Category: Medical

We “fixed” my patient!* She was meeting all the milestone that we arranged for de-escalating her care, namely lowering her triglyceride levels with an insulin drip and so we were able to take her off the drip. She still had some abnormalities on her labs and possible an infection brewing, but nothing that was going to keep her in ICU level of care for much longer. I will say getting regular tangible results like this is a cool thing about ICU. That said, for a lot of the other patients on our unit, things are not at all cut-and-dry and I feel like there will certainly be a degree of intellectual dissatisfaction no knowing whether or not you are treating the right thing, whether or not the patient is doing better because of something you did, or what the actual cause of death is in some patients.

Any ways so far I have been enjoying my time in the ICU. I really like my team so far and the attending and fellow are also super nice and good teachers. Looking forward to working with everyone more. Though I’m going to be off tomorrow for my first residency interview. I’m really nervous, but it is also with my home institution so I think it will definitely help to see some familiar faces throughout this first residency interview experience. We had the pre-interview social with some of the residents tonight, all of whom I had met before (and I just want to be friends with all of them, but that’s beside the point), not sure if the event helped my nerves or not though.

*”Fixed” is a term we use a lot in medicine, often jokingly especially when patients get better inexplicably, or sometimes sarcastically. I’ve always felt it somewhat dehumanizing so I personally try to avoid it, but I also think it is very important to have a sense of humor in this line of work. Also saying “my patient” also is kinda a weird thing.

I regained access and was back in action. I picked up my first ICU patient who was pretty straightforward but and interesting pathology that I hadn’t see before; hypertriglyceridemia-induced acute pancreatitis. It was a good one for me to get my feet back in the water, with a relatively straight forward course and minimal confounding comorbidities and stuff, but still a good learning case that I had to read up on.

I felt pretty confident with my presentation, event though we present a bit differently in the ICU compared to on wards, and I think I did pretty well. The attending and fellow asked some questions and I think I did a decent job of answering appropriately. Personally I felt like my presentations were on par with at least the interns, but that’s probably bias, and also most of the other patients were more complicated than mine. My seniors said I did a good job though which always feels good.

As far as first impression, while I like the acuity, complexity, and the turnover in the ICU, I don’t get to interact with patients as much or as directly simply because these patients are just so much sicker. They are either intubated or sedated (often both) or just straight up sleepy/ not mentally all there at baseline. That said I can imagine my self finding conversation with family and patients (in whatever capacity they are able to participate) regarding goals-of-care and just treatment plans, so we’ll see how much opportunity I get to see/ do that.

This is my first time back in the hospital in almost 2 months. I had a hard time sleeping last night because I was afraid I had forgotten all of medicine and how to work in the hospital. Fortunately when I got there, everyone was super nice helping me get oriented. The only issue was my access to the EMR was disabled so basically was locked out of the one thing that makes me useful as a medical student. So I spent the majority of the day figuring that out, but did follow the team for rounds, then got sent home early. It felt good to be back in the hospital and think about medicine-y things again.

Overall I’m looking forward to this rotation because I’m thinking I’ll get to see some pretty interesting pathology and hopefully see/ participate in some cool procedures.

Artificial intelligence, large language models, and generative AI are likely going to be a part of our future as a society whether we like it or not. Just like with any new technology, there seems to be a lot of concern that this kind of technology is going to take people jobs and ruin livelihoods and the economy, or even destroy humanity as we know it.

What I do know is that in the past, when emerging technologies (such as automated machining tool, weaving mechanism, etc) were presenting similar concerns, it changed how people worked instead of replacing people outright.

I think AI is going to change how we practice medicine and how people engage with their health, with doctors, and with health systems, but I don’t (or perhaps can’t/ refuse to) believe that this kind of technology could ever replace flesh and blood physicians, at least when it comes to the things that matter. I believe AI will prove to be a powerful tool in our ability to deliver high-quality, evidence-based care and in our ability to analyze large data held in EMR systems, currently limited by the time and volition of exhausted medical students.

What I also believe is that if we don’t acknowledge a place for AI in the future of medicine and take an active role in its integration, the current practice of medicine will be replaced with one that involves AI, whether that involves real physicians at the helm or not. (Check out one example of a company trying to address this)

Let’s talk about it.

This second half of my Sub-I went by super fast. After the team change I felt like I had to pick up more responsibility for various reasons. Part of it being that I was the only person on the team with prior experience with the large majority of our patient and knew their cases pretty well, so even with patients I wasn’t directly following, the interns and senior looked to me to get a sense of the patients’ overall trajectories and trends. In one case, we had a patient who kinda kept cycling between health and decompensation (often right before we would be planning discharge), and I had a random thought to ask about potential ingestion that were not on his med list. Turns out he kept getting this supplement from home that was tanking his blood pressure. This was more of my own imagination and the influence of watching House than my personal relationship with the patient, but it still felt good to be the one who figured it out. We also had the most jaundiced, healthiest-acting person with likely terminal liver disease that I had ever seen. It looked like he had been colored over with a highlighter, but he was always in a good mood, feeling good and just overall a nice guy. I’m sad that my sub-I ended before I was could see one of the patients I had been working with the whole time. I had gotten to know the family and was seen as the primary point of contact from the medical team. Our plan for this last week I was on was to have a goals of care discussion with the family. The patient and family asked if I could be there, but sadly my last day was the day before. I hope he did well and is now on the way to a decent recovery.

Having this rotation right after doing a month of inpatient family medicine was nice. I think I definitely confirmed that I want to at least train with inpatient components and possible continue being able to do inpatient after residency.

This week as gone by super fast. Not too much to update on. Still the usual feelings of not doing enough but at the same time feeling like I’m miles ahead of where I used to be and that I am making real contributions to the team and patient care. I did get feedback from the attending this week who said that he thought I was doing well and above what was expected of me which felt good, but can’t help that voice that says it’s not really real.

I think for the first time, one of the patients I was following passed away while in the hospital. It was very sad and I fear that her last days were not the most comfortable (she had Alzheimer disease and was constantly fighting us off, even her daughter). The patient past away early in the morning before shift change and with the family in the room. My resident spoke with the daughter afterward which I think was really impressive example of empathic medical condolences, something I would like to be able to practice, but feels like an opportunity I probably won’t be allowed to have until I’m a resident myself.

Otherwise this week we also got a bounceback, though it’s questionable whether or not she needed to be admitted, but it’s ok I don’t mind, she is a very nice lady, easy to talk to and she would help me practice my Spanish.

It’s been a long week, but I don’t feel super drained. I have a baseline tiredness, but I feel relatively energized to go in to the hospital. The only terrible, worst-ever thing is the traffic to get there and go back home. It’s the worst.

Weekends are half-days on at this hospital which is kinda interesting, but it makes the 6 day work week a bit more bearable so that’s nice. Today I picked up a new altered mental status (AMS) patient. These cases are always interesting because the differential for what could be causing it is so broad (also I don’t mean to refer to patient’s as their presenting problem, but in these I’m trying to depersonalize the story as much as possible). We get to do a lot of test and narrowing things down. The unfortunate part is that, at least in the cases of AMS that I’ve seen, sometimes we never get a hard and fast answer. Either it resolves because we are treating multiple things at once or it never resolves despite us addressing most of the typical things that would cause it and the rest of the work up is negative (diagnoses of exclusion are often unsatisfying to me).

Anyways we did a quick rounds with a different attending (from our sister team), finished our notes, our senior signed out and we got to go home by the early afternoon.

For those that know me, you know I really hate traffic. It is one of the few reasons I would not want to live long term in LA. It’s not just the enormous waste of time and resources the traffic causes, but it also is just a full-frontal confrontation with everything that is wrong with society. Perhaps I’m being a bit dramatic, but when I look at traffic all I can think about is how much car exhaust is being spewed into the atmosphere and how sucky our public transportation is and how selfish we are as individuals to have personal vehicles and how unaffordable housing is so people live far from where they work and how we just accept all of this as our reality.

Anyways, I typically feel happier and more energized when I get to the hospital. Today was a pretty chill day. We were on call, but didn’t really get many admits fortunately, though I was kinda hoping for some because my patients right now are pretty straightforward and I want new things to think about. But if any came in after I left, I will pick them up tomorrow. I keep telling myself I will be productive when I get home after being at the hospital, but I want to do is vedge (I deem this the proper spelling cause veg and vej simply are wrong) and sleep. While I enjoy what I’m doing, I’m looking forward to my day off.

The theme today was “goals-of-care.” With really sick patients who are nearing the end of their life or for whom are treatment options are limited, we have a discussion with the patients and their families regarding what the goals of care are and through shared decision-making, figure out how we are going to proceed in light of the present limitations. Fortunately I wasn’t leading any of these discussions today, but was able to be a witness to my senior residents having these kinds of discussions under multiple circumstances, including during a patient’s acute decompensation. This event was a whole experience in itself. Perhaps surprisingly, this is the first time I can think of where I was present and involved in a code. It wasn’t a code blue, it was a code sepsis, but it was still exciting, not in a fun way, but in a “spring-into-action-I’m-not-sure-if-I’m-being-helpful-but-I-want-to-make-myself-available-and-also-I’m-a-little-scared” kind of way.

First (couple) day jitters are gone and I am definitely feeling a bit more confident in my presentations and also just with talking to and caring for my patients. Two of my patients are primarily Spanish-speaking and it’s kinda crazy to see how far my Spanish has come from 10 months ago. It’s still not perfectly fluent, but I can mostly get through brief interview and updates with patients without the use of a translator (though I always offer or have one on standby). I also spoke with a patient and their family today, and they told me how impressed they were with me which was a nice bit of affirmation that always just hits different than being give positive reinforcement by residents or attendings, for some reason it feels more real.