ、これらのディスカッションの中で「20分間の診療時間の中で、現実的にどのようなことに集中すればよいか」「この検査をするにはどのような診断をして請求をすればいいか」「どのようなフォローアッププランを立てれば良いか」といったようなかなりpracticalな議論をすることが多く、クリニックを運営していく上での苦労などを一緒に学ぶことが重要視されている。どの検査・薬にはどれだけのコストがかかるか、クリニックとしての収入はどれくらいになるのかなど、Primary Care Physicianとして身を立てるには避けて通れないマネージメントの問題も絡めて学ぼうというのが狙いである。

(vol.3に続く）

3ヶ月の内科の実習が終わり、年明けからFamily Medicineの実習が始まった。このClerkshipは6週間に渡って行われ、学生は週1日の講義の日を除いて配属先のクリニックで実習を行う。

☆ Primary Care

実習内容を説明する前にアメリカのPrimary Careのシステムを簡単に説明する。この国の医療システムでは有保険者は所謂「Primary Care Physician (以下PCP)＝かかりつけの医師」というのを持つことになる。PCPは健康診断や予防医学、風邪や腰痛などオフィス内で処置のできる症状などを扱い、専門領域に踏み込む場合は専門科の医師に紹介状を書いてその結果をフォローアップしたりと、基点となって各患者さんのケアを統括する。高度医療施設が必要となって入院することになった場合はその病院まで出向いてその患者さんのAttendingとなって意思決定をしたりもする（これは病院によるが、たとえば内科の実習をしたThe Miriam Hospitalの患者さんの多くはこのような「昔ながらの」PCPを持つ患者さんがたくさんいた。現在は入院した場合はその病院のHospitalistと呼ばれる入院患者さんを専門に診る医師に任せる場合が増えている）。

☆ 家庭医学

PCPは患者さんが自由に選ぶことができるのだが、通常は外来中心の内科医かFamily Medicineの医師を選ぶ。Family Medicineの医師は子供から老人まで年代・性別を幅広く、通常は家族のメンバーを全員診ることになる。診療領域は内科・小児科・産婦人科・精神科・皮膚科・整形外科を網羅することになるので、幅広い知識と簡単な外科的処置に関する技術も要求される分野である。家庭医は地域に根ざしたサービスを行うのが通常で、各家族を数代に渡って診続けるということがよくあり、自分の研修時代にお産を手伝った赤ちゃんが今年大学に入った！と喜んでいるAttendingの話を聞いたりする。

☆ 配属先

このようにFamily Medicineのpracticeは家族全員を診るのが基本であるが、その中にも地域によって「子供中心」とか「女性中心」といったような特徴が各クリニックに表れてくる。そこでこの実習では事前に学生がどのような患者人口に興味があるかアンケートを取り、また指導教官の特徴（学生にどれだけ診察機会を与えるかなど）や興味のある分野なども含め、総合的にClerkship Programの方で判断をする。筆者は「autonomy（自主性を重んじる＝学生にも一人で診察をさせてくれる）」「患者人口は赤ちゃんから老人まで均一」「診療分野も満遍なく」といった項目を要望したところ、Newportにある米海軍基地にあるクリニックに配属された。

(vol.2に続く)

12/17 (Sun) Two ICU transfers, DKA and pneumonia, capping before noon. nsulin regimen before switching from drip to SQ.
12/18 (Mon) Morning report with Dr. Parisi, last EKG lecture by Mike
12/19 (Tue) T's morning round, studying for OSCE tonight.
12/20 (Wed) Last day, being put on the spot, making STAT orders, farewell lunch with Drs. W, S, and chief residents, so long to Miriam for now.

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12/17 (Sun) Two ICU transfers, DKA and pneumonia, capping before noon. nsulin regimen before switching from drip to SQ.

Long-call. Picked up 2 ICU patients. One is a 31 y/o female with type 1 diabetes with recurrent DKA. She was nauseated and vomitted several times before coming to ED. Last night she came in with glucose of 858 and stayed a night in ICU with vigorous hydration and insuling drip. Etiology of DKA was unclear at this point; she says she is very compliant with her insulin regimen. She was using insulin pump but it was switched after her last DKA episode a couple of weeks ago. She is on 18U Lantus & IRSS. She also had some hydradenitis on her left axillary which is draining, so that could be an infectious etiology. Sent blood cx and see what happens.

Went for lunch. We capped before noon which is amazing. R is very busy today, so didn't get to round until later. The second patient FW was a 55 y/o HIV/AIDS, hep B/C, COPD, and DVT who came in with SOB. Blood culture + for strep x2, and was started on IV ftriaxone. He had a strep pneumonia a couple of months ago with basically the same condition. He hasn't been taking HAART and all other meds. Will check CD4/PVL. Start on Bactrim for PCP prophylaxis just in case. He's also running low on BP, around 80 systolic and 50 diastolic. Immunology clinic knows him well and they said that's his baseline. He's a pretty sick man but quite a pleasant guy. He definitely needs to quit drugs and adhere to HAART.

I was done by 1530 and basically spent the rest of my time reading. DKA lady was transferred to the floor. There was some trouble with D/C'ing insulin drip (regular insulin needs to be given prior to
D/C'ing drip) and we needed to closely monitor her labs. Started rounding on old patients around 7pm. David and I took off around 8pm.

12/18 (Mon) Morning report with Dr. Parisi, last EKG lecture by Mike

Post-call. Finished pre-rounding before morning report. Dr. Parisi was there and R presented dilated cardiomyopathy case. Morning round was a little bit chaotic b/c the attending round was pushed to 10am. Dr. F talked about his take on tox-screen.
Radiology conference was cancelled, and we had our last EKG lecture by Mike. He is by far the best lecturer. Talked about cardiology elective in TMH vs RIH. He suggested doing it at RIH because I'd be able to see more diverse cases. Yet, he also commented that there will be more interaction with faculty at Miriam. Hmm... a tough decision to make. Took off after the lectur.

12/19 (Tue) T's morning round, studying for OSCE tonight.

Short-call. R's clinic day, so T filled in. He is very smart and organized. He is pretty good at making teaching point as well, and gets work done efficiently. Kinda like an ideal resident. Anyway, DKA lady is still inhouse because of her gastroparesis. She is very nauseaous and is not tolerating any liquid either. During the round her nurse stopped us and said she vomitted something red. We went to her bedside and, sure enough, it was the red Jello she had for breakfast (we OB'ed it though, which was negative). GI is following her as well. Our goal was to have her pump started and send her home soon, but I guess she will stay a couple of more nights because of the nausea.

FW is doing well, and he marked BP of 112/60! That's HTN for him. CD4 came back to be 29, and we started on MAI prophylaxis. No noon conference today, so I studied for OSCE. Preceptor round with Dr. G and M talked about a case of colon CA/pancreatic CA/liver and lung mets/stroke in one person. Took off after the preceptor round. A will be taking a day off tomorrow, so today was actually the last day with her. She gave me a hug and good luck. Yeah, I will need it.

12/20 (Wed) Last day, being put on the spot, making STAT orders, farewell lunch with Drs. W, S, and chief residents, so long to Miriam for now.

Pre-call. Last day with the team. Morning round as usual but didn't have time to go to M&M. DKA lady was fine until I saw her; she started to complain about nausea. At this point we have no idea what to do with her. N started to consider psych component on this issue; she seems to have some secondary gain by avoiding home situation. FW is doing well respiratory-wise. His main complaint is the shoulder pain that we were recommended not to do anything about by ortho people. Finished both notes completely and started rounding.

We couldn't finish rounding much before Dr. F called us and move up the attending round to 10am, and I hadn't presented any of my patients. We met in DOM conference room and R left immediately because she needed to cover for A. Dr. F asked how FW is doing. Since A is not in today amd R left the room, I presented the case and current status. Then, he put me on the spot and started asking me of why certain tests and consults aren't made yet. Some of the orders were the plans that I wrote this morning, which we had't had a chance to discuss during the round (medstudents aren't allowed to write orders alone). Anyway, he wanted me to make ortho consult one more time, change pain medication to oxycontin because Dr. F doesn't like other pain meds, and call for social worker to talk about the follow-up plan, all in STAT. So I did, and D helped me calling the social worker. We went after the lunch and arranged to see FW tomorrow morning. I'm so glad that D was in the team, he's a REALLY nice guy.

This is part of the problem working with the system here at Miriam. Each patient has different attending when they are admitted to the team. Each medicine team also has an attending for the team, and we talk about cases during attending round. The attending for the team will give "curbside" advice to each patient, but the final decision is made by each pt's attending. In this case, Dr. F followed FW in outpt clinic, but different attending from the immunology clinic was FW's attending for this admission. We've been contacting this attending and had solid plan for FW so far. At any rate, I felt really shocked when Dr. F started basically accusing me of not giving him "the right treatment". I thought there was better way to address those comments.

Lunch with Drs. W, S, and chief residents. Talked about random stuff about the clerkship. I was surprised that Dr. S started talking about "C incident" in front of everybody, but that's the way he is. Today's N's clinic day so R was all alone this afternoon. Helped her with rounding, and took off around 4pm. Everybody seems to be off by 2pm or so, and other interns were suggesting us to take off early. Well, D and I are getting a day off tomorrow, so we didn't mind staying til R is all set and sign out. A pretty tough day to end the clerkship.
It was fun working in this team, and I'm glad that M and I made that move. Will study all day tomorrow and get ready for the shelf on Friday.

12/13 (Wed) Presentation went well, cardiology journal club, casebook, non-post-MI pt
12/14 (Thu) cardioversion, mock OSCE in physical diagnosis round, presented VK during preceptor round, last casebook by Dr. F
12/15 (Fri) Overview of EP people, cardiac MRI, drug eluting stent controversy.

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12/13 (Wed) Presentation went well, cardiology journal club, casebook, non-post-MI pt

CCU week (day 3). Came in to preround my patient, and went to M&M. Dr. Wittels presented a case of AML with extensive infiltration into everywhere in the body. Went back, and round started at 8am. I did a presentation on my patient, and it went well. I got good feedback from everyone in the team. I mean, he came in with a very simple chest pain, and it wasn't that hard to come up with a succinct presentation compared to the patients I've had on the floor.

There was basically nothing to do after the round because there was no one coming to the unit. M and A did some teaching for me, and I went downstairs for cardiology jounal club. Kin was presenting two articles from recent JACC; one was about protective effect on LV function by carvedilol in anthracyclin-induced cardiomyopathy, and the other one was about circumferential pulmonary vein ablation VS antiarrhythmic drug therapy in PAF. Fellows, Dr. Crain, Dr. Korr and several other attendings gave good comments and insights on both of the articles.

Casebook by Dr. B. After that, went back to CCU and found a new patient with h/o CAD s/p CABG and CHF. He was intubated when he arrived here but per his wife he was given tapering dose of prednisone for COPD exacerbation last week, which he religiously took. That caused fluid retention, which put some strain on left atrium, which triggered afib. Since his preload was dependent on atrial contraction, he started retaining fluid and backed up to the lung. Very interesting case, and I wish I had time to follow him up closely.

12/14 (Thu) cardioversion, mock OSCE in physical diagnosis round, presented VK during preceptor round, last casebook by Dr. F

CCU week (day 4). Pre-round and morning round as usual. The new patient has developed afib, and we decided to cardiovert him. One shock brought him back to sinus. Dr. K' teaching round started at 10am, but I had a physical diagnosis round at 10:30 so I excused myself. Today we were assigned to fake a patient and did practice interview & physical exam on each other. I was assigned to osteoarthritis, so I gave D some history like stiff in the morning, worse with use, unilateral involvement, etc. D faked a CHF patient, and his CC was "fatigue". I successfully drew out that he's been short of breath and directed toward CHF workup. It was pretty helpful, since this is supposed to be the format of OSCE on Tuesday.

Journal club by a resident about differences in hypoglycemic agents. Went back to CCU and M gave me a lecture on ARF. Preceptor round at 2pm, and I presented VK. Rescheduled casebook by Dr. Feller at 3pm, and I was literally half asleep. I don't know why but I feel like I got nothing done today.

12/15 (Fri) Overview of EP people, cardiac MRI, drug eluting stent controversy.

CCU week (day 5). Pre-round and morning round as usual. The patient who was cardioverted yesterday will go to EP lab sometime next week, and we talked about how EP people find foci and ablate them. It's such a tedious procedure to map the entire atrium and find the foci, but I'm sure it's really rewarding when you can CURE pt's arrhythmia so that s/he doesn't have to take anti-arrhythmic meds.

New patient had a demand ischemia and started leaking troponin last night. Diagnostic cath was done, and she was made a candidate for CABG. Surgeons want TEE b/c of her valve status, and MRI for viability of the myocardial wall. Went downstairs and saw cardiac MRI. It will replace diagnostic cath someday; images are so clear and so compelling. Pt was given some Ativan b/c she became a little bit agitated while in the MRI. After receiving one dose, she became sleepy and fell asleep a couple of times (hence the motion artifacts).

Still quiet day in the unit, so I started searching for information regarding the recent ado about drug eluting stent. This week, probably all the patients who got cathed received bare metal stents. Data in WCC/ESC and TCT meeting earlier this year have not been disclosed in paper form (as far as I could find), but interventionalists are already making some changes in their practice. Pretty interesting...

Preceptor round with Dr. Goula and S presented a case of HIV pt with diarrhea. Tomorrow is a day off, and will have the last call on Sunday.

12/11 (Mon) TA survived o/n, meet the new team, yet another code, free wall rupture? EKG lecture by M (intern) and M (fellow)
12/12 (Tue) Picked up a patient with antero-septal MI, death of TA

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12/11 (Mon) TA survived o/n, meet the new team, yet another code, free wall rupture? EKG lecture by M (intern) and M (fellow)

CCU week (day 1). Got a call from R at 6:30 and she said TA did fine overnight. I was worried when my phone rang, but it was so nice of R to give me that call. Arrived in CCU around 8am, and nobody was there. Found S, a resident, and an intern M in the kitchen. Dr. K and M showed up and we started rounding. Dr. K is the attending for this week. He's pretty nice, I've seen him a couple of times in echo lab. 6-7 patients were in the unit, and sometimes their own cardiologist comes in and write notes. There are 10 different cardiology group in Providence, so I felt like there's an interesting dynamics there. Dr. K and M were pretty good about giving appropriate data and studies to explain why we are doing this and that.

After the morning round, Dr. Parisi came in and we were about to start a teaching round for house staff (interns, residents, and students) when one of our patients coded. She came in with chest pain but her family member didn't want to cath her (but she was still full code). We were treating her medically, and this morning she was hallucinating/baseline dementia (I don't really know her) but was in no acute distress. When we went into the room she had a full blown JVD and was in PEA (pulseless electrical activity). We intubated her and gave her 3 rounds of epi, but she never came back. After the code, we were discussing what happened, and considering her JVD and recent MI, she might have had a free wall rupture and went into tamponade.

When everything was settled, M spent some time teaching EKG to me. I've read Dubin to prepare for this week, and her explanation made so much more sense now. Noon conference by Dr. Gordon (neurologist). He's a good lecturer. Radiology and EKG lectures as usual. EKG is starting to make more sense, and M is pretty good facilitator.
Checked TA in ICU several times during the day. Her code status is now DNR/DNI. Family members were all gathered. BP was upper 80s/50s, and MAP was around 75. I believe in miracles; she's already made a few during this hospital course.

12/12 (Tue) Picked up a patient with antero-septal MI, death of TA

CCU week (day 2). Morning round at 8am. One got discharged yestserday, and we'll have two coming in today. Dr. K was called because there is no interventionalist in the hospital, but he's only certified for diagnostic cath. I guess he had to go in anyway, and once he scrubbed in his partner from the same office showed up. He knew this was gonna happen.

Anyway, finished rounding and this bow-tied attending came in for teaching round. He just started talking about random facts that were not really useful at all. During the lecture, I got paged by a strange number, and for some reason I couldn't make the call. After that M finished up the EKG lecture with me. She was pretty good.

Journal club by M, and we talked about intensive insulin regimen study. M presented a mysterious aphasia case during preceptor round. Went back to CCU and picked up a new case. A male in early 80s presenting with sharp epigastric pain, turned out to have ST elevation in anterolateral leads. Had a bare metal stent in proximal LAD and placed in CCU. Put on aspirin and Plavix, metoprolol as long as he can tolerate the pressure, ACEI once we know his creatinine, and statin after checking LFT. Titrate NTG drip, check serial enzymes, and wean off oxygen. Very standard protocol for post-cath observation. He's probably ready to go upstairs (medicine floor) but since the hospital is full he'll probably be D/C'd home from CCU directly. Presented to J, an ER resident. She is so nice and went over standard management of CCU patients and typical pimping questions from the attending. Will check in tomorrow morning.

* Death of TA

When I went to ICU after lunch, her bed was empty. There was a chart on the desk saying that she was made CMO earlier this morning.
It's been long two months with her and I did think about this moment several times. Each time she came back and at one point I also thought about sending her to a SNF. She did fight off HIV with HAART, but I guess we might have not given her the right treatment for mycobacterial infection, because we couldn't identify the exact species. She had a birthday in late November, and I gave her a birthday card signed by several other medstudents. She was probably at her best then, and things just didn't come right after that. It was unclear why she wasn't putting much weight despite she had decent PO intake with BOOST, and reintroduction of PEG tube was the only resort. Something happened after the PEG tube that is not really well understood and eventually she became septic. Too much myseteries.

What was bothering me was that after TA passed away, someone pulled her PICC line out and took the bottle of morphine attached to her. No one other than the family members was in the room, so ICU crews were making it a HUGE deal and saying what a horrible thing for them to do. You know what, when someone's life ended after 68 days of intense battle against HIV and mycobacterium, I DON'T REALLY CARE WHETHER A BOTTLE OF MORPHINE IS MISSING OR NOT. I do feel so bad for the family regardless; she had such a difficult marital life, and her children have serious medical problems as well (one is paraplegic and the other is born with HIV). TA's mother flew in from Puerto Rico and stayed with her almost everyday in the hospital. When I was talking to R (she DID page me when TA passed away...), one of the nurses started repeating the story to us. Then, R stood up and said "Nobody saw that they took the bottle, and we shouldn't assume that they did." Those words saved me a lot. R followed her since day 1 of admission with me, and I was glad that someone is sharing the same compassion and thoughts for her.

Compared to the death of FS, I think I was a little more prepared for this moment, but I still can't register the fact that she is gone. She taught me a lot of things, and I am simply sad that I lost my very good friend (despite the language barrier) in the hospital. She'll stay in my mind for the rest of my career.
I went to the floor and found that VK was about to leave for transfer to BI. Sounds like they want to put bi-V pacer right away. I said farewell to her; she was another memorable patient who'll stick to me forever.

12/9 (Sat) CHF vs CRI, fluid or no fluid, I hate fax machine, bed-side echo, acute endocarditis?
12/10 (Sun) Cards won and she tolerated diuresis, troponin going up, lots of drama on the floor, TA transferred to ICU again, it'll be a long night.

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12/9 (Sat) CHF vs CRI, fluid or no fluid, I hate fax machine, bed-side echo, acute endocarditis?

Long-call. Came in around 9am, and we already had a patient. VK is a female in late 50s with h/o IDDM, CHF, CRI , HTN, and asthma who presented after hypoglycemic episode. Earlier in the morning she tripped and fell on the floor, and she measured the blood glucose, which was 28, and was taken to ED. Before she came into ED she took OJ with extra sugar, and upon presentation her glucose shooted to 394. ED physicians didn't listen to her insulin regimen, which she's been on for 35 years, and just gave her 10U total of regular insulin. She has been experiencing SOB and fatigue and she "self-adjusted" diuretics. She is extremely sensitive to medications, and in the past she couldn't tolerate ACEI or beta-blocker, she is truly allergic to sulfa drug (including Lasix) and thus she is taking Edecrin (non-sulfa loop diuretic). She has had a lot of medical problems that she obviously knows about them really well; however, she is pretty demanding and will try to take over the medical management. This morning her potassium level was screaming at us at 6.7. We gave her kayexalate but she doesn't want to drink it and tries to come up with her own plan. She's got EF of 20% and LBBB, we were pretty worried that she will go to VT anytime soon. She said she can't take aspirin because she takes Plavix and it's "contraindicated to take both at the same time." A cardiology fellow talked her out and she agreed to take it. She usually goes to BIDMC up in Boston, so I called them up and have them fax her recent echo and cardiac MRI result. The secretary on the floor gave me a wrong fax number, and then they sent me a blank page first. I hate fax; I'm sure I spent about an hour having them send the records.

Meanwhile, she doesn't have SOB, leg edema, or JVD, her creatinine is already up to 3.1 and BUN is 85, and CXR didn't show any pleural effusion; only vascular congestion. She has a S3 and BNP was up at 1700, but she's got GFR of 16. Cardiology saw her and they said she's got CHF and start on diuretics. So, here comes my question from two days ago; is this person in heart failure? Cards said she is, and I'm thinking if we talk to renal team they'll say she's got acute pre-renal failure on CRI. Her story sounded like she was dehydrated from increase in her diuretics, and A and I initially agreed on giving her some fluid very slowly and see how it corrects her renal function and excretes extra K and glucose out. Cards said stop the fluid and give her diuretics. I'm sure they have lots of experiencing calling CHF but this still was unclear to us. Will see what her chem-7 looks like in the morning.

Next case was PR, a male in mid 80s with h/o CHF, AVR, DM and bladder cancer s/p transurethral resection who presented with 2-day h/o chills and SOB. When we first saw him he looked pretty sick and had to be on HF oxygen with a face mask. He was nauseated and vomitting, and bacteremia was suspected. Since he had an AVR we called cards and Ar came up to do a bedside echo. Ar said there isn't an obvious vegetation, but he needs to have TEE to r/o endocarditis anyway. We drew ABG which came back pretty normal, and put him on empiric vanco. Will see how he does o/n.

Two great cases today. The first one was a dilemma whether we should be treating heart or kidney first. I thought she was volume depleted and considering she doesn't have any SOB or CP, I thought she could tolerate the fluid. I mean, I don't see any fluid that's hanging around in her chest or lower extremities; where does the diuretic pull out fluid from? I wasn't really convinced, but we followed the recs. The other case was sort of an acute setting that I got to see the bedside echo. I really like echo, much more than cath (well, I don't like invasive stuff in general). It did look like an acute presentaiton of endocarditis, and we were kind of worried about his respiratory status (even thought about intubating him). He seemed to be satting fine at facemask. I hope he feels better tomorrow.

12/10 (Sun) Cards won and she tolerated diuresis, troponin going up, lots of drama on the floor, TA transferred to ICU again, it'll be a long night.

Post-call. PR did well overnight. He has been switching back and forth between facemask and nasal canula, but he is not rigoring anymore. No CP or petechiae. CXR from this morning did show some lobar pneumonia, which he was already started on empiric moxi. Blood cx also showed some staph in it, so we'll keep the vanco running as well.

Overnight, she tolerated the diuretics and her creatinine didn't go up. So, cards won. It was probably a good idea because VK's troponin creeped up to 6.7 and this morning it was 9.1. Probably her ischemic ventricle at baseline is screaming at us to reduce the strain and workload by reducing the preload. Last night Re had hard time convincing her to take IV heparin, but she finally agreed. Ar saw her this morning and he convinced her to take other meds as well. Maybe we should talk to Ar first before starting any more meds. Her husband is such a nice guy, he thanked me for getting all the records from BIDMC (I didn't think that I will be thanked by the family member on this!) At this point, her condition is pretty stable but all her meds may be masking the symptoms. We discussed with cardiology what kind of diagnostic test she can go through to assess her coronary status (she has asthma and CRI) and we'll decide after we get the lab work done tomorrow.

Felt like I saw a lot of patients today including the ones I'm not really involved. There was a meeting with the family member of LT, who has long standing schizophrenia and VSD that his right heart basically stopped working anymore. He has a very bad leg edema and he is not tolerating diuretics (he doesn't understand the treatment pjlan and just drinks more fluid). We've tried everything to make his heart pump but looks like everything failed at this point. Family member wants SNF placement with IV Bumax. He'll most likely bounce back to us, but at least he has a decision maker. Re's x-cover patient went into respiratory failure but we successfully brought her back. A lot of drama happening on Sunday afternoon.

I saw Dr. R in 4B and asked her about TA, and he asked me if I wanted to see her. We went in, and she was lying in bed, not really responsive. We thought she was given morphine earlier, but turned out that her blood pressure was bottoming down. Earlier CT abdomen showed some complication by the PEG tube, and she was subsequently transferred to ICU. I went to ICU with her, talked to R who is rotating ICU this month. At this point, TA looked like she is in septic shock, so we started on vanco & cipro, and pressors were given to bring her up to MAP of 50-60. Very critical condition. R said she'll call me up when things deteriorate and told me to go home. I debated if I should stay or not, but I concluded that I can't handle another catastrophe happening in front of my eyes tonight. I'm so tired, I need some rest to handle what's going on.

Tonight will be a long night for TA; I hope I won't get a call from R.

12/5 (Tue) New team with caring resident/interns, syncope and CHF exacerbation, letrozole vs tamoxifen study in journal club, felt like a short day.
12/6 (Wed) Thoracentesis, chatting with Dr. S, both patients got D/C'd.
12/7 (Thu) Day-off! but came in for lectures, diagnosing CHF, syncopal workup, TA getting a new PEG tube.
12/8 (Fri) Attending round in Seven-Star bakery, reaction to Bactrim? get ready for another call weekend.

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12/5 (Tue) New team with caring resident/interns, syncope and CHF exacerbation, letrozole vs tamoxifen study in journal club, felt like a short day.

Long-call. Grand round at 8am, and met my new resident Re at 9am. New interns are N and A. New schedule started, and I'm on call again. Assigned a new patient who came in with syncope; Re thought this would be a good exercise for syncopal workup. Went down to ED but the pt wasn't in. Turned out that ED physician already ordered carotid US, CT and MRI right away. I found her in non-invasive lab and started getting history. JH is a lady in late 70s with h/o left breast cancer s/p lumpectomy who passed out while she was helping her husband, who is also in ED, sitting on the toilet in the bathroom. Considering her negative history of cardiac causes, sounded like a classic vasovagal syncope, and of course everything came back negative. I've got no idea why MRI was sent (were they worried about brain mets?), and this is one of those things that turns me away from going into emergency medicine.

Ethics round at 11am, and Journal club by S at 12pm. M presented a GI bleeder case during preceptor round. Finished up writing H&P on JH and picked up another one. GA is a female in early 80s with h/o of The Miriam Special who came in with SOB. Most likely an early CHF, put her on diuretics. Didn't interact with the interns because we were doing our own stuff. Re took some time and let me present a case. She obviously cares about teaching. After the second case, she let me go home.

12/6 (Wed) Thoracentesis, chatting with Dr. S, both patients got D/C'd.

Post-call. Came in early and finished seeing both. JH was doing absolutely fine. GA weaned off O2 but apparently she had been picking her nose or something, and since she is on Coumadin and her INR was 4.0 the day before, she started to bleed for a long time. She was somewhat distressed about it, and made sure that she won't touch it again.

M&M was about gadolium toxicity and dermatological manifestation. Went to the morning report by residents for the first time. The case was about a man with ITP since childhood who came in with HA and severe thrombocytopenia. Interesting to see residents, chiefs, and attendings doing basically a PBL.

Started rounding, and we decided to do thoracentesis on one of the patients. It was my resident's second time doing it, so I got to watch this time. Got out about a bag full, and subsequent CXR showed pretty good improvement. The attending round with Dr. F was cancelled because of the urgency of the procedure, but we chatted with him for 5 minutes. He's very nice.

Noon conference was about depression by Dr. B. There was a family meeting about making patient CMO, and it was pretty painful because the pt didn't look really bad. Did a couple of stuff and somehow I ended up going to the applicant's meeting with Re. Chatted with Dr. S and Su. Dr. S' son is going to Kyoto next April for a conference. He strikes me as a great mentor/father, and I always feel relaxed after talking with him. JH got somehow discharged, and even A didn't know when she was discharged. She was basically staying o/n for observation, so she was pretty much clear from the beginning.

GA's INR was floating around 3.4 and the attending wanted her to stay one more night. GA insisted going home and she looked very anxious. After discussing with the attending again, we made a deal with her and gave her a lab slip to check her INR tomorrow and follow up with her cardiologist immediately. Re and A are very good at teaching. They give me very good tips and always pimps me in a very nice way. N seems to be caught up with her stuff but very nice regardless. Followed several other patients with the team and went home.

12/7 (Thu) Day-off! but came in for lectures, diagnosing CHF, syncopal workup, TA getting a new PEG tube.

Day-off. Since I didn't get a day off for the past 2 weeks and I'll be working again on both Sat and Sun, Re and I decided I get a day off today. Well, there is still a physical diagnosis round and preceptor round to go to, but at least I could sleep in the morning.
It was actually my turn to present something during physical diagnosis round, and I got an article from last year's JAMA titled "Does this dyspneic patient in the emergency department have congestive heart failure?" (Wang CS et al, Oct. 19, 2005, 294, 15, 1944-1956). The article is a literature review that talked about the cardinal features that distinguishes CHF from other dyspneic conditions (like COPD exacerbation), and briefly touched upon the current consensus about the use of BNP. The problem with these studies is that Dx of CHF is so clinical that there is significant limitation in comparing different studies. To me, the lack of clear criteria for heart failure other than 78% specific Framingham criteria makes any kind of studies a little ambiguous. ACC/AHA doesn't have a threshold for initiating treatment but ESC is saying EF of less than 40-45%. Looks like a lot of studies are picking arbitrary numbers for setting up a cutoff number for diagnosis of CHF (like 30-50%). Somebody set the definite bar so that we the humble medical students have less trouble reading these articles.

Kicked out of intern report after grabbing subway sandwitch, and went down to library to do some work. Preceptor round at 2pm and presented a case of JH. I think Dr. Goula is doing a great exercise for us; it really helps as going through thorough differential diagnosis and approach as well as realistic management and plan.

Went to see TA, and found her emaciated once again. They re-introduced PEG tube and started tube feeding because she is not putting any weight recently. Talked to the Dept. of Health for ID of AFB and they told me they could only disclose the information to Dr. Kojic who is the designated attending because of the HIPAA rule; however they told me that things are getting more complicated/interesting b/c so far they failed to show any of the mycobacterial organisms we thought it would be...

12/8 (Fri) Attending round in Seven-Star bakery, reaction to Bactrim? get ready for another call weekend.

Pre-call. Morning report, Cl presented a poem and a case, Ru presented a post-call question. N got a day off today and Amanda has clinic in the pm. Census doesn't look too bad, and we D/C'd several patients or made them non-teaching. We'll carry over only 4 patients to a call day tomorrow.

Attending round by Dr. F. He proposed walking to Seven-Star bakery and talk about stuff there other than cases. It was a very nice encephalitis talk and a cup of coffee with a scone, except today was the coldest day we've got thus far.

Basically worked with Re all day. One patient with HIV and PCP was an interesting case; after he was given the 3rd dose of Bactrim, he became pretty rigorous. Question was, is this a reaction to Bactrim but since he already had similar episodes for a couple of days before he was started on Bactrim, ID people said go ahead and finish the course with IV Benedryl ready on the side. He tolerated the 4th dose so it's probably not a reaction. ID attending said that it's probably not a good idea to put a stigma on him for the future that he's allergic to Bactrim given his HIV status, and that's probably a good point.

Noon conference was HPV vaccine, and S presented a hypertension case in preceptor round. Re spent some time doing EKG with me in the afternoon. She is such a nice resident. Signed off around 4pm. We'll get ready for the weekend call.