Treatment of acute pulmonary embolism in patients with lower gastrointestinal bleeding risk

Tomorrow (12/13/2012) at 8-9 am, I'm giving a brief conference presentation on "Treatment of acute pulmonary embolism in patients with lower gastrointestinal bleeds" at St. Luke's Episcopal Hospital in the Texas Medical Center, Houston, Room C030 on Level B1 near the Cooley auditorium (St Luke's Episcopal Hospital TMC).  I'm happy to have the opportunity to do this and I am fortunate to have received considerable advice and assistance from the attending physician (a gastroenterologist) on this rotation Dr. Lyone Hochman.  I like this topic because there is relatively little guidance in the literature and a potential for optimizing patient safety.  I may explore this topic further as well in the future.

Gastroenterology rotation

This month I started a gastroenterology rotation at a private hospital. I have the privilege of working with a very experienced and highly respected gastroenterologist attending physician. In terms of workload we see 2 to 4 patients and maybe one or two consults. The attending has more patients than this, of course. However discussing and supervising the "teaching" patient cases is relatively time-consuming for the attending physician and if there are too many teaching patients to be seen (not a problem on this part of the rotation), rounding and supervision becomes very rushed and sometimes not very useful from a training perspective. Fortunately we have plenty of time for observing procedures such as EGD's and colonoscopies. A third-year medical student is also rotating on the service. This medical student is extremely smart and very helpful. Depending on how many patients we have on our service or what lectures the medical student must go to, I may have the student see all the patients and then pre-round the the patients with him. At this hospital with hospital we (the residents and attending doctors) can addend medical student notes and depending on what the schedule is exactly, I may write a few complete or all of the progress notes and consult history and physical notes (documents). This way I can talk about the patients and pathologies with the student before we meet with the attending. The medical students On my service usually find this helpful and they are more prepared when the attending asks them questions about the patient and associated illnesses and treatments. I certainly learned a lot from teaching the material as well. I just started this rotation and thus far the cases have been relatively straightforward. I hope to see a difficult or complicated or unusual case soon because need to give a presentation next week as part of the gastroenterology conference. Although I'm not required to work on weekends for the gastroenterology service at this time, I am on call for the hospital where I'm rotating. I may see an interesting gastroenterology case during my overnight call because I see so many patients. Another possibility for the discussion at the hospital gastroenterology conference this coming week might be some of the cases from last month when I was on the transition rotation. Patients with cerebral palsy and spina bifida and other congenital conditions can have life threatening problems with chronic severe constipation not effectively treated with laxatives, bowel motility agents or rectal enemas and have surgical anatomical modifications to their GI tract in addition to daily motility agents or laxatives (such Polyethylene Glycol 3350 - brand name Miralax) to help prevent bowel perforation and other medical complications of chronic . For example, see the MACE modification (see http://en.m.wikipedia.org/wiki/Malone_antegrade_continence_enema).

Ambulatory Month

End of the rotation
I'm winding down my day here at 1 AM and thinking about how this month has gone. It's not quite over, but I have the evaluation notice e-mail in my inbox so the end-of-month or end-of-rotation can't be far away.  At the end of every rotation we are required to evaluate the rotation itself, the attending physicians, and supervising residents (if applicable).  I usually try to put down something meaningful.  It gives me an opportunity to reflect what I might want to do in the future to be a reasonably pleasant upper level resident someday.

The ambulatory itinerary 
All categorical Internal Medicine residents here at BCM spend a month in various outpatient clinics. I feel a bit like being a gypsy or traveler because there are so many different clinics.  For example, later today I will start at a VA infectious disease clinic in the morning before going to my regular primary care clinic in the afternoon.  Earlier this month I was at an outpatient neurology specialist clinic.  A couple of days ago, I was on call at St. Luke's admitting patients for a wide variety of conditions and writing orders for patients who needed adjustments to their therapy overnight ... this is probably why my sleep schedule is abnormal as I adjust from overnight back to day service.  Frequently this vagrant schedule means missing morning report sessions, noon conferences, and Grand Rounds because of the inevitable issue of closing out one's work at one site before moving to another clinic (or simply allowing time to travel across the medical center). Many attending physicians don't go to these teaching sessions and more or less seem to be unaware of them; they do have busy clinics to run, after all.

Benefits
The benefit of the above arrangement is that, as a resident, you see a variety of settings and probably learn a broader scope of outpatient care. Each specialty clinic has its own way of operating and unique set of patients from which to learn. For me it helps me remember diagnostic criteria and treatment options if I have seen at least one patient with a particular condition, whether liver failure or arthritis.  Another excellent benefit of the ambulatory rotation is that it allows time for life outside the residency program.  I spent a lot of time with my family this past month and that will change a bit on ward months.