Surgery

Right now I'm in my surgery rotation. Today, even though it's Sunday, we had to amputate the great toe from a man who was diabetic, and also on chemo, and despite the fact that his toe was infected and gangrenous, the fact that we also need to amputate the other 3 toes, and the fact that he's already lost one toe, he was still caught smoking in the hospital bathroom. People. Please.

Other than that, it's been a lot of gall bladders and appendix removals, and surprisingly a lot of bowel resections. Nothing like holding someone's warm, wet innards in your hands and smelling burning colon as the surgeon dissects it...yum. The surgeons are surprisingly easy to work with (considering surgery in general kinda has a reputation) and it's been so busy it's gone by pretty fast. One of the surgeons set a record for number of surgeries last month, my first 4 weeks there. I'm on call 24/7 with them too- sometimes still rounding at 9pm when a call from the ER comes in. Interesting, busy busy life.

prison

I never thought I'd be sitting here at home in the evening, practicing square knot technique, and worrying about a prisoner. But I'm sitting here thinking about a guy who came in today worried about a mass he found on one of his testicles. If I were working on "the outside" at the moment, I'd order labs and an ultrasound, possibly even a CT or MRI after that, in a heartbeat. But working within federal government rules and protocol, all I can do is get the labs and put in a request for an ultrasound, hoping and praying it goes through. I even had to argue my case: this guy is 34- prime age for testicular cancer. The mass is hard, immobile, and unilateral. He's lost some weight in recent months. And he's worried crapless. As I would be, if I were in his situation. Ok, yes, he is a prisoner, he did a crime, and in general, I agree that you loose many basic privileges if you commit a crime. I even think that extends to some areas of health care, for example, cosmetic procedures or medications, or even just the luxury of having medical at your beck and call. But for something potentially life-threatening like a mass growing on a body part, I do believe that some form of diagnosis should be available. So I'm sitting here thinking about how I worded the report, hoping the government agrees with my recommendation that an ultrasound is necessary. At least I'll have the lab results I suppose, which include some tumor markers, but that still doesn't make up for an ultrasound. I'll probably be on to my next rotation before I even know what happens to this guy. Kinda sucks.

Balls?

So I'm doing a physical exam on this girl who comes in with her mother. I'm feeling her neck for lymph nodes and she's saying yes it hurts pressing on them and her mom says "She has balls in there, can you feel the balls in there??" Obviously she means lymph nodes, which feel like little rounded things under the skin, so I say yes. And she says "I have balls in my neck. I always get balls in my neck and I can feel them, little balls in there." Hahaha, and her kid and I are totally cracking up but trying to cover it up, it was hilarious. Probably the funniest thing I've heard a patient say yet, and she was so adamant about it too!

Green vegetable apparently cure diabetes, news to me...

Me: "Your A1C is 13.6. This is very very high, as the normal range is 5-6. Have you been taking your diabetes medications?"

Patient: "Well, I take them when I feel like my blood sugars are high."

Me: "You're measuring your blood sugars with your glucometer then?"

Patient: "Oh, no, I can tell they're high when I eat certain food. Like meat. Or when I don't eat enough vegetables."

Me: ...

Patient: "But when I eat green vegetables my blood sugars are better. I think I don't need the medication, I feel fine when I eat the green vegetables. I think that's all I need to do."

Me: " are you exercising?"

Patient: "no"

Me: "Do you have excessive thirst?"

Patient: "Oh I've had that for years"

Me: "That's from your severely high blood sugars. Has your vision changed?"

Patient: "Well yes but my whole family has eye problems"

Me: "Your whole family also has diabetes, and your poor vision is actually due to your high blood sugars too. Do you have to urinate a lot?"

Patient: "I always pee a lot. But I think if I just eat more green things I'll be fine, it really makes my blood sugars go down when I eat green things. But meats make it go up. So I think I don't need the medication, I can just eat more greens"

At this point I had to convince this patient that she REALLY needed to take her medications because with sugars this high she would end up like the rest of her family, all of whom had diabetes and the ones that were older than her had already died of complications, including both parents, all 4 grandparents, and 2 siblings- leg infections, amputations, and such. What could be more convincing than her family history?? But she seriously believes that if she eats more greens she'll be fine.

A scary and frightening life is the best kind!

A scary and frightening life is the best kind! ?? Really. That was my thought as I was driving home tonight.

Tonight I volunteered at a free clinic that's available for area people without insurance. I wasn't too excited at first to spend an extra 3-4 hours in a clinic, after 9-10 hours in my rotation clinic all day. But after I got there things changed. There were 2 first year students there who would go into a room with me and watch how I took a patient history and did a physical exam. It was a nice feeling to be able to teach something to someone, and teaching is after all, the best way to get something ingrained into your head. Plus, it was really nice to meet more first year students and talk to them.

Another great thing was having one of my professors there. Of course, it was really good just to see her again. But also, there's a reason teachers are teaching and clinicians are in the clinic. When you're following a clinician, they're teaching you, but at the same time they're seeing the patients that they've maybe been following for years, and they're taking care of clinic business, and a million other things. When you're following a teacher, yes, they're seeing patients, but they also know that the secondary objective is to teach you how to be a great PA and they know how to teach, they know what sort of things to explain to you, and how to correct what you're doing... I learned new things tonight about common diseases that I've seen a ton of times already. So that was good.

But the thing is, it was hard. When you're in the clinic day in and day out, you can adjust to the clinic routine, adjust to what your preceptor wants, adjust to how your preceptor treats certain disorders. You start to go with the flow. But when I was in the free clinic it was different- I was with a teacher I'd never had precept me before, being asked thinks I'd never been asked before, and being challenged in new ways. I looked dumb in front of some first year students, and in front of my professor. But I learned more there in 3 hours than I might in 3 hours at my daily clinic. There's always the risk that routine will breed complacency, something no clinician wants, and something that can be potentially harmful to patients. But when things are challenging, and maybe a little scary, then you start thinking, using your brain, you get challenged in new ways, and you grow. I wouldn't be who I am today if I hadn't gone through some of the challenges I've gone through in my life. They've strengthened me. And I think even though the clinic tonight was kinda scary, it helped me grow as a PA. And I thought that was cool. So those were my thoughts tonight!

Rotation #1!!!

So clinical rotations began just yesterday. My first rotation is in family medicine, so there's quite a variety of issues that patients come in with. Flus/colds/sore throats/etc are far and away the leading causes of people coming in. The first day was probably the hardest since I didn't know the flow of the clinic, or the preceptor's preferences, etc. Now that I know just a little big more about things it's a bit easier. I still forget a lot, and feel dumb most the day, but today I think I did several things right, and answered a few questions correctly, so that's encouraging! I know I'll progress as time goes on, it's just hard being patient, waiting for improvement (and working VERY hard for it too- I've been studying all night!). I won't bore you with the few cases I've seen, like I said, mostly just pretty typical stuff. But if I get a funny story or something interesting I'll definitely post it!

Also, it's amazing how fast I've adjusted to the move- this new place already seems like a temporary home and I think it helps to feel like I'll only be here a few months because it makes me feel like my home is now elsewhere...which it is, back home where my heart is. Living at my other place in the first year of school seemed more permanent somehow, so it's kinda nice to know that I'll only be here a short while and that soon (soon being relative when it's 15 months) I'll be back where I belong. But for now, it's quite an adventure!

Money and Moving

So we've all just gotten our financial aid letters for the next year, and the amount is pretty similar to what it was this year, but it's still always shocking to see. So I calculated it out, and INCLUDING weekends and breaks, we pay $154 PER DAY to be in this program. So not including weekends and breaks, it's probably closer to $235.56/d. Wowza. We call that incentive! So I've been keeping busy, making my money work- lots of studying for our huge monster final last test tomorrow am, packing and selling furniture to get ready for clinicals, finding housing for my first rotation, preparing financial aid, studying for this weekend's ACLS class (Advanced Cardiac Life Support), and lots of other things. So here's the current countdown:

This weekend: ACLS
Next week: Whole Patient module
Week after: packing, moving, etc. Last break!
Week after: PPS (professional seminars)
Week after: BEGINNING OF ROTATION #1 (12 weeks of Family Medicine)

First Time in the Clinic...as a student

So a couple of weeks ago I had my first experience "working" in a clinic as a student provider. A couple other students and myself got to "shadow" a professor at a clinic in town. For the first patient we just observed, but after that we got to get a history (ask them questions about what's going on), do physical exams, and help with the thought process behind the diagnosis and treatment.

-first patient: coming in with hypertension for a medication refill. Ho hum.
-Second patient: coming in with a "strange itchy rash" that ended up being eczema, poor guy. The eczema (which is a chronic skin disorder) was on all of his extremities, huge, itchy and painful. Get that guy some steroids!
-Third patient: Lady coming in with knee pain. Another student did her physical exam, and the professor/PA and I agreed it was probably her lateral collateral ligament- so nice to have a PA concur with my "diagnosis"!
-Fourth patient: Got a history from a lady with an itchy dark rash in her neck creases amongst other places... Looked like Acanthosis Nigricans! That's a skin discoloration most often caused by diabetes- and she had a family history of diabetes. Got a blood sugar- way high! Referred her for follow up (and also treatment for a couple other things). That was pretty awesome to recognize something for what it really is instead of what it's being presented as. Wish I knew what happened with her follow up...
-Fifth patient: Lady in for a refill on meds... ho hum

Overall, a fun night! Very tiring though, considering that our buns are plastered in chairs for 90% of the day either in class or studying- all that walking around wore me out! How sad. I'm sure once clinicals start for real in a few weeks that I'll get used to it fast.

Skills

So lately we've been having a lot of skills labs in class, preparing us for the Emergency Room, Surgery, and just practice in general. It's pretty fun! So I thought I'd share some of the things we've learned to do:

-how to do a sterile scrub and prep for the OR (scrubbing into surgery to assist)
-how to do different types of sutures (stitches)
-how to start an IV
-how to draw blood

Those are just a few. Plus all the crazy stuff we're learning- how to clean up large wounds and burn patients, how to treat overdoses, what to do with heart attack/stroke/pulmonary embolism/respiratory distress/etc, and random other emergency situations. Next weekend after our test we're taking ACLS (Advanced Cardiac Life Support). After that is Whole Patient week, then we're officially done with classes!!! It's crazy.

Story of a Chest Pain Patient

So I had an interesting experience that I wanted to share. Scary for me actually, but it's a good teaching point.

Two nights ago my mom called me. I knew she'd been having some angina in the past week, off and on, and I (and everyone else) had been trying to get her to see a doctor, but good luck with that. So she calls me Thursday night and says "Last night I had jaw pain, and suddenly today I'm feeling nauseous and freezing and the chest pain is really increasing, it's lasting longer". When asked what the pain feels like she reported that it is a "pressure", a dull pain that is not severe, but definitely not comfortable (was impossible to get #/10). For some background, she's a 55y/o female with no significant family hx for any disease or disorder other than that her father died of colon cancer; she also takes a baby aspirin QD, and has not changed any medications recently.

Finally I convinced her that it was worth going at least to Urgent Care to get it figured out. Her boyfriend drove her, and by the time they got there he says she was faint and almost passed out. The Urgent Care providers did an EKG-- normal. But based on her sx they were very concerned of the possibility of an MI still, and sent her by ambulance to the hospital.

At the hospital they did another EKG-- normal again. Her vital signs were all normal except for temp which was 100.5 (barely even considered a temp). They drew blood for CPK and Troponin levels, and also took an x-ray. She had absolutely no other symptoms- negative GI, negative pulm, negative HEENT, etc. They also gave her pain medication because her chest pain was still intense.

So at this point I'm thinking MI, anxiety, flu, pulmonary embolism, pericarditis, etc, none of which seemed to fit exactly. So here's what I thought was the surprising part- she was diagnosed with lingular pneumonia. What?!?! Ok. So the lingula of the left lobe is just under the heart, and apparently when she pointed to where it hurt the doc said, "Yup, that's it". No real fever, no cough, nothing to signal pneumonia. But I thought it was an interesting teaching moment, at least for me, because it was so easy to think of heart and acute lung conditions immediately, and not spend enough time considering a broader differential. So when you can't figure out with a patient, think broader! Widen the diagnosis! Don't narrow it down too fast (this is something I have a problem with, so I really thought this experience taught me a good lesson)

And just so you know, they did an IV antibiotic drip (I was lucky to get the word "lingula" from my brother, definitely did not get the names of the medication), then sent her home with 5 days worth of Moxifloxacin, an inhaler, and pain medication (because the chest pain is still there). And she's doing a bit better now. Thank goodness for smart ER providers!

Ah, Pediatrics

What can I say? It's a complete review of pretty much everything we've learned so far this busy, busy year. So my day is study, study, study. How boring. The business of running errands is complicated by the fact that once you're outside in the sun/rain/hail/snow you most definitely do not want to go home after you've finished, sit down at your desk in your dark room, head bent over papers and laptop frantically trying to stuff etiologies, manifestations, and treatment plans into your already over-packed cranium. The light at the end of the tunnel is that spring break officially starts with the completion of the pediatrics test, only 5 days away now. The frightening part is that after spring break, we only have the Emergency/Surgery module, and Whole Patient module before we have our first PPS to prepare us for the coming year of rotations, and then it's out to our clinicals! Clinical rotations start May 17, which at the moment is just about exactly 9 weeks away. So studying our pediatric-review-of-everything-we're-supposed-to-already-know is slightly intimidating because it means finding that there are BIG gaps in memory of what we've already covered...oh well! Power on to get through Pediatrics to our wonderful, blissful, carefree week off!

The Beginning of the long Road

The Road goes ever on and on
Out from the door where it began.
Now far ahead the Road has gone,
Let others follow it who can!
Let them a journey new begin,
But I at last with weary feet
Will turn towards the lighted inn,
My evening-rest and sleep to meet.
-JRR Tolkein, LOTR

Man, I wish I could sleep right now.... Oh well, more stuff to prepare for clinicals (background check, drug test, packing, car checkup, etc), not to mention studying for the last few modules...