I chose to do a fellowship in Hospital Internal Medicine because I wanted to learn the challenges of managing sick patients in the hospital. I certainly got what I asked for. In ten months, I’ve seen as many zebras as horses. I have laughed with patients, and I have cried with patients. Most importantly I have gained experience and knowledge to begin a career in hospital medicine.
My day starts when I call the physician I am working with and they assign patients for me to see in the morning. Usually they give me their most interesting cases. My first patient doesn’t have just a UTI, she has a complicated UTI with both yeast and bacteria, that is resistant to almost every antimicrobial. This patient needed to be in the hospital, as she could go from not feeling well to septic shock with end organ failure in a very, very short time. Her husband was my first test of the day. He grills me with questions. After fifteen minutes with the patient and her husband, I am able to decrease the patient’s anxiety and answer all their questions. I feel good that I can help ease patients’ fears and anxieties, while educating them as well. After finishing my progress note, I head to the next patient.
Immunocompromised patients can get just about any type of infection. My next patient has SLE on high dose steroids and now has a positive Quantiferon (TB) and Cocci EIA. “What is a Quantiferon anyway?” The physician and I spend a few minutes talking about what the test measures. We then look at her nodule on chest x-ray and CT Scan, and agree on her plan for the day.
I continue rounding on my patients for the morning. One of my patients just admitted last night is presenting with syncope, a common observation admission. Syncope can be diagnostically challenging, and has a wide differential. This very nice gentleman took a sublingual nitroglycerin tablet in the 100 degree Phoenix heat. After completing a careful history and physical exam, I explain to him he was admitted to rule out any life threatening causes of his syncope. He is stable for discharge (have I missed anything?).
It’s now time to attend the medical resident’s noon conference. It’s a lecture on oncological emergencies, very pertinent for a hospitalist PA to know. I have seen most of them this year already, hypocalcaemia, tumor lysis syndrome, SVC syndrome, PE, and cord compression.
Five minutes after conference my pager goes off. I am asked to admit a renal transplant patient with dyspnea. He is hemodynamically unstable. He is on 6 liters of oxygen already, heart rate is 130, and his temp is 38.9. Pneumonia? It could be your typical pathogens we were taught in school. But it could also be MRSA, RSV, legionella, PCP, cocci, histoplasmosis, tuberculous etc. I have seen streptococcus strands I can not even pronounce. After I have looked the records, labs, vitals, and have seen the patient I present the patient to my attending physician. We discuss differentials. I present my plan. The physicians have been considering my opinion more and more as I learn more in the fellowship. I start entering in a myriad of orders: cultures, scans, urine antigens, and respiratory treatments. Have I forgotten anything? Just as I am about to leave, the ER nurse comes up and tells me my patient’s blood pressure is 66/38. I walk swiftly. I try not to run (although it’s really the first thing I want to do). Can I buy confidence somewhere? The patient appears to be septic. How many lines do we have? Begin sepsis protocol. I wish someone would take a picture of me in this situation 9 months ago and compare it to a picture now. Nine months ago I would look like one of two things: Either a deer in the headlights or someone grappling for the nearest phone to call someone to help. Now, I approach this differently, what type of shock is this? Bolus fluids etc. Patient stable…for now.
I usually will have another admission to do, then do afternoon rounds. It’s 6pm, all my dictations are done, and I update our service sign out sheet. My physician thanked me for the help. I wonder if I helped… but I saved someone’s life by resuscitating them, decreased one patient’s fears and anxiety, learned when to consider a fungal source for a UTI, and learned what a quantiferon actually measures(it’s actually very interesting physiology). That’s a normal day in the fellowship.