IM.

Yesterday I was assigned to follow one of the internal medicine residents. This particular physician was currently on the cardiology service, so we spent the entire morning rounding on about a dozen patients.

For those not familiar with academic medicine, perhaps I should explain how rounds work. At least once a day, a particular team of physicians and students will visit their patients, discussing what adjustments need to me made to the patients' medications, etc., and creating a plan for the next 24 hours or so. The ringleader of the circus is the attending physician, and his job is to guide the learning process by asking questions which may or may not directly pertain to the patients the team is treating - it's the Socratic method, basically. The resident doctors and med students attempt to answer the attending's questions while simultaneously writing orders, signing papers, and generally running around like chickens without their heads. If the attending is particularly nasty (or is just in a crappy mood), he will resort to what is known amongst students as "pimping," in which questions are asked in rapid-fire with the sole intent of making the student flustered enough to give a wrong answer. It's not a fun event to witness, and I don't care to think about being on the receiving end of that particular bit of unpleasantness in the future.

Anyway, because the resident was working with cardiology, our team consisted of myself, the resident, another resident, a medical student, and one of the cardiologists. This was a relatively small group; in larger hospitals there can easily be 10 or 15 people on a service. It took nearly three hours to get through all the patients, though only two were new admissions. Since I didn't have the patient list ahead of time, I didn't know much about the patients beyond the two-line blurb on the computer-generated list.

One female patient had pneumonia and bradycardia (slow heart rate). Bradycardia is treated with a pacemaker, but in this case, because she was had no cardiac symptoms, the cardiologist recommended that they skip the pacemaker. Her antibiotics were adjusted and she was told that as long as she could get up and walk around a bit, she would most likely be discharged the next day.

A middle-aged male patient was told that he needed a cardiac catheterization, which would be scheduled for the next day. His Coumadin (blood thinning drug) was halted and he was put on potassium, which reverses the effects of the anticoagulat. Generally, a patient who is about to undergo a surgical procedure is taken off of blood thinners to prevent them from bleeding out. Coagulants can be given if an emergency arises, but those drugs can cause unpleasant side effects, so if possible the easiest thing to do is to wait for the blood thinners to wash out from the patient's system; hence the daylong wait before this particular patient's cath.

Two more patients were discharged after we visited them - the first was an elderly male with atrial fibrilation. I'm certainly not an expert at reading EKGs, but this was obvious even to me - there were three or four extra waves after the QRS complex, and the T and P waves were buried in the "picket fence" waves. The second discharge was a hemodialysis patient who was meeting with a nephrologist as we were filling out her paperwork. I don't recall exactly what put her on the cardiology service.

After we finished rounding, the cardiologist left and the residents and med student finished up their charting and other tasks. Not feeling the need to stand around and watch them fill out paperwork, I left for lunch. I was supposed to return in the afternoon, but had other work to finish up, so I opted to skip the afternoon rounds. Shhh, don't tell my coordinator. ;)