Done with neph

Today was my last day of nephrology. It was a quiet week--I don't think I did any consults. The last three days we have finished rounds before noon and I have spent the afternoons wandering aimlessly through the hospital and drinking a lot of coffee (I drink way more coffee on light rotations than on busy). Yesterday I studied a lot, today I played games on my PDA. I think this month has gone by faster than any other rotation I've been on.

Monday I'll start my pediatric sub-i in the intermediate ICU of our children's hospital. I'll share call with three interns--naturally, I'll be up Monday.

I still only have one interview invitation--fortunately most of the other students I know who are applying to surgery also only have one or two, I think a lot of programs haven't even started reviewing applications yet. My friend who is applying to family medicine, on the other hand, has 16 interview invitations a week after turning his application in.

Busy

Things have picked up this week. Instead of leaving sometime between 1 and 4 it's been around 6 or 7. Today though, we finished rounding early and have not gotten any consults. Which is why I'm typing this now.

One of the consults I saw on Monday was a woman in her early 30s who came in with a blood pressure of 220/100, elevated troponin (measure for heart attack), and chest pain (we saw her because she's had renal failure for the last few months). The EKG showed some s-t depressions but no elevations. The cardiologists weren't sure if she had had an MI or just a bad hypertensive episode. What was particularly interesting was that her brother had been admitted the day before for a heart attack. Yesterday she was transferred from the ICU to the floor in the room across from her brother. When I went to see her, she and her brother were both playing cards in her room in their hospital gowns. It was kind of funny in a not-funny sort of way.

We've had a lot of really sick people who have very poor prognoses. For most of them their kidney disease is just the tip of the iceberg.

I got my first interview invitation a couple days ago--as I had gotten two rejections the week before I was (am) very excited--I might actually be a surgeon someday.

Sitting around

We rounded this morning--we finished around 1:00 and there were no consults so I went home and asked the NP to page me if anything comes up. While I'm definitely not complaining about the free time, and there is something kind of fun about being able to leave a note in the chart and have someone else actually do all the work of caring for the patient, I find that I'm looking forward to my pediatric sub-I next month. Hopefully in 4 weeks I won't re-read this post and think what an idiot I was for wanting more to do.

Conference

It's been slow. I go in on the morning and write a note on 2-4 patients. We round for a couple hours. In the afternoon I read or occasionally see a consult. I go home at 4-5. Tuesdays we have case conference from 3-4. Last week I left at four with all the other students and residents because the PAs told me I didn't need to stay for the 4-5 conference. Naturally, the next day my attending asked why I hadn't been there (the PA told her she told me to go home). So, today I stayed for the 4-5 conference--all the students and residents left, leaving me in a room full of many attendings and 3 fellows. I asked my attending if I should stay and she gave me an non-commital answer which meant that I should. So I stayed--the speaker came fifteen minutes late. He then tried to get his power point presentation up--he was gradually joined by three other doctors who tried to help him. I looked around and realized that my attending had left. At 4:30 the chief announced the talk would be postponed until next week. This whole situation struck me as incredibly amusing--all these doctors completely thwarted by a stupid computer. It also showed how dependent we are on power point these days--public speaking has become a lost art.

Gulliver's Travels

I've been debating whether or not I should post this, and have decided that I will. Let me preface it by saying that there are many, many really great lawyers, I have known several great God-fearing lawyers, and I am of the strong opinion that we need many more Christian lawyers and would in fact encourage Christians to go into law. That being said, here is a passage from Gulliver's Travels (published in 1726), that, if nothing else, I think hits home the fact that there is nothing new under the sun. Gulliver is talking to his houyhnhnm master about law in Britain:

I assured his honour, that law was a science wherein I had not much conversed, further than by employing advocates, in vain, upon some injustices that had been done me. However, I would give him all the satisfaction I was able.

I said there was a society of men among us, bred up from their youth in the art of proving by words multiplied for the purpose, that white is black, and black is white, according as they are paid. To this society all the rest of the people are slaves.

For example, if my neighbour hath a mind to my cow, he hireth a lawyer to prove that he ought to have my cow from me. I must then hire another to defend my right; it being against all rules of law that any man should be allowed to speak for himself. Now in this case, I who am the true owner, lie under two great disadvantages. First, my lawyer being practised almost from his cradle in defending falshood; is quite out of his element when he would be an advocate for justice, which as an office unnatural, he always attempts with great aukwardness, if not with ill-will. The second disadvantage is, that my lawyer must proceed with great caution: or else, he will be reprimanded by the judges, and abhorred by his brethren, as one who would lessen the practice of the law. And therefore, I have but two methods to preserve my cow. The first is, to gain over my adversary's lawyer with a double fee; who will then betray his client, by insinuating that he hath justice on his side. The second way is, for my lawyer to make my cause appear as unjust as he can; by allowing the cow to belong to my adversary; and this, if it be skilfully done, will certainly bespeak the favour of the bench.

Now, your honour is to know, that these judges are persons appointed to decide all controversies of property, as well as for the tryal of criminals; and picked out from the most dextrous lawyers, who are grown old or lazy: and having been byassed all their lives against truth and equity, lie under such a fatal necessity of favouring fraud, perjury and oppression; that I have known some of them to have refused a large bribe from the side where justice lay, rather than injure the faculty, by doing any thing unbecoming their nature or their office.

It is a maxim among these lawyers, that whatever hath been done before, may legally be done again: and therefore they take special care to record all the decisions formerly made against common justice, and the general reason of mankind. These, under the name of precedents, they produce as authorities to justify the most iniquitous opinions; and the judges never fail of directing accordingly.

In pleading, they studiously avoid entering into the merits of the cause; but are loud, violent and tedious in dwelling upon all circumstances which are not to the purpose. For instance, in the case already mentioned: they never desire to know what claim or title my adversary hath to my cow; but whether the said cow were red or black; her horns long or short; whether she were milked at home or abroad; what diseases she is subject to, and the like. After which, they consult precedents, adjourn the cause, from time to time, and in ten, twenty, or thirty years come to an issue.

It is likewise to be observed, that this society hath a peculiar cant and jargon of their own, that no other mortal can understand, and wherein all their laws are written, which they take special care to multiply; whereby they have wholly confounded the very essence of truth and falshood, of right and wrong; so that it will take thirty years to decide whether the field, left me by my ancestors for six generations, belong to me, or to a stranger three hundred miles off.

In the tryal of persons accused for crimes against the State, the method is much more short and commendable: the judge first sends to sound the disposition of those in power; after which he can easily hang or save the criminal, strictly preserving all the forms of law.

Here my master interposing, said it was a pity, that creatures endowed with such prodigious abilities of mind as these lawyers, by the description I gave of them must certainly be, were not rather encouraged to be instructors of others in wisdom and knowledge. In answer to which, I assured his honour, that in all points out of their own trade, they were usually the most ignorant and stupid generation among us, the most despicable in common conversation, avowed enemies to all knowledge and learning; and equally disposed to pervert the general reason of mankind, in every other subject of discourse, as in that of their own profession.

Wasting time

This is a very light service--we have an attending, a medicine resident, and 2-3 PAs/NPs depending on the day to monitor about 12 patients. My duties consist of visiting my two very straightforward patients in the morning and writing a note. So far I have also done one H&P on a new patient. The rest of the day we round, then I go home (5:30 yesterday, 1:00 today:). The attending is constantly teaching me and the resident though, which is a rather unique experience for me--since the teaching occurs in between patients on rounds, the PAs find it a little frustrating though. Since this is an elective, I also get weekends off.

Yesterday I went to a medicine M&M for the first time (when I was on medicine last year, M&M and grand rounds were cancelled for the summer)--it was the total opposite of surgical M&M which consists of residents' presenting their patients who either died or had something bad happen to them, followed by the residents' being grilled and yelled at by the attendings (despite the fact that the attending is the one who actually made the poor decision). The medicine M&M however did not pick on the residents at all--one of the chief residents presented a patient and the chairman called on attendings to ask what their thought processes were. I tend to favor the medicine method, though I have to admit I don't think they needed to spend an hour on the one patient (surgical M&M goes over at least 5 patients in an hour). I went to medicine grand rounds this morning which was exactly like surgical grand rounds: 5 minutes of useful information embedded in 55 minutes of sleep-inducing information that is useless to everyone except for the person in charge of the research.

One of my two patients is an 81 year old woman who has been on peritoneal dialysis for the last year (peritoneal dialysis is dialysis that consists of injecting the dialysate directly into the abdominal cavity--the abdominal wall acts kind of like a filter, then the dialysate is drained back out). She came into the hospital over the weekend with an umbilical hernia which she had repaired--she now needs to be on hemodialysis (the patient's blood is sent through a filter and put back into the patient) for a month. I find that I am much more interested in her from a surgical standpoint than a medical.

Nephrology

I have finished the breast disease rotation. Nothing particularly interesting happened the last few days except that I missed a really interesting operation because no one told me they decided to operate on Friday instead of this week.

I got a three day weekend, and started nephrology consults yesterday. As a consult service, we basically just give advice, so we are not responsible for writing orders, dictating discharge summaries, etc, which means it is a pretty easygoing rotation. They do love rounding though--fortunately, the attending also likes teaching so I am learning instead of just tagging along with a team whose attending does not even make eye contact with the students (rare, but it does happen).

Last night I submitted my residency application--once submitted, one can no longer make changes--it was a little nervewracking. Now, I will be obsessively checking the website to see who was downloaded my application (so far about half of the programs). My last letter and transcript have not been uploaded to the site yet though.