Well, that's that.

All done, last Friday was the final day of my clinical rotations. Graduation is this coming week, and then it's time to hunker down for a couple of weeks in preparation for my national licensing exam, the PANCE.

I'll also continue applying for employment over the next few weeks. I've had a few offers to interview, from pediatrics to neurosurgery. I've been offered employment at my last clinical site (internal medicine/pain management), but I'm keeping my options open at the moment.  First thing to do ... is pass that test!

Thanks for walking alongside me during my journeys through this clinical year. I'll keep you posted on how things turn out and what I end up doing. I hope that all of you continue on with your dreams ... don't ever let anyone tell you that you can't. 

Sometimes it pays to go the extra mile.

Today was my last day at my current site, and it ended on a soundly resonate note.

This site sees a lot of pain management patients, who are thus tested with toxicology screens once a month. These screens are urine tests which show any other substances in their system, such as cocaine, methamphetamine, or opiates other than those which they are prescribed.

I was doing a screen on a patient, a female in her 40s, and when I was doing the lab work I noticed a color to her urine that struck discord with my clinical sense. Although we are not to dip the urine of these particular patients with a standard lab dip (which will show the overall physiologic impression of the urine, for patients who we see outside of a pain management situation), I did anyways. Sure enough, it was positive for bilirubin and a significant amount of blood. Urine can sometimes show bilirubin in cases of dehydration or fasting (as well as pathophysiologic conditions such as hepatitis), but shouldn't normally show blood. It can show blood in certain situations, one being if a female is menstruating.

I went in and asked the patient if she was on her period, and she stated that she had a complete hysterectomy in 1996. She also had not recently engaged in sexual activity. So there was little chance the blood was associated with anything other than some type of pathology. What that pathology was, was unknown (it could be due to a plethora of possibilities, from kidney stone to UTI to cancer to etc). I did a thorough abdominal exam and found extreme tenderness to palpation at her RUQ (right upper quadrant), which narrowed the focus a bit.

I went to get my preceptor, the Doc who owns and runs the practice (the man who was an ER Doc for many years). I told him that I had done a standard urine dip on this patient, to which he responded fiercely that I should have consulted him before doing such a thing outside of protocol. I told him what I had found and we went to see the patient together. He examined her and asked her a few questions, then sat down to help her figure out what she should do next. I had already started seeing another patient, so I said, "my work here is done" and opened the door to leave the room. "Thank you", he said to me as I walked out.

Sometimes you just have to go with your gut.

5 more weeks at one last site, and then I will officially be done with my clinical year. If all goes well, I will then graduate and be ready to sit for the national licensing exam. Fingers crossed.

Seekers.

'Seekers' are people who are addicted to prescription medication (usually narcotics), who have typically been denied at their first source so they move on from clinic to clinic. The Doc who runs this clinic is pretty stringent, I've seen 3 new 'patients' taken out in handcuffs in the 4 weeks I've been there. He catches them by calling their 'references' or following up on their 'records'. He placates them long enough to keep them where they are, so that the police have time to get there (they usually arrive in a few minutes).

Today we had a seeker, but that Doc was already off for the day. The other two Docs are older and, while brilliant, couldn't defend themselves against a fly. Well, when the seeker discovered that he was being found out and wasn't going to receive his 'medication', he flew into a rage. I am certainly not a violent person and only fight out of necessity, but I have in my past brought people down who needed to be subdued. I got very aggressive back at him to let him know I meant business, but not far enough to provoke a physical attack. He ended up leaving empty-handed a few minutes later.

I remember a somewhat similar experience in one of the ERs I worked in, with a schizophrenic patient who hadn't been taking her meds. I was in her room washing my hands at the sink, and she started speaking jibberish filled with expletives. A tech walked in the room and she lept out of her bed and attacked them so forcefully that the glass door they fell into, fell out into the hall taking both of them with it. Of course there were about 8 of us right there to cease the attack, but it was still a pretty jarring experience (especially for the poor tech, who thankfully was unharmed physically).

Always good to be on the defense, especially when there are narcotics (or schizophrenics off their meds) involved.

Movin' along ...

I've been on 40 hour weeks, four 10 hour days, but I don't get a lunch break so it's pretty strenuous work. Here's a synopsis of my day today, in short order form:

Osteoarthritic degeneration of both knees
Low back pain related to spinal fusion surgery
Hyperlipidemia
Migraine and tension headache
Urinary tract infection
Obesity/type II diabetes
Spinal pain caused by lipoma
Cervical disc herniation
Crushing injury to thumb
Tibial fracture
Pain related to injury from explosion (loss of right arm and deformed left hand)
Ankle sprain
Pneumonia
Pain related to occupation involving shipyard heavy labor
Right foot fracture
Diabetic in need of podiatry referral
Osteoarthritis of left hand


That was everything I remembered to write down, there are probably a few more I need to add to the list. Exhausted and it's only the first day of my week.

Second day.

We saw 89 patients today, between me and two Docs. Most of the patients I saw they didn't even see after me, they just signed off on the charts. I've never had that level of responsibility before, I was glad to find myself feeling confident but careful.

My feet hurt. 

First day of Preceptorship II (part a)

Our Preceptorships are to be 10 weeks each (my first was), but for reasons beyond control my program had to split my second one between two sites. So for the first 4 or 5 weeks, I'm at one 'primary care' clinic and then I'll end at a different one. This clinic is run by a very experienced ER Doc, and is smack in the middle of a secular area with large production plants on all sides (most of his patients are workers from those plants).

The main Doc is like your own personal lecturer, he is a walking encyclopedia of medicine who bestows gifts of knowledge every minute. It's going to be a blessing to be under his wing for these coming weeks, and I'm sure the time is going to fly by way too fast. The only thing I don't like is that they are simply too liberal with some of their pain management cases, in my opinion ... not all of them, but some. But the clinic is seriously set up, they do their own X-rays, EKG, minor surgical procedures, etc.

Here is a play by play of some patients we saw today ...

1. This patient (40 year old, 20 year smoker) had been feeling short of breath for a few weeks and had started noticing blood in his sputum the past few days. The last practice to see him had diagnosed him with bronchitis and sent him home with antibiotics and an albuterol inhaler. It wasn't bronchitis. There it was on the x-ray, a lumpy, circular-ish sort of mass, compressing on his vena cava. His mediastinum was enlarged from all the other metastases, and we found out later from the radiologist that it had taken over his liver.
 
His wife came in and they both sat there crying while the Doc gave them the bad news (metastatic, 2 to 3 months prognosis). Almost cliche, he said, "I thought I'd have more time". Nope. 

I hate nicotine with every last bone in my body. What a way to begin the day, for all of us. 


2. Sprain of the rotator cuff (shoulder)

3. "Low back pain" ... this was the first pain management case that I saw, and it floored me. The man was on oxycontin, percocet, xanax, and straight up morphine. His doses were maxed and he was asking for more. When the Doc (a different one) asked him where his pain was, he said, "everywhere". I am sure there is more to this than I am educated on yet, from all sides of things, but I don't think I could appease that man by writing for more pain meds. What he needs is locked rehab, and pronto. 

4. Well visit. We saw quite a few of these today, standard physical exams that are required by employers. Check everything, make sure they're in good health.


5. Migraine history, refill of Imitrex. 


6. A guy with radial nerve pain, legitimate. Referred him to a specialist for EMG (electromyography). 


7. A man with no erectile dysfunction, but he couldn't orgasm/ejaculate. His labs showed low testosterone so the Doc started him on testosterone supplement. 


8. Prepatellar bursitis. Rest and ibuprofen.


9. A worker had been hammering and the hammer had slipped out of his hand and flown into his eye. Eye area, I should say, it had lacerated the skin below his eye. His eye was red and obviously irritated, but the patient was a different person once he was reassured that his eye had not been damaged. The Doc sewed him up, took about 6 stitches. 


10. Knee sprain. Rest and ibuprofen.


11. A worker had stepped on a threaded bolt that had gone through his shoe and penetrated his foot, which was now infected. I had never heard of treating cellulitis outpatient before, I was only familiar with it being done in the hospital since it requires IV administration. But nope, they do it there at the clinic, the patient just comes in for a couple hours every day for the drip, and both they and the hospitals save money. Great! This one had been treated with Augmentin (amoxicillin/clavulanate) since Friday but it wasn't getting better, so they started him on an IV cephalosporin and added oral Bactrim (trimethoprim/sulfamethoxazole) to the mix. The Doc also did an I&D (incision and drainage) of the tissue around the puncture site, as an abscess had started to form.


12. Sprained ankle. Rest and ibuprofen.


13. Another case of cellulitis, this one was the elbow joint and the dude had an elbow that stuck out to THERE, if you get my drift. The Doc performed thoracentesis and aspirated the fluid out. It was dark and turbid, and was sent off to the lab to be cultured. Patient was started on Bactrim for now. 


14. Shoulder dislocation. It had actually already been reduced in the ER, he was just here to follow up. 



All in all ... quite a first day, I'm sure I missed some details and patients here and there but you get the idea. 12 hour shifts, starting at 7am. Goodnight!

Wrapping up ...

This Preceptorship is coming to an end, and I'm a bit sad about it. Next will be Family Practice for 10 weeks and then that will be the last of my clinical year. We've endured some gnarly testing on campus over the last weeks, and I'm glad to have made it through. I've started applying for positions already, even though it's a bit early, and was surprised to receive two offers to interview should the positions be open after my graduation. One is in Pediatrics, the other in Neurosurgery. We'll see what happens.

Today we had a young woman who was in for a yearly physical that is required by schools in this area. She checked out, but something just didn't feel right. Her BP was low (90/50), but she was of very thin stature so I wasn't overly concerned. I asked her for a urine sample just for the heck of it and was so glad that I had. Her bilirubin level was high and there was protein spilling. Put it all together with the low BP and what do you have? Dehydration. I asked her if she drinks water during the day, she said, "yes." I asked her how many glasses, and she replied, "one." We sent her for bloodwork just to be on the safe side, along with instructions to drink 6 glasses of water daily. She said she doesn't like the taste of water, so I suggested splashes of lime, lemon, berry or other juice, or to throw in an herbal tea packet which will flavor and color even ice water. It's funny how some people don't understand that dehydration = organ death. Moving on ...

Another thing that's strange is the fact that there are parents in the world who refuse to believe that their children could have poor vision. Take the mom a couple weeks ago, when her daughter's eyes were 20/50 and I told them she would need glasses. The girl started balling and wailing, 'I don't wanna wear glasses!!" ... the mother says to her, "don't worry honey, you won't have to wear glasses." Wth lady, did you not just hear what I said? Of course I didn't say that, but I did say, "yes, she probably will", to which the young lady started bawling again. Then it turned into a little dance between the mom and I, of "no you won't", "yes, she will", for a minute or so.

Then today, we had a young man, age of 6, who was straining just a little too hard to read that 20/25 line. He mistook a C for an O, and read a couple other letters incorrectly, all which led to a visual acuity reading of 20/30. I had him read the lines over twice to be sure. The mom said, "oh, he just couldn't see the letters." She walks him up to the eye chart and asks him, "now tell me, what letter is this?" The young man says, correctly, "C." She looks at me and says, "see? he just needed to see it up close." "Ma'am", I said, "that's the whole point of the test." "No no", she persisted, "he just couldn't see what letter it was." "Right", I said, "that's what makes his vision 20/30." She finally got it, but she wasn't happy about it. The thing that boggles my head is, I understand you want your kids to be this or that, but would you really forsake their better health in an attempt to fool yourself? Oh well, it makes for amusing stories.

I saw Epstein's pearls for the first time today, in the mouth of a 1 week-old. Those are benign and will go away in a couple weeks, but his sclera and buccal mucosa were slightly jaundiced, so we're sending him for some blood work. More than likely it's just his physiology kicking in and getting started, but always better to be safe. Then a 1 month-old with some serious atopic dermatitis, and no, parents, you shouldn't be washing his clothes in Tide.

One of the most sobering things I encountered recently was a 16 year-old father. The mother was 17. He sat in the corner, looking like your typical teen, shaggy hair that hung over his eyes, black t-shirt with some rock band on it. Who would have figured that he would get up to change the baby and hold it protectively and lovingly before the exam started.

You learn something new every day.

The little things.

Such a great day today, I had to share. We have a 15 year-old young man who is hypoandrogenic, his body doesn't produce adequate testosterone and so he needs monthly testosterone injections. He is of very small stature, and is very sensitive about it. Well, he had grown half an inch over the last month, to a current height of 5'5". When he walked out of that office, he looked like he felt 6'6".

Awesome day.

Today

I saw a 19 year-old male, he had been in the ER a few days prior for malaise and viral symptoms. They had run labs on him there, and sent him home. Yet here he was in our office, 6 pounds lighter in only a few days. He didn't look good, poor kid, and he was slightly jaundiced. He complained of pain when I palpated his lower abdomen, but his liver didn't feel enlarged nor did he feel pain when I palpated it specifically. Still, I got a urine sample, which was maxed out in bilirubin and urobilinogen (i.e. definite liver infection). We sent him straight back to the ER, even though the mother said they had run hepatitis tests on him the last time. The Docs called us from the ER (which was considerate of them), to tell us he had been admitted.

Another one of our patients was also admitted to the hospital today. We had seen her a few times over the last month, with viral symptoms. We had even started her on antibiotics on her last visit, just to be careful. Whatever it was, she still worsened and needed in-patient care. In looking through her chart, I was glad to see that my notations had been written impeccably.

A child's gift.

We had a family in today, the father had to work so it was just the mother and the kids ... 3 girls, ages 1 to 8, and the boy, 16 days old. They are a very poor family, with hardworking and caring parents who take the bus to their office visits. This visit was primarily for the newborn, he had blepharitis and had lost 6 ounces. The girls all had rhinorrhea, and the oldest also had some tonsilar/cervical lymphadenopathy with a low-grade fever. The viral sisters needed to stop kissing their little brother on the face, basically. Anyhow, I saw them first and managed well ... no easy task to see 4 kids at once, I can assure you.

My preceptor, a very good PA, had worked a long day operating on a shorter nights sleep. After she came in to wrap things up, the 8 year old held out something to her, a piece of paper with something on it, that she had just ripped out of some book she was holding.

My preceptor didn't respond harshly, but she didn't take the paper. Instead she fussed at the child, slightly berating her for ripping a page out of a book. We finished up, and I opened the door and started to move out into the hallway. The older girl came out behind me, and she held the paper out to me, saying, "do you want this?" I took it from her as I started going to get a broom and dustpan from the hall closet, to clean up their tortilla chip-droppings.  I didn't look at the paper, as I looked over my shoulder to tell her that she shouldn't rip pages out of books. I put it on a shelf in the closet without looking at it, took out the broom and went to clean up.

I saw a few more patients, and then the day was at an end. The front room was littered with crumbs and what not, so I went back to the closet to get the vacuum cleaner. I opened the door and saw the paper resting there on the shelf, so I picked it up and looked at it. She had drawn a picture of my preceptor, writing on her prescription pad and saying, "you come do". And there next to her, she had drawn herself, saying, "thank you". Actually, it looked more like "yoU CoME dO" and "THaNk yOu", but anyhow. I saw too that the 'book' the paper had been torn from had simply been one of those cheap, disposable crossword type coloring books for kids ... hardly a work of literature that was intended for repeated readings by too many more sets of eyes.

I vacuumed and cleaned up, and then sat and waited until my preceptor got off the phone with the pharmacy.  I approached her gently, showing her the paper and the drawing. Her eyes lowered and she stated how terrible she felt, for having not taken the paper and having only offered discipline. She taped the drawing up on the wall, in full view. They'll be back next week for follow-up, and I really hope I get to be there when that young girl sees that her message of appreciation was heard.

2 weeks down ... 7 more to go.

Some cool things happened this week.

I detected a heart murmur that no one else had heard (I owe it all to my Harvey Elite stethoscope, which has become an extension of my brain). The boy is about 9, and there it was ... faint, but present with an almost musical tone, 'hmm dub, hmm dub, hmm dub'. I told my preceptor and she said she doubted it, that no one had ever heard a murmur in this patient before. I stood silently as she listened carefully, then she rose and explained to the mother what a murmur meant in this case (most likely an atrial septal defect that hadn't yet closed, but which probably would in time).

I solved the case of a toddler's constipation. The parents disagreed that her belly was distended, but it plainly was. I asked if there had been any change in her diet? No, they said, she's still on formula. I palpated her abdomen and then turned around and asked, "are you feeding her formula that's been supplemented with iron, by any chance?" They looked surprised and said that yes, that had been the kind on sale the last time they shopped. Well folks, guess what ... that iron has constipated your beautiful baby girl. Based on how lumpy her guts felt, I was surprised she wasn't a bit more cantankerous ... I sure would be!

A young teen, about 14, had been 'forgetting' to turn in her homework. She had been doing it, but it was staying in her locker. Oddly enough, her mother said that her memory was fine in other areas, such as when it was time to go swimming with friends, etc. My preceptor understood that it was rebelling and gave her a little talk on the importance of education and that she needed to ship that into shape. The mom was nodding and agreeing vigorously, and the young lady was just sitting with her head down, dealing with the barrage. When they were done and there was a moment of silence, I said, "may I make a suggestion"? All eyes turned to me, I think they had forgotten that I was in the room. I looked directly at the mother and said, "I would suggest that you make sure your daughter has some more room in her life to make her own decisions." It was obvious to me that she was exerting independence in what was probably the only space that she had as her own ... her school locker. Mom and dad could make her do the homework, but they couldn't make her turn it in ... she had that power and she was using it. "I don't know you well enough to say how, but maybe you could think of another part of her life where she can exert her power to say no, I don't want to do that, or yes, I do want to do that." The mother stuttered and sputtered a bit, because she wasn't expecting to be put on the hot seat. But based on the fact that she had mentioned earlier how the situation was creating a lot of stress and strife at home (yelling, fighting), it seemed to me that there was an A + B that was leading up to the C (which was probably the grade her daughter was headed for, if things didn't change). My preceptor spoke with me later, agreeing about my comment and the situation, and she's been treating me a bit differently since that day. I've always had an affinity for working with teens, I think it's important to remember where they are in their development and how important it is that they be allowed to grow (with guidance) into responsible individuals who are capable of making decisions (that they can handle).

I learned the importance of asking about cough when I thought it was simply musculoskeletal pain ... turned out the patient had one, so we sent her for an x-ray to rule out mycoplasma pneumonia, which presents with dry cough that creeps up on you. I'm fine-tuning my newborn and infant exams, no easy task ... it's so easy to look and say, 'oh, the baby looks fine', but are the testicles descended? Is there a hypo/epispadia? Hernia? How are the femoral pulses, to rule out coarctation of the aorta? Any cardiac sounds which could indicate a defect in the heart? Any evidence of a spinal defect? Any retinal hemorrhaging, which can indicate shaken baby syndrome? Are all the neurological reflexes intact and how well is their neurological development? Kids are no easier than adults, and in many ways more of a challenge because some can't talk to you in words.

Other than the little girl who screamed bloody murder because she didn't recognize me (you could easily have heard her down the block, as she sat in the hallway refusing to budge ... man, I didn't know a face could turn that shade of red!), the kids are awesome and I love working with them. The ones who just want to talk to you, even though it's in a language that no one but they are understanding, they're the really fun ones, as are the 6 year olds who just can't wait to tell you all about everything and anything they can think of.

No more freakin kids!!!! GAHHH!!!!!!!

Yes, sometimes it gets this way, especially when it's a busy day and it's one screamer/protester after the other. You can't explain the logic to them of WHY you need to look in their ear, and that's when you have to be more firm, hold the head (with their young vocal cords and lungs testing your decibel capacity level, right at your ear), and just look.

But after the "No more freakin kids!!!! GAHHH!!!!!!!", comes the 'okay, I can deal with this', and my boo-boo (ear) feels better. :) No major illnesses so far; otitis media, bronchitis, lower back pain. Lots of newborn checks and well-visits (immunizations = more screaming). The parents have been great.

Some of the kids are seriously amusing, like this one 9 year old girl, when I asked her what her favorite food was, she thought for a few seconds, and then said (very seriously), "pork". I laughed and she gave me a look which said, 'I really don't care WHAT you think'. Some of the kids make me laugh ... actually, if I walk in and they're screaming, a little scream back at them can help sometimes ... it seems to shock them, and then they just stare at you in puzzlement.

Ending ... and a new beginning.

Last day with Surgery today. All in all, it was hard work but a great experience. Tomorrow's the exam and then I jump right into my first of two preceptorships. Preceptorships are basically long rotations, each of them lasts ten weeks. One has to be in Family Medicine, the other can be Emergency Medicine, Pediatrics, or Family Medicine. Even though I have ER experience, and even though it was probably not the most lucrative choice (ER would probably have looked better on the CV, for a larger amount of employers), I chose Peds for my first one. Even if I never do go into the field, it's an area where I've had a lesser amount of training and for me it's all about learning. So, come Monday morning, I'll be back working with newborn to 21 year old patients and their families.

I really enjoy Peds. I value being an influence on the formative years. My Peds rotation preceptor recommended on my evaluation that I consider working with adolescents. I guess I remember what it was like, to be that age. In all honesty, I think they just respond well to me treating them like they're human beings who deserve to be understood. Maybe it's that or my bad jokes! Still, while teens are fine and dandy, I get just as much enjoyment from working with the little ones. Most Peds practices see a combination of both. I enjoy caring for the family unit as well.

The practice where I'll be working has a PA on staff so I'm looking forward to seeing things from her standpoint, especially if I might consider this as my chosen field. My Surgery experience was so positive that I'm also thinking of a possible career in Pediatric Surgery. I'm hoping there might be some room on this preceptorship to get some hospital/OR time in. Either way, I'm probably in for a lot of viruses, shots and lollipops. It is, however, important to remember that the anatomy and physiology of the pediatric population bring a completely new set of variables, including specific considerations, conditions and pathologies. Amongst the myriads of kids you'll see who are there for their immunizations or yearly check-ups, you can't miss the one who is in serious need. I think that's where the challenge lies for me, and the reward.

20 more weeks and it's time to graduate, but the road is not yet quite over.

Workin' workin' workin' day and night ...

I have two projects due Friday, one is an article critique related to my Master's thesis, and the other is a 30-minute powerpoint presentation on short-bowel syndrome that I am to present to the Attendings and Residents. After sitting in on their presentations, I know that it has to be top-notch all-blowout. So yea, no pressure there! I've been working on both so I should be good. But after 11-12 hour days, it's tough to sit down and just start thinking while I type and format, you know? Whatever, you do what you have to do. I will say that I never used to be a coffee drinker until now.

Surgeries have been wonderful. I assisted in a supra-cervical hysterectomy today, where the uterus had grown fibrous. What we took out didn't even look like a uterus, it was this misshapen thing filled and covered with hard growths and nodules ... sort of like a large, hard, bulbous root thing, like a deflated basketball that had been dipped in some kind of super-strength rubber cement. It was great to help take something out of a body which was then going to feel and function so much better. We left her ovaries and cervix, so she'll still have her hormones as well as better vaginal/pelvic support.

One funny thing happened today ... I was not scrubbed in, for a simple incision and drainage of a large sebaceous cyst on the back of a man's head. So the Attending was working on the right of it, and the Resident was working on the left of it, and I was standing behind them in the middle, just observing from a safe distance of about 4 feet or so. Even tho I wasn't scrubbed in and sterile, I was still wearing my safety glasses and nose/mouth mask, and good thing too, as the cyst decided to erupt from the local anesthetic that they had injected into it, 'peeing' its contents straight out into the air, about 4 feet or so, all over my forehead and shirt. I was in shock for a moment, not only because it felt like someone was peeing on me in a steady stream, but because of the stench from the pus that was now on my skin and clothing. Good times, good times.

I'd love to share more of these joyous experiences, but it's time to get back to work. Until next time!

;)

P.S. To the last post

So, I'm standing behind my preceptor, as he's reviewing the chart of a patient who we're about to take back. Michael Jackson's 'Don't Stop 'Till You Get Enough' comes on the radio, and I guess I must have started grooving in place because he turned around and asked me, "are you doing the moonwalk?" I said, "umm, no, I don't think so? But I can?" And then I proceeded to do my poor rendition of the move. He laughed and said, "you know what you say when they offer you two gloves in the OR, don't you?" I shook my head. He said, "when they hold up the second glove ... say, 'I only need one'. And then give 'em a moonwalk."

I know, you'd have to have been there. This guy is full of so much good humor, he keeps me laughing all day long. It's a good ride this time around.

Oh yea, I forgot to mention ... with the splenectomy, I had done my homework. So when we went to begin, I asked the Doctor, "left costal incision?" He said, "hmm, no, midline abdominal". We gathered around and waited to begin, when he said, "you know, actually, I think the left costal is the way to go with this one due to her body habitus. Let's begin." And begin we did :)

Surgery.

I haven't written in a while; life has been a whirlwind. This rotation is turning out to be, not only a stellar rotation, but one of the best experiences of my life. The reason for this? My preceptors.

Both are 60. The one who is technically my preceptor, is the kindest, GOOD man. He is a good man. He is kind, respectful, and lives his life with peace and humor. He's softspoken, of smaller height and frame. You would probably not take too much notice of him, should you pass him on the street. But he is a Surgeon, man oh man yes he is. And he is a teacher. And he is good to people. I have always considered myself to be a good man, but this man puts me to shame. The other preceptor has a bit more bite to him, but is such a wonderful fellow. I feel so proud of him when I sit across from him at his desk, the wall behind his chair is literally covered with awards, about 30 of them. Best Surgeon this, Best Surgeon that. I dusted them all off and straightened them.

This is a General Surgery rotation, with a concentration in Oncology. So, we do a bit of everything. Today we took out a spleen, removed a hemorrhoid, biopsied two breasts, and removed a necrotic butt (yup, exactly that). Every day is different. But the Doctors and the teams are all so amazing and positive, it's truly a pleasure to go in every day. And they are long, hard days, 10-13 hour days on your feet. But they're good days.

Moving on ...

Adult Med is out of the way, at least as far as rotations go, and now it's time for Surgery. Looking forward to this one! Not just because it's my last rotation, but also because I do well in the surgical environment. I've always been good with my hands, and plus I'm a longtime horror movie aficionado so I have no aversion to blood and guts.

What is all this about, anyhow?

I thought you might like to get a better glimpse into what's required of us as PA students. Most PA programs require prior coursework in the sciences which are equal in many respects to pre-med students, more or less. For example, PA students for most programs must have already completed a Biology series with labs, Chemistry series with labs, Organic Chemistry with Labs, Biochemistry, Microbiology with Lab, Anatomy with Lab, and Physiology. Pre-meds are not required to take Anatomy or Microbiology in undergrad, but PA students are. This is so they can jump you straight into deeper study of medicine from day one. The other main difference with undergrad requirements is that pre-meds are required to take Physics in preparation for the MCAT, but most PA schools don't require Physics. Of course if you're going for a Bio degree in undergrad then you'll probably have taken Physics regardless.

Medical school does still go deeper into physiology and pathophysiology, but PA students are nonetheless expected to handle a great deal of material. A great deal. Most make it through the first year, but alas some do not. We had an attrition of about 5 or 6 students this year. Some are trying a second time, some have moved on towards other careers. I think no less of any of them, the first year is a hard kick in the face and there is unfortunately little to no forgiveness offered for failure.

PA program accreditation involves representatives from quite a few Physician organizations, including the AMA, American Academy of Family Physicians, and the American College of Surgeons. 

People ... who can understand them?

So, the patient I was writing about, the man who's been bedridden for four years. To make his history short, he's status post left renal transplant and pancreatic transplant also. I mentioned in my last post that he has issues with depression. Well, today, some smart-ass Doctor who's never even worked with him before, goes into his room and tells him that his pancreas has failed. His blood sugars have been high because he's been on steroids to deal with renal transplant rejection, and while the pancreas is also being rejected to somewhat of a degree, it's not technically failing yet. Yet this Doctor, without even speaking to the patient's parents first (who were out in the waiting room), goes in and tells him his pancreas has been rejected. The man was in tears when I went in to remedy the situation. He wanted to sign out AMA and I told him I didn't blame him one bit. I called his Attending, and we discussed. His anemia that had brought him in (the reason for his admittance) was now better resolved after 4 units of red blood cells, tho not optimum but it was enough that he could leave. His urinary tract infection had resolved. He hadn't had fever for days. His strength was better. Granted, his BUN/creatinine was still elevated and his blood pressure was high, but he could go to dialysis and get his prescriptions at the pharmacy just as easy as he could in the hospital. So, the Doctor said he would sign him out first thing in the morning, to which the mom emphatically shook her head no, to which the Doctor said, "fine, sign him out AMA then." So, that's what we did. They called their ambulance service and he should be leaving right about now.

My main issue here is the insensitivity, not to mention the incompetent behavior, of the Doctor who conveyed this 'news' to the patient. She didn't know a thing about him, yet she took it upon herself to relay this (wrong) information. I came across this earlier, with a different Doctor, after I attempted to bring Physical Therapy on board. He's been in bed here for 2 weeks, and while the nurses turn him every so many hours, to ward off bedsores, he has a pressure ulcer on his left heel that's already reaching grade 2 or 3. I wanted someone to work his legs to better his circulation and also just to help keep his muscles from complete atrophy. The Doctor said, "sure, although I'm not sure what good it's going to do him NOW" ... right at the door of the patient.

I could have strangled him. I understand that things get busy and sometimes we forget that patients are real people, listening to our every word. But I mean, really, is it so difficult to move down the hall or even go into the Physician lounge to state your case? And in fact, the Doctor was in fact wrong, just because someone is bedridden with little hope of walking again is no reason to think that PT will do no good "NOW". It can still do a LOT of good "NOW".

To make things even worse, the patient had said that if he could get into a wheelchair he would stay. I had been off with other patients when they all tried to get him in. If I had only been there, I lift heavy weights and even though I have a bad back from years of lifting boxes/concrete/hay, I KNOW I could have gotten him into that wheelchair. Just the fact that he asked to do it sends a strong message. So, when I was with the family later, I told them about a lift that I used with a woman with Multiple Sclerosis who I took care of for a few years. It's a hydraulic lift that has a belt attached to a chain that raises up with really minimal exertion on the part of the person who turns the crank. I just got home when I remembered that I hadn't told the family how they could get one, and in fact realized that I myself don't know. So I called his nurse, who told me that would be something they would request through their social worker, and she said she would relay the information to the parents before they left with the transport ambulance.

We could have gotten him in the chair. I hope they follow through with that.

Tough times.

There has been a tragedy in my life and I'm trying my best to immerse myself in my education and work. Some days are easier than others, but there is nothing else to do. Sometimes life deals heavy blows and all we can do is keep going. There are others who have gone through worse. All we can do is survive.

Life is a gift. Or is it?

This last week I've been working with a patient who got meningitis and now four years later is bedridden and unable to move. He was a normal man before that happened. His mother and father take care of him now completely themselves, from bathroom to feeding. I spoke with his mother who told me that the reason he refuses treatment is because he wants to die. He is most likely going to need dialysis soon and he's told her that he'll refuse that too. If that happens, then he will die. A psychiatrist comes to the house twice weekly for him. I made a few suggestions that might help, getting him a computer (his right hand moves enough that he could type), perhaps learning a skill such as a new language (he likes Italian).

Sometimes life is sad.

Well, let's see.

I got here at 7 this morning, it's 7 pm now and there's no way I'm leaving for another few hours. I just finished up with all the patients, but now I have to stay in the library and begin my submissions that are due at the end of the week ... two 7 page papers and one 2 page paper. Plus one of our top Attendings gave me a paper on Acid-Base Disorders that she's going to quiz me about on Thursday. I just inhaled a salad. Do I have time to check my email? Okay, back to work.

Moving into the 3rd week.

Last week was so busy, man do my feet still hurt. We have a board review exam coming up the day after the exam for this rotation, so I've been having to study after work until midnight and thus have gotten 5-6 hours a night for the last 7 days and it's wearing me thin. Then again, pain is weakness leaving the body ... I'll sleep when I die.

Lots of patients. Most are great, but a few are rarely just plain stupid. We had one guy sign out ama (against medical advice) because, even though we had just taken a liter of fluid out of his belly, another liter (filled with pus and blood) from the spaces around his lungs, and found two pulmonary embolisms in his lungs as well, he "felt better" and would "goto church and pray". We begged, we pleaded, we yelled, and ... off he went. He was so uneducated and ignorant, he actually thought we were keeping him there to practice procedures on him as a human guinea pig. Oh well, sayonara dude. Next.

There was one day when my resident had an interview for something, and my intern was called to another part of the hospital for the rest of the day, so that left myself and the 3rd-year medical student in charge. We rocked. Did what needed to be done. My resident's wife, also a resident in the hospital, had his pager, and I would just call her with orders to put into the computer after I saw each patient. "Okay, no problem", she would say. Gee whiz, I felt so grown up! Soon enough, can't wait. I'm proud of my decision-making thus far, I'm going to do just fine.

Moving into the second week.

Last week was a challenge, not only in that it's a new rotation with a new team who all have to get used to one another, but also because none of them really knew anything about PAs or PA education. So, I sat them down at lunch and answered all of their questions. They had some misconceptions ("you don't take call, right?" "you have much less responsibility, such as not having to work on the weekends"), but all that took was some gentle correction. All week I saw their eyes widen as I relayed my knowledge about certain subjects. Then again, they're talking to someone who has a neverending thirst for knowledge, especially when it comes to physiology. But, in all fairness, I have to admit that much of what I knew in front of them came from my recent teachers (and a bit from you too, Ms. O).

Today we worked with an attending in Transplant Nephrology, and I mean this man is a D.O.C.T.O.R. Brilliant. All I could do was hang on his every word. He had us all come down to the pathology labs where the Pathology M.D. took us through the biopsy slides in detail, using large digital wall screens that are connected to their microscopy equipment. I was just in awe the entire time; they pointed out the glomeruli, the nephrons, the pathology, the immune response. It turned out that the patient has borderline transplant rejection (4 years ago), but the organ is still working well enough that there is hopefully time to change some meds and improve the situation.

Other than that, we just continued on with our patient care, monitoring labs and meds, changing labs and meds, ordering procedures, performing procedures, consulting with surgery/infectious disease/CAT/MRI/cardiology/GI constantly. Busy busy.

Now I'm home, I've had some soup and put my feet up for a few minutes, and it's time to fill my water bottle with some vitaminwater and head back to the library for a few hours of study. Then it's up at 6 for ... Tuesday! :)

First day.

Good resident, good intern, good medical student ... I lucked out. Only a handful of patients at a time (today we had 5), but they are so multi-presenting that there was no lack of things to take care of. Dialysis monitoring, insulin regulation, nutritional consideration, meds, labs, charting. My background education in physiology is coming into gear at full throttle. Many, many details to keep track of.

One of our patients is an older woman in her 60s, who has ESRD (end stage renal disease). She has hyperparathyroidism, which is resulting in high levels of calcium in her body. The calcium has nowhere to go, so it deposits in the tissues, including blood vessels and the valves of the heart. She is being given a calcium-binder, but it can only do so much ... she needs dialysis every day for a minimum of 4 hours. Problem is, she is non-compliant and leaves after 2 hours. I'm not sure she understands that she's basically killing herself because her blood is not being properly cleansed of the overload. I saw her in dialysis today and reminded her that she needed to stay as long as possible, and made sure she had a TV to watch. She'll be getting an X-ray tomorrow to look for blood vessel calcifications in her legs. Oh yea, that's the other thing about this patient, her legs and feet, due to the lack of adequate blood supply, are dying. They're developing sores which can't heal and she will most likely need amputation. Very sad, but even more tragic when you consider that her lazy attitude is such a strong contributor to her condition. You can lead a horse to water ...

I'll be given my own patient(s) to follow tomorrow, so I'm really looking forward to that.

Next up ...

Nephrology.

My classmate's first circumcision :)

And the little man slept through practically the whole thing! Unbelievable, usually they scream their head off, but he was just zzzzzzzzzzzzzzz

Heading into home stretch ...

Well. What a time it's been. So many patients, so many situations. Lots of conditions, lots of labs, a few tears.

Grand rounds this morning, on vulva abscess. Very interesting and educational ... especially that antibiotics are not always necessary, sometimes just incision and drainage is all that's needed. 

We saw a woman today, her baby died this morning in her womb. 18 weeks old, it just wasn't meant to be. My Doc sat on her bed while I stood at the foot, and he asked her if she would like to hold the baby after it was delivered. She said no, and he told her that many who make that decision regret it afterwards. She thanked him for his compassion. I was of course starting to tear up, as tears had been rolling down her face since before we had walked in the room. He gave her the news that it would most likely not happen to her again, should she decide to have any more children. He was stellar with her, I was very proud of him.

The rest of the day we spent rounding in the hospital. We saw a patient who had delivered while she was pre-eclamptic, and was then being monitored for 48 hours after delivery. We went to lunch and then got a call that a patient was delivering so we dropped our meals and ran. After the baby was out and resting on her mother's breast, the mother wouldn't let the nurses take her new daughter from her. The Doctor had to plead with her, "okay Mommy, we need to take her so that we can clean her, okay?" She shook her head and said "noo!" "Okay?" he asked again. She finally acquiesced. Can you imagine her face? Shining like the sun, so in love, crying and looking down at her little girl. Good times, good times.

Lots of study to come over the next week, a lot.

Surreal day

Helped deliver this morning. My Doc told me he wanted me to watch his technique ... he dropped the baby. Thank The All for the afterbirth bin! I was sort of in shock when it happened ... the father just said, "what..." All day, I would remember and burst out laughing. It happened at really inopportune times, of course, where I would have to mask my guffaw with a 'terrible cough' ... righteous. Yes, the baby was just fine! Poor thing, with her head in all that muck, just laying there, like, 'look man, this wasn't how I intended to enter the world ...'

Anyhow, then a little later on I noticed the chaplains in a room. I stood outside a few feet away, just listening and trying to figure out what was going on. I heard someone say that the baby was dying, so I went and asked one of the chaplains how old it was. He said, "three weeks", which didn't make any sense, so I went in myself (the mother, a young mentally retarded woman, was in a different room). The baby was 21 weeks. The cutoff for assistance at this hospital is 24 weeks, so they were just letting her pass away. She was so tiny ... frail. Her eyes were fused shut, but other than that she just looked so small and fragile ... almost even normal .. almost. She was lying naked in the bin, and every so often she would let out an agonal gasp. Her lungs weren't hardly developed, so there was no chest rise, but she tried. Her little heart was beating away, ignorantly unaware. There were nurses and nursing students just standing around, not doing anything for this little life who was doomed. So I just stepped in front of all of them and grabbed a blanket and covered her nakedness, and to help keep her warm. Then I took the top of the blanket that was under her, and pulled it up over her head, in a little head covering. My fingers brushed against her skull and it was barely there, it felt so paper-thin that it was probably more what was there of her brains more than anything. Anyhow, they ended up dressing her and waiting for her heart to stop before they took her to the mother, and I said, you know, it would be nicer if you let her die in the arms of her mother, so they listened to me and took her in to her.

I left and moved down the hall to another room, where a delivery was about to take place. I started to tear up, so I stopped and pretended to look at some pictures while I mustered up my strength. I went in just as an observer on this one, but started tearing up again and had to leave the room. I took a few seconds in the bathroom, shook myself off, and went back in. This time the baby was delivering, and the sight of it made me start crying, silently of course. When they put the baby in the heated bin, the father saw that I was crying and he must have thought I was crying out of joy because then he started crying as he walked over to where I was standing next to the baby. Bless his face, what innocence ... he will make a wonderful father, no doubt.

Hours later, I heard a calloused nurse say, "isn't that baby dead yet??" I wanted to slap her, but instead I went back into the room where the dying baby was. There was a wonderful nurse in the room, she was putting everything together in preparation for presentation to the family ... the blanket, the footprints, a few pictures they had taken. I asked if she was still living, and she said she didn't know and would I listen for a heartbeat? I did, and there wasn't one. There was just the body, of this little soul who visited momentarily. I don't know if anyone else loved her while she was here, but I did. Maybe I'll see her around in the next dimension, who knows ... maybe one day she'll do the same for me.

1st week

A lot of what you can probably imagine ... pap smears, taking cultures, breast exams, prevention counseling. I like viewing cultures under the microscope, I had thought that my days of microbiology lab were over. Nothing else too exciting ... one patient was having unprotected sex with her boyfriend who shoots heroin. She and I had a serious talk, which ended with me saying, "come on, surely you've had this talk with a medical professional before." She said, "I've never had this talk with ANYone before." That made me feel good, but my main concern is that she wisen up and take better care of her health and her life.

Anyhow, as I was leaving my preceptor said, "strong first week, I like it". So that was good. Now a weekend of heavy study on dysmenorrhea and every other subject under the sun, and then back to the clinic on Monday. Tuesday ... hospital scrub in at L&D.

2nd day in Ob/Gyn

Two Docs at the practice, one NP. The Docs were on vacation Monday, so I worked with the NP who seriously rocked the Universe. Very impressive. The head Doc came back today and was just as impressive. He speaks 8 languages and his brain just doesn't stop. We had a great conversation at lunch about student protests. I met and spoke with the other Doc later in the day, he is definitely intent on my knowing my textbook page for page. I LOVE that.

I got to interpret in ASL for a deaf patient yesterday, that was cool. I was reminded how little I use my ASL! Practice makes perfect and ... I hadn't practiced in a while. But we got through it and mission accomplished.

I'm really looking forward to this rotation, it will consist of clinical care (prenatal care, annual exams, etc) and surgical (deliveries including c-section).  The Docs and NP say they have a motto ...'don't read, do. read later.' So, I'm gonna be busy, but I will definitely try to post weekly updates.

Next up ... Ob/Gyn

I've been working on my graduate thesis over the last few weeks, and just today started to hunker down in my readings for the next rotation.

There's a lot.

It is what it is.

I'm not allowed to say too much about this rotation for legal reasons, but I will say that I've developed a serious respect for the clinicians who deal with this patient population. There's a fine line between patient and offender here, and I'm trying my best to observe and sort it out in my mind. This rotation is just about the complete opposite from my last one, but it is allowing me to get a closer look at a darker side of both psyche and pediatrics. Knowledge is power, and I'm definitely learning a great deal.

Tomorrow is a new day.

I just heard back from my classmate who last finished the Psych rotation I'll be starting tomorrow. She said it was a lot of observing ... very little one on one interaction with patients. You are with the Psychiatrist almost all of the time, and it's all mental status exams that are performed monthly/weekly, there are few to no physical examinations (the internal medicine Doc handles all of that). She did say that it was difficult being around the patients, as those in the building where we rotate are either criminally insane, pedophiles, or violent sex offenders.

Anyhow, she was very reassuring and told me that as long as I watch my back at all times that I'll be fine, and that there will always be adequate staff around. She mentioned that there are back exits and entrances which she utilized a lot. She also said that a majority of the cases involve schizophrenia, so I'll be reading up on that this evening.

Here goes ...

Almost finished.

And sorry to say it. It's been a great experience, not just because it's Pediatrics but also because of my preceptor. A D.O. with many years of experience, he is intelligent, caring, thoughtful, and perhaps most importantly, lacks ego issues. He has been open to discussion, even to learning. I consider him a bit of a role model and colleague, as I too try and live the same way ... I don't ever want my ego to come in the way of my acquiring useful knowledge.

I've seen a lot of 'less serious' conditions ... many viral in origin. Still, I've also seen RSV bronchiolitis turn into serious bacterial pneumonia, as well as other more urgent conditions. The young girl with septic arthritis who we sent directly to be admitted. The woman who has been sleeping a lot, only to find that she's pregnant. So many details that can't be overlooked.

My time on this one has been both a challenge and an honor. Next up ... state mental institution for Psych. I've been warned to be on the watch for patients in the dementia unit who like to "cop a feel". Then again, maybe the convicts deemed criminally insane will be easier. I think I may miss family practice *gulp* ...

Mid-way thru ...

Anyone who thinks Pediatrics is 'easier' has another thought coming. Younger humans have less developed anatomy and physiology, including immunity. Babies can get pneumonia. Peritonsilar abscesses can stay hidden behind enlarged tonsils. A 5 year old can develop rheumatoid arthritis. It takes a keen and careful eye to stay on constant alert. So far, I've done very well.

Something I've always heard as rote from others is "oh, I love the kids ... it's the parents that I can't stand!" For the most part, parents have been wonderful. There have been a couple of nightmares ... the ones who let their daughter crawl around on the dirty floor, the ones who smoke in the car with the windows rolled up. There was one couple with triplet boys ... when the boys were kicking the table they were sitting on, the mother told them to stop. They didn't listen and continued, so I said, "hey you guys, listen to your mom." She let off into me, telling me I didn't know how to deal with children. I was astounded, considering that I was backing up her attempt. Anyhow, they were spoiled kids and eventually she'll understand that ... or maybe she won't. That's the other part of Peds, you can do your best to help in any way you can, but in the end they leave and go out and live their own lives.

Do I still want to do Peds? Definitely. I have had so many good experiences so far, and learned so much. I'll be sad to see this one end. Next is a State Mental Institution that houses convicts who've had their pleas of insanity granted. Gonna be quite a change from cooing and gurgling babies.

The beginnings.

Doc had me see a 5 day old yesterday, I love those visits. Just checking things, making sure everything's working out. He then gave me a 6 month old patient with developmental issues. The infant was at the level of a 4 month old, with some musculoskeletal and other developmental issues. I noticed almond shaped eyes but ... anyhow, when we went in together, he showed me how it's done. He was very calm and cool, pleasant, and then asked, "so whose eyes she got, she got Daddy's eyes?" in his Italian way. The mother and aunt said no, and he just smoothly then asked if there had been any genetic testing? No. He said he wanted a CT of the brain, and that he also wanted to test for Down's. He broke it to them very coolly, basically. They were so down, it was hard for me. I noted her improvement since the report of the last visit, where she had obviously gained strength, but they kept shooting it all down as not meaning much. I disagreed with them, saying that it meant more than they were making it out as. You couldn't tell in usual ways when she was smiling and laughing, but she still made it obvious when she was. They knew that, and it was obvious that they still loved her very much ... it was just a big disappointment with daunting overtone.

So, I went into the big texts and looked up all the genetic defects possible. I searched and searched for anything else it could be, something less major. I searched my handheld device that I enter all the patients I see into, and searched for something like, 'developmental delay'', anything that could offer better hope. Well, when I got home I searched Down's syndrome and pulmonary issues, since the baby's lungs had sounded like bellows. Sure enough, a majority have them. So, I gave up and went back in and changed the diagnosis officially to Down's. It might actually be Mosaic Down's (she didn't seem to fit all the criteria for Trisomy 21), those individuals tend to have IQs 10-30 points higher than those with Trisomy 21. Either way, there's hope.

The whole thing was like the antithesis of the 5 day old who was the perfect little baby. Still, altho their lifespan is sometimes relatively short due to oftentimes having congenital defects, with therapy and work Down's children can grow into productive people all their own. Some go onto independent living situations. Some have even won best actor awards (Cannes, BAFTA). I hope I was able to impart some hope and caring to that family's darker day. I hope I get to see them again so I can relay all the information I've learned since we saw them.

Anyhow, I've worked in and around Emed for so many years now that it was the majority of what I knew clinically. But I knew by the end of my second day on this rotation where my calling lies. I had a feeling before even starting that this would happen, and it did. Not to say that I won't work in the ER as well, part- time. Anyhow, let me work on graduating and getting my license before I start working anywhere at all ;) But it's almost as if my appetite for medicine has been whet all over again. Not only do you get to practice medicine with all the age ranges up to adult, you get to work with their families. You're there to help drive an important point home that the parents have been trying to impart with their child not listening. And likewise, you're there to help block some of the blows parents can sometimes unwittingly impart towards a child who is simply beginning to explore life as a young adult. And most important, I get to cure pneumonia. I'm home.